NC0087921_Renewal Application_20160217

PAT Iv1CCRORY
DONALD R. VAN DER VAART
S. JAY ZIMMERMAN
Water Resources
ENVIRONMENcA QUAL rY
February 17, 2016
RECEIVEDINCDEQ/DWR
MEMORANDUM FEB 22 2016
Water Quality
TO: Charles Weaver Permitting Section
NPDES Unit
FROM: George Smith, Division of Water Resources, Winston-Salem Regional Office
SUBJECT: Green Valley Town Homes WWTP, NC0087921
Submittal of NPDES Application— Form D
Attached you will find the Form - D application submitted for the subject facility.
If you have any questions please contact George Smith at 336-776-9700.
cc: WSRO Files RECEIVED/NCDEQ/DWR
FEB 2 2 2016
Water Quality
Permitting Section
State of North Carolina Environmental Quality!Water Resources
150*est Hanes Mill Road State 300 'NSnstor-Salem "IC 27 35
Prone 336-776-9800 lstersei..'N`Nv, tov

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 NC00 £S'71 2- I
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 k i GLtt rI Weu�J( 61(.0 tj
C�
Facility Name Nye el I(-P Tc--yi I. S tA;v i
Mailing Address 19)12_ C, 1-114,' i q
City '' rr
�'�GC'YiF NC. 2 s‘te�7
State / Zip Code kr C 2 g a•�
Telephone Number (i5 lf� ) S74Cell S)S- Z(uS -
Fax Number (8.2g ) 214- _3(i
e-mail Address M,IGt 90, ( it) C,o1.1 . tan
RECEIVED/NCDEQ/DWR
2. Location of facility producing discharge:
Check here if same address as above ❑ FEB 2 2 2016
Street Address or State Road s C cte btil Tarry L Lz i
J �D1' Water Quality
City
G.)01t,
Permitting Section
State / Zip Code CZ g(vC',
County
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 (i/
Mailing Address 'V
City
State / Zip Code
Telephone Number ( )
Fax Number ( )
e-mail Address
1 of 3 Form-D 11112

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 kfA Callf)h-tCett
School ❑ Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served:
5. Type of collection system
Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s) 601
Is the outfall equipped with a diffuser? ❑ Yes ❑ No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
True 1-641
8. Frequency of Discharge: E Continuous El 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.
911 1\1 E- Olt vc-117/ -
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: /VIP — ti 64- Lb1131-YLL ct c UL kj e t b
Treatment Plant Design flow MGD
Annual Average daily flow MGD (for the previous 3 years)
Maximum daily flow _ MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes yi No
12. Effluent Data /f
NEW APPLICANTS:ProvidL�to 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 currengy in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS)
Fecal Coliform
Total Suspended Solids
Temperature (Summer)
Temperature (Winter)
pH
13. List all permits, construction approvals and/or applications: Ai/II- / uAVY11.
Type Permit Number Type Permi umber
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.
Printed name of Person)Signing Title
g q 2oi
Signature of Applicant Da e
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 11112