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Cicy: ------Invoice Mailing Company: ------State: ----- Zip: --- Invoice Mailing Address: ------Telephone: ARKANSAS DEPARTMENT OF ENVID.ONMENTAL QUAUTY NOTICE OF INTENT INDIVIDUAL TREATMENT FACIUTIES NPDES GENERAL PERMIT ARGSSOOOO • Application Type: New 0 Renewal D (Permit# ARGSS.___ --J I. PERMITTEE/OPERATOR INFORMATION Pennittee (Legal Name): Heath and Mia Stanley Operator Type: Permittee Mailing Address: 154:2. S. A;~ fl.~~~ fbv- D State D Partnership Pennittee City: H.t."(effev: H-e. 0 Federal D Corporation* Pennittee State: ~ Zip: ~J-70 l ~ole Proprietorship/Private Pennittee Telephone Number: .lf?~ ~ ~ - ~..;l *State of Incorporation: ____ Permittee Fax Number: The legal name of the Permittee must be ------------~------------ identical to the name listed with the Pennittee E-mail Address: h.s~(e'"-(~ttY'l2esf..ct>A.I\ Arkansas Secretary of State. n. INVOICE MAH.ING INFORMATION {Home owners are exempt.) Invoice Contact Person: ------------------------- Cicy: ---------------- Invoice Mailing Company: ----------------- State: ----- Zip: --- Invoice Mailing Address: ----------------------- Telephone: -------------------- Ill. FACILITY INFORMATION Facility Name: Stanley residence Facility Contact Person: -~--C_a..-t:__/t __ 5_'f_'a_,_:_t....,- c.>"fY?'____ _ Facility Address: 2413 Autumn View Telephone Number: _if.:.... .:...1..:..9_-...;5 __ J'...;(;_-- .::.tf_::::c.._··JL.:=:z=-. __ Facility County: _W.:.:.=as=hi=ngt=o.;;.;n;...._______ Facility City, State & Zip: Fa tt elltv//e . Ale 7c2 7 0/ I I Facilicy Latitude: 36 Deg 5 Min 36 Sec Facility Longitude: 94 Deg 3 Min 57 Sec Accuracy: Method: ---- Datum: ___ Scale: ___ Description: ____ IV. DISCHARGE INFORMATION Outfall Number: Flow: 500 gpd (Gallons per Day) Stream Segment: 31 Hydrologic Basin Code: .....;.;11;.;:1.;;.01;;.:0~3 ___________ Outfall Latitude: 36 Deg S Min 36Sec Outfall Longitude: 94Deg 3 Min 57 Sec Accuracy: Method: _____ Datum: Scale: Description: _____ Type of Treatment: _;Aero:=..:::ctec=h::..:A.:::T=-5:::.:0::..:0'---------------------------------------------- Receiving Stream: _Wh..:..:...::::::.ite=-Ri::.::·:..:..ve=r______________________________________ _ V. FACILITY PERMIT INFORMATION NPDES Individual Pennit Number (IfApplicable): --'AR:=O=O'--------------------­ NPDES General Pennit Number (IfApplicable): _;AR:=G=--------------------­ State Construction Pennit Number: NPDES General Construction Stonnwater Pennit Number (If Applicable): -=-=ARR==lS'-------------------------------------------- WATER DIVISION 5301 NORTHSHORE DRlVE/ NORTH LITTLE ROCK, ARKANSAS 72118 PHONE 501-682-0623/FAXSOI-682-0880 www.adeq.state.ar.us -5- VI. OTHER INFORMATION: Operator Name: Rebecca Corbitt Operator License Number: _.::.;10:.;:5:..=6.::.5 ______________;L:=.t:.;:·ce~n=s:.;;.e...;:C~las=s:...;:II=---------- Consultant Contact Name: ...:R.!:.:e=.:b:.:e:.;;.cal=..;C::;.:o=r.::.:bitt=----------------------- Consu:~:m:~ ~::l:~ ~=:f®cox.n~~ty: Lowell State: AR Zip: 72758 Consultant Phone Num6er: 479-466-6183 Consultant Fax Numbe....::.::r:::..:_'-_-_-=_-=_-=_ ________ Has this treatment system bell approved by AHD? Yes D No D Disclosure Statements: Arkansas Code Annotated Secqon 8-1-106 requires that all applicants for the issuance or transfer of any pennit. license, certification or operational authority issued by the Arkansas Department of Environmental Quality (ADEQ) file a disclosure statement with their applications! The filing of a disclosure statement is mandatory. No application can be considered complete without one. Yoo must submit a new disclosure statement even ifyou have one on file with the Department. The form may be obtained from ADEQ web site at: htto:l/www.adeg.state.ar.us/disclosure stmtpdf. ERTIFICATION OF OPERATOR (Initial) "I certifY that. if this facility is a corporation, it is registered with the Secretary of the State of Arkansas." I (Initial) "I certifY that the cognizant official designated in this Application is qualified to act as a duly authorized representative under the provisions of 40 CFR 122.22(b). If no cognizant official has been designated, I ,,/L2 understand that the Department will accept reports signed only by the Applicant." ~(Initial) "I certify under penalty of law that this document and aU attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons directly responsible for gathering the information, the infonnation submitted is, to the best ofmy knowledge and belie~ true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility offine and imprisonment for knowing violations." Responsible Official Printed Name: H~~th~~ Title: homeowner Responsible Official Signature: __ Date: _.....,71-f-'/J-L/=--Y/'-'"(_4_______ _ i L /) r' f 1 Responsible Official Email: h.SJRJI\).e'"(~ .CL>W\ Cognizant Official Printed Name: Heath and Mia Stanley Title: homeowner Cognizant Official Signature: ---------­ Cognizant Official Email: X. PERMIT REQUIREMENT VERIFICATION Please check the following to verity completion of permit requirements. Yes No * II No is answered for any of the questions, then a pcnuit can not be issued! Submittal of Complete NOI? D D Submittal ofR.!equired Permit Fee? D D Check Number: Submittal of AHD Form BHP-19? 