820556_Complete File - Historical_20140211

1.
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Animal Feeding Operations Permit Application Form
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
GENERAL INFORMATION:
1.1 Facility name: KooBa Dairy, Inc.
1.2 Print Land Owner's name: KooBa Dairy, Inc.
1.3 Mailing address: 1719 Penny Tew Mill Road
City, State: Roseboro, N.C.
Telephone number (include area code): (704 ) 682 - 2560
1.4 Physical address: 1719 Penny Tew Mill Road
City, State: Roseboro, N.C.
Telephone number (include area code): ( 704 ) 682 - 2560
1.5 County where facility is located: Sampson
1.6 Facility location (directions from nearest major highway, using SR numbers for state roads):
1.7 Farm Manager's name (if different from Land Owner):
1.8 Lessee's / Integrator's name (if applicable; circle which type is listed):
1.9 Facility's original start-up date: 1990 Date(s) of facility expansion(s) (if applicable): 2014
Plete
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State General Permit — New or Expanding Animal Waste Operations
DENRFRO
FEB I 2014
2. OPERATION INFORMATION:
2.1 Facility number: 82-556
2.2 Operation Description:
Please enter the Design Capacity of the system.
management structures were designed.
Type of Swine
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean (# sow)
❑ Farrow to Feeder (# sow)
❑ Farrow to Finish (# sow)
❑ Wean to Finish (# sow)
❑ Gilts
❑ Boar/Stud
No. of Animals
CMQ
Zip: 28382
Zip: 28382
F 1: 3 0 7 ;>
4
Water Quality Regime
Operations Section
The "No. of Animals" should be the maximum number for vhich the waste
Type of Poultry No. of Animals Type of Cattle No. of Animals
❑ Layer 0 Beef Brood Cow
❑ Non -Layer ❑ Beef Feeder
0 Turkey 0 Beef Stocker Calf
❑ Turkey Poults 0 Dairy Calf
0 Dairy Heifer
❑ Dry Cow
® Milk Cow 1408
❑ Other Type of Livestock on the farm: No. of Animals:
FORM: AWO-STATE-G-N/E 1/10/06
Page 1 of 5

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2.3 Acreage cleared and available for application (excluding all required buffers and areas not covered by the application
system): 521 Required Acreage (as listed in the CAWMP): 150
2.4 Number of lagoons: Total Capacity (cubic feet): Required Capacity (cubic feet):
Number of Storage Ponds: 2 Total Capacity (cubic feet): 551254 Required Capacity (cubic feet): 551254
2.5 Are subsurface drains present within 100' of any of the application fields? YES or NO y (circle one)
2.6 Are subsurface drains present in the vicinity or under the waste management system? YES or NO` (circle one)
2.7 Does this facility meet all applicable siting requirements?
r NO (circle one)
3. REQUIRED ITEMS CHECKLIST:
Please indicate that you have included the following required items by signing your initials in the space provided next to ech
item.
3.1 One completed and signed original and two copies of the application for State General Permit -
Animal Waste Operations;
3.2 Three copies of a general location map indicating the location of the animal waste facilities and
field locations where animal waste is land applied and a county road map with the location of the
facility indicated;
3.3 Three copies of the entire Certified Animal Waste Management Plan (CAWMP). If the facility
does not have a CAWMP, it must be completed prior to submittal of a permit application for
animal waste operations.
Applicants Initials
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The CAWMP must include the following components. Some of these components may not have been required at the time
the facility was certified but should be added to the CAWMP for permitting purposes:
3.3.1 NRCS Site Evaluation Form NC-CPA-17 or equivalent
3.3.2 A hazard classification of the proposed lagoons, if required
3.3.3 Documentation that proposed swine facilities meet the Swine Farm Siting Act, including a site map prepared by
a Registered Land Surveyor. The scale of this map shall not exceed 1 inch = 400 feet. At a minimum, the site
map shall show the distance from the proposed houses and lagoons to occupied residences within 1500 feet,
schools, hospitals, churches, outdoor recreational facilities, national parks, state parks, historic properties, or
child care centers within 2500 feet, property boundaries within 500 feet, water supply wells within 500 feet.
The map shall also show the location of any property boundaries and perennial streams or rivers located within
75 feet of waste application areas.
3.3.4 Documentation showing that all adjoining property owners, all property owners who own property located
across a public road, street, or highway from the facility, the local health department, and the county manager
or chair of the county board of commissioners if there is no county manager, have been notified by certified
mail of your intent to construct or expand a swine farm at this location.
3.3.5 A wetlands determination
3.3.6 The lagoon/storage facility design
3.3.7 Proposed runoff control measures, if required
3.3.8 Irrigation or other land application method design
3.3.9 The Waste Utilization Plan (WUP) must include the amount of Plant Available Nitrogen (PAN) produced and
utilized by the facility
3.3.10 The soil series present on every waste disposal field
3.3.11 The crops grown on every waste disposal field
3.3.12 The Realistic Yield Expectation (RYE) for every crop shown in the WUP
3.3.13 The PAN applied to every waste disposal field
3.3.14 The waste application windows for every crop utilized in the WUP
3.3.15 The required NRCS Standard specifications
FORM: AWO-STATE-G-N/E 1/10/06 Page 2 of 5

