NC0055271_Renewal (Application)_20160202

To: Renewal Dept.
From:James M. Carson
ORC/Field Lab
Reference: Change in new permit
Under our current permit we are required to sample Effluent Temperature two times a week.
I would like to request that under the new permit that the Temperature sample to be reduced to
sampling Temperature once a week. Due to Mr.Shields is 80 years old and having some health
problems, which has made it harder for him to collect this sample. To have someone else to perform
this would add additional cost to them,which would be a hardship on them due to they are retired and
on a fixed income.
Historically the Temperature does not change that much in a week on our effluent looking back the last
3 years.
Sincerely,
JaKnes M.Carson.
ORC/Field Lab

To:Whom it may concern
Date: 1/18/2016
Ref: Requesting permit renewal for permit number NC0055271
Our permit will expire on May 312016
Sincerely, `' 1
Jerry L. Sl ields

Shields Mobile Home Park
Permit # NC 0055271
Sludge Management: Contracts with Pee Wee Septic Tank Cleaning and have the
system pumped out two times a year and more if needed due to problems in
operations, Pee Wee off loads at the City of Burlington Wastewater Plant.
Pee Wee's Septic Tank cleaning
1830 Almond Ln
Dixon Rd
Graham, NC
Jerry L. Shields '\>ti1, ----: ICrA^��,�,,) Date: 1 1
J
RECEIVEDINCDEQIDWR
FEB 0 2 2016
Water Quality
Permitting Section

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NPDES APPLICATION FOR PERMIT RENEWAL - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <0.1 MGD
Mail the complete application to:
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit fCOO5527I
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 Mr. Jerry L. Shields
Facility Name Shields Mobile Home Park
Mailing Address 1341 N HWY 87 North
City Elon
State / Zip Code NC / 27244
Telephone Number [phone]
Fax Number N/A
e-mail Address N/A
2. Location of facility producing discharge:
Check here if same address as above 0
Street Address or State Road 1355 NC HWY 87 North
City Elon
State / Zip Code NC / 27244
County Alamance
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 James M. Carson
Mailing Address 1356 St. Regis Dr
City Burlington
State / Zip Code NC / 27217
Telephone Number [phone] RECEIVED/NCDEQ/DWR
Fax Number [phone] FEB 0 2 2016
Water Quality
Permitting Section
104 Form-D4/05

NPDES APPLICATION FOR PERMIT RENEWAL - FORM D
For privately owned treatment systems treating 100%domestic wastewaters <0.1 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees _ __
Commercial ❑ Number of Employees
Residential ® Number of Homes 13
School ❑ Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Mobile Home park
Population served: 24
5. Type of collection system
® 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 ® No
7. Name of receiving stream(s) (Provide a map showing the exact location of each outfall
Travis Creek
8. Frequency of Discharge: ® 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.
Components as follows:
Six septic tanks, Recirculating surface sand filter, Recirculation tank, UV system (tablet
Chlorination) for back-up, Contact chamber, Pumps * Reaeration.
See attachment for capacities
2 of 4 Form-D 4/05

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Facility Information Facility ,‘, = - T
e. Sub-13osin 03-06-02
Lon >ude: 79°22148"
Quad Name: Lake Burlington .
Stream Class- GNSW Shields Mobile flume Parte
Receivirrg Stream Travis Creek North NC 055271
A1amarce County

NPDES APPLICATION FOR PERMIT RENEWAL - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <0.1 MGD
10. Flow Information:
Treatment Plant Design flow .006 MGD
Annual Average daily flow .0035 MGD (for the previous 3 years)
Maximum daily flow .0063 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® 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 daily maximum.
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BOD5) 5.5 2.2 Mg/1
Fecal Coliform 1.0 1.0 #/100 (GM)
Total Suspended Solids 7.0 2.9 Mg/1
Temperature (Summer) 28.6 23.1 °C
Temperature (Winter) 21.3 12.8 ° C
pH 7.0 —- 6.6 Units
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 NC0055271 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.
Jerry L. Shields Owner
Printed name of Person Signing Title
3 014 Form-D 4/05

NPDES APPLICATION FOR PERMIT RENEWAL - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <0.1 MGD
Signat re of A.iplicant Pate
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 knowly 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.)
4 of 4 Forth-0 4/05

PAT MCCRORY
DONALD R. VAN DER VAART
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY !>irrclnr
February 4, 2016
Jerry L. Shields
Shields Mobile Home Park
1341 N HWY 86 North
Elon,NC 27244
Subject: Acknowledgement of Permit Renewal
Application No. NC0055271
Shield Mobile Home Park
Alamance County
Dear Permittee:
The Water Quality Permitting Section has received your permit renewal application on February 2,
2016. A member of the NPDES Unit will review your application. They will contact you if additional
information is required to complete your permit renewal. Per G.S. 150B-3 your current permit does not
expire until permit decision on the application is made. Continuation of the current permit is contingent on
timely and sufficient application for renewal of the current permit. Please respond in a timely manner to
requests for additional information necessary to complete the permit application.
If you have any additional questions concerning renewal of the subject permit,please contact Charles
Weaver at 919-807-6391 or [e-mail].
Sincerely,
WIrevvT oL
Wren Thedford
Wastewater Branch
cc: Central Files
NPDES
Winston-Salem Regional Office
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,North Carolina 27699-1617
919-307-6300