NC0087980_Permit (Issuance)_20161114

Water Resources
ENVIRONMENTAL QUALITY
November 14, 2016
Mr. Ricky D. Goias
Stokes County Schools
P.O. Box 50
Danbury, NC 27016
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
Subject: Issuance of NPDES Permit NC0087980
Pine Hall Elementary School WWTP
Class WW-1
Stokes County
Dear Mr. Goins:
The Division of Water Resources (the Division) hereby issues the attached NPDES permit for the
subject facility. This permit is issued pursuant to the requirements of North Carolina General
Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S.
Environmental Protection Agency dated October 15, 2007, or as subsequently amended.
We have made the following updates to your previous permit with no subsequent changes from the
draft permit mailed to you:
> Section A. (3) has been added to require electronic submission of effluent data. Federal
regulations require electronic submittal of all discharge monitoring reports (DMRs), effective
December 21, 2016.
> Regulatory citations have been added to the permit.
> An updated outfall map has been included.
No later than December 21, 2016, federal regulations require electronic submittal of all discharge
monitoring reports (DMRs) and specify that, if a state does not establish a system to receive such
submittals, then permittees must submit DMRs electronically to the Environmental Protection
Agency (EPA). The final NPDES Electronic Reporting Rule was adopted and became effective on
December 21, 2015.
The requirement to begin reporting discharge monitoring data electronically using the NC DWR's
Electronic Discharge Monitoring Report (eDMR) internet application has been added to your final
NPDES permit. [See A. (3)] For information on eDMR, registering for eDMR and obtaining an
eDMR user account, please visit the following web page:
http://deq.nc.gov/about/divisions/water-resources/edmr.
For more information on EPA's final NPDES Electronic Reporting Rule, please visit the following
web site:
http://www2.epa.gov/compliance/final-national-pollutant-discharge-elimination-system-npdes-
ele ctronic-rep orting-rule .
If any parts, measurement frequencies, or sampling requirements contained in this permit are
unacceptable, you have the right to an adjudicatory hearing, upon written request submitted within
thirty (30) days after receiving this letter. Your request must take the form of a written petition
conforming to Chapter 150B of North Carolina General Statutes, and you must file it with the Office
State of North Carolina I Environmental Quality I Water Resources
1617 Mail service Center I Raleigh, North Carolina 27699-1617
919 807 6300

of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless
such a demand is made, this permit shall remain final and binding.
Please note that this permit is not transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the permit. This permit does not affect the legal
requirements to obtain other permits which may be required by the Division of Water Resources or
any other Federal, State, or Local governmental permits that may be required.
If you have questions, or if we can be of further service, please contact Meredith Wojcik at
[[e-mail]] or call [phone].
S. Jay Zimmerman, P.G., 'rector
Division of Water Resources, NCDEQ
Enclosure: NPDES Permit NC0087980 (Issuance Final)
hc: Central Files
NPDES Program Files
WSRO Files
ec: Mr. Ricky D. Goins [[e-mail]]

Permit NC0087980
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other
lawful standards and regulations promulgated and adopted by the North Carolina
Environmental Management Commission, and the Federal Water Pollution Control
Act, as amended,
Stokes County Board of Education
is hereby authorized to discharge wastewater from a facility located at the
Pine Hall Elementary School WWTP
1400 Pine Hall Road
Pine Hall
Stokes County
to receiving waters designated as Eurins Creek in subbasin 03-02-01 of the Roanoke River
Basin in accordance with effluent limitations, monitoring requirements, and other conditions
set forth in Parts I, II, III and IV hereof.
This permit shall become effective March 1, 2017.
This permit and authorization to discharge shall expire at midnight on February 28, 2022.
Signed this day November 14, 2016.
S. Zimmerman, P.G., Direc or
Division of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 7

