NC0059536_Fact Sheet_20190816

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
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
Emily DelDuco 3/20/2019
Permit Number
NCO059536
Facility Name
Hilltop Living Center WWTP
Basin Name/Sub-basin number
Yadkin -Pee Dee 03-07-04
Receiving Stream
UT Yadkin River
Stream Classification in Permit
WS-V
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?
Yes - High Rock Lake Re -opener
Does permit have instream monitoring?
Yes - Temperature & D.O.
Is the stream impaired (on 303(d) list)? For
whatparameter?
No
Any obvious compliance concerns?
No
Any permit mods since last permit?
No major modifications
New expiration date
5/31/24
Comments received on Draft Permit?
Please note the following modifications to this draft:
• HUC was added to site description (page 2)
• Regulatory citations were added as necessary
• Part I Section A. (3.) was updated to be current
• The outfall map was updated
Compliance History
• 3 enforcements in 2018.
o BOD5, $366 paid
o Nitrogen monthly average exceedance, $341 paid
o Fecal & ammonia, $356 paid
• Long history of violations

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
Analysis Variable: Value
0010 - Temperature, Water Deg. Centigrade
0300 - Oxygen, Dissolved (DO)
0400 - pH
1616 - Coliform, Fecal MF, MFC Broth, 44.5 C
8260 - Surfactants (MBAS)
0050 - Flow, in conduit or thru treatment plant
0060 - Chlorine, Total Residual
'0310 - BOD, 5-Day (20 Deg. C) - Concentration
'0530 - Solids, Total Suspended - Concentration
'0600 - Nitrogen, Total - Concentration
'0610 - Nitrogen, Ammonia Total (as N) - Concentration
'0665 - Phosphorus, Total (as P) - Concentration
Meanj
Minj
Maxi
N
18.38
5.00
27.00
1222
6.32
6.10
6.70
496
-
6.50
6.80
114
-
1.00
12000.00
125
8.12
0.10
435.00
113
0.00
0.00
0.00
250
10.00
10.00
10.00
496
4.34
2.00
17.80
118
5.04
1.00
11.00
114
10.79
3.81
35.20
19
1.93
0.10
7.06
120
1.78
0.16
2.97
19

DocuSign Envelope ID: DEE8A948-5C72-4092-137D9-6481221 B62CD
From:
man, Jeff
To:
DelDuco, Emily
Cc:
Kaufman, Tammy; Hudson, Eric
Subject:
FW: PWS Comment, Approval NCO059536
Date:
Friday, May 24, 2019 10:20:52 AM
Attachments:
imaae001.Dna
NCO059536 DRAFT 2019.Ddf
imaae004.Dna
Re: Hilltop Living Center WWTP (renewal), Davidson County
Emily,
We concur with issuing the permit provided the facility is maintained and operated properly, and the
stated effluent limits are met.
Thank you for providing the permit for our review.
Jeff
Jeff H. Bryan, P.E.
Assistant Regional Engineer
Public Water Supply Section
Department of Environmental Quality
336 776 9663 office
336 403 1092 mobile
aeff. bryan ft_ncdenr.gov
Winston Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston Salem, NC 27105
: `Nothing Compares,.,
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: DelDuco, Emily
Sent: Monday, April 29, 2019 10:50 AM
To: Bryan, Jeff <[e-mail]>
Subject: PWS Approval NC0059536
Hi Jeff,

