NC0073741_Renewal (Application)_20150422

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MOD
Mail the complete application to:
N. C. DENR/ Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617 -
NPDES Permit 1NC0073741
If you are completing this form in computer use the TAB key or the up - down arrows to moue 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 A&D WATER SERVICE, INC.
Facility Name MOUNTAIN VALLEY WWTP
Mailing Address P. 0. BOX 1407
City PISGAH FOREST
State / Zip Code NC 28768
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same address as above 0 RECEIVEDIDENRIDWR
Street Address or State Road 2276 CUMMINGS ROAD
City ETOWAH APR 2 2 2015
State / Zip Code NC 28729 Water Quality
Permitting Ser tIr n
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 A& D WATER SERVICE, INC.
Mailing Address P. 0. BOX 1407
City PISGAH FOREST
State / Zip Code NC 28768
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
1 of 3 Form-D 11/12

NPDE8 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 X Number of Homes 62
School ❑ Number of Students/Staff
Other 0 Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
RESIDENTIAL SUBDIVISION; 100% Domestic sources.
Number of persons served: est. 150
5. Type of collection system
X Separate (sanitary sewer only) 0 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
outfall):
FRENCH BROAD RIVER
8. Frequency of Discharge: X 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.
Existing Treatment System:
1. Aeration Basin;
2. Rectangular Clarifier,
3. Tablet Feed Chlorinator, Chlorine Contact Chamber;
4. Tablet Feed De-Chlorinator,
5. Effluent Flow Meter;
6. Sludge Holding Basin.
2 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MOD
10. Flow Information:
Treatment Plant Design flow .020 MOD
Annual Average daily flow .008 MOD (for the previous 3 years)
Maximum daily flow .020 MOD (for the previous 3 years)
NOTE: WEIR BLOCKED BY LEAVES ON THIS DAY
11. Is this facility located on Indian country?
0 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 parameters `N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS) 40 7 mg/1
Fecal Coliform 200 1 # colonies
Total Suspended Solids 45 9 mg/1
Temperature (Summer) 28 22 C
Temperature (Winter) 22 12 C
pH 7.5 7.0 s.u.
13. List all permits, construction approvals and/or applications: NONE
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.
AUBREY L. DEAVER PRESIDENT
Printed name of Person Signing Title
iff
IIrjfe Mar. 9, 2015
Signat •pplicant 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 Artide 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 11112

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