NC0037176_Renewal (Application)_20150414

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 INC0037176
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. OtkEttivgiryErtowype.
1. Contact Information: APR t 1. 2 015
Owner Name Bon Worth, Inc.
Water Quality
Facility Name Bon Worth Permittina Sectior
Mailing Address P. 0. Box 2890
City Hendersonville
State / Zip Code NC 28739
Telephone Number 828-697-2216
Fax Number 828-697-2170
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above 0
Street Address or State Road 40 Francis Road
City Hendersonville
State / Zip Code NC 28739
County Henderson
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 Bon Worth, Inc.
Mailing Address P. 0. Box 2890
City Hendersonville
State / Zip Code NC 287439
Telephone Number 828-697-2216
Fax Number 828-697-2170
e-mail Address
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NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generati Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial x Number of Employees
Residential Number of Homes
School Number of Students/Staff
Other Explain: Nursing Home
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Bathroom waste only
Number of persons served:
5. Type of collection system
X Separate (sanitary sewer only) 0 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? 0 Yes X No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
Allen Branch of the French Broad River Basin
8. Frequency of Discharge:
X Continuous ❑ Intermittent
If intermittent: Duration:
Days per week discharge occurs:
9. Describe the treatment system
List all installed components, including capacities,provide design removal for BOD, TSS, nitrogen and
attch the description of the treatment system in a
phosphorus. If the space provided is not sufficient,
separate sheet of paper.
A 0.006 MGD facility with manual bar screen, aeration basin with dual blowers providing
diffused air, hoppered clarifier with skimmer and sludge returns,i tabletbchlorination,
chlorine contact basin, tablet dechlorination, effluent pump
Form-D 11/12
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NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.006 MGD
Annual Average daily flow .001 MGD (for the previous 3 years)
Maximum daily flow 0.002 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes X No
12. Effluent Data
ASW 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 aN/A".
Daily Monthly Units of
Parameter Maximum Average Measurement
Biochemical Oxygen Demand (BODS) 20.2 12.1 MG/L
Fecal Coliform 600 83.3 CFU/100ML
Total Suspended Solids 28.2 17.6 MG/L
Temperature (Summer) 22.1 20.1 C
Temperature (Winter) 11.3 7.5 C
pH 7.5 7.1 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 NC0037176 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.
/1ieg ,f�iKyTglycz ya C'FO
Printed namerson Signing Title
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/ I ,� 7 /' i 020/r
Signature of Applic:ar
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.)
Form-D 11/12
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