NC0033600_application_20200121

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 NCO033600
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.
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1. Contact Information:
Lisa Leatherwood Heritage Trust, Jodi Pierce Heritage Trust,
Owner Name Jean Longley Irrevocable Trust
Facility Name. Pigeon Valley'Rest Home
Mailing Address 100 Silver Bluff Drive
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City Canton
State / Zip Code NC 28716
Telephone Number [phone]
Fax Number [phone]
e-mail Address lleatherwoodgsilverbluffvillage,com €
2. Location.of facility producing discharge:
Check here if same address as above
Street Address or State Roadl
City r
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 100 Silver Bluff Drive
City Canton
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State/ Zip Code NC 28716
Telephone Number [phone]
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Fax Number [phone]
e-mail Address lleatherwood a silverbluffvillage.corn
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N'PDES 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 185
Residential ❑ Number of Homes
School ❑ Number of Students/Staff
Other ❑ Explain: l
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers, F
restaurants, etc.):
Nursing home, assisted living facility
Number of persons served: 400 K
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
7. Name of receiving stream(s) (NEW applicants: Provide,a map showing the exact location of each
outfall):
Pigeon River
5. Frequency of Discharge: Z 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(SO gpm), flow diverter box, aeration basin, sludge digestor,
decant and skimmer sludge pumps and 60 cfm blower, tablet chlorination, tablet
dechlorination and post aeration.
2 of 3 Form-D 11112

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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
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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 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 or parameters curreitly in your pen7mnit, Marlc other parameters "N/A
DailyMonthly Units of
Parameter a
Maximum .[average Measurement
Biochemical Oxygen Demand (BODs) 45 27.2 Mg/l
Fecal Coliform 700 32.7 #/ 100 ml
Total Suspended Solids 32.5 18 Mg/1
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Temperature (Summer) 26 24.5 Degrees C
Temperature (Winter) 22 20 Degrees C
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pH 7.7 N/A units
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES NC0033600 Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non-attainment program (CAA)
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14. APPLICANT CERTIFICATION
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, corxiplete, and accurate.
Lisa L. Leatherwood Administrator
Printed namename of Person Signing Title
12/ 11119
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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. 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.)
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ENVIRONMENTAL
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Mailing Address: PO Box 954, Cullowhee,NC 28723
Physical Address: 2675 Skyland Drive,Sylva,NC 28779 [phone]
Plysical Address: 240-D Swannanoa River Road,Asheville,NC 28805 [phone]
Toll Free: [phone], Fax: [phone],Email ��,%i"ivii*�)Isr�l("�:� li�i o) Cst.� f.) mI
http://www,environt-nentalinc.info/
Sludge.Management Plan
December 15, 2019
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N PDE>S Permit �011t�S�6O®
Pigeon Valley Rest Hoene WW'IP
100 Silver Bluff Drive
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Canton
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NC / 28716 j
Lisa Leatherwood
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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:
Mark Teague, Environmental, Inc.
Contract Operational Firm
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