NC0087963_Renewal (Application)_20150128

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 Resources / NPDES Program
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit NCO() 97 94 3
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:
vvR
Owner Name f/Q/gjV K LIN /T�FJ� W/�.4/6°1
5
Facility Name )3u�,�e 7 C (-REEKl RECEIVED/DFN�p
Mailing AddressD / AVER 96 /r/✓F/Q a • JHtV G S 2U15
City 1Qiz.H�DA/Dj -
State / Zip Code VAZ32- 2?
Permitb�ng 0
Telephone Number (goy ) g 74/ '70 9 o
Fax Number ( )
e-mail Address NEE. W i 4 L imin s Z a N 0. c a in
2. Location of facility producing discharge:
Check here if same address as above 0 iv y 2/ /1/Lee KNOB
Street Address or State Road ,E57- Ot I?Le cot,V&. Rock — lc/ n91,4 G.fJ 44,V7 /
City
State / Zip Code 2- Ff 6 0 S
County IN or 19(46-f)
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
Mailing Address
City
State / Zip Code
Telephone Number ( )
Fax Number ( )
e-mail Address
1 of 3 Form-D 9/2013

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 ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served:
5. Type of collection system
❑ Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s)
Is the outfall equipped with a diffuser? ❑ Yes El No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
8. Frequency of Discharge: ❑ Continuous ❑ Intermittent
If intermittent:
I 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.
2 of 3 Form-D 9/2013

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow MGD
Annual Average daily flow MGD (for the previous 3 years)
Maximum daily flow 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 for parameters currently in your permit. Mark other parameters `N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS)
Fecal Coliform
Total Suspended Solids
Temperature (Summer)
Temperature (Winter)
pH
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 Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non-attainment program (CAA)
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, complete, and accurate.
f745Nvke..1,v / ee-b iv(L.Lifit�'lS 2T pu AiEi
Printed name of Person Signing Title
,1,...xvie..:. /2„,.,,______-___ter ,
) 4.4.44-1444-Z II 4 °IC
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.)
3 of 3 Form-D 9/2013

Franklin Reed Williams,II
9601 River Rd.
Richmond,VA 23229
01/26/15
To:Mr. Wren Thedford
NC DENR/DWR/NPDES Unit
1617 Mail Service Center
Raleigh,NC 27699-1617
Dear Mr.Thedford,
I am requesting renewal of permit#NCOO 87963.This permit has never been activated
upon and no construction of a sewer plant has been done so nothing has changed since
the permit was first granted in 2005.
Would you please let me know you have received this package either via phone or email?
Contact information below:
Many thanks.
Sincerely, 171
Reed Williams Cell: 804 874 7090. [e-mail]

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 Resources / NPDES Program
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit INCOO 27,4 3
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 fifyitr y/i L 1/I/ A e`E 2) /1.1-‘1604 5
Facility Name /q u ck Y C C.ReeK
Mailing Address ,b0 / ni VE/Q i? D•
City R/Z-Hr»ON b j. _
State / Zip Code VA, 232.2?
Telephone Number (gay ) g 7q 709 0
Fax Number ( )
e-mail Address REED 0/4 t j i 5 e z O I f 0. coin
2. Location of facility producing discharge:
Check here if same address as above 0 f/wY 2.21
21 /tPFeR Kfo13 9
Street Address or State Road E57" 0t R40'0 /N6- ROO< — 4144/7t/
City
State / Zip Code Z 8 6 0.c.
County W q?l9(4AM
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
Mailing Address
City
State / Zip Code
Telephone Number ( )
Fax Number ( )
e-mail Address
1 of 3 Form-D 9/2013

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MOD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial 0 Number of Employees
Commercial 0 Number of Employees
Residential 0 Number of Homes
School 0 Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater(example: subdivision,mobile home park, shopping centers,
restaurants, etc.):
Number of persons served:
5. Type of collection system
❑ Separate (sanitary sewer only) 0 Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s)
Is the outfall equipped with a diffuser? ❑ Yes 0 No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
S. Frequency of Discharge: 0 Continuous 0 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.
2 of 3 Foran-D 912013

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow MGD
Annual Average daily flow MGD (for the previous 3 years)
Maximum daily flow 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 for parameters currently in your permit. Mark other parameters 'N/A'.
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS)
Fecal Coliform
Total Suspended Solids
Temperature (Summer)
Temperature (Winter)
pH
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 Dredge or fill(Section 404 or CWA)
PSD (CAA) Other
Non-attainment program(CAA)
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, complete, and accurate.
i 7,VkL/4/ /pea £Qk.L./fr34f „V QuiA/E<
Printed name of Person Signing Title
42.44*"41.442/ 2. 01S—
Signature
. 0/sSignature 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.)
3013 Form-D912013

Aii„A
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
January 28, 2015
Franklin R. William,II
Buckeye Creek
9601 River Rd
Richmond,VA 23229
Subject: Acknowledgement of Permit Renewal
Permit NC0087963
Watauga County
Dear Mr.William:
The NPDES Unit received your permit renewal application on January 28, 2015. A member of the
NPDES Unit will review your application. They will contact you if additional information is required to
complete your permit renewal. You should expect to receive a draft permit approximately 30-45 days
before your existing permit expires.
If you have any additional questions concerning renewal of the subject permit, please contact Bob
Sledge(919) 807-6398.
Sincerely,
WreArti T e,ol fo-rro(
Wren Thedford
Wastewater Branch
cc: Central Files
Winston-Salem Regional Office
NPDES Unit
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604
Phone:[phone] Fax:[phone]/Customer Service:1-877-623-6748
Internet:www.newater.orq
An Equal OpportunitylAffirmative Action Employer