NC0073571_Permit Issuance_20060412

Michael F. Easley, Governor
State of North Carolina
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
April 12, 2006
Mr. Mervyn R. King
Countryside Manor, Inc.
7700 U.S. Hwy. 158 East
Stokesdale, North Carolina 27357
Subject: NPDES PERMIT ISSUANCE
Permit Number NCO073571
Countryside Manor WWTP
Guilford County
Dear Mr. King:
Division personnel have reviewed and approved your application for renewal of the subject
permit. Accordingly, we are forwarding the attached final 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).
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 permit shall be final and binding.
Please take notice that this permit is not transferable. 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, Coastal Area Management Act, or any other
Federal or Local governmental permits which may be required.
If you have any questions or need additional information, please do not hesitate to contact
Maureen Crawford of my staff at [phone], extension 538.
Sincerely,
FwT ; Alan W. Klimek, P.E.
Director, Division of Water Quality
cc: Central Files
NPDES Unit Files
Winston-Salem Regional Office
1617 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1617 -TELEPHONE [phone]/FAX [phone]
VISIT US ON THE WEB AT http://h2o.enr.state.nc.us/NPDES

Permit NCO073571
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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,
Mervyn R. King
is hereby authorized to discharge wastewater from a facility located at the
Countryside Manor WWTP
7700 U.S. Highway 158
Guilford County
to receiving waters designated as Troublesome Creek in the Cape Fear 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 May 1, 2006.
This permit and authorization to discharge shall expire at midnight on April 30, 2011.
Signed this day April 12, 2006.
lx'46._
r
f-vv-'. Alan W. Klimek, P.E., DireCtor
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NC0073571
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.
Mervyn R. King is hereby authorized to:
1. Continue to operate an existing 0.015 MGD wastewater treatment facility with the following
components:
♦ Bar screen
♦ Aerated equalization tank
♦ Aeration tank
♦ Clarifier
♦ Sludge holding tank
♦ Sludge air lifts
♦ Dual blowers
♦ Tablet chlorination with chlorine contact basin
♦ Alum feeder for phosphorus removal
♦ Rock step reaeration
♦ Dual -feed power supply
This facility is located near Stokesdale off U.S. Highway 158 at the Countryside Manor WWTP in
Guilford County.
2. After receiving an Authorization to Construct from the Division, construct and operate a 0.03 MGD
wastewater treatment facility.
. I Discharge from said treatment works at the location specified on the attached map into
Troublesome Creek, classified WS-III NSW waters in the Cape Fear River Basin.

54
DISCHARGE
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Facility
Countryside Manor, Inc.
Location
County:Rockingham Stream Class: WS-IB, NSW
Receiving Stream: Troublesome Creek Sub -Basin: 030601
(not to scale)
Latitude: 36° 57' 41" Grid/Ouad: CI9NW
Laneltude: 79° 57' 30"
NORTH
NPDES Permit No. NCO073571
-

Permit NCO073571
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS (0.015 MGD)
During. the period beginning on May 1, 2006 and lasting until expansion above 0.015 MGD, the Permittee is
authorized to discharge from outfall 001. Such discharges shall be limited and monitored by the Permittee as
specified below:
EFFLUENT
LIMITS
MONITORING REQUIREMENTS,...
CHARACTERISTICS
Monthly
Daily
Measurement
Sample Type
Sample Locations
Averse
Maximum
Frequency -
Flow
0.015 MGD
Weekly
Instantaneous
Influent or Effluent
BOD, 5-day (20°C)
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Residue
30.0 mg/L
45.0 mg/L
Weekly
Grab.
Effluent
NH3 as N
5.4 mg/L
27.0 mg/L
Weekly
Grab
Effluent
(April 1— October 31)
NH3 as N
23.5 mg/L
35.0 mg/L
Weekly
Grab
Effluent
(November 1— March 31)
Dissolved Oxygen .
Weekly
Grab
Effluent,
Upstream &
Downstream
Fecal Coliform
200 / 100 ml
400 / 100 ml
Weekly
Grab
Effluent,
(geometric mean)
Upstream &
Downstream
Total Residual Chlorine3
28 /Cg/L
2/Week
Grab
Effluent
Temperature CC)
Daily
Grab
Effluent
Temperature (°C)
Weekly
Grab
Upstream &
Downstream
Total Nitrogen
Quarterly
Grab
Effluent
(NOz+NO3+TKN) •
Total Phosphorus4
2.0 mg/L
Weekly
Grab
Effluent
pHs.
Weekly
Grab
Effluent
Footnotes:
1. Upstream = at least 100 feet upstream from the outfall. Downstream = at NCSR 2103.
2. The daily average dissolved oxygen effluent concentration shall not be less than 5.0 mg1L.
3. The limit for total residual chlorine will take effect November 1, 2007. Until then, the permittee shall
monitor TRC (with no effluent limit).
4.. Compliance is based upon a quarterly average of weekly samples.
5. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE AMOUNTS.

