NC0073571_Renewal (Application)_20160301

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 27699-16117
NPDES Permit NC0073571
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 (dr.. Art-kV/AI /Z/✓�
CCCEIVED/NCDEQ/DWR
Facility Name Countryside Manor WWTP
Mailing Address r7,70 0 us �,` k& /S- c' FEB 2 9 P016
S
City j �-e- Water Quality
��s Nniiitting Section
State / Zip Code C
Telephone Number ( ) to 7 _ 630
l
Fax Number cm) 43.6 — 99.06
e-mail Address iging�_eL - / � �.Q f
2. Location of facility producing discharge:
Check here if same address as above
Street Address or State Road
City
State / Zip Code
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 Meritech Inc.
Mailing Address PO Box 27
City Reidsville
State / Zip Code NC
Telephone Number 336-342-4748
Fax Number 336-342-1522
e-mail Address [e-mail]
1 of 4 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
School ❑ Number of Students/Staff
Other X Explain: Below
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Retirement Community, domestic waste, with Independent & Assisted living plus a 60
bed nursing care facility.Q
Number of persons served: -1s--
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, diffuser at chlorine contact
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
Troublesome Creek in the Cape Fear River Basin
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.
See last page
2 of 4 Form-D 11/12

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 0.0076 MGD (for the previous 3 years)
Maximum daily flow 0.014 MGD (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 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 currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS) 25.3 11.5 I Mg/1
Fecal Coliform >600 5 #/ 100m1
Total Suspended Solids 40.0 28.5 Mg/1
Temperature (Summer) 27 26 Deg C
Temperature (Winter) 20 17 Deg C
pH 7.6 6.2 (min) I 6-9 SU
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 NC0073571 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—ofd-my knowledge and belief such information is true, complete, and accurate.
�JOZ� Split.ilIt✓►� pICaa]I-o di On 5 Inee.lJf.�q�✓
Printed name of Person Signing r Title 1 r/
;.:nature of Applicant Date
North Carolina General Statute 143- 15.6 (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 4 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
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.
4 of 4 Form-D 11112

PAT MCCRORY
omemor
DONALD R. VAN DER VAART
Secretory.
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY Dnectur
March 1, 2016
•
Dr.Mervyn King
Countryside Manor WWTP
7700 US Highway 158
Stokesdale,NC 27357
Subject: Acknowledgement of Permit Renewal
Application No.NC0073571
Countryside Manor WWTP
Guilford County
Dear Permittee:
The Water Quality Permitting Section has received your permit renewal application on February 29,
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 Sonia
Gregory at 919-807-6333 or [e-mail].
Sincerely,
WreAA,Tkevbfard,
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
919-807-6300
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