0 0 Submittal of Site Map? 0 0 Submittal ofDisclosure Statement? D D WATER DIVISION 5301 NORTHSHORB DRIVE I NORTH LITTLE ROCK, ARKANSAS 72118 PHONE 50lp682p0623/ FAX 501-682-0880 www.adeq.state.ar. us -6- Bailey, John From: Wentz, Nathan Sent: Wednesday, October 22, 2014 1:53 PM To: Solaimanian, Jamal Cc: Bailey, John; Clem, Sarah Subject: ARG55 Jamal, Sarah said that you asked for an email that outlined Planning's request for additional monitoring of mineral, particularly sulfates, and nutrient constituents for the individual treatment application near Fayetteville. Per section 5.5 of ARG550000 (Justification of Permit Limits and Conditions), the Department may determine that additional parameters may be required to comply with water quality standards. Reach -023 (HUC 1101001} is currently listed in Category 5 for sulfate; however, there is no empirical evidence of the efficacy of individual domestic treatment systems to remove or reduce mineral constituents. Regarding monitoring of total phosphorus and total nitrogen, Planning received data from the City of Fayetteville as part of a Use Attainability Analysis that indicates organic loading within the reach is affecting aquatic life; however not to the point of impairment. Again, Planning is unable to procure empirical data that documents the nutrient concentration within the effluent of these units. Planning has further reservations regarding this and future units within segment -023 and segment -022 due to the current Category 5 listing for pathogens in upper portion of Beaver Lake (segment -021}. Section 1.2.2.3 (ARG550000- Exclusions) notes that, "Discharges to waterbodies listed on the most current 303 (d) list as impaired by pathogens, nutrients, or low dissolved oxygen," will not be covered by a General Permit and applicants should apply for an individual NPDES permit. While this is not a direct discharger to an impaired waterbody; there is a cumulative impact from multiple sources, including individual domestic treatments systems. Tate O, ol M&D .>~ k .M no....; worrJ ~~ iL C.. vd c-.\;-.~ C. I rl\(?e- J- 1 w- r:p }c (A)c..I'I'J t:-) t.· AnA. ..12 fr!CM ~ h f ; /1J ( e ~ ." I Grn. J .> · fufvl:'t V'o ..?)L 1L~ ~(1- i+ i.S J ("~ .:...~ rr, ,... en ) c-f; (IV\_ I..) e. Instructions for the Completion of this Document: A. Individuals, firms or other legal entities with no changes to an ADEQ Disclosure Statement, complete items 1 through 5 and 18. B. Individuals who never submitted an ADEQ Disclosure Statement, complete items 1 through 4, 6, 7, and 16 through 18. C. Firms or other legal entities who never submitted an ADEQ Disclosure Statement, complete 1 through 4, and 6 through 18. Mail to: Hand Deliver to: ADEQ ADEQ DISCLOSURE STATEMENT DISCLOSURE STATEMENT [List Propel' Division(s)] [List Proper Division (s)] 5301 Northshore Drive 5301 Northshore Drive North Little Rock, AR 72118-5317 North Little Rock, AR 72118-5317 I. APPUCANT:(F.UName} f-(~ + )v{;a.,. ~{e'-( 2. MAILING ADDRESS (Number and Street, P.O.Box Or Rural Route) : IS4~ S. 02..~ ~ev-- Meo.dt>~ bv. 3. CITY,STATE,ANDZIPCODE: 1-u'-fe l.fa.;; ((e_ ~ ?J.Ibf . I 4. (ch&ek all tllllt apply.) tplindivld••l 0 Corporate or Oilier Entity ~Permit D LlceiiSC 0 Certi6eatlon D Operational Authority ~ew AppUeation 0 Modffieotlo• 0 Renewnl Applieofion (1£ no changes from previous disclosure statement, complete 011mber 5 a11d 18.) 0Air @Wakr D HIZardous Wnstc D Regulated Stor2gc Tanlt 0Mtnlng D Solid Waste 0 Environmcotal Prcsernfion and Technical Service s. IW:Iaratiu II[ till Cbnagcs: The 'riolntioa history, experience and credentials, ia¥Oivemeat in current or pending ePvironmentallows•ils, civil and criminal, have not cl~aaced since the last Dlsclesure Statemeot I filed with ADEQ oa Signot.re oflndlvidual or Authorized Rcprescatatlve of Firm or Legal Entity (Also complete 1#18.) 6. Describe the experience and uedentials orthe Applicant, including the rea:lpt ohny past or present penni($, licenses, a:rtit"~eations or operational authorization relaling to elll'ironmental regulation. (Attach additional pages, if necessary.) 7. List and explain aU c:ivil or criminallcplactions by government agcndes involving environmental protcctiu t.ws or regulations agaill.lit the
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