DocuSign Envelope ID: DEEM948-5C72-4092-137D9-6481221 B62CD
NCO059536 / Hilltop Living Center WWTP is a grade I Biological WPCS facility in Davidson County
which discharges into an unnamed tributary to Yadkin River, currently classified WS-V.
Please send me any comments when you are able.
Please note that we're transitioning to paperless communication. As such, NPDES will no longer
send the separate approval memo for PWS comments on this permit draft. The email response from
you (or another PWS contact) will suffice to document the draft permit review by PWS.
Thanks for your help, and let me know if you have any questions.
Emily DelDuco
Division of Water Resources
Department of Environmental Quality
919-707-9125
emiIy.deIduco(@ncdenr.goov
'Nothing Compares,
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221 B62CD
42008646
J000642985
AFFIDAVIT OF PUBLICATION
OLINA
DAVIDSON COUNTY STATE OF NORTH CARLEXINGTON, NC May 8, zaT9
I, Lynn Bowers OF THE DISPATCH, A NEWSPAPER PUBLISHED IN THE CITY
OF
AFORESAID, OF
EING DULY SWORN, SAYS THE FOREGOING LEGAL OF WHICH THE ATTACHED IS A TRUE COPY,
WAS PUBLISHED IN SAID NEWSPAPER ONCE, BEGINNING THE 8th DAY LEXfNGTON, COUNTYAND STATE
PUBLICATION FEE. $ 132.09 OF May, 2019.
4A_�
(SEAL)
'7
&STOAND SUBSCRIB D BEFORE ME THIS
DAY OF
MY COMMISSION EXPIRES /
Ad Copy:
Publi� c
North C
Enviro"mental OtfficIArie
ement
Commission/NPDES Unit
1617 Mail Service Center
Ra1ei h NC 27699-169 7
NPD!_S Wastewater Permit
The North Carolina
Environmental Management
Commission proposes to issue
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 significant degree of
public interest. Please mail
comments and/or information
requests to DWR at the above
address. Interested persons
may visit the DWR at 512 N.
Salisbury Street, Raleigh, NC
to review information on file.
Additional information on
VPDES permits and this notice
nay be found on our website:
tt 1/de .nc. ov/abeut/divisio'
!water r-resources/water-
,Sources- ermits/wastewater-
anch/nodes-
astewaterl ubllc-notices or by
calling [phone]. Kurz
Transfer Products,
requested renewal of L.P
NC0070637/Kurz Permit
Products Transfer
Count , WWTP m Davidson
y Facility discharges to
Reedy Creek/Yadkin-Pee Dee
River Basin. Currently, Total
Residual Chlorine is water
Huality limited. illtop Living C
Center requested
renewal of permit for the Hilltop
Living Center NIVVTP;
Davidson County. This
permitted discharge is treated
wastewater to an unnamed
tributary to the Yadkin River;
Yadkin -Pee Dee River Basin.
Currently, 130D, Ammonia -
Nitrogen, MBAS and Total
Residual Chlorine are water
quality limited. Fred P Cox
requested renewal of NPDES
permit NC0070033/4uail Run
Mobile Home Park
WWTP/Davidson County.
Facility discharges to Miller
Creek/Yadkin-Pee Dee River
Basin, Currently ammonia
nitrogen, total residual chlorine,
and fecal co"form are water
quality limited.
May 8, 2019
•
\\\`.50iN I L A4
F�
s%
Notary PubtIC
Davidson County
=My Cornmission Expires=
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DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
MONITORING REPORT(MR) VIOLATIONS for: Report Date: 07/03/19 Page: 1 of 3
Permit: nc0059536 MRS Between 6 - 2014 and 7 - 2019 Region: % Violation Category% Program Category:
Facility Name: % Param Name % County: % Subbasin:% Violation Action: %
Major Minor:
i
PERMIT: NCO059536 FACILITY: Tisha T Tuttle - Hilltop Living Center WWTP COUNTY: Davidson REGION: Winston-Salem
Limit Violation
MONITORING VIOLATION UNIT OF CALCULATED %
REPORT OUTFALL LOCATION PARAMETER DATE FREQUENCY MEASURE LIMIT VALUE Over VIOLATION TYPE VIOLATION ACTION
01 -2015 001 Effluent BOD, 5-Day (20 Deg. C) - 01/31/15 2 X month mg/I 10 11.45 14.5 Monthly Average Proceed to NOV
Concentration Exceeded
02 -2015 001 Effluent BOD, 5-Day (20 Deg. C) - 02/28/15 2 X month mg/I 10 10.86 8.6 Monthly Average Proceed to
Concentration Exceeded Enforcement Case
04 -2015 001 Effluent BOD, 5-Day (20 Deg. C) - 04/10/15 2 X month mg/I 7.5 8.13 8.4 Daily Maximum Proceed to NOV
Concentration Exceeded
04 - 2015 001 Effluent BOD, 5-Day (20 Deg. C) - 04/30/15 2 X month mg/I 5 6.42 28.4 Monthly Average Proceed to NOV
Concentration Exceeded
10 - 2015 001 Effluent BOD, 5-Day (20 Deg. C) - 10/22/15 2 X month mg/I 7.5 8.1 8.0 Daily Maximum Proceed to NOV
Concentration Exceeded
12 - 2015 001 Effluent BOD, 5-Day (20 Deg. C) - 12/15/15 2 X month mg/I 15 17.8 18.7 Daily Maximum Proceed to NOV
Concentration Exceeded
01 - 2016 001 Effluent BOD, 5-Day (20 Deg. C) - 01/31/16 2 X month mg/I 10 11.29 12.9 Monthly Average Proceed to NOV
Concentration Exceeded
04 - 2016 001 Effluent BOD, 5-Day (20 Deg. C) - 04/06/16 2 X month mg/I 7.5 11.3 50.7 Daily Maximum Proceed to NOV
Concentration Exceeded
04 - 2016 001 Effluent BOD, 5-Day (20 Deg. C) - 04/19/16 2 X month mg/I 7.5 8.54 13.9 Daily Maximum Proceed to NOV
Concentration Exceeded
04 - 2016 001 Effluent BOD, 5-Day (20 Deg. C) - 04/30/16 2 X month mg/I 5 6.94 38.8 Monthly Average Proceed to NOV
Concentration Exceeded
04 - 2017 001 Effluent BOD, 5-Day (20 Deg. C) - 04/06/17 2 X month mg/I 7.5 8.73 16.4 Daily Maximum Proceed to NOV
Concentration Exceeded
06 - 2017 001 Effluent BOD, 5-Day (20 Deg. C) - 06/02/17 2 X month mg/I 7.5 9.14 21.9 Daily Maximum Proceed to NOV
Concentration Exceeded
04 - 2018 001 Effluent BOD, 5-Day (20 Deg. C) - 04/30/18 2 X month mg/I 5 6.71 34.2 Monthly Average Proceed to
Concentration Exceeded Enforcement Case
03 - 2019 001 Effluent BOD, 5-Day (20 Deg. C) - 03/19/19 2 X month mg/I 15 15.2 1.3 Daily Maximum None
Concentration Exceeded
09 - 2014 001 Effluent Coliform, Fecal MF, MFC 09/19/14 2 X month #/100m1 400 8,000 1,900 Daily Maximum Proceed to NOV
Broth, 44.5 C Exceeded