Permit NC0073571
A. (2.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS (0.03 MGD)
During the period beginning expansion above 0.015 MGD 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:
EFFLUENT
LEMITS
MONITORING REQUIREMENTS
CHARACTERISTICS
-
Monthly
Daily
Measurement
Sample
Sample Location'
Average `
Maximum <
Frequency.,
Type
Flow
0.030 MGD
Continuous
Recording
Influent or Effluent
BOD, 5-day (20°C)
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
Total Suspended Residue
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
NH3 as N
3.2 mg/L
16.0 mg/L
Weekly
Composite
Effluent
(April 1- October 31
NH3 as N
13.0 mg/L
35.0 mg/L
Weekly
Composite
Effluent
(November 1-March 31
Dissolved Oxygen
Weekly
Grab
Effluent,
Upstream &
Downstream
Fecal Coliform
200 / 100 ml
400 / 100 ml
Weekly
Grab
Effluent,
(geometric mean)
Upstream &
Downstream
Total Residual Chlorine
28 µg/L
2/Week
Grab
Effluent
Temperature CC)
Daily
Grab
Effluent
Temperature CC)
Weekly
Grab
Upstream &
Downstream
Total Nitrogen
Quarterly
Composite
Effluent
OZ+NO3+
Total Phosphoms3
2.0 mg/L
Weekly
Composite
Effluent
pH4
Weekly
Grab
Effluent
Footnotes:
1. Upstream = at least 100 feet upstream from the outfall. Downstream = at NCSR 2103.
2. The daily average dissolved oxygen effluent concentration shall not be less than 5.0 mg/L.
3. Compliance is based upon a quarterly average of weekly samples.
4. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE AMOUNTS.

NU I II:C
PUBLIC
NOTICE
AFFIDAVIT OF INSERTION OF
The Times -News Publishing Company
Burlington, NC
Alamance County
I, LINDA GIBSON Legal Advertising Manager of The Times -News Publishing Co,
Do certify that the advertisement of Division of Water Quality
Entitled
NOTICE
PUBLIC
NOTICE
State of North Carolina
Measuring 102 lines appeared in the Times -News, a newspaper published in
Alamance County, Burlington, NC, in issues of February 5, 2006/'N�'^'I
Legal Advertising Manager
Sworn to and subscribed before me this day of 2006
Notary Public
My commission expires �] 1 maw
State of
North
Carolina
Environmental
Management
Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notification of Intent to
Issue A NPDES
Wastewater Permit
On the basis of thorough
staff review and application
of NC General Statute
143.21, Public law 92-500
and other lawful standards
and regulations, the North
Carolina Environmental
Management Commission
proposes to issue a Nation-
al Pollutant Discharge
Elimination System
(NPDES) wastewater dis-
charge permit to the per-
son(s) listed below effeo-
live 45 days from the pub-
lish date of this notice.
Written comments regard-
ing the proposed permit will
be accepted until 30 days
after the publish date of this
notice. All comments re-
ceived prior to that date are
considered in the final de-
terminations regarding the
prorector of Csed permit.
ilDivision of
Water Quality may decide
to hold a public meeting for
the proposed permit should
the Division receive a sig-
nificant degree of public in-
terest.
Copies of the draft permit
and other supporting infor-
mation on file used to de-
termine conditions present
In the draft permit are avail-
able upon request and pay-
ment of the costs of repro-
duction. Mail comments
and/or requests for infoh
mason to the NC Division
of Water Quality at the
above address or call the
Point Source Branch at
919-733-5083, ext. 520 of
363. Please include the
NPDES .permit number
(attached) in any communi-
cation. Interested persons
may also visit the Division
of Water Quality at 512 N.
Salisbury St., Raleigh, NC
27604-1148 between the
hours of Sam and 5pm to
review Information on file.
Countryside Manor, Inc.,
7700 US Hwy 158 E., Sto-
kesdale, North Carolina
has applied for renewal of
NPDES permit NC
0073571 or its countryside
Manor WWTP in Guilford
County. This permitted fa-
cility discharges treated
wastewater Troublesome
Creek in the Cape Fear
River Basin. Currently,
CBOD and ammonia nitro-
gen are water quality limit-
ed. This discharge may af-
fect future allocations in
this portion of the water-
shed.
February 5, 2006