Permit NC0087980
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are
hereby revoked, and as of this issuance, any previously issued permit bearing this number
is no longer effective. Therefore, the exclusive authority to operate and discharge from this
facility arises under the permit conditions, requirements, terms, and provisions included
herein.
Stokes County Board of Education
is hereby authorized to:
1. Continue to operate an existing 0.004 MGD wastewater treatment system with the
following components:
• Septic tank
• Dosing chamber
• Recirculation system
• Surface sand filter
• Ultraviolet disinfection
The facility is located at Pine Hall Elementary School, located at 1400 Pine Hall Rd
near Pine Hall in Stokes County.
2. Discharge from said treatment works via Outfall 001, at the location specified on
the attached map into Eurins Creek [stream index: 22-26], currently classified
WS-IV waters in subbasin 03-02-01 [HUC: 0301010303] of the Roanoke River
Basin.
Page 2 of 7

Permit NC0087980
Part I
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
[15A NCAC 02B.0400 et seq., 15A NCAC 02B.0500 et seq.]
Beginning with the effective date of this permit and lasting until expiration, the Permittee is
authorized to discharge treated wastewater from Outfall 001. Such discharges shall be
limited and monitored 1 by the Permittee as specified below:
EFFLUENT CHARACTERISTICS
Parameter Code
EFFLUENT LIMITATIONS
MONITORING REQUIREMENTS
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Location
Flow 50050
0.004 MGD
Continuous
Recording
Influent or
Effluent
BOD, 5-day, (20°C) C0310
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
Total Suspended Solids C0530
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N C0610
Monthly
Grab
Effluent
pH 00400
'_ 6.0 and < 9.0
standard units
2/Month
Grab
Effluent
Fecal Coliform 31616
(geometric mean)
200/100 mI
400/100 mI
2/Month
Grab
Effluent
Temperature (°C) 00010
Weekly
Grab
Effluent
Total Nitrogen C0600
(NO2+NO3+TKN)
QuarterlyGrab
Effluent
Total Phosphorus C0665
Quarterly
Grab
Effluent
Footnotes:
1. No later than December 21, 2016, the permittee shall begin submitting discharge monitoring
reports electronically using the NC DWR's eDMR application system [see A. (2)].
See Condition A. (3) for instructions should the facility's permitted UV system fail and an alternate
means of disinfection is required. Total residual chlorine monitoring requirements and limits are
applicable if chlorine compounds are used for disinfection.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN
TRACE AMOUNTS.
Page 3 of 7

Permit NC0087980
A. (2) ELECTRONIC REPORTING OF MONITORING REPORTS
[NCGS 143-215.1 (b)]
Federal regulations require electronic submittal of all discharge monitoring reports
(DMRs) and program reports and specify that, if a state does not establish a system to
receive such submittals, then permittees must submit monitoring data and reports
electronically to the Environmental Protection Agency (EPA). The final NPDES Electronic
Reporting Rule was adopted and became effective on December 21, 2015.
NOTE: This special condition supplements or supersedes the following sections within
Part II of this permit (Standard Conditions for NPDES Permits) :
• Section B. (11.)
• Section D. (2.)
• Section D. (6.)
• Section E. (5.)
Signatory Requirements
Reporting
Records Retention
Monitoring Reports
1. Reporting Requirements {Supersedes Section D. (2.) and Section E. (5.) (a)1
Effective December 21, 2016, the permittee shall report discharge monitoring data
electronically using the NC DWR's Electronic Discharge Monitoring Report (eDMR)
internet application.
Monitoring results obtained during the previous month(s) shall be summarized for each
month and submitted electronically using eDMR. The eDMR system allows permitted
facilities to enter monitoring data and submit DMRs electronically using the internet.
Until such time that the state's eDMR application is compliant with EPA's Cross -Media
Electronic Reporting Regulation (CROMERR), permittees will be required to submit all
discharge monitoring data to the state electronically using eDMR and will be required to
complete the eDMR submission by printing, signing, and submitting one signed original
and a copy of the computer printed eDMR to the following address:
NC DEQ / Division of Water Resources / Water Quality Permitting Section
ATTENTION: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
If a permittee is unable to use the eDMR system due to a demonstrated hardship or due
to the facility being physically located in an area where less than 10 percent of the
households have broadband access, then a temporary waiver from the NPDES electronic
reporting requirements may be granted and discharge monitoring data may be
submitted on paper DMR forms (MR 1, 1.1, 2, 3) or alternative forms approved by the
Director. Duplicate signed copies shall be submitted to the mailing address above. See
"How to Request a Waiver from Electronic Reporting" section below.
Regardless of the submission method, the first DMR is due on the last day of the month
following the issuance of the permit or in the case of a new facility, on the last day of the
month following the commencement of discharge.
Page 4 of 7