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
MONITORING REPORT(MR) VIOLATIONS for:
Permit: nc0059536 MRS Between 6 - 2014 and 7 - 2019 Region: %
Facility Name: % Param Name % County: %
Major Minor: %
Report Date: 07/03/19 Page: 2 of 3
Violation Category:% Program Category: %
Subbasin:% Iq
Violation Action:
PERMIT: NCO059536
FACILITY: Tisha T Tuttle - Hilltop Living Center WWTP
COUNTY: Davidson
REGION: Winston-Salem
Limit Violation
MONITORING
VIOLATION
UNIT OF
CALCULATED
%
REPORT
OUTFALL
LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT
VALUE
Over
VIOLATION TYPE
VIOLATION ACTION
02 -2015
001
Effluent
Coliform, Fecal MF, MFC
02/20/15
2 X month
#/100ml
400
660
65
Daily Maximum
Proceed to
Broth, 44.5 C
Exceeded
Enforcement Case
03 _2015
001
Effluent
Coliform, Fecal MF, MFC
03/06/15
2 X month
#/100ml
400
12,000
2,900
Daily Maximum
Proceed to NOV
Broth, 44.5 C
Exceeded
01 -2016
001
Effluent
Coliform, Fecal MF, MFC
01/27/16
2 X month
#/100ml
400
2,420
505
Daily Maximum
Proceed to NOV
Broth, 44.5 C
Exceeded
12 - 2016
001
Effluent
Coliform, Fecal MF, MFC
12/08/16
2 X month
#/100ml
400
2,420
505
Daily Maximum
Proceed to NOV
Broth, 44.5 C
Exceeded
08 - 2017
001
Effluent
Coliform, Fecal MF, MFC
08/16/17
2 X month
#/100ml
400
2,420
505
Daily Maximum
Proceed to
Broth, 44.5 C
Exceeded
Enforcement Case
08 - 2017
001
Effluent
Coliform, Fecal MF, MFC
08/18/17
2 X month
#/100ml
400
2,420
505
Daily Maximum
Proceed to
Broth, 44.5 C
Exceeded
Enforcement Case
01 -2018
001
Effluent
Coliform, Fecal MF, MFC
01/02/18
2 X month
#/100ml
400
1,600
300
Daily Maximum
Proceed to NOV
Broth, 44.5 C
Exceeded
01-2018
001
Effluent
Coliform, Fecal MF, MFC
01/08/18
2 X month
#/100ml
400
2,420
505
Daily Maximum
Proceed to NOV
Broth, 44.5 C
Exceeded
01 -2018
001
Effluent
Coliform, Fecal MF, MFC
01/12/18
2 X month
#/100ml
400
2,420
505
Daily Maximum
Proceed to NOV
Broth, 44.5 C
Exceeded
10 - 2015
001
Effluent
Nitrogen, Ammonia Total (as
10/31/15
2 X month
mg/I
2
2.45
22.5
Monthly Average
Proceed to NOV
N) - Concentration
Exceeded
03 - 2016
001
Effluent
Nitrogen, Ammonia Total (as
03/31/16
2 X month
mg/I
4
4.08
2
Monthly Average
No Action, BPJ
N) - Concentration
Exceeded
08 - 2017
001
Effluent
Nitrogen, Ammonia Total (as
08/31/17
2 X month
mg/I
2
4.16
108.3
Monthly Average
Proceed to
N) - Concentration
Exceeded
Enforcement Case
10 - 2017
001
Effluent
Nitrogen, Ammonia Total (as
10/31/17
2 X month
mg/I
2
2.32
15.8
Monthly Average
Proceed to
N) - Concentration
Exceeded
Enforcement Case
05 - 2019
001
Effluent
Nitrogen, Ammonia Total (as
05/31/19
2 X month
mg/I
2
2.84
41.8
Monthly Average
None
N) - Concentration
Exceeded
05 - 2019
001
Effluent
pH
05/16/19
2 X month
su
9
21
133.3
Daily Maximum
None
Exceeded
05 - 2019
001
Effluent
pH
05/17/19
2 X month
su
9
22
144.4
Daily Maximum
None
Exceeded

