860010_Application_20230412

11
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Animal Feeding Operations Permit Application Form
(THIS FORJW MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
State General Permit - Existing Animal Waste Operations
GENERAL INFORMATION:
1.1 Facility name: KooBa Farms
L2 Print Land Owner's name: KooBa Farms, LLC
1.3 Mailing address: 1719 Penny Tew Mill Road
City, State: Roseboro, NC Zip: 28382
Telephone number (include area code): ( 704 ) 682 2560
1.4 Physical address: 131 Horton Road
City, State: Mount Airy, NC Zip: 27030
Telephone number (include area code): ( 704 ) 682 2560
1.5 County where facility is located: Surry
1.6 Facility location (directions from nearest major highway, using SR numbers for state roads): Exit 6 off HWY 74W, N on I1WY
89N, Left on Pine Ridge, Farm on
1.7 Farm Manager's name (if different from Land Owner): Right
1.8 Lessee's / Integrator's name (if applicable; circle which type is listed):
1.9 Facility's original start-up date: Date(s) of facility expansion(s) (if applicable):
2. OPERATION INFORMATION:
2.1 Fa.cility number: 86-10
2.2 Operation Description:
Please enter the Design Capacity of the system. The "No. of Animals" should be the maximum number for which the waste
management structures were designed.
"Type of Swine
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean (## sow)
❑ Farrow to Feeder (# sow)
❑ Farrow to Finish (# sow)
❑ Wean to Finish (# sow)
❑ Gilts
❑ Boar/Stud
No. of Animals Type of Poultry No. of Animals
❑ Layer
❑ Non -Layer
❑ Turkey
❑ Turkey Poults
❑ Other Type of Livestock on the farm:
Tvpc of Cattle
❑ Beef Brood Cow
❑ Beef Feeder
❑ Beef Stocker Calf
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Milk Cow
No. of Animals:
No. of Animals
200
800
FORM: AWO-STATE-G-E 10/31/18 Page 1 of 5

KJ
2.3 Acreage cleared and available for application (excluding all required buffers and areas not covered by the application
system): 365.1 Required Acreage (as listed in the CAWMP): $8
2.4 Number of lagoons: Total Capacity (cubic feet): Required Capacity (cubic feet):
Number of Storage Ponds: 2 Total Capacity (cubic feet):267,792 Required Capacity (cubic feet):187.839
2.5 Are subsurface drains present within 100` of any of the application fields? YES or a
(circle one)
2.6 Are subsurface drains present in the vicinity or under the waste management system? YE or(circle one)
2.7 Does this facility meet all applicable siting requirements? YES or NO (circle one)
REQUIRED ITEMS CHECKLIST:
Please indicate that you have included the following required items by signing your initials in the space provided next to each
item.
Applicants Initials
3.1 One completed and signed original and two copies of the application for State General Permit -
Animal Waste Operations;
3.2 Three copies of a general location map indicating the location of the animal waste facilities and
field locations where animal waste is land applied and a county road map with the location of the
facility indicated;
3.3 Three copies of the entire Certified Animal Waste Management Plan (CAWMP). If the facility
does not have a CAWMP, it must he completed prior to submittal of a permit application for
animal waste operations.
The CAWMP must include the following components. Some of these components may nut have been required t 7thtie
the facility nvas certified but should be added to the CAWMP for permitting purposes:
3.3.1 The Waste Utilization Plan (WUP) must include the amount of Plant Available Nitrogen (PAN) produced and
utilized by the facility
3.3.2 The method by which waste is applied to the disposal fields (e.g. irrigation, injection, etc.)
3.3.3 A snap of every field used for land application
3.3.4 The soil series present on every land application field
3.3.5 The crops grown on every land application field
3.3.6 The Realistic Yield Expectation (RYE) for every crop shown in the WUP
3.3.7 The PAN applied to every land application field
3.3.8 The waste application windows for every crop utilized in the WUP
3.3.9 The required NRCS Standard specifications
3.3.10 A site schematic
3.3.11 Emergency Action Plan
3.3.12 Insect Control Checklist with chosen best management practices noted
3.3.13 Odor Control Checklist with chosen best management practices noted
3.3.14 Mortality Control Checklist with the selected method noted
3.3.15 Lagoon/storage pond capacity documentation (design, calculations, etc.); please be sure to include any site
evaluations, wetland determinations, or hazard classifications that may be applicable to your facility
3.3.16 Operation and Maintenance Plan
If your CAWMP includes any components not shown on this list, please include the additional components with your
submittal. (Composting, waste transfers, etc.)
FORM: AWO-STATE-C-E 10/31/18 Page 2 of 5