Permit NC0087980
Starting on December 21, 2020, the permittee must electronically report the following
compliance monitoring data and reports, when applicable:
• Sewer Overflow/Bypass Event Reports;
• Pretreatment Program Annual Reports; and
• Clean Water Act (CWA) Section 316(b) Annual Reports.
The permittee may seek an electronic reporting waiver from the Division (see "How to
Request a Waiver from Electronic Reporting" section below).
2. Electronic Submissions
In accordance with 40 CFR 122.41(1)(9), the permittee must identify the initial recipient
at the time of each electronic submission. The permittee should use the EPA's website
resources to identify the initial recipient for the electronic submission.
Initial recipient of electronic NPDES information from NPDES-regulated facilities means
the entity (EPA or the state authorized by EPA to implement the NPDES program) that is
the designated entity for receiving electronic NPDES data [see 40 CFR 127.2(b)].
EPA plans to establish a website that will also link to the appropriate electronic
reporting tool for each type of electronic submission and for each state. Instructions on
how to access and use the appropriate electronic reporting tool will be available as well.
Information on EPA's NPDES Electronic Reporting Rule is found at:
http: / / www2.epa.gov/ compliance / final-national-pollutant-discharge-elimination-
system-npdes-electronic-reporting-rule.
Electronic submissions must start by the dates listed in the "Reporting Requirements"
section above.
3. How to Request a Waiver from Electronic Reporting
The permittee may seek a temporary electronic reporting waiver from the Division. To
obtain an electronic reporting waiver, a permittee must first submit an electronic
reporting waiver request to the Division. Requests for temporary electronic reporting
waivers must be submitted in writing to the Division for written approval at least sixty
(60) days prior to the date the facility would be required under this permit to begin
submitting monitoring data and reports. The duration of a temporary waiver shall not
exceed 5 years and shall thereupon expire. At such time, monitoring data and reports
shall be submitted electronically to the Division unless the permittee re -applies for and
is granted a new temporary electronic reporting waiver by the Division. Approved
electronic reporting waivers are not transferrable. Only permittees with an approved
reporting waiver request may submit monitoring data and reports on paper to the
Division for the period that the approved reporting waiver request is effective.
Information on eDMR and the application for a temporary electronic reporting waiver are
found on the following web page:
http://deq.nc.gov/about/divisions/water-resources/edmr
4. Signatory Requirements (Supplements Section B. (11.) (b) and Supersedes
Section B. (11.) (d)1
Page 5 of 7

Permit NC0087980
All eDMRs submitted to the permit issuing authority shall be signed by a person
described in Part II, Section B. (11.)(a) or by a duly authorized representative of that
person as described in Part II, Section B. (11.)(b). A person, and not a position, must be
delegated signatory authority for eDMR reporting purposes.
For eDMR submissions, the person signing and submitting the DMR must obtain an
eDMR user account and login credentials to access the eDMR system. For more
information on North Carolina's eDMR system, registering for eDMR and obtaining an
eDMR user account, please visit the following web page:
http://deq.nc.gov/about/divisions/water-resources/edmr
Certification. Any person submitting an electronic DMR using the state's eDMR system
shall make the following certification [40 CFR 122.22]. NO OTHER STATEMENTS OF
CERTIFICATION WILL BE ACCEPTED:
"I certify, under penalty of law, that this document and all attachments were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of
the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fines and imprisonment for knowing
violations."
5. Records Retention [Supplements Section D. (6.)1
The permittee shall retain records of all Discharge Monitoring Reports, including eDMR
submissions. These records or copies shall be maintained for a period of at least 3 years
from the date of the report. This period may be extended by request of the Director at
any time [40 CFR 122.41].
Page 6 of 7

