NC0086959_Issuance of Permit_20030908

O \1\11". 6)Q6-
AT9QG Michael F. Easley
�� Governor
7 NC ENR William G. Ross,Jr., Secretary
North Carolina Department of Environment and Natural Resources
O `< Alan W. Klimek, P.E., Director
Division of Water Quality
September 8,2003
Mr.Eddie Coltrain
Northwestern Wayne Sanitary District
P.O.Box 1583
Goldsboro,North Carolina 27533
Subject: Issuance of NPDES Permit NC0086959
Memorial Church Road WI"P
Wayne County
Dear Mr. Coltrain:
Division personnel have reviewed and approved your application for renewal of the subject permit. Accordingly,we are
forwarding the attached NPDES discharge permit. This permit is issued pursuant to the requirements of North Carolina General
Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S. Environmental Protection Agency
dated May 9,1994(or as subsequently amended).
This final permit includes one major change from the draft permit sent to you on July 16,2003:
➢ The monitoring frequencies for Total Nitrogen(TN),TN components and Total Phosphorus have been reduced to
semi-annually,based on your request dated August 18,2003.
• This reduction in sampling frequency makes it imperative that representative samples are collected. Collect the
TN and TP samples on days when flow is monitored.
■ Data from the semi-annual samples will be used to calculate the TN load for the facility. The Permittee should
maintain accurate estimates of the total discharge each month(total monthly flow,or TMF). The TMF values
will be multiplied by the TN values for the semi-annual samples to calculate a TN load for the facility.
This permit includes a TRC limit that will take effect on April 1,2005. If you wish to install dechlorination equipment,
the Division has promulgated a simplified approval process for such projects. Guidance for approval of dechlorination projects
is attached.
If any parts,measurement frequencies or sampling requirements contained in this permit are unacceptable to you,you
have the right to an adjudicatory hearing upon written request within thirty(30)days following receipt of this letter. This request
must be in the form of a written petition,conforming to Chapter 150B of the North Carolina General Statutes,and filed with the
Office of Administrative Hearings(6714 Mail Service Center,Raleigh,North Carolina 27699-6714). Unless such demand is
made,this decision shall be final and binding.
Please note that this permit is not transferable except after notice to the Division. The Division may require
modification or revocation and reissuance of the permit. This permit does not affect the legal requirements to obtain other
permits which may be required by the Division of Water Quality or permits required by the Division of Land Resources,the
Coastal Area Management Act or any other Federal or Local governmental permit that may be required. If you have any
questions concerning this permit,please contact Charles Weaver at(919)733-5083,extension 511.
Sincerely,
ORIGINAL SIGNED BY
PRAInITOR it'�C'. mlek P.E.
cc: Central Files
Washington Regional Office/Water Quality Section
NPDES Unit
N.C.Division of Water Quality/NPDES Unit Phone:[phone]
1617 Mail Service Center,Raleigh,NC 27699-1617 fax:[phone]
Internet:h2o.enr.state.nc.us DENR Customer Service Center: 1 800 623-7748

• Permit NC0086959
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended, the
Northwestern Wayne Sanitary District
is hereby authorized to discharge wastewater from a facility located at the
Memorial Church Road WTP
NCSR 1342 at NC Highway 581
Wayne County
to receiving waters designated as Great Swamp in the Neuse River Basin in
accordance with effluent limitations, monitoring requirements, and other conditions
set forth in Parts I, II, III and IV hereof.
This permit shall become effective October 1, 2003.
This permit and authorization to discharge shall expire at midnight on January 31, 2008.
Signed this day September 8, 2003.
lnick
ORIGINAL SIGNED BY
Tom Be
Alan W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

• Permit NC0086959
SUPPLEMENT TO PERMIT COVER SHEET
All previous Nl'D1'.S Permits issued to this facility, whether for operation or discharge are hereby revoked. As of
this permit issuance, any previously issued permit bearing this number is no longer effective.Therefore, the
exclusive authority to operate and discharge from this facility arises under the permit conditions, requirements,
terms, and provisions included herein.
The Northwestern Wayne Sanitary District is hereby authorized to:
1. Continue to operate a drinking-water treatment plant with a discharge of filter-
backwash wastewater. This facility is located at the Memorial Church Road WTP
off NCSR 1342 at NC Highway 581 in Wayne County.
2. Discharge from said treatment works at the location specified on the attached
map into Great Swamp, classified C-Swamp NSW waters in the Neuse River
Basin.

