NC0073571_Permit Issuance_20110421

North Carolina
Beverly Eaves Perdue
Governor
NCDENR
Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
April 21, 2011
Mr. Ernie Newman
Plant Operations Manager
Countryside Manor, Inc.
P.O. Box 829
Stokesdale, North Carolina 27357
Dear Mr. Newman:
Dee Freeman
Secretary
Subject: NPDES PERMIT ISSUANCE
Permit Number NCO073571
Countryside Manor W WTP — Class 2
Guilford County
Division personnel have reviewed and approved your application for renewal of the subject
permit. Accordingly, we are forwarding the attached final 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 October 15, 2007 (or as subsequently amended).
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 permit shall be final and binding.
Please take notice that this permit is not transferable. 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, Coastal Area Management Act, or any other
Federal or Local governmental permits which may be required.
If you have any questions or need additional information, please do not hesitate to contact
Maureen Scardina of my staff at [phone].
pColeen
rely,
H. Sullins
cc: Central Files
NPDES Unit Files
Winston-Salem Regional Office
1617 Mail Service Center, Ralegh, North Carolina 27699-1617
Location: 612 N. Salisbury St Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet http:llportal.ncdenr.orgtweblwq/home
An Equal Opportunity l Afinre6ve Action Employer
Nne
orthCarolina
Nawrally

Permit NCO073571
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 provisions 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,
. Mervyn R. King
is hereby authorized to discharge wastewater from a facility located at the
Countryside Manor WWTP
7700 U.S. Highway 158
Guilford County
to receiving waters designated as Troublesome Creek in the Cape Fear 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 June 1, 2011.
This permit and authorization to discharge shall expire at midnight on April 30, 2011.
Signed this day April 21, 2011.
*ion of Water Quality
By Authority of the Environmental Management Commission

Permit NC0073571
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby
revoked, and as of this 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.
Mervyn R. King is hereby authorized to:
1. Continue to operate an existing 0.015 MGD wastewater treatment facility with the following
components:
♦ Bar screen
♦ Aerated equalization tank
♦ Aeration tank
♦ Clarifier
♦ Sludge holding tank
♦ Sludge air lifts
♦ Dual blowers
♦ Tablet chlorination with chlorine contact basin
♦ Tablet dechlorination basin
♦ Rock step reaeration
♦ Dual -feed power supply
This facility is located near Stokesdale off U.S. Highway 158 at the Countryside Manor WWTP in
Guilford County.
2. After receiving an Authorization to Construct from the Division, construct and operate a 0.03 MGD
wastewater treatment facility.
3. Discharge from said treatment works at the location specified on the attached map into
Troublesome Creek, currently classified WS-III, NSW waters in sub -basin 03-06-01 of the Cape
Fear River Basin.
4 •

..70.' '54
vDISCHARGE
POINT 001 jC C
i a Ov
r
1900
BY
0 ti
WX
_ •D'tO 0 � � 0 � p S1�
US h
CD.
i
fit
. o o m s
Facility
Countryside Manor, Inc.
Countryside Manor WWTP
Location
County Rockingham Stream Class:WS-III, NSW
Receiving_ Stream: Troublesome Creek Sub -Basin: 03-06-01
(not to scale)
Latitude: 36-14' W Grid uad: C19NW
Longitude: 79'57'30'
NORTH
NPDES Permit: NC0073571

