NC0037311_Permit Issuance_20071005

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Govemor William G. Ross, Jr., Secretary
Coleen H. Sullins, Director
October 5, 2007
Mr. David A. Bolling
Creekside Manor Rest Home
P.O. Box 485
Kernersville, NC 27285-0485
Subject: Issuance of NPDES Permit NCO037311
Creekside Manor Rest Home W WTP
Forsyth County
Dear Mr. Bolling:
Division personnel have reviewed and approved your application for renewal of the subject permit.
Accordingly, we are forwarding the attached NPDES discharge permit. 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 May 9, 1994 (or as subsequently
amended).
This final permit includes no major changes from the draft permit sent to you on August
15, 2007.
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty (30)
days following receipt of this letter. This request must be in the form of a written petition, conforming to
Chapter 150B of the North Carolina General Statutes, and filed with the Office of Administrative Hearings
(6714 Mail Service Center, Raleigh, North Carolina 27699-6714). Unless such demand is made, this
decision shall be 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 Quality or permits
required by the Division of Land Resources, the Coastal Area Management Act or any other Federal or Local
governmental permit that may be required. If you have any questions concerning this permit, please
contact Charles Weaver at telephone number [phone], extension 511.
Sincerely,
s
taP-r,�Coleenll. Sullins
cc: Central Files
Winston-Salem Regional Office/Surface Water Protection
NPDES Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604 NorthCayrrolina
733-07191
An Equal Opportunity/Affirmative ActionEmployer— 50W/ °www.ncwaterquali�.org
Post Consumer Paper

Permit NCO037311
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PP..RMTT
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, the
Hammond Properties
is hereby authorized to discharge wastewater from a facility located at the
Creekside Manor Rest Home
6206 Reidsville Road
Kernersville
Forsyth County
to receiving waters designated as an unnamed tributary to Belews 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 November 1, 2007.
This permit and authorization to discharge shall expire at midnight on February 29, 2012.
Signed this day October 5, 2007.
Yiveen H. Sullins, Director
ision of Water Quality
By Authority of the Environmental Management Commission

Permit NC0037311
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.
Hammond Properties is hereby authorized to:
1. Continue to operate an existing 0.01 MGD extended aeration wastewater
treatment system with the following components:
♦ Bar screen
♦ Aeration basin
♦ Secondary clarifier
♦ Aerobic digester
♦ Chlorination
The facility is located in Kernersville at Creekside Manor Rest Home off Reidsville
Road in Forsyth County.
2. Discharge from said treatment works at the location specified on the attached
map into an unnamed tributary to Belews Creek, classified C waters in subbasin
03-02-01 of the Roanoke River Basin.

Permit NC0037311
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of this permit and lasting until
expiration, the Permittee is authorized to discharge from outfall 001. Such discharges
shall be limited and monitored by the Permittee as specified below:
PARAMETER
LIMITS
MONITORING REQUIREMENTS
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample Type
Sample Location'
Flow
0.010 MGD
Weekly
Instantaneous
Influent or Effluent
BOD, 5-day (20°C)
30.0 mg1L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Solids
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
NH3 as N
(April 1— October 31
2.0 mg/L
10.0 mg/L
Weekly
Grab
Effluent
NH3 as N
November 1— March 31
4.0 mg/L
20.0 mg/L
Weekly
Grab
Effluent
Dissolved Oxygen
Daily average > 5.0 mg/L
Weekly
Grab
Effluent
Dissolved Oxygen
Weekly
Grab
Upstream &
Downstream
Fecal Coliform
(geometric mean
2001100 ml
400/100 ml
Weekly
Grab
Effluent
Total Residual Chlorine (TRC)2
17 Ng/L
2/Week
Grab
Effluent
Temperature (°C)
Daily
Grab
Effluent
Temperature (°C)
Weekly
Grab
Upstream &
Downstream
pH
> 6.0 and < 9.0 standard units
Weekly
Grab
Effluent
Footnotes:
1. Upstream: approximately 100 feet upstream from the outfall.
Downstream: approximately 300 feet downstream from outfall.
2. TRC limit takes effect May 1, 2009. Until that time, the Permittee shall monitor
TRC [with no effluent limit]. Limit and monitoring requirements apply ONLY if
chlorine is used for disinfection.
There shall be no discharge of floating solids or visible foam in other than trace amounts