Memorial Church Road WTP
Northwestern Wayne Sanitary district
Latitude:
35' 33' 06" N
State Grid/Ouad:
Renly East. N.C.
Loneitude:
77` 03' 10" W
Permitted Flow:
Not Limited
Receivine Stream:
(.heat S«amp
River Basin:
Neuse River Basin
Stream Class:
('Swamp NSW
Sub -Basin:
03-04-07
Facility
Location x
not to scale
North NPDES Permit NCO086959
Wayne County
•, .

Permit NC0086959
•
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of this permit and lasting until expiration, the Permittee is
authorized to discharge filter backwash from outfall 001. Such discharges shall be limited and monitored by
the Permittee as specified below:
EFFLUENT LIMITS MONITORING REQUIREMENTS
CHARACTERISTICS
Monthly Daily Measurement Sample Type SampleLocationi
�Ecag�,�aximum Frequency
Flow
0„3
-Estinte1g Effluent
�?h��59m7�rOrl•c
Total Suspended Solids 30.0 m 45. mg/L 2/Month Grab Effluent
cool?.. Sottleahia Weekly (;rah Effluent
Iron V.9eK y Grab Effluent
Total Residual Chlorine2 17 Ng/L /Week) Grab Effluent
;F Turbidity3 Weekly — Grab - .Upstream&Downstream
Total Monthly Flow 4 Monitor&Report Monthly Calculated Effluent
(million gallons/month)
Total Nitrogen(TN)4 Monitor&Report(mg/L) Semi-annually Grab Effluent
Nitrate/Nitrite Nitrogen4 Monitor&Report(mg/L) Semi-annually Grab Effluent
(NO2+NO3)
Total Kjeldahl Nitrogen (TKN)4 Monitor&Report(mg/L) Semi-annually Grab Effluent
TN load(pounds/month)4 Monitor&Report Monthly Calculated Effluent
(pounds per month)
TN load(pounds/year) Monitor&Report Annually Calculated Effluent
(pounds per year)
Total Phosphorus Monitor&Report(mg/L) Semi-annually Grab Effluent
Aid 4r>16.4-11
Footnotes:
1. Upstream = at least 50 feet upstream from the outfall. Downstream = at least 50 feet downstream from the
outfall.
2. Limit takes effect April 1, 2005. Limits and monitoring apply only if chlorinated water is used to backwash
filters.
3. The discharge from this facility shall not cause turbidity in the receiving stream to exceed 50 NTU. If the
instream turbidity exceeds 50 NTU due to natural background conditions. the discharge cannot cause
turbidity to increase in the receiving stream.
4. See A. (2) for Total
Nitrogen monitoring and reporting requirements.
Akt �llsampleescolectelb m
a representative discharge event.
There shall be no discharge of floating solids or visible foam in other than trace amounts.
-4 jea
Al4 nQ112.4e-, 106%4-1+b Grp �-
7

Permit NC0086959
A. (2) CALCULATION OF TOTAL NITROGEN LOADS
a. The Permittee shall calculate monthly and annual TN Loads as follows:
i. Monthly TN Load (pounds/month) = TN x TMF x 8.34
where:
TN= TN concentration(mg/L)of the sample collected during the semi-annual monitoring event. Use the
TN value for the month in which the sample was taken and successive months until another TN
sample is collected.
TMF= Total Monthly Flow of wastewater discharged during the month(MG/month). If all discharges are not
recorded at the facility,document the calculation(s)used to determine total monthly flow.
8.34= conversion factor,from(mg/L x MG)to pounds
ii. Annual TN Load (pounds/year) = Sum of the 12 Monthly TN Loads for the
calendar year
b. The Permittee shall report the semi-annual Total Nitrogen results in the discharge
monitoring report (DMR) for that month. The calculated pounds of TN load per month
will be reported on each month's DMR. The Permittee shall report each year's annual
results (pounds per year) on the December DMR.
-i • -