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
MONITORING REPORT(MR) VIOLATIONS for:
Permit: nc0059536 MRS Between 6 - 2014 and 7 - 2019 Region: %
Facility Name: % Param Name % County: %
Major Minor: %
Report Date: 07/03/19 Page: 3 of 3
Violation Category:% Program Category: %
Subbasin:% Iq
Violation Action:
PERMIT: NCO059536
FACILITY: Tisha T Tuttle - Hilltop Living Center WWTP
COUNTY: Davidson
REGION: Winston-Salem
Limit Violation
MONITORING
VIOLATION
UNIT OF
CALCULATED %
REPORT
OUTFALL
LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT
VALUE Over
VIOLATION TYPE
VIOLATION ACTION
02 -2015
001
Effluent
Surfactants (MBAS)
02/20/15
2 X month
ug/I
750
1,120 49.3
Daily Maximum
Proceed to
Exceeded
Enforcement Case
Monitoring Violation
MONITORING
VIOLATION
UNIT OF
CALCULATED %
REPORT
OUTFALL
LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT
VALUE Over
VIOLATION TYPE
VIOLATION ACTION
11 -2014
001
Effluent
Chlorine, Total Residual
11/01/14
2 X week
ug/I
Frequency Violation
No Action, Facility
Reporting Error
11 - 2014
001
Effluent
Flow, in conduit or thru
11/01/14
Weekly
mgd
Frequency Violation
No Action, Facility
treatment plant
Reporting Error
11 -2014
001
Effluent
Oxygen, Dissolved (DO)
11/01/14
Weekly
mg/I
Frequency Violation
No Action, Facility
Reporting Error
10 -2015
001
Effluent
Oxygen, Dissolved (DO)
10/10/15
Weekly
mg/I
Frequency Violation
Proceed to NOV
10 -2015
001
Effluent
Oxygen, Dissolved (DO)
10/17/15
Weekly
mg/I
Frequency Violation
Proceed to NOV
10 -2015
001
Effluent
Oxygen, Dissolved (DO)
10/24/15
Weekly
mg/I
Frequency Violation
Proceed to NOV
10 -2015
001
Effluent
Oxygen, Dissolved (DO)
10/31/15
Weekly
mg/I
Frequency Violation
Proceed to NOV
01 -2015
001
Effluent
Surfactants (MBAS)
01/31/15
2 X month
ug/I
Frequency Violation
Proceed to NOV
11 -2014
001
Effluent
Temperature, Water Deg.
11/01/14
5 X week
deg c
Frequency Violation
No Action, Facility
Centigrade
Reporting Error
02 -2015
001
Effluent
Temperature, Water Deg.
02/21/15
5 X week
deg c
Frequency Violation
Proceed to
Centigrade
Enforcement Case
05 -2019
001
Effluent
Temperature, Water Deg.
05/18/19
5 X week
deg c
Frequency Violation
None
Centigrade
Reporting Violation
MONITORING
VIOLATION
UNIT OF
CALCULATED %
REPORT
OUTFALL
LOCATION
PARAMETER
DATE
FREQUENCY
MEASURE
LIMIT
VALUE Over
VIOLATION TYPE
VIOLATION ACTION
12 -2015
001
Effluent
Coliform, Fecal MF, MFC
12/31/15
2 X month
#/100ml
Parameter reported with
No Action, BPJ
Broth, 44.5 C
invalid Unit of Measure