Permit NC0087980
A. (3) TEMPORARY MEANS OF DISINFECTION
[NCGS 143-215.3 (a)(2)]
In the event that the wastewater treatment plant's ultraviolet (UV) disinfection system
should fail, underperform, or otherwise be removed from effective service, the permittee
or his agent should immediately inform the Water Quality Regional Operations Section
staff of the Wilmington Regional Office of this development and discuss temporary,
alternate means for disinfection of the effluent.
If chlorine compounds are used as temporary means of disinfection, the total residual
chlorine (TRC) concentration of the effluent must be monitored on a daily basis while
this method of disinfection is in use and values must be reported on the discharge
monitoring report. TRC in the effluent may not exceed 17 µg/ L; therefore,
dechlorination methods may also be necessary to ensure protection of water quality in
the receiving stream.
In the event that TRC monitoring should occur, the Division shall consider all effluent
TRC values reported below 50 pg/L to be in compliance with the permit. However, the
Permittee shall continue to record and submit all values reported by a North Carolina
certified laboratory (including field certified), even if these values fall below 50 pg/L.
Use of a disinfection system other than the permitted UV system during circumstances
not deemed as emergency and/or temporary (replacement of lamps, lamp cleaning or
maintenance, etc.) will be considered a violation of the terms of this permit.
Page 7 of 7

Stokes County Schools
Pine Hall Elementary School WWTP
NPDES Permit 86011
Receiving Stream: Eurins Creek
Stream Segment: 22-26
River Basin: Roanoke
County: Stokes
Stream Class: WS-IV
Sub -Basin #: 03-02-01
HUC: 0301010303
SCALE
1:24,000
,ram"#"117,41
4
arikik,VM/AlleAAlkipiel
Facility Location ,M*,.�
scale not shown,
36.333056°,-80.048889°
USGS Quad: Belews Lake

Winston-Salem Journal
Advertising Affidavit
NC DIVISION OF WATER RESOURCES
ATTN: JENNIFER BURDETTE
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
P.O Box 3159
Winston-Salem, NC 27102
OCTflE@MOWM
1 7 2016
DEQ-WATER RESOURCES
401 & BUFFER PERMITTING
Account Number
4023513
Date
October 10, 2016
Date Category
Description
Ad Size Total Cost
10/10/2016
Legal Notices
Public Notice North Carolina Environmental Management Comi 2 x 33 L
402.78
KIMALEY JOHNSON
NOTARY PUBLIC
i FORSYTH COUNTY
4 STATE OF NORTH CAR
1 MY COMMISSION EXPIRES
820
Publisher of the
Winston-Salem Journal
Forsyth County
Before the undersigned, a Notary Public of Forsyth County, North Carolina, duly
commissioned, qualified, and authorized by law to administer oaths, personally appeared D.
H. Stanfield, who by being duly sworn deposes and says: that he is the Controller of the
Winston-Salem Journal, engaged in the publishing of a newspaper known as
Winston-Salem Journal, published, issued and entered as second class mail in the City of
Winston-Salem, in said County and State: that he is authorized to make this affidavit and
sworn statement: that the notice or other legal advertisement, a true copy of which is
attached hereto, was published in the Winston-Salem Journal on the following dates:
10/10/2016
and that the said newspaper in which such notice, paper document, or legal advertisement
was published was, at the time of each and every such publication, a newspaper meeting all
the requirements and qualifications of Section 1-597 of the General Statutes of North
Carolina and was a qualified newspaper within the meaning of Section 1-597 of the General
Statutes of North Carolina.
This i 0th day of October, 2016
1
(signature of person ' . i'ng affidavit)
Sworn to and subscribed before me, this I0th day of October, 2016
My Commission expires Skid • 1? Z0 2,0
(No . Public)
TLJ10 10 klfT A 1311 1 Ell = A 0C 1) A V CDAl1A 11k1\inir. TLJ A h11! Vf11 1