N • 1 1 1
Permit NCO073571
A. (l.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS (0.015 MGD)
During the period beginning on June 1, 2011 and lasting until expansion above 0.015 MGD, the
Permittee is authorized to discharge from outfall 001. Such discharges shall be limited and monitored
by the Permittee as specified below:
EFFLUENT
LIMITS .
MONITORING REQUIREMENTS
CHARA ERIST_ ICS
Monthly
Daily
Measurement
Sample
Sample
Parameter Code
Average
Maximum
Frequency
Type
Location'
Flow
0.015 MGD
Weekly
Instantaneous
Influent or Effluent
50050 ,
BOD, 5-day (20°C)
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
00310
Total Suspended Solids
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
00530
NH3 as N — Summer*
5.4 mg/L
27.0 mg/L
Weekly
Grab
Effluent
00610
NH3 as N — Winter*
23.5 mg/L
35.0 mg/L
Weekly
Grab
Effluent
00610
Dissolved Oxygen
Daily Average > 5.0 mg/L
—
Weekly
Grab
Effluent
00300
Fecal Coliform (geometric mean)
200/100 ml
400/100 ml
Weekly
Grab
Effluent
31616
Total Residual Chlorine2
28.0 µg/L
2/Week
Grab
Effluent
50060
Temperature CC)
Daily
Grab
Effluent
00010
Total Nitrogen (NO2+NO3+TKN)
Quarterly
Grab
Effluent
00600
Total Phosphorus3
2.0 mg/L
Weekly
Grab
Effluent
00665
pH
Not < 6.0 nor > 9.0
Weekly
Grab
Effluent
00400
Standard Units
Dissolved Oxygen
Weekly
Grab
Upstream & Downstream
00300
Fecal Coliform (geometric mean)
Weekly
Grab
Upstream &Downstream
31616
Temperature (°C)
Weekly
Grab
Upstream & Downstream
00010
*Summer: April 1— October 31
*Winter. November 1— March 31
Footnotes:
1. Upstream = at least 100 feet upstream from the outfall. Downstream = at NCSR 2103.
2. The Division shall consider all effluent TRC values reported below 50 ug/l to be in compliance with the permit.
However, the Permittee shall continue to record and submit all values reported by a North Carolina certified laboratory
(including field certified), even if these values fall below 50 ug/l.
3. Compliance is based upon a quarterly average of weekly samples.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE AMOUNTS.

- -Permit NCO073571
A. (2.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS (0.03 MGD)
During the period beginning expansion above 0.015 MGD and lasting until expiration, the Permittee is
authorized to discharge 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
Sample
Parameter Code
Average
Maximum
Frequency
a
Locations
Flow
0.030 MGD
Continuous
Recording
Influent or Effluent
50050
BOD, 5-day (20°C)
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
00310
Total Suspended Residue
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
00530
NH3as N —Summer*
a
3.2 mg/L
16.0 mg/L
Weekly
Composite
Effluent
00610
N —Winter*
13.0 mg/L
35.0 mg/L
Weekly
Composite
Effluent
0061
0060
Dissolved Oxygen
Daily Average > 5.0 mg/L
Weekly
Grab
Effluent
00300
Fecal Coliform (geometric mean)
200/100 ml
400/100 ml
Weekly
Grab
Effluent
31616
Total Residual Chlorine2
28.0 µg/L
2/Week
Grab
Effluent
50060
Temperature CC)
Daily
Grab
Effluent
00010
Total Nitrogen (NO2+NO3+TKN)
Queerly
Composite
Effluent
00600
Total Phosphorus3
2.0 mg/L,
Weekly
Composite
Effluent
00665
Quarterly Average
pH
Not < 6.0 nor > 9.0
Weekly
Grab
Effluent
00400
Standard Units
Dissolved Oxygen
Weekly
Grab
Upstream & Downstream
00300
Fecal Coliform (geometric mean)
Weekly
Grab
Upstream & Downstream
31616
Temperature (°C)
Weekly
Grab
Upstream & Downstream
00010
`Summer. April 1— October 31
* Winter: November 1— March 31
Footnotes:
1. Upstream = at least 100 feet upstream from the outfall. Downstream = at NCSR 2103.
2. The Division shall consider all effluent TRC values reported below 50 ug/1 to be in compliance with the permit.
However, the Permittee shall continue to record and submit all values reported by a North Carolina certified laboratory
(including field certified), even if these values fall below 50 ug/l.
3. Compliance is based upon a quarterly average of weekly samples.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE AMOUNTS.

�+ : '
MCDE�
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
February 21, 2011
11_ l - TT 0l1 101
To: Lisa Edwards
NC DENR / DEH / Regional Engineer
Winston-Salem Regional Office
From: Maureen Scardina
919-807-6388
NPDES Unit
Subject: Review of Draft NPDES Permit NCO073571
Countryside Manor WWI?
Guilford County
rr 3
Dee Freeman
Secretary
Please indicate below your agency's position or viewpoint on the draft permit and return this form by March
12, 2011. If you have any questions on the draft permit, please feel free to contact me at the telephone number
shown above.
RESPONSE: (Check one)
Concur with the issuance of this permit provided the facility is operated and maintained properly, the stated
effluent limits are met prior to discharge, and the discharge does not contravene the designated water quality
standards.
Concurs with issuance of the above permit, provided the following conditions are met:
F-1 Opposes the issuance of the above permit, based on reasons stated below, or attached:
Signed ate,
1617 Mal Service Center, Raleigh, North Carorma 27699.1617 ,
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 One
Phone: [phone] FAX: [phone] t Customer Service:1-877.623.6748 NO Carolina
Internet www.nctvatemuaiitv.ore
An Equal Opportu ft I Aif rmatW Adon Employer