`NORTH CAROLINA
FORSYTH COUNTY
AFFIDAVIT OF PUBLICATION
Before the undersigned, a Notary Public of said County and State, duly
commissioned, qualified, and authorized by law to administer oaths, personally
appeared D.H. Stanfield, who being duly sworn, deposes and says: that he is
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 Winston-Salem Journal on
the following dates:
August 18, 2007
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 20th day of August, 2007 p"g"`011� ` "�y`
STATE OF NOM CAROLINA `
ENVIRONMENTAL MANAGEMENT
(signature of per on a -ng affidavit) '�, _ ; , !`' COMMiSSION/NPDES uNli': ;
A..... % _1617 MAIL SERVICE CENTER .. e
RALEIGH, NC VGW1617
NOTIFICATION OF INTENT TO ISSUE
Sworn to and subscribed before me, this 20th day of August, 2007 A NPDES WASTEWATER PERkIiT
My Commission expires: September 28, 2010
ESTATE
tWALEY JOHNSON
NOTARY PUBLIC
ORSYTH COUNTY
OF NORTH CAA i 40
ISSION EXPiHE
On the basis of thorough staff review and
92R500 and ofNC
lawful standardsanda�ndlregulatioas.
the North Carolina Environmental Management
Commisslon proposes to issue a National Pollutant
Discharge Elimination System (NPDES) wastewater ,
discharge permit to the person(s) listed below
effective 45 days from the publish date of this
notice.
Written comments regarding the proposed permit
will be accepted until 30 days after the publish date
of this notice. All comments received prior to that
date are considered in the final determinations
re ardlrtg the proposed permit. The Director of the
N� Division of Water Quality may decide to hold a
public meetin for the proposed permit should the
Division reee�ve $,.significant degree of public
Interest..
Coples of the draft permit and' other supporting
Information on file used to determine conditions
' present. In. the draft permit... are .available upon
reqquest and payment of the costs of reproduction.
Illlail comments and/or requests. for Information
to the NC Division of Water Quality at the
above address or call Ms., Frances andelaria
[phone], extension 520 at the. Point Source,
Branch. Please Include •the NPDES permit number-
Xattached) An -any, communication. liiterested
persotu may also visit the Division of Water Quality
at 51� N�Salisbury Street. Raleigh,. NC 276044148 I
between 'the hours •.of• 8:00 a.m. and 5:00' p^ to i
review•informatlon on film, ~`
;creekside marior'Rest Nome (P.O. Box 485, Kerners-
� HhL_,NC_'.272a5.80M has aon[led for renewal of
wastewater to an unnamed tributary to ,Belews.
Creek in the Roanoke. River Basle. 'Currently
dissolved oxygen, ammonia nitrogen, fecal, eollform
and total residual chlorine are , water , quality
•limited. This discharge may affect •futurealloca
tions iR-this portion pf Belews Creek..
Mill ltldge Property Owners AssocEatlaM
has applied for renewal of a wastewater rmit for,
discharging to the Watauga River, a -class, B-Trout-
HQW stream In the Watauga River Sarin. .
N Colony htWstrie - 6 'penntt . number
has applied for renewal �Qf� Its permit•;
tirgI " to the Watauga River In 9e Watauga*
River Basin.
Yonahlossee WWTP.ft-mhos applied for
renewal of its permit lance Creek In
the Watauga River Basin..,

RESEARCh & ANAlyTICAI
LAbORATORIES, INC.
Analytical/Process Consultations
September 1, 2006
Mr. Charles H. Weaver, Jr.
NPDES Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: Renewal of NPDES Permit No. NC0037311
Creekside Manor Rest Home W WTP
Forsyth County
Dear Mr. Weaver,
I
OCT - 9 700�
DENR - 8'ATFR DUALITY
Please renew NPDES Permit NO.NC0037311 for the wastewater treatment plant at Creekside
Manor Rest Home. The signed application form in triplicate, a description of the method of
sludge disposal and a map of the location of the discharge are all attached.
Sincerely,
Research & Analytical Labs
� &
James M. Cheshire
Authorized Agent
JMC/sl
cc. David A. Bolling, Creekside Manor
0112002 P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2841 • Fax [phone]
W0w:e99eaMh1[hdbd1A ia§lmorn
Public \Water Supph Secliun. %n n: Data t:ntr,. 1634 Mail Scn ice ('enter. RalciRh, N(2704-1634
la, 919.-1i66:7

