NC0075353_Application_20190227

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 C0075-353
If you are completing this form in computer use the TAB key or the up -- down arrows to move from one
geld 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
McDowell Assisted Living, LLC
Facility Name
McDowell Assisted Living
Mailing Address
P. O. Box 909
City
Marion
State / Zip Code
NC 28752
Telephone Number
828-652-3033
Fax Number
[phone]
e-mail Address
[e-mail]
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 52.35 NC Highway 226 5o (A '
City Marion
State / Zip Code N C 'a
County McDowell
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 ORQ
Name McDowell Assisted Living, LLC
Mailing Address P. O. Box 909
City Marion
State / Zip Code NC 28752
Telephone Number 828-652-3033
Fax Number [phone]
e-mail Address [e-mail]
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 applyft
Industrial
Number of Employees
Commercial X
Number of Employees(p
Residential
Number of Homes
School
Number of Students/ Staff
Other X
Explain: Residents
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Assisted Living Home
Number of persons served:
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
outfall�.
North Muddy Creek in Catawba River Basin
S. 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.
0.010 MGD facility with extended aeration basin, clarifier, chlorination equipment and
sludge digester
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 0.010 MGD
Annual Average daily flow 0.0014 MGD (for the previous 3 years)
Maximum daily flow 0.007 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes X No
12. Effluent Data
.ANEW 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 currentlu in your hermit. Mark nthn_r narnmPtPrs "N/a "_
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BODS)
22.3
12.7
MG/L
Fecal Coliform
102
2.5
CFU/ 100ML
Total Suspended Solids
36.7
21.6
MG/L
Temperature (Summer)
27.1
24.9
C
Temperature (Winter)
14.0
13.0
C
pH
8.1
7.6
UNITS
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES NCO075353
PSD (CAA)
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
Permit Number
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.
Printed name of Person Signing Title
ref
Signature of Applicant
ate
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 11 /12

James & James Environmental Management, Inc.
3801 Asheville Hwy., Hendersonville, N. C. 28791
OFFICE: [phone] FAX: [phone]
E-Mail: [e-mail]
RECEWED/DENMDWR
MAR 13 2919
McDowell Assisted Living Water Resources
NCO075353 Permitting Section
Enclosed you will find your permit renewal. It is due to the state by 04/15/2019.
There are a couple of items that you will need to put on the form:
Section 1 & 3 —fax number and email address if needed
Section 4 — fill in number of employees, and the number of persons served
Section 13 — Print name & Title, sign & date
Original and 2 copies of everything enclosed needs to be sent to the address at the top of the 15`
page of the Application Renewal. I have also included a letter requesting that the permit be
renewed, one letter stating the sludge removal plan and a map of the Outfall. These 2 letters can
be adapted if you would like to do your own. If there are changes that you would like me to
make, I can do that and email the corrected form back to you.
This packet needs to be mailed to the State as soon as possible. We do recommend that you mail
it Certified with Return Receipt requested. Also, please email or mail us a copy of the completed
application for our records. It will be several months before you receive your new permit from
the State. Once you receive the new permit, please send us a copy for our records as we do not
receive one from the State.
If you have questions, please give me a call at the number below.
Thank you,
Ashley Ogle "
Administrative Assistant
James & James Environmental Management, Inc.
[e-mail]
828.697.0063
828.697.0065 - Fax