15Su2 ; �!'211ii
W(0
Name
North Carolina, Guilford County
News & Record
Published by
News & Record, Inc.
Greensboro, North Carolina
AFFIDAVTT OF
Before the undersigned, a Notary Public of said County and State, duly commissioned, qualified and authorized by law to
administer oaths, personally appeared the Publisher's Representative who being first duly sworn, deposed and says:
1. That he/she is the Publisher's Representative of the Greensboro News & Record, Inc. a corporation, engaged in the
publication of newspapers known as "News & Record", published, issued and entered as second class mail in the City of
Greensboro in said County and State.
2. That he/she is authorized to make this affidavit and sworn statement; that the notice or other legal advertisement,
a copy of which is attached hereto, was published in the News & Record on the dates listed below.
3. That the said newspaper (or newspapers) in which such notice, paper, document, or legal advertisement was published
was, at the time of each and every such publication, a newspaper meeting all of the requirements and qualifications of
Section 1-597 of the General Statutes of North Carolina d was a qt ali ied new p r within the meaning of Section 1-59i
of the General Statutes of North Carolina. NE //
Publisher's Representative (^/� �/�/� /� pA ��//i
AR
Sworn to and subscribed before me. this ` day of Y r tav&)oil � Co m p
Notary Public
Ad # Date Edition
Class PO Ad Copy
y611512014
PuBoo
NCDENR DWC NPDES 34172500 03/04/11 News & Record 400 Countryside Public NoticeNorth Carolina Environmenta

Ad 10134172500 Date 03/03/2011 Time 1:57 PM
Public Notice
North Carolina, Frnimnnental
Maragenent Co.... brV
NPDB Unit
1617 Mal Servim Center
Nale' f, NC 27599-1617
Notice of intent to Issue a NPDB
Wastewater Pemit
The North Carolba Enrimnnentel
Managerren t Gorrrrissbn proposes
m ssae a NPDESwastewater
discharge permtmthe person(s)
listed below
Written mnrrena regarding the
Proposed Penric will be ao:epted
urltll 30 days after the publish date of
U"Wn or Water Quallry iLNW4) may
hold ayyubk hearing should there be
a sim fft cleanse of oubk interest
penors
N Salsbury
infometion on NPDB pemds and
this notm my be found on our
website:
FMpfIpo na L mden cor9%wbMgkv4*
stn r/ralenclar, or by calling (919)
6304
Cnumbysde Manor, Inc, has requested
renewal of pernit NCO073571 for its
Countryside ManorWJVrP in
Guilford County. This pemltted
facility discharges treated wastewater
to Troublesome Creek in the Cape
Fear Neer Basin.
Ad shown is not actual print size

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require
full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile
home parks, etc) that can be administratively renewed with minor changes, but can include
facilities with more complex issues (Special Conditions, 303(d) listed water, toxicity testing,
instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
PermitWriter/Date
MCLUreeil Sccc%i,. r21 11
Permit Number
3571
Facility Name
c.— wwtp
Basin Name/Sub-basin number
_ p G - & I
Receiving Stream
e
Stream Classification in Permit
Me,- a 9 4.5;u✓
Does permit need Daily Max NH3 limits?
No
Does permit need TRC limits a
e No If Yes, add TRC language below
Does permit have toxicity testing?
Yes If Yes, attach tox data summary
Does permit have Special Conditions?
Ye If Yes, discuss with Supervisor
Does permit have instream monitoring?
o If Yes, attach data summary
Is the stream impaired (on 303(d) list)? For
whatparameter?
Yes No If Yes, add 303(d) language below
Any obvious compliance concerns?
Attach BIMS Report; discuss with Region
Any permit mods since lastpermit?
Current expiration date
New expiration date
Comments received on Draft Permit?
Yes No If Yes, discuss response with
Supervisor
Most Commonly Used Expedited Language:
• 303(d) language for Draft/Final Cover Letters: "Please note that the receiving stream
is listed as an impaired waterbody on the North Carolina 303(d) Impaired Waters List.
Addressing impaired waters is a high priority with the Division, and instream data will
continue to be evaluated. If there is noncompliance with permitted effluent limits and
stream impairment can be attributed to your facility, then mitigative measures may be
required".
• TRC language for Compliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values below 50 ug/1 will be treated as zero
for compliance purposes."
BIMS Compliance Download: Queries>Reports>Violations>Monitor Report Violations>Limit
Violations for Past 3 Years
Reminder: Permits that are not subject to expedited renewal include the following: 1) Major
Facility (municipal/industrial); 2) Minor Municipals with pretreatment program; 3)
Minor Industrials subject to Fed Effluent Guidelines (lb/day limits for BOD, TSS, etc); 4)
Limits based on reasonable potential analysis (metals, GW remediation organics); 5)
Permitted flow > 0.5 MGD (requires full Fact Sheet); 6) permits determined by Supervisor to be
outside expedited process.
Note: This sheet is located on NPDES Server/CurrentVersions/Expedited Fact Sheet May2010