DocuSign Envelope ID: DEEM948-5C72-4092-137D9-6481221 B62CD
Permit: NC0059536 Facility:
Region: Winston-Salem County:
Penalty
Assessment Penalty Enforcement
Case Approved Amount Costs
Permit Enforcement History by Permit
Hilltop Living Center WWTP
Davidson
Remission Enforcement EMC
Request Conference Hearing
Damages Received Held Held
Owner:
Collection
Memo Sent
To AGO
Tisha T Tuttle
Total Paid
Balance Due
Has
Payment
Plan
Case
Closed
LV-1998-0285
12/15/98
$1,500.00
$53.00
$0.00
$1,553.00
$0.00
No
01/06/99
LV-2002-0482
10/07/02
$2,250.00
$76.00
$2,326.00
$0.00
No
11/14/02
LV-2002-0630
12/09/02
$1,000.00
$76.00
$1,076.00
$0.00
No
01/07/03
LV-2003-0251
05/06/03
$250.00
$76.00
$326.00
$0.00
No
05/22/03
LV-2003-0677
10/21/03
$250.00
$86.00
$336.00
$0.00
No
11/13/03
LV-2004-0131
05/25/04
$450.00
$87.00
$537.00
$0.00
No
06/18/04
LM-2004-0038
09/13/04
$450.00
$94.00
$544.00
$0.00
No
10/01/04
LV-2005-0414
10/19/05
$250.00
$110.00
$360.00
$0.00
No
10/27/05
LV-2006-0174
05/01/06
$400.00
$110.00
$510.00
$0.00
No
06/20/06
LV-2006-0228
07/13/06
$450.00
$110.00
$560.00
$0.00
No
07/21/06
LV-2006-0293
08/10/06
$375.00
$117.20
$492.20
$0.00
No
09/07/06
LV-2006-0346
09/08/06
$250.00
$117.20
$367.20
$0.00
No
09/20/06
LM-2006-0056
11/29/06
$437.50
$95.00
$532.50
$0.00
No
12/19/06
LV-2007-0001
01/02/07
$312.50
$95.00
$407.50
$0.00
No
01/31/07
LV-2007-0173
05/02/07
$375.00
$98.00
$473.00
$0.00
No
05/31/07
LV-2007-0219
06/12/07
$525.00
$98.00
$623.00
$0.00
No
06/21/07
LV-2008-0014
01/08/08
$350.00
$101.72
$451.72
$0.00
No
02/06/08
LV-2008-0067
02/08/08
$750.00
$101.72
$851.72
$0.00
No
03/07/08
LV-2008-0197
06/03/08
$312.50
$101.72
$414.22
$0.00
No
07/09/08

DocuSign Envelope ID: DEEM948-5C72-4092-137D9-6481221 B62CD
Penalty Remission Enforcement
Assessment Penalty Enforcement Request Conference
Case Approved Amount Costs Damages Received Held
EMC Collection
Hearing Memo Sent
Held To AGO
Total Paid
Balance Due
Has
Payment
Plan
Case
Closed
LV-2008-0244
07/11/08
$437.50
$101.72
$539.22
$0.00
No
08/07/08
LV-2008-0278
08/05/08
$562.50
$101.72
$664.22
$0.00
No
08/19/08
LV-2008-0337
09/09/08
$750.00
$101.72
$851.72
$0.00
No
10/09/08
LV-2008-0424
11/18/08
$525.00
$103.67
$628.67
$0.00
No
12/05/08
LV-2009-0033
02/05/09
$375.00
$103.67
$478.67
$0.00
No
02/13/09
LV-2009-0042
02/17/09
$375.00
$109.31
06/15/09
$484.31
$0.00
No
08/24/09
LV-2010-0195
06/22/10
$250.00
$103.00
$353.00
$0.00
No
07/09/10
LV-2010-0230
07/20/10
$250.00
$103.00
$353.00
$0.00
No
08/11/10
LV-2012-0143
08/10/12
$350.00
$134.13
$484.13
$0.00
No
09/04/12
LV-2013-0100
05/21/13
$350.00
$136.72
$486.72
$0.00
No
06/12/13
LM-2015-0016
08/03/15
$500.00
$141.64
$641.64
$0.00
No
08/14/15
LV-2018-0006
01/11/18
$250.00
$106.43
$356.43
$0.00
No
02/13/18
LV-2018-0059
03/06/18
$250.00
$91.65
$341.65
$0.00
No
04/09/18
LV-2018-0216
08/26/18
$312.50
$54.20
$366.70
$0.00
No
09/17/18
Total Cases:
Total Penalties:
33
$16,475.00
$3,296.14
$19,771.14
Total Penalties after
$19,771.14
$0.00
$19,771.14