Public Notice
North Carolina Environmental Management Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a NPDES Wastewater Permit
The North Carolina Environmental Management Commission proposes to is-
sue a NPDES wastewater discharge permit to the person(s) listed below.
Written comments regarding the proposed permit will be accepted until 30
days after the publish date of this notice. The Director of the NC Division of
Water Resources (DWR) may hold a public hearing should there be a signifi-
cant degree of public interest. Please mail comments and/or information re-
quests to DWR at the above address. Interested persons may visit the DWR
at 512 N. Salisbury Street, Raleigh, NC to review information on file. Addi-
tional information on NPDES permits and this notice may be found on our
website• http://deq.nc.qov/about/divisions/water-resources/water-resourc
es-permits/wastewater-branch/npdes-wastewater/public-notices , or by
calling [phone].
Carolina Water Service requested renewal of permit NC0060461/Abington
Subdivision WWTP/Forsyth County; Facility discharges to Belews
Creek/Roanoke River Basin. Currently Dissolved Oxygen, Fecal Coliform,
Total Residual Chlorine, and Ammonia Nitrogen are water quality limited.
Town of Walnut Cove requested renewal of permit NC0025526 for its
WWTP/Stokes County; Facility discharges to Town Fork Creek/Roanoke Riv-
er Basin. Currently, ammonia nitrogen, fecal coliform, and total residual
chlorine are water quality limited.
Stokes County Schools requested renewal of permit NC0087980/Pine Hall El-
ementary School WWTP. Facility discharges to Eurins Creek/Roanoke River
Basin. Currently, fecal coliform is water quality limited.
WSJ: October 10, 2016

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require
full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile
home parks, etc) that can be administratively renewed with minor changes, but can include
facilities with more complex issues (Special Conditions, 303(d) listed water, toxicity testing,
instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Meredith Wojcik — 9/19/2016
Permit Number
NC0087980
Facility Name
Pine Hall Elementary School WWTP
Basin Name/Sub-basin number
Roanoke / 03-02-01
Receiving Stream
Eurins Creek
Stream Classification in Permit
WS-IV Stream Index: 22-26
Does permit need Daily Max NH3 limits?
No
Does permit need TRC limits/language?
No
Does permit have toxicity testing?
No
Does permit have Special Conditions?
No
Does permit have instream monitoring?
No
Is the stream impaired (on 303(d) list)?
No
Any obvious compliance concerns?
No. Fecal coliform and total suspended solids
exceedance violations are the main source of
NODs for the current permit cycle
Any permit mods since last permit?
No
New expiration date
2/28/2022
Changes to 2011 Permit?
Added eDMR requirements
Added regulatory citations
Changes to Draft Permit?
Most Commonly Used Expedited Language:
• 303(d) language for Draft/Final Cover Letters: "Please note that the receiving stream
is listed as an impaired waterbody on the North Carolina 303(d) Impaired Waters List.
Addressing impaired waters is a high priority with the Division, and instream data will
continue to be evaluated. If there is noncompliance with permitted effluent limits and
stream impairment can be attributed to your facility, then mitigative measures may be
required".
• TRC language for Compliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values below 50 µg/L will be treated as zero
for compliance purposes."