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit 000037311
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
Hammond Properties
Facility Name
Creekside Manor Rest Home
Mailing Address
P. O. 485
City
Kernersville
State / Zip Code
NC/ 27285-0485
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 6206 Reidsville Rd
City Kernersville
State / Zip Code NC/27285
County Forsyth
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
City Kernersville
State / Zip Code NC/27284
Telephone Number [phone]
Fax Number [phone]
1 of 4 Form-D 1106

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 applyj:
Industrial
❑
Number of Employees
Commercial
❑
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/ Staff
Other
®
Explain: RestHome
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Population served:
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
?. Name of receiving stream(s) (Provide a map showing the exact location of each outfallJ.
unnamed tributary to Belews Creek
S. Frequency of Discharge:
If intermittent:
Days per week discharge occurs_
Continuous
7
❑ Intermittent
Duration:
9. Describe the treatment system
List all installed components, including capacity, 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.
0.01 wastewater facility consisting of the following:
-aeration basin with diffused air
-clarifier
-tablet chlorination
-chlorine contact basin
-sludge holding tank
2 of 4 Form-D 1 /46

NPDE$ APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.010 MGD
Annual Average daily flow 0.004 MGD (for the previous 3 years)
Maximum daily flow 0.007 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
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. Effluent testing data must be based on at least three samples
and must be no more than four and one half years old.
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Number of
Samples
Biochemical Oxygen Demand
(BODs)
12.0
3.0
mg/1
Fecal Coliform
> 12,000
62.0
col/ 100mis
Total Suspended Solids
34.0
13.4
mg/1
Temperature (Summer)
24.0
21.0
°C
Temperature (Winter)
16.0
12.4
°C
pH
6.74
6.13-6.74
SU
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES NCO037311 Dredge or fill (Section 404 or CWA)
PSD (CAA) Special Order of Consent (SOC)
Non -attainment program (CAA) Other
14. APPLICANT CERTIFICATION
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.
James M. Cheshire Authorized Agent
Printed name of Person Signing Title
3 of 4 Form-D 1 /06

NPDES APPLICATION - FORM D
For privately owned "atment systems treating 100% domestic wastewaters <1.0 MGD
/- v
Signat of Applicant ' " Date
North C lina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement
represen 'on, 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 knowly 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.)
4of4
Form-D 1106

SLUDGE MANAGEMENT PLAN
CREEKSIDE MANOR WASTEWATER TREAMENT PLANT
NPDES PERMIT NO. NC0037311
Sludge from the Creekside Manor wastewater treatment plant are disposed of in the
following way:
Solids are collected in the sludge holding tank and digested
aerobically. The excess solids are periodically pumped and
halved by a licensed septic pumper contractor and disposed
of at the City of Greensboro wastewater treatment plant.

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
Basic Information to determine potential for expedited permit renewal
Reviewer/Date
9 p
Permit Number
Cb0 311
Facility Name
Atemov
Basin Name/Sub-basin number
R©ap © - a 1
Receiving Stream
al: ic
Stream Classification in Permit
Does permit need NI13 limits?
Y -Sew $fie
Does permit need TRC limits?
Does permit have toxicity testing?
Does permit have Special Conditions?
hi 0
Does permit have instream monitoring?
ES
Is the stream impaired (on 303(d) list)?
V40
Any obvious compliance concerns?
ND
Any permit mods since lastpermit?
No
Existing expiration date
g IQ 8 1poor7
Reissued permit expiration datelaola-
New proposed permit effective date
YES This is a SIMPLE EXPEDITED permit renewal (administrative
renewal with no changes, or only minor changes such as TRC, NH3,
name/ownership changes). Include conventional WTPs in this group.
YES_ This is a MORE COMPLEX EXPEDITED permit renewal (includes
Special Conditions (such as EAA, Wastewater Management Plan), 303(d)
listed, toxicity testing, instream monitoring, compliance concerns, phased
limits). Basin Coordinator to make case -by -case decision.
YES_ This permit CANNOT BE EXPEDITED for one of the following reasons:
• Major Facility(municipal/industrial)
• Minor Municipals with pretreatment program
• Minor Industrials subject to Fed Effluent Guidelines (lb/day limits for BOD, TSS,
etc)
• Limits based on reasonable potential analysis (metals, GW remediation organics)
• Permitted flow > 0.5 MGD (requires full Fact Sheet)
• Permits determined by Basin Coordinator to be outside expedited process
TB Version 8/18/2006 (NPDES Server/Current Versions/Expedited Fact Sheet)
R W Q)TP