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
ROY COOPER NORTH CAROLINA
Governor Environmental Quality
-NIICaAEL S_ REG_AN
Sscretmv
L=A CULPEPPER
Inrsri n Director
December 11, 2018
Tisha Tuttle
Tisha T Tuttle
1025 Lamb Rd
Lexington, NC 27292
Subject: Permit Renewal
Application No. NCO059536
Hilltop Living Center WWTP
Davidson County
Dear Applicant:
The Water Quality Permitting Section acknowledges the December 10, 2018 receipt of your permit renewal application
and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW
permitting branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Sincerely,
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
n: an D-F Q
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North Carolina Department of Environmental Quality I Division of Water Resources
1617 Mad Service Center I Raleigh, North Carolina 27699-1617
919-807-6300

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
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 C0059536
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
Plemmons Enterprises, Inc. t/a Hilltop Living Center by Tisha
Tuttle, President
Facility Name
Hilltop Living Center
Mailing Address
1025 Lamb Rd
City
Lexington
State / Zip Code
NC
Telephone Number
336-853-7670 ext 26
G D/DENR/DWR
Fax Number
[phone]
DEC 10 2018
e-mail Address
[e-mail]
Water Resources
Section
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 212 Plemmons Dr.
City
Linwood
State / Zip Code
NC 27299
County
Davidson
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 Luther Leonard
Mailing Address 502 Northside Dr.
City Lexington
State / Zip Code NC 27295
Telephone Number (336-)239-0842
Fax Number ( )
e-mail Address [e-mail]
1 of 5 Form-D 11/12

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
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
Other XR) Explain:
Assisted
Living
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Waste water for Assisted Living 65 bed capacity
Number of persons served: 65
5. Type of collection system
X14 Separate (sanitary sewer only)
6. Outfall Information:
❑ Combined (storm sewer and sanitary sewer)
Number of separate discharge points 1
Outfall Identification number(s) See Map
Is the outfall equipped with a diffuser? ❑ Yes X❑ No
7. Name of receiving stream(s) (NEW awnlicants: Provide a map showing the exact location of each
outfall):
n/a - renewal application maps on file (Yadkin river)
S. Frequency of Discharge: X® Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: 7 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.
Two Septic Tanks
Flow Splitter
Grease Trap
Two pump tanks
Two Surface Sand filters
Recirculation diversion box
Tablet chlorinator
Chlorine Contact tank
Dechlorine
2 of 5 Form-D 11/12

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
3 of 5 Form-D 11/12

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Iriforfnation; C) ri 0 3
Treatment Plant`Design flow w MGD
Annual Average daily flow U• 00,l MGD (for the previous 3 years
Maximum daily flow Q. Uo / 7-4 MGD (for the previous 3 years) ,
11. Is this facility located on Indian country?
❑ Yes X[j. 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 currently in your permit. Mark other parameters "N/A".
Parameter
Daily
Maxi um
Monthly
Average
, Units of
Measurement
Biochemical Oxygen Demand (BODs)
_7,�m
L')10
Fecal Coliform
C./ U L) iu v 4, L
1l16
Total Suspended Solids
, V A L.
Temperature (Summer)
Temperature (Winter)
pH
. U a N.! �,
O
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
NCO059536
14. APPLICANT CERTIFICATION
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.
Plemmons Enterprises, Inc t/a Hilltop Living Center by Tisha Tuttle
President
Printed name of Person,Signing Title
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
4 of 5 Form-D 11/12

DocuSign Envelope ID: DEE8A948-5C72-4092-B7D9-6481221B62CD
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
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.0 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.)
5 of 5 Form-D 11 /12