Stokes County Schools
STOKES COUNTY BOARD OF EDUCATION
Sonya M. Cox, Chair
Patricia M. Messick, Vice Chair
Rebecca P. Boles
William F. Hart
Jamie B. Yontz
SUPERINTENDENT
Dr. Brad Rice
ASSISTANT SUPERINTENDENT
Tony George
www.stokes.k12.nc.us . t00 Courthouse Circle . PO Box 50 . Danbury, NC 27016 . Phone: [phone] . Fax: [phone]
August 5, 2016
NCDENR/DWR/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Attn: Mr. Wren Thedford
Re: Pine Hall Elementary School WWTP NPDES Renewal Application Cover Letter
NC NPDES Permit No. NC0087980
Stokes County, NC
Dear Mr. Thedford,
'�T`'y�.,-aka +r"�•���y � @gr�. ,�^ y �t ZT11 �{
ECEI S7' :r.FI V �C L QJD
AUG 162016
v
As required for all NPDES renewal application packaages, on behalf of the Stokes County Board of Education,
we request renewal of the Pine hall Elementary School WWTP NPDES Premit No. NC0087980.
There have been no modifications to the facility since the issuance of the last permit.
Sincerely,
Stokes County Schools
Ricky Goins, Director of Maintenance

Stokes County Schools
STOKES COUNTY BOARD OF EDUCATION
Sonya M. Cox, Chair
Patricia M. Messick, Vice Chair
Rebecca P. Boles
William F. Hart
Jamie B. Yontz
SUPERINTENDENT
Dr. Brad Rice
ASSISTANT SUPERINTENDENT
Tony George
www.stokes.k12.nc.us . 100 Courthouse Circle . PO Box 50 . Danbury, NC 27016 Phone: [phone] . Fax: [phone]
August 5, 2016
Description of Waste Water Treatment System Components
Pine Hall Elementary School WWTP
1400 Pine Hall Road
Pine Hall, NC 27042
Stokes County, NPDES Permit No.: NC0087980
NC - LQ/.lV,V:
AUG 16 2016
Water Quality
Permitting Section
The existing Pine Hall Elementary School WWTP includes the following components:
• Septic tank (+8,000 gallons)
• Dosing chamber (+2,800 gallons)
• Recirculation tank (3,500 gallons)
• Surface sand filter (+1,640 sq. ft.)
• Dual ultraviolet disinfection unit
„ 92.Z emPIGT:

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
INC0087980
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 Stokes County Board of Education
Facility Name Pine Hall Elementary School WWTP
Mailing Address P.O. Box 50
City Danbury
FECL
State / Zip Code NC 27016
AUG 16 2016
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road
City
State / Zip Code
County
1400 Pine Hall Road
Pine Hall
NC 27042
Stokes
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 Research and Analytical Laboratories, Inc.
Mailing Address P.O. Box 473 - 106 Short Street
City Kernersville
State / Zip Code NC 27285 - 27284
Telephone Number [phone]
Fax Number
e-mail Address
( )
[e-mail]
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 ❑ Number of Employees
Residential ❑ Number of Homes
School ® Number of Students/ Staff 180 / 30
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
High School
Number of persons served: 210
5. Type of collection system
® 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 ® No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
Eurins Creek
8. Frequency of Discharge: ® 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.
See description of waste water treatment system components on separate sheet of paper
attached.
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 0.004 MGD
Annual Average daily flow 0.0013 MGD (for the previous 3 years)
Maximum daily flow 0.0072 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ►/ 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 currentlq in our permit. Mark other parameters "N/A".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
14.6
2.10
MG/L
Fecal Coliform
<2420
1.47
C01 / 100ML
Total Suspended Solids
35.8
3.61
MG/L
Temperature (Summer)
28
21.02
°C
Temperature (Winter)
18
11.03
°C
pH
6.9
N/A
SU
13. List all permits, construction approvals and/or applications:
Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
Permit Number
NC0087980
14. APPLICANT CERTIFICATION
Type
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
Permit Number
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Ricky Goins Director of Maintenance
Printed name of Person Signing Title
Signature of Applicant Date
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.)
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