4. APPLICANT'S CERTIFICATION:
1 (Land Owner's name listed in question 1.2), attest that
this application for K en" U - C. �� r 5 (Facility name listed in question I.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included, this application package
will be returned to me as incomplete.
Signature Date 0(.a—�1
5. MANAGER'S CERTIFICATION: (complete only if different from the Land Owner)
(Manager's name listed in question 1.6), attest that this
application for (Facility name listed in question 1.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included, this application package
will be returned as incomplete.
Signature
Date
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION, MATERIALS, AND ANY
DESCRIPTION OF THE FACILITY OR MODIFICATIONS SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DIVISION OF WATER RESOURCES
ANIMAL FEEDING OPERATIONS & GROUNDWATER PROTECTION SECTION
ANIMAL FEEDING OPERATIONS PROGRAM
3 636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
FAX NUMBER: [phone]
FORM: AWO-STATE-G-E 10131/18 Page 3 of 5

6. SURFACE WATER CLASSIFICATION:
This form must be completed by the appropriate DWR regional office and included as a part of the
project submittal information.
INSTRUCTIONS TO NC PROFESSIONALS:
The classification of the downslope surface waters (the surface waters that any overflow from the facility would flow toward) in
which this animal waste management system will be operated must be determined by the appropriate DWR regional office.
Therefore, you are required, prior to submittal of the application package, to submit this form, with items 1 through 6
completed, to the appropriate Division of Water Resources Water Quality Regional Operations Supervisor (see page 6 of 10).
At a minimum, you must include an 8.5" by I I " copy of the portion of a 7.5-minute USGS Topographic Map which shows the
location of this animal waste application system and the downslope surface waters in which they will be located. Identify the
closest downslope surface waters on the attached map copy. Once the regional office has completed the classification,
reincorporate this completed page and the topographic map into the complete application form and submit the
application package.
6.1 Farm Name:
62 Name & complete address of engineering firm:
Telephone number: (
6.3 Name of closest downslope surface waters:
6.4 County(ies) where the animal waste management system and surface waters are located
6.5 Map name and date:
6.6 NC Professional's Seal (If appropriate), Signature, and Date:
TO: REGIONAL WQROS SUPERVISOR
Please provide me with the classification of the watershed where this animal waste management facility will be or has been
constructed or field located, as identified on the attached snap segment(s):
Name of surface waters:
Classification (as established by the Environmental Management Commission):
Proposed classification, if applicable:
Signature of regional office personnel:
(All attachments must be signed)
Date:
FORM: AWO-STATE-C-E 10131/18 Page 4 of 5

DIVISION OF WATER RESOURCES REGIONAL OFFICES (10/2018)
Asheville Regional WQROS Supervisor Washington Regional WQROS Supervisor Raleigh Regional WQROS Supervisor
2090 U.S. Highway 70
943 Washington Square Mall
1628 Mail Service Center
Swannanoa, NC
28778
Washington, NC 27889
Raleigh, NC 27699-1628
[phone]
[phone]
[phone]
Fax [phone]
Fax [phone]
Fax [phone]
Avery
Macon
Beaufort Jones
Chatham Nash
Buncombe
Madison
Bertie Lenoir
Durham Northampton
Burke
McDowell
Camden Martin
Edgecombe Orange
Caldwell
Mitchell
Chowan Pamlico
Franklin Person
Cherokee
Polk
Craven Pasquotank
Granville Vance
Clay
Rutherford
Currituck Perquinrans
Halifax Wake
Graham
Swain
Dare Pitt
Johnston Warren
Haywood
Transylvania
Gates Tyrell
Lee Wilson
Henderson
Yancey
Greene Washington
Jackson
Hertford Wayne
Hyde
Fayetteville Regional WQROS Supervisor Mooresville Regional WQROS Supervisor Wilmington Region WQROS Supervisor
225 Green Street, Suite 714
610 East Center Avenue, Suite 100
127 Cardinal Drive Extension
Fayetteville, NC 28301-5094
Mooresville, NC 28115
Wilmington, NC 28405-3845
[phone]
[phone]
[phone]
Fax [phone]
Fax[phone]
Fax [phone]
Anson Moore
Alexander Lincoln
Brunswick New Hanover
Bladen Richmond
Cabarrus Mecklenburg
Carteret Onslow
Cumberland Robeson
Catawba Rowan
Columbus Pender
Harnett Sampson
Cleveland Stanly
Duplin
Hoke Scotland
Gaston Union
Montgoinery
Iredell
Winston-Salem Regional WQROS Supervisor
450 Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Phone [phone]
Fax [phone]
Alamance Rockingham
Alleghany Randolph
Ashe Stokes
Caswell Surry
Davidson Watauga
Davie Wilkes
Forsyth Yadkin
Guilford
FORM: AWO-STATE-G-E 10/31/18 Page 5 of