NC0073571_Renewal (Application)_20201110

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MICHAEL S. REGAN -*,,._.,�• -
Secretary
S. DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
November 10, 2020
Countryside Manor
Attn: Mervyn R. King
7700 US Hwy 158
Stokesdale, NC 27357 I
Subject: Permit Renewal
Application No. NC0073571
Countryside Manor WWTP
Guilford County
Dear Applicant:
The Water Quality Permitting Section acknowledges the October 28, 2020 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deo.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
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Wren Thedford
Administrative Assistant
Water Quality Permitting Section
cc: Joshua Powers-Envirolink, Inc.
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NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit NC0073571
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type.
1. Contact Information:
Owner Name Dr. Mervyn R. King
Facility Name Countryside Manor
Mailing Address 7700 US HWY 158
City Stokesdale
State / Zip Code NC 27357
Telephone Number [phone] P F C F I\i E D
Fax Number (N/A) k; 8 ?020
e-mail Address pomcsm(atriad.rr.com NCDEQ/DWRINPDES
2. Location of facility producing discharge:
Check here if same address as above ❑x
Street Address or State Road
City
State / Zip Code
County Guilford
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Envirolink, Inc.
Mailing Address 4700 Homewood Court, Ste. 108
City Raleigh
State / Zip Code NC 27609
Telephone Number [phone]
Fax Number (N/A)
e-mail Address (N/A)
1 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial ❑X Number of Employees 85
Residential ❑ Number of Homes
School ❑ Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Employees and residents of this assisted-living facility
Number of persons served: 107
5. Type of collection system
❑X Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes ❑X No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
Troublesome Creek
8. Frequency of Discharge: ❑X Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration:
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
This is a Grade II activated sludge plant featuring an equalization tank, digester,
aeration basin, circular clarifier, chlorine and dechlor tablet feeders, and diffused air.
2 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.015 MGD
Annual Average daily flow 0.0086 MGD (for the previous 3 years)
Maximum daily flow 0.043 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ❑X No
12. Effluent Data
NEW APPLICANTS:Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab
samples,for all other parameters 24-hour composite sampling shall be used. If more than one analysis is reported,
report daily maximum and monthly average. If only one analysis is reported, report as daily maximum.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average
over the past 36 months for parameters currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BOD5) 43.2 5.192 mg/L
Fecal Coliform 3100 1.875 ml
Total Suspended Solids 97 12.735 mg/L
Temperature (Summer) 30 18.239 Celsius
Temperature (Winter) (not seasonal)
pH 8.2 7.08 su
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping(MPRSA)
NPDES NC0078571 Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non-attainment program (CAA)
14. APPLICANT CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the
best of my kno e and belief such information is true, complete, and accurate.
J0sl.\ '6...-)e15 rec. 010-noter
Printed name of P Signing IS4A.3/a-0
Si at e of Applicant D e
North Carolina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement representation, or certification in any
application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the Environmental Management
Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method
required to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be
guilty of a misdemeanor punishable by a fine not to exceed$25,000,or by imprisonment not to exceed six months,or by both. (18 U.S.C.Section 1001
provides a punishment by a fine of not more than$25,000 or imprisonment not more than 5 years,or both,for a similar offense.)
3 of 3 Form-D 11/12