NC0089095_Renewal Application_20150706

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 Resources / NPDES Program
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit INC0089095
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 A&D Water Service, Inc.
Facility Name High Vista Falls
Mailing Address P.O. Box 1404
City Pisgah Forest
State / Zip Code N.C. 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 RECEIVED/DENR/DWR
Street Address or State Road Creasman Hill Rd JUL 0 (i 1015
City Mills River
Water Quality
State / Zip Code N.C. Permitting Section
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 8a D Water Service, Inc.
Mailing Address P.O. Box 1407
City Pisgah Forest
State / Zip Code N.C. 28768
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
1 of 3 Form-D 912013

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 Unk
Residential ❑ Number of Homes 140
School ❑ Number of Students/Staff
Other ❑ Explain: Nursing Home 60 beds
Describe the source(s) of wastewater(example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Subdivision, Club House, Nursing home
Number of persons served: Unk
5. Type of collection system
X Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points one
Outfall Identification numbers) 001
Is the outfall equipped with a diffuser? 0 Yes X No
?. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfalls
Line Creek
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.
45,000 gpd
EQ tank, Conventional aeration, digester, clarifier, filter cell, post air cell
2 of 3 Form-D 9/2013

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.O MOD
10. Flow Information:
Treatment Plant Design flow 0.045 MOD
Annual Average daily flow MOD (for the previous 3 years)
Maximum daily flow MOD (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 Cohform, 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 EN/A'.
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS) 5.6 mg/1
Fecal Coliform 600 9 ml
Total Suspended Solids 17 4.6 mg/i
Temperature (Summer) 33 13.8 C
Temperature (Winter) C
pH 8.2 6.7 S. U.
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 NC 0089095 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 Deaver President
Printed name of Person Signing Title
June 30. 2015
Sign re 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