Ad # 80174 Date 02/02/2006 Time 9:37 AM
PUBLIC NOTICE
STATE OF NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION/
NPDES UNIT
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
NOTIFICATION OF INTENT TO ISSUE A NPDES
WASTEWATER PERMIT
On the basis of thorough staff review and appli-
cation of NC General Statute 143.21, Public law
92-500 and other lawful standards and reggula-
tions, the North Carolina Environmental Man-
agem ant Commission proposes to issue a Na-
tional 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 per-
mit will be accepted until 30 days after the
publish date of this notice. All comments re-
ceived priortothat date are considered in the
final determinations regarding the proposed
permit. The Director of the NC Division of Wa-
ter Quality may dedde to hold a public meet-
ing forthe proopposed permit should the Division
receive a significant degree of public interest.
Copies of the draft permit and other supporting
information on file used to determine condi-
tions present in the draft permit are available
upon request and payment of the costs of re -
or
any
also
nigh, NC
a.m. and
p.m. to review intonnation on
Countryside Manor, Inc, 7700 US Hvry 158 East,
Stokesdale, North Carolina has applied for re-
newal of NPDES permit NC0073571 for its Coun-
tryside Manor WWTP in Guilford County. This
permitted facility discharges treated wastewa-
ter to Troublesome Creek in the Cape Fear River
Basin. Currently CBOD and ammonia nitrogen
are water quality limited. This discharge may af-
fect future allocations in this portion of the wa-
tershed.
Ad shown is not actual print size

Michael F. Easley, Governor
State of North Carolina
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
February 1, 2006
MEMORANDUM
RECEIVED
N.C. Deof. of ENR
To: Lee Spencer
NC DENR / DEH / Regional Engineer FS U 2 20
Winston-Salem Regional Office
_Ry nmi m�;n
From: Maureen Crawford (n•// Regio�l ofRo@
919-733-5083 x-538
NPDES Unit
Subject: Review of Draft NPDES Permit NCO073571
Countryside Manor, Inc.
Guilford County
Please indicate below your agency's position or viewpoint on the draft permit and return this form by March 10,
2006. If you have any questions on the draft permit., please feel free to contact me at the telephone number shown
above.
RESPONSE: (Check one)
oncur with the issuance of this permit provided the facility is operated and maintained properly, the stated
effluent limits are met prior to discharge, and the discharge does not contravene the designated water quality
standards.
❑ Concurs with issuance of the above permit, provided the following conditions are met:
❑ Opposes the issuance of the above permit, based on reasons stated below, or attached:
Signed Date:
1617 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1617 - TELEPHONE [phone]/FAX [phone]
VISIT US ON THE WEB AT http://h2o.enr.state.nc.us/NPDFS