Countryside Manor, Inc.
Professional Care Center for the Elderly
Mrs. Dina Sprinkle
NC DENR/DWQ/Point Source Center
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Mrs. Sprinkle,
Oct. 11, 2010
Enclosed you will find the required information with application for renewal of
W WTP permit # NC0073571.
There has been one physical change at our WWTP facility since the issuance of
the last permit may 1, 2006. Under the direction of the ORC Patrick Merritt, Certificate
#11794, of Meritech, Inc. Our in house maintenance staff assisted Kace Environment,
Inc. to install dechlorination facility. Re: A to C #073571A01, Oct. 5, 2007.
The sludge management for WWTP #NC007351 is provided by Gann Brothers
Septic Service, Inc. (License #107311) phone # [phone]. When sludge pumping is
required or requested by ORC, Gann Brothers Septic Service is contacted to remove same
and be responsible for proper disposal.
If you have any questions please contact me at Countryside Manor, Inc. at 336-
643-6301. Thank you.
S' cerely,
*1ant
wman,
erations Manager
OCT 132010
7700 U.S. Highway 158 • P.O. Box 829 • Stokesdale, North Carolina 27357 • Telephone [phone] • Fax [phone]
www.retireatcountryside.com • [e-mail]

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 OCOO 3 6 '
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��y
Facility Name C� � I J ,� rywlw i o-j c_�
Mailing Address '�0 ,� �2Cr ^ --1 -10 D co.-S Aw-(,
City 4,- - /J& -
State / Zip Code A-75- -1
Telephone Number
Faz.Number
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above Da -
Street Address or State Road
city
State / Zip Code
County
coo
3. Operator Information:
`dame 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
Mailing Address 1�:1
city R�1((S •� E t
State / Zip Code J� j
Telephone Number (3 ) 3 42, q-7 q<d
Fax Number (3? ) 3 0 Z / t2-7,
1 of 3 Form-D 05/08

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 G
Other R3 Explain: / , 4PY 7'1bg'W1
� �_�' ` k
Describe the source(s) of wastewater (example: subdivision, mobile h me , arkshopping centers,
P PP g
restaurants, etc.): _
Population served: '09 � - /,vClr -�
V
5. Type of collection system
Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary seweri
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s)
Is the outfuM equipped with a diffuser? W- Yes ❑ No
7. Name of receiving stream(s) (Provide a map shouring the exact location of each outfall}.
8. Frequency of Discharge: [- Continuous 12 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.
jRaY xeq--GZ4-'
atk tt - (L
6(err-, ft, 1
iAry i`�'w L Eon vW c co dAti7 Pow A
R ck � �k fll,�r?E1 ifJ +v
-N-4A Ptd
2 of 3 Form-D 05/08

V
l
NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0, 015 MGD
Annual Average daily flow MGD (for the previous 3 years)
> CL
GL- • � % •� vu .
Maximum daily flow • 013 'MGD (for the previous 3 years) r
11. Is this facility located on Indian country?
❑ Yes f9 No
12. Effluent Data
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 dailrl. maximum.
_
- - —_ -iiju-IMK
Biochemical Oxygen Demand (BODS)
�,CI �`
_ 3 /-
_—
Fecal Coliform _
> 1 A00141
I1,00,0hi-
Total Suspended Solids
erf 4
Temperature (Summer)
'�6 o L
c
aG
Temperature (Winter)
06
lb a G
aG
P H
7
Sti.
13. List all permits, construction approvals and/or applications?
Type Permit Number Type
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES p� 'S7) ; Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
hermit 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 nee of Person Signing Title
/ rr / /_ / 4)
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 05108