NC0033600_Renewal (Application)_20200129

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 INCO033600
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 Lisa Leatherwood Heritage Trust, Jodi Pierce Heritage Trust,
Jean Longley Irrevocable Trust
Facility Name. Pigeon Valley Rest Home
Mailing Address 100 Silver Bluff Drive
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
Canton
NC 28716
[phone]
[phone]
lleatherwood@silverbluffvillage. cam
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 Silver Bluff LLC
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
1 of 3
100 Silver Bluff Drive
Canton 9
NC 28716
[phone]
[phone]
[e-mail]
RECEIVED
JAN $ 9 2020
Form-D 11112
NCDEO/DWR/NPDEb

NPDES APPLICATION - FORM D
For privately -owned. treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Faeility.Generating
Wastewater(check all that apply):
Industrial
❑
Number of Employees
Commercial
®
Number of Employees 185
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Nursing home, assisted living facility
Number of persons served: 400
6. 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 numbers) 001
Is the outfall equipped with a diffuser? ® Yes ❑ No
7. Name of receiving stream(s) (NEW applicants: Provide.a snap showing the exact location of each
outfall):
Pigeon River
S. Frequency of Discharge: ®. Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: 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.
The treatment system consists of Flow EQ tank with (2) 43 gpm pumps, Influent bar
screen, Influent grinder(80 gpm), flow diverter box, aeration basin, sludge digestor,
decant and skimmer sludge pumps and 60 cfm blower, tablet chlorination, tablet
dechiorination and post aeration.
2 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.03 MGD
Annual Average daily flow 0.018 MGD (for the previous 3 years)
Maximum daily flow 0.024 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
NEW APPLICANTS: Provide data for the parameters listed. Fecal Coliforrn, 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 ma.zimum.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average over
the past 36 months for parameters cumre'tty in your permnit. Maric other parameters "NIA',
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
45
27.2
Mg/l
Fecal Coliform
700
32.7
#/ 100 ml
Total Suspended Solids
32.5
18
Mg/1
Temperature (Summer)
26
24.5
Degrees C
Temperature (Winter),
22
20
Degrees C
pH
7.7
N/A
units
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)
NESHAPS (CAA)
Ocean Dumping (MPRSA)
N00033600 Dredge or fill (Section 404 or CWA)
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.
Lisa L. Leatherwood Administrator
Printed name of Person Signing Title
-'.
12/11/19
Signature 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
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. Sectlon 1001
provides a punishment by a fine of not more than $25,000 or imprisonment not more than 6 years, or both, for a similar offense.)
3 of 3 Form-D 11/12

G.'e&.VWA% 470'
Mailine Address: PO Box 954, Cullowhee, NC 28723
Physical Address: 2675 Skyland Drive, Sylva, NC 28779 [phone]
Physical Address: 240-D Swannanoa River Road, Asl►eville, NC 28805 [phone]
Toll Free: [phone], Fax: [phone], Email: environiv�ent:alin� al.f s7t�l
http://www.environmentalinc.info/ �w
Sludge Management Plan
December 15, 2019
NPDES Permit NC0033600
Pigeon Valley Rest Home WWTP
100 Silver Bluff Drive
Canton
NC / 28716
Lisa Leather -wood
Sludge is pumped out of the digester. The solids are pumped and hauled by a licensed
septage management firm.
The solids are disposed of at a local municipality facility.
Signature: Awi
Mark Teague, Environmental, Inc.
Contract Operational Firm