NC0044750_Renewal (Application)_20161209

RESEARCh & ANA[yTICA1
LAbORATWES, INC.
Analytical/Process Consultations
November 18, 2016
N.C. DENR
Division of Water Quality\
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: NPDES Permit Renewal Application Permit No. NCO044750
Jacob's Creek Nursing & Rehabilitation Center
Permit No. NCO044750
Rockingham County
RECEIVED1NCH 21DWR
DEC 0 9 2016
,tinter Quality
P"-nitting Section
Enclosed are one (1) signed original and two (2) copies of the NPDES Permit
Application: Form D requested renewal of NPDES Permit No.NC0044750 for the wastewater
treatment plant at Jacob's Creek Nursing & Rehabilitation Center. There have been no significant
changes to the wastewater treatment facility.
If you have any questions concerning this application renewal, please so advise.
Sincerely,
Research & Analytical Labs
i
James M. Cheshire
Authorized Agent
JMC/JM
Cc. Shannon Knight, Jacob's Creek Nursing & Rehabilitation Center
P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2841 • Fax [phone]
www.randalabs.com

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 INCO044750
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
Granite Falls Ltc. LLC
Facility Name
Jacob's Creek Nursing & Rehabilitation Center
Mailing Address
1721 Bald Hill Loop
City
Madison
State / Zip Code
North Carolina/27025
Telephone Number
[phone]
3 ff^e1116-190t
Fax Number
[phone]
t L U °V 2016
e-mail Address
[e-mail]
Water Quality
Permittina Section
2. Location of facility producing discharge:
Check here if same address as above
Street Address or State Road
City
State / Zip Code
County
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 & Analytical Laboratories, Inc.
Mailing Address P.O. Box 473
City Kernersville
State / Zip Code North Carolina/27285
Telephone Number [phone]
Fax Number [phone]
1 of 3 Form -D 1/06

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 J
School
❑
Number of Students/Staff
Other
®
Explain: Nursing
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Nursing Home
Population served: 161
S. Type of collection system
❑ Separate (sanitary sewer only)
6. Outfall Information:
® Combined (storm sewer and sanitary sewer)
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) (Provide a map showing the exact location of each outfall):
Hogans Creek
S. Frequency of Discharge: ® Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: 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.
0.025 Wastewater facility consisting of the following:
-Flow equalization
-Comminator
-Aeration basins
-Clarifiers
-Sand filters
-W Disinfection
-Back-up Chlorine contact chamber and Chlorination
-Flow measurement
-Aerobic digester
-Effluent pump station
2 of 3 Form -D 1/06

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.025 MGD
Annual Average daily flow 0.0065 MGD (for the previous 3 years)
Maximum daily flow 0.0344 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
Biochemical Oxygen Demand (BOD5)
15
<2
mg/L
Fecal Coliform
> 12000
6.8
col/ 100 mis
Total Suspended Solids
20.7
<5
mg/L
Temperature (Summer)
30
23.75
°C
Temperature (Winter)
23
14
°C
pH
8.1
N/A
SU
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES NCO044750
PSD (CAA)
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Special Order of Consent (SOC)
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.
James M. Cheshire Authorized Agent
Printed name of Person Signing Title
of
Date
1116rth 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 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.)
3 of 3 Form -D 1/06

SLUDGE MANAGEMENT PLAN
Jacob's Creek Nursing & Rehabilitation Center
WASTEWATER TREAMENT PLANT
NPDES PERMIT NO. NC0044750
Sludge from the Jacob's Creek Nursing & Rehabilitation Center wastewater treatment plant
is disposed of in the following way:
Solids are collected in the sludge holding tank and digested
aerobically. The excess solids are periodically pumped and
hauled by Billingseley Septic Tank, a licensed septic pumper
contractor and disposed of at the City of Reidsville.