NORTHWESTERN WAYNE SANITARY DISTRICT
P.O. Box 1583
Goldsboro, N.C. 27533
[phone]
tv$F'
August 18, 2003
-- /those /55U13 A/'
Charles Weaver, Jr. Me56 5M4 l/ 40,5
NPDES Permit Unit
NC Division of Water Quality
1617 Mail Service Center — V /ve 50211 -a44(44/
Raleigh, NC 27699-1617 ic77,V/79
SUBJECT: Monitoring Requirements
Draft NPDES Permit No. NC0086959
Northwestern Wayne Sanitary District
Wayne County, NC
Dear Mr. Weaver:
Monitoring requirements for nutrients appear excessive in subject draft NPDES Permit inasmuch
as the effluent is treated filter backwash from a potable water treatment plant with groundwater
supply. Numerous wells are in the area with a history of data indicating low nitrogen levels (see
attached sample reports). There are no additives involving nitrogen in the water treatment process.
A polyphosphate is added in the treatment process (maintained less than 1 mg/1) and is monitored
daily with field test kits. A written record of phosphate levels is maintained by the Sanitary District.
Inasmuch as nitrogen is present only at low background levels it is recommended the frequency
be revised to once per year. More frequent monitoring of phosphorous maybe justified due to the
addition of phosphate in the treatment process; however, semi-annual sampling of phosphorous is
believed adequate since daily sampling and records are maintained for the addition of phosphate.
Your consideration and approval of this request will be appreciated. If you have any questions,
please do not hesitate to contact me.
Sincerely,
NORTHWESTERN WAYNE SANITARY DISTRICT
diewce—
Eddie
Coltrain
District Manager
Attachments
cc: McDavid Associates, Goldsboro (w/attach)
\\G-PC1\D805\FTL\2003\NWWMREQ.LTR 1
NWWSD-MONITORING-REQ-NPDES.LTR 030818

Rug 18 03 03: 18p McDRVID ASSOCIATES, INC. 919-735-7351 p. 3
NORTHWESTERN WAYNE SANITARY DISTRICT
P.O. Box 1583
Goldsboro, N.C. 27533
[phone]
August IS, 2003
Charles Weaver, Jr.
NPDES Permit Unit
NC Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
SUBJECT: Monitoring Requirements
Draft NPDES Permit No. NC0086959
Northwestern Wayne Sanitary District
Wayne County, NC
Dear Mr. Weaver:
Monitoring requirements for nutrients appear excessive in subject draft NPDES Permit inasmuch
as the effluent is treated filter backwash from a potable water treatment plant with groundwater
supply. Numerous wells are in the area with a history of data indicating low nitrogen levels (see
attached sample reports). There are an additives involving nitrogen in the water treatment process.
A polyphosphate is added in the treatment process (maintained less than 1 mg/I) and is monitored
daily with field test kits. A written record of phosphate levels is maintained by the Sanitary District.
Inasmuch as nitrogen is present only at low background levels it is recommended the frequency
be revised to once per year. More frequent monitoring of phosphorous maybe justified due to the
addition of phosphate in the treatment process; however, semi-annual sampling of phosphorous is
believed adequate since daily sampling and records are maintained for the addition of phosphate.
Your consideration and approval of this request will be appreciated. If you have any questions,
please do not hesitate to contact me.
Sincerely,
NORTHWESTERN WAYNE SANITARY DISTRICT
642 i84r/
Eddie Coltrain
District Manager
Attachments
cc: McDavid Associates, Goldsboro (wiattach)
\\G-PCIRD805\FCL\2003\NWHTMREQ.LTR 1
NWWSD-MONITORING REQ NPDES.LTR WM1S

f:t_}.)
NORTH CAROLINA
WAYNE COUNTY.
AFFIDAVIT OF PUBLICATION CLIPPING OF LEGAL
ADVERTISEMENT
Before the undersigned, a Notary Public of said County and State, ATTACHED HERE
duly commissioned, qualified,and authorized by law to administer oaths, PUBLIC NOTICE
STATE Of NORTH CAROLINA
ENVIRONMENTAL
personally appeared MANAGEMENT
COMMISSION/NPOES UNIT
Cynthia Foye 1617 MAIL SERVICE CENTER
RALEIGH,NC 27699-1617
who beingfirst dulysworn, deposes and says: that he (she) is NOTIFICATION of INTENT TO
P ISSUE A NPDES
WASTEWATER PERMIT
Legal Clerk On the basis of thorough staff
review and application of NC
(Publisher, or other officer or employee authorized to make affidavit) General Statute 143.21,Public
of WAYNE PRINTING COMPANY,INC., engaged in the publication of law 92-500 and other lawfulstandards and regulations,the
a newspaper known as GOLDSBORO NEWS-ARGUS; published, North Carolina Environmental
Management Commission pro-
issued, and entered as second class mail in the city of Goldsboro in said poses to issue a National Pollu-
County and State; that he (she) is authorized to make this affidavit and taut Discharge Elimination Sys-
•
tem(NPDES)wastewater dls-
sworn statement; that the notice or other legal advertisement, a true listed argebpermit toelow the
heeper45 days
)
copy of which is attached hereto, was published in GOLDSBORO from the publish date of this
NEWS-ARGUS on the following dates: notice.
Written comments regarding
the proposed permit will be ac-
,
cepted until 30 days after the
publish date of this notice.All
comments received prior to
July 21, 2003 that date are considered in the
final determinations regarding
the proposed permit.The Direc-
tor of the NC Division of Water
Quality may decide to hold a
and that the said newspaper in which such notice, paper, document, or public meetingfor the proposed
legal advertisement was published was, at the time of each, and every permit shoulthe Division re-
calve a significant degree of
such publication, a newspaper meeting all of the requirements and public interest.
Copies of the draft permit and
qualifications of Section 1-597 of the General Statutes of North Carolina other supporting information on j
and was a qualified newspaper within the meaning of Section 1-597 of the file used to determine condi-I
tions present in the draft permit
General Statutes of North Carolina. are available upon request and
� payment of the costs of repro-
31 July duction.Mail comments andfor
This day of ,20 03 requests for information to the
n NC Division of Water Quality at
I. -.. I.All
the above address or call Ms.
Valery Stephens at(919)733-
: 5083,extension 520.Please in-
ignature of person 4n;affidavit) dude the NPOES permit num-
ber(attached)in any communi-
31 cation.Interested persons may
Sworn to and subscribed before me,this day of also visit the Division of Water
Quality at 512 N. Salisbury
Street,Raleigh,NC 27604-1148
July 20 03 , between the hours of 8:00 am.
.m.
and 5:00 rthwe ternw afore
mation on file.
The Northwestern Wayne
i Sanitary District has applied for
tar Public renewal of NPDES permit
Y NC0086959 for its memorial
Church Road This permit-
, WTP.ted facility discharges My Commission expires: filter-
backwash wastewater to Great
Swamp In the Neuse River Ba-
sin.Currently the total residual
chlorine is water quality limit-
ed.This discharge may affect
future allocations in this portion
of Great Swamp.
The Eastern Wayne Sanitary
District has applied for renewal I
of NPDES permit NC0086918
for its Rockfor Church Road'
WTP.This permitted facility dis-,
charges fitter-backwash waste-
water to an unnamed tributary I
to the Neuse River in the Neuse
River Basin.Currently total re-
sidual chlorine is water quality
.limited.This discharge may af-
fect future allocations in this
portion of the Neuse River.
Legal 41895
July 21,2003
,r

Invoice's/peanit status
<Ns::x� .4� /s!/i:,t/>J,/.�ir� .l/Y,.,dx///��.
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u�;7F�. .�4 ./i. 7 ,. Y v "•:, .%n s,:.'�'uz, is y:;y�ui. / .�r„'.:3;hg.;sj>,
/: i �e�i � :.r, et!6r S. f, „< .%:: �.j'�r3:; .:>.>s.�..�.. �r:::s: .� ..�,,,;s;
,,:..< : s :,.:: .'. � ..�; ,,:y .» `�sa, ;s,f:y. :k�.;,II^� ✓.,,.. .t� �l'��n.r,E�'z......,.�ssr„' s ✓�.,..,:. ..> .�.:{:.:.:.,:c..;.
To:Fran McPherson<[e-mail]>,Robert Farmer<Robert.Farmer@ncmaiLnet>
CC:Dave Goodrich<Dave.Goodrich@ncmaiLnet>,Mike Templeton<Mike.Templeton@ncmaiLnet>
Fran - I received a call from Landis Davis, the contact for permit
NC0086967. He received an annual fee invoice for the permit; he wishes
to return the invoice because the Wayne County government has decided
not to use that facility. He will return that invoice.
He also said that no invoice had yet been received for permit
NC0086959. I told him that the billing month may not have been reached
yet, but that I would let you know. That permit will remain active, so
if the annual fee is due please send an invoice to the permittee.
Robert - when the invoice for NC0086967 is returned we can use it to
start the rescission process.
Dave/Mike - this is FYI, as these are both Neuse facilities. . .and both
assigned to me.
CHW
1 of 1 6/25/2003 8:25 AM

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OMIT LATE COLLISIONS: 01

•
•
SOC PRIORITY PROJECT: YES NO_X_
IF YES,SOC NO.
To: Permits and Engineering Unit
Water Quality Section
-� SEP 4 J
Attn: Charles Weaver - 2002 -J
Date: August 19, 2002 N - WATER QUALITY
PG 'VT SOUFrr PRANCH
NPDES STAFF REPORT AND RECOMMENDATION
Northwestern Wayne Sanitary District
Memorial Church Road Water Treatment Plant
Permit No.NC0086959
PART I-GENERAL INFORMATION
1. Facility and Address: Northwestern Wayne Sanitary District
Memorial Church Road Water Treatment Plant
Wayne County
P.O.Box 1583
Goldsboro,NC 27533
2. Date of Investigation: July 31, 2002
3. Report Prepared by: Kristin Jarman
4. Person(s) contacted and telephone number(s):
Joey Threewitts- Operations Manager
919-731-2310
5. Directions to Site: Located on the West side of NC Hwy 581 at its intersection
with SR 1342
6. Discharge Point:
001-- Latitude: 35°33' 06"N Longitude: 78°03'10"W
Attach a USGS map extract and indicate treatment facility site and discharge
point on map.
USGS Quad. No. USGS Quad Name: Kenley East
7. Site size and expansion area consistent with application?
X Yes No If No, explain:

8. Topography(relationship to flood plain Included) : Flat with elevation of approx.
140 feet
9. Location of nearest dwelling: Approximately 200 feet
10. Receiving stream or affected surface waters: Great Swamp
a. Classification: C-SWP-NSW
b. River Basin and Subbasin No. : 03-04-07
c. Describe receiving stream features and pertinent downstream uses:
Drainage, fishing
PART II—DESCRIPTION OF DISCARGE AND TREATMENT WORKS
1. a. Volume of Wastewater to be permitted: NA
b. What is the current permitted capacity of the Wastewater Treatment
facility?NA
c. Actual treatment capacity of the current facility(current design capacity)?
NA
d. Date(s)and construction activities allowed by previous Authorizations to
Construct issued in the previous two years: NA
e. Please provide a description of existing or substantially constructed
wastewater treatment facilities: NA(Bids are in)
f. Please provide a description of proposed wastewater treatment facilities:
40'x 40' (67,000 gallon) concrete settling basin
g. Possible toxic impacts to surface waters: Chlorine
h. Pretreatment Program(POTWs only): NA
2. Residuals handling and utilization/disposal scheme:
a. If residuals are being land applied, please specify DWQ permit
no.
Residuals Contractor
Telephone No.
b. Residuals stabilization: PSRP PFRP Other
c. Landfill: x
d. Other disposal/utilization scheme(Specify):
Treatment plant classification(attach completed rating sheet): Grade 1

4. SIC Code: 4941
Wastewater Code of actual wastewater,not particular facilities.
001-- Primary_22_ Secondary————
Main Treatment Unit Code: 5 0 0 _ 1
PART HI–OTHER PERTINTENT INFORMATION
1. Is this facility being constructed with Construction Grant Funds or are any public
monies involved?(municipals only) No
2. Special monitoring or limitations(including toxicity)requests:NA
3. Additional effluent limits requested: None
4. Other: None
PART IV–EVALUATION AND RECOMMENDATION
This proposed discharge will result from the backwash of filters for iron removal.
Softeners are not proposed therefore chlorides are not expected to be a problem The
Washington Regional Office recommends that this permit be reissued at the same
location.
Signa of Report Preparer
d2-Water Quality Regional Supervisor
X// /p L
Date

NORTHWESTERN WAYNE SANITARY DISTRICT
P.O. Box 1583
Goldsboro, N.C. 27533
[phone]
June 27, 2002 D 2 f2 0 �/) 2
E
-, 15 LS U
Mr. Charles H. Weaver, Jr. JUL - 2 2002 -'
NPDES Unit
Division of Water Quality
1617 Mail Service Center DENR-WATER QUALITY
Raleigh, NC 27699-1617 POINT SOURCE BRANCH
SUBJECT: Request for Permit Renewal
NPDES Permit NC 0086959
Northwestern Wayne Sanitary District
Wayne County, NC
Dear Mr. Weaver:
Attached please find one signed original and two copies of each of the following:
1. Cover Letter
2. Application Form
Wastewater discharged via this Permit is backwash and rinse water from water filters treating
potable water. Solids retained (iron residual) are anticipated to be removed on an annual basis (less
than 3000 lbs) and be transported to the Wayne County landfill for disposal.
If you have any questions concerning this, please do not hesitate to contact me.
Sincerely,
NORTHWESTERN WAYNE SANITARY DISTRICT
Eddie Coltrain
District Manager
\\G-PC 1\D 805\FTL\2002
NWWSD-DWQ-NPDES-PERMrr-RENEWAL.wpd 1 020627

•
NPDES PERMIT APPLICATION - SHORT FORM C
For manufacturing or commercial facilities with a discharge <1 MOD (or WTPs)
N. C. Department of Environment and Natural Resources
Division of Water Quality/NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
North Carolina NPDES Permit Number NCO() 86959
Please print or type
1. . Applicant and facility producing discharge
A. Name Northwestern Wayne Sanitary District
•
B. Mailing address of applicant:
Street address P.O. Box 1583 •
•
City Goldsboro County Wayne
State NC • Zip Code 27533
Telephone Number ( 919 ) 731-2310
Fax Number ( 919 ) 734-5994
e-mail address N/A
C. Location of facility:
Street .. Memorial Church Road WTP
City Fremont County Wayne
State NC Zip Code 27533
Telephone Number ( ) N/A
2. Standard Industrial Classification (SIC)code(s):
3. Number of employees: 15
4. Principal product(s) produced: Potable water
Principal raw material(s)consumed: Groundwater
5. Principal process(es): Potable water system
6. Amount of rrincspal prnduct produced or raw material consumed
(List specific amounts consumed and/or units of production)
Product Produced or Raw Material Consumed Product Produced or Raw Material Consumed
(AVERAGE) (PEAK)
per Day 1.000.000 GPD 1.000.000 GPn
per Month
per Year
7. Check here if discharge occurs all year QX , or
Circle the month(s) in which discharge occurs: January February March April
May June July August September October November December
Days per week discharge occurs: 7 dans/week
NOTE:If the facility has separate discharge points(outfalls)or multiple industrial processes,include a schematic diagram
of wastewater flow at the facility.
Page 1 of 2 Version-11/2000

NPDES PERMIT APPLICATION - SHORT FORM C •
For manufacturing or commercial facilities with a discharge <1 MGD (or WTPs)
8. Types of wastewater discharged to surface waters only(check as applicable).
Discharge per operating day Flow Volume treated before discharging
(GALLONS PER OPERATING DAY) (PERCENT)
Sanitary-daily average
N/A
Cooling water,etc.-daily average
_ N/A •
Process water-daily average
33,000 GPD
Maximum per operating day for
total discharge (all types) 66,000 GPD
9. If any of the types of wastewater identified in item 8 (either treated or untreated) are discharged to places
other than surface waters, record the amount(s) discharged below:
A. Municipal sewer system gpd
B. Underground well gpd
C. Septic tank qpd Sanitary wastewater disposed
on-site via septic system
D. Evaporation lagoon or pond gpd
E. Other, specify qpd
10. Number of separate discharge points: 1
11. Name of receiving stream(s): Great Swamp
12. Does your discharge contain or is it possible for your discharge to contain one or more of the following
substances added as a result of your operations, activities,or processes? Circle all that apply:
aluminum ammonia beryllium cadmium chromium (chlorine (residual
copper cyanide lead mercury nickel oil and grease
• phenols selenium zinc None of the above
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.
Eddie Coltrain District Manager
Printed name of Person Signing Title
a.
A4/168 g/4/ ‘.)1/-o2--
Signature of Applicant Date
North Carolina General Statute 143-215.68(i)provides that:Any person who knowingly makes any lalse 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$10,000,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$10,000 or imprisonment not more than 5 years,or both,for a similar offense.)
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