NC0074110_Renewal (Application)_20150428

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
April 29, 2015
Robert Crummie,Administrator
Mizpah Healthcare,Inc.
Mountain View Assisted Living
PO Box 1029
Marion,NC 28752
Subject: Acknowledgement of Permit Renewal
Permit NC0074110
Henderson County
Dear Permittee:
The NPDES Unit received your permit renewal application on April 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 Joe
Corporon(919) 807-6394.
Sincerely,
W re.Av Tln.20 1oroL
Wren Thedford
Wastewater Branch
cc: Central Files.
Asheville 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.ncwater.orq
An Equal Opportunity\Affirmative Action Employer

• 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 pC0074110
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 Mizpah Healthcare, Inc.
Facility Name Mountain View Assisted Living
Mailing Address P. 0. Box 1029
City Marion RECEIVED/DENRIDWR
State / Zip Code NC 28752 APR 2 8 2015
Telephone Number 828-652-3038
Water Quality
Fax Number [phone] Permitting Sectior
e-mail Address robert(acrummie.name
2. Location of facility producing discharge:
Check here if same address as above 0
Street Address or State Road 238 Brookside Camp Road
City Hendersonville
State / Zip Code NC 28792
County Henderson
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
Mizpah Healthcare, Inc.
Mailing Address P. 0. Box 1029
City Marion
State / Zip Code NC 28752
Telephone Number 828-652-3038
Fax Number [phone]
e-mail Address robert(acrummie.name
1 of 3 Form-D 11/12

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 R Explain: Assisted Living 37
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers.
restaurants, etc.):
Nursing Home 51 C �O gCS/4�i/S 2 7
Number of persons served: 37
5. Type of collection system
X 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 X No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfalls
Unnamed tributary to Featherstone Creek in the French Broad River Basin
8. Frequency of Discharge: X 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.
A 0.005 facility with extended aeration basin with gravity flow to 5000 gallon treatment
system with grease trap and bar screen, clarifier, sludge holding basin, dual blowers,
tertiary filter, tablet-feed chlorinator, chlorine-contact chamber, tablet dechlorinator,
post aeration tank, effluent discharge line.
2 of 3 Form-D 11112

- NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.005 MGD
Annual Average daily flow 0.002 MGD (for the previous 3 years)
Maximum daily flow 0.002 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes X 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 pararneters aN/A".
( ► Daily I Monthly I — Units of
I Parameter Maximum } Avera`e Measurement
IBiochemical Oxygen Demand (BODS) 23.1 8.6 MG/L
i Fecal Coliform 5.0 2.0 1 CFU/100ML
i
' Total Suspended Solids ; 48.0 25.7 4 MG/L
Temperature (Summer) 25.6 16.7 I C __
Temperature (Winter) 12.7 9.7 f C
p H' 7.6 7.3 UNITS
111
13. List allpe rmits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste(RCRA) NESHAPS(CAA)
U1C (SDWA) Ocean Dumping(MPRSA)
NPDES NC0074110 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.
Rate d Cr u e-miJdaiipliwnop-
Printed name of Person Signing Title
442,........L..... y/ehs
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.)
3of3 Form-D11/12

, 110 - •
Is 4 - * sJames & James Environmental Management, Inc.
4,4 3801 Asheville Hwy.,Hendersonville,N.C. 28791
+f; "070/ OFFICE: [phone] FAX: [phone]
N. C. Department of Environment and Natural Resources
Division of Water Quality/NPDES Unit
1617 Mail Service Center
Raleigh,N. C. 27699-1617
Regarding All Waste Water Facilities Operated by James&James Environmental Mgt., Inc.
To Whom It May Concern:
Sludge from this facility(Mountain View Assisted Living WWTP NC0074110) is pumped by Mike's
Septic Tank Service and is permitted to be dumped at Brevard Waste Treatment System and MSD.
Sincerely
eiU
iM-e/w a/
Juanita J es
James and James Environmental Mgt., Inc.
[e-mail]