3.3.16 Emergency Action Plan
3.3.17 Insect Control Checklist with options noted
3.3.18 Odor Control Checklist with options noted
3.3.19 Mortality Control Checklist with options noted
3.3.20 Documentation proving this facility is exempt from the Moritoria on Construction or
Expansion of Swine Farms, if the application is for a swine facility
3.3.21 A map showing the topography of the proposed facility location showing features
that affect facility design, the dimensions and elevations of any existing facilities,
the fields used for waste application, and areas where surface runoff is to be
controlled
If your CAWMP includes any components not shown on this list, please include the addifonal components with your
submittal. (Composting, waste transfers, etc.)
4. APPLICANT'S CERTIFICATION:
1 /
1 �'\/1 Y� CQ C C•1`4h
(Land Owner's name listed in question 1.2), attest that
this application for - 7)c-) c.� "'NL t l t.._ C . (Facility name listed in question 1.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts (Allis
application are not completed and that if all required supporting information and attachments are not included, this application package
will be returned to me as incomplete.
Signature
C—/
Date
-
5. MANAGER'S CERTIFICATION: (complete only if different from the Land Owner)
I� (Manager's name listed in question 1.6), attest that this
application for (Facility name listed in question 1.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts ofhis
application are not completed and that if all required supporting information and attachments are not included, this application package
will be returned as incomplete.
Signature Date
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION AND MATERIALS,
SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DIVISION OF WATER RESOURCES
AQUIFER PROTECTION SECTION
ANIMAL FEEDING OPERATIONS UNIT
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
FAX NUMBER: [phone]
FORM: AWO-STATE-G-N/E 1/10/06 Page 3 of 5

6. SURFACE WATER CLASSIFICATION:
This form must be completed by the appropriate DWR regional office and included as a part of the
project submittal information.
INSTRUCTIONS TO NC PROFESSIONALS:
The classification of the downslope surface waters (the surface waters that any overflow from the facility would flow toward)n
which this animal waste management system will be operated must be determined by the appropriate DWR regional office.
Therefore, you are required, prior to submittal of the application package, to submit this form, with items 1 through 6
completed, to the appropriate Division of Water Resources Regional Aquifer Protection Supervisor (see page 6 of 10). At a
minimum, you must include an 8.5" by 11" copy of the portion of a 7.5 minute USGS Topographic Map which shows the
location of this animal waste application system and the downslope surface waters in which they will be located. Identify th
closest downslope surface waters on the attached map copy. Once the regional office has completed the classification,
reincorporate this completed page and the topographic map into the complete application form and submit the
application package.
6.1 Farm Name: KooBa Dairy, Inc.
6.2 Name & complete address of engineering firm:NCDA&CS DSWC/William Carl Dunn
Telephone number: ( 252 ) 948 - 3900
6.3 Name of closest downslope surface waters: Hornet Swamp
6.4 County(ies) where the animal waste management system and surface waters are located Sampson
6.5 Map name and date: USGS Topo on GIS 2006
6.6 NC Professional's Seal (If appropriate), Signature, and Date:
TO: REGIONAL AQUIFER PROTECTION SUPERVISOR
Please provide me with the classification of the watershed where this animal waste management facility will be or has been
constructed or field located, as identified on the attached map segment(s):
Name of surface waters:
Classification (as established by the Environmental Management Commission):
Proposed classification, if applicable:
Signature of regional office personnel: Date:
(All attachments must be signed)
FORM: AWO-STATE-G-N/E 1/10/06 Page 4 of 5

DIVISION OF WATER RESOURCES REGIONAL OFFICES (9/05)
Asheville Regional APS Supervisor
2090 U.S. Highway 70
Swannanoa, NC 28778
[phone]
Fax [phone]
Avery Macon
Buncombe Madison
Burke McDowell
Caldwell Mitchell
Cherokee Polk
Clay Rutherford
Graham Swain
Haywood Transylvania
Henderson Yancey
Jackson
Fayetteville Regional APS Supervisor
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
[phone]
Fax [phone]
Anson Moore
Bladen Richmond
Cumberland Robeson
Harnett Sampson
Hoke Scotland
Montgomery
Washington Regional APS Supervisor
943 Washington Square Mall
Washington, NC 27889
[phone]
Fax [phone]
Winston-Salem Regional APS Supervisor
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
Fax [phone]
Alamance Rockingham
Alleghany Randolph
Ashe Stokes
Caswell Surry
Davidson Watauga
Davie Wilkes
Forsyth Yadkin
Guilford
Beaufort Jones
Bertie Lenoir
Camden Martin
Chowan Pamlico
Craven Pasquotank
Currituck Perquimans
Dare Pitt
Gates Tyrell
Greene Washington
Hertford Wayne
Hyde
Mooresville Regional APS Supervisor
610 East Center Avenue
Mooresville, NC 28115
[phone]
Fax [phone]
Alexander
Cabarrus
Catawba
Cleveland
Gaston
Iredell
Lincoln
Mecklenburg
Rowan
Stanly
Union
Raleigh Regional APS Supervisor
1628 Mail Service Center
Raleigh, NC 27699-1628
[phone]
Fax [phone]
Chatham Nash
Durham Northampton
Edgecombe Orange
Franklin Person
Granville Vance
Halifax Wake
Johnston Warren
Lee Wilson
Wilmington Region APS Supervisor
127 Cardinal Drive Extension
Wilmington, NC 28405-3845
[phone]
Fax [phone]
Brunswick
Carteret
Columbus
Duplin
New Hanover
Onslow
Pender
FORM: AWO-STATE-G-N/E 1/10/06
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