Countryside Manor, Inc.
Professional Care Center for the Elderly
September 26, 2005
Mrs. Carolyn Bryant
NC DENR/ DWQ/ Point Source Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Mrs. Bryant
Enclosed you will find the required Information package, with Application for Renewal
of WWTP permit # NC 0073571.
There has been only one physical change at our W WTP facility since the issuance of the
last permit. Under The Direction of The ORC Patrick Merritt, certificate # 11794 of
Meritech Inc., our in house maintenance dept. replaced air defusers in the Aeration tank.
This up graded from down flow bottom discharge defusers to up flow fine bubble
defusers, for better oxygen transfer.
If you have any questions please contact me at Countryside Manor Inc. 339-643-6301.
Thank you
Sincerely,
Ernie Newman
Operations Manager
Countryside Manor Inc
7700 U.S. Highway 158 • P.O. Box 829 • Stokesdale, North Carolina 27357 • Telephone [phone] • Fax [phone]
www.retireatcountryside.com • [e-mail]

NPDES APPLICATION FOR PERMIT RENEWAL- SHORT FORM D
To be filed only by privately -owned dischargers of 100% domestic wastewater (<1 MGD flow)
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
http://h2o.enr.state.nc.us/NPDES/
North Carolina NPDES Permit Number I NC00 325'7
b Er 2 9 2005
Please print or type
1. Contact Information: II�'
L�_'.
Facility Name
Owner Name
Street Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
Operator Name
Street Address
City
State / Zip Code
County
Telephone Number
2. Location of facility producing discharge:
Check here if same as above 0
Facility Name (If different from above)
Street Address or State Road
City
State / Zip Code
County
3. Reason for application:
Expansion/Modification * Existing Unpermitted Discharge
Renewal / New Facility
* Provide a description of the expansion/modification:
Page 1 of 3 Version 12102

NPDES APPLICATION FOR PERMIT RENEWAL- SHORT FORM D
To be filed only by privately -owned dischargers of 100% domestic wastewater (< 1 MGD flow)
4. Description of the- existing treatment facilities (list all installed components urith
capacitiesp. ;. tJ% fllGt!! P
`Q. ©1.j M&D �N�lS� lx3� . " t7 i ri�ov��-1 w1(6 9 GcnSw"/2a C 1 �1C'.9, r lw .�i'�
F�h,.A-L 24 �/ tbs,,A4 fk AoWt P74A) 1 tI494- 4 . _ZJ o .. 4
S. Description of wastewater (check all that applyj:
Tvue of Facilitv Generating Wastewater
Industrial
Commercial
Residential/ j?,breM4,1 t ahjA. G
School
Number of Employees
Number of Employees
Number of Homes -
Number of Students/ Staff
04
%0
/-3 - -- �A_1&40
a
Other
Describe the source(s) of wastewater (example: subdivision, mobile ome park, etc.):
QG
6. List all permits, construction approvals and/or applications (check all that applyj:
XlRe Permit Number Tyne Permit Number
RCRA Non -Attainment
UIC Ocean Dumping
NPDES ����� Dredge/Fill Permits
40�0PSD Other
NESHAPS
?. Number of separate wastewater discharge pipes (wastewater outfalls): C_11Y�
8. If the facility has multiple discharge outfalls, record the source(s) of wastewater for each
outfall:
9. Name of receiving stream(s) (Provide a map showing the exact location of each outfallp.
Page 2 of 3
Version 12102

NPDES APPLICATION FOR PERMIT RENEWAL- SHORT FORM D
To be filed only by privately -owned dischargers of 100% domestic wastewater (< 1 MGD flow)
10. Is this facility located on Native American lands? (check one)
YES- NO ❑
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.
Printed Name of Person Signing
Title
�;-'<:^eS
Applicant Date Signed
North Carolina General Statute 143-215.6(b)(2) provides that: 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 $10,000, 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 $10,000 or imprisonment not more than 5 years, or both for a
similar offense.)
Page 3 of 3 Version I

r
FACT SHEE71 FOR axpamrcaD RENCHAL
Permit Number
Facility Name
EN
jde �
Reviewer
S
Basin/Sub-basin
_ 0(P 01
Receiving Stream
Stream Classification in permit
Stream Classification in BIMS
Is the stream impaired (listed on 303(d))?
Is stream monitoring required?
Does the permit need NH3 limit(s)?
Does the permit need TRC limit(s)?
Does the permit have toxicity testing?
Are there special conditions?
Any obvious compliance concerns?
Existing Expiration Date
30
New Expiration Date
3o I I
Miscellaneous Comments: