WQ0041299_Application_20191105

Stoltzfus Engineering, Inc.
irl
TRANSMITTAL MEMO
To: NCDENR Winston-Salem Regional Office
Water Quality Section
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
From: Aden Stoltzfus, PE
V20V062619
Date: 11/05/2019 Winston-Salem
Regional Ci -,2
Subject: Courtyards at Harmon Mill
Private Sanitary Sewer Extension &
Pump Station Permit
Forsyth County
Attached are one (1) original and one (1) copy of the completed Fast -Track Application including the Fast
Track Form, Flow Tracking Acceptance Form, and the Site Maps along with Check #1018 in the amount
of $480.00 for the permit fee. The Developer's Operation Agreement is also attached with the permit.
I have also included two copies of the project plans. The project is a 35-lot subdivision off of
Harmon Mill Road with proposed private gravity sanitary sewer, pump station and force main.
Please call me at [phone] with any questions.
747 Park Lawn Court ♦ Kernersville, NC 27284 ♦ [phone]

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: w � (�`� I Al be completed by owR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION: f / I ci r re 1L ("7 S cy �r
1. Applicant's name: Nova Harmon, LLC (company, municipality, HOA, utility, tc.) +t
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Andrew Dreyfuss per 15A NCAC 02T .0106(b)
Title: Manaeer
Pt L. Dcl3artir�ent of
4. Applicant's mailing address: 206 N. Spruce Street, Suite 2B Environmental Quality
Received
City: Winston-Salem State: NC Zip: 27107-_
5: Applicant's contact information: EN 0 6 20M
Phone number: [phone] Email Address:adrevfuss(rd-,piedmont-metro.com Winston-Salem
H. PROJECT INFORMATION: Regional Office
1. Project name: Courtyards at Harmon Mill
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date:
If new construction but part of a master plan, provide the existing permit number: W000
3. County where project is located: For
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.10786' Longitude:-80.1171'
5. Parcel ID (if applicable): 6875-09-0876
(or Parcel ID to closest downstream sewer)
M. CONSULTANT INFORMATION:
1. Professional Engineer: Aden R. Stoltzfus, PE License Number: 026461
Firm: Stoltzfus Engineering, Inc.
Mailing address: 747 Park Lawn Court
City: Kernersville State: NC Zip: 27284
Phone number: [phone] Email Address: [e-mail]
seiengineerine.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Archie Elledee Permit Number: NCO037834
Owner Name: Winston-Salem/Forsyth County Utility Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): W CSQ 00003 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00003
Owner Name(s): Winston-Salem Forsyth County Utility Commission
FORM: FTA 04-16 Page 1 of 5

VI, GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No ❑N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
® Yes ❑No ❑N/A
3. If the Applicant is a Home/Pro er�rty Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
❑ Yes [—]No ❑N/A
4. Origin of wastewater: (check all that apply):
® Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ®No
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow °.b
No. of Units
Flow
2-Bedroom Residential Dwelling
240 gal/dwelling
35
8,400 GPD
gal/
GPD
gal
GPD
gal
GPD
gal
GPD
gal
GPD
Total
8,400 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located neat high public use
areas; and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 8 400 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16 Page 2 of 5

VH. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8"
88
Class-50 DIP
8"
1344
VCP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the AMC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Courtyards at Harmon Mill Private Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.1079' Longitude:-80.1176'
3. Design flow of the pump station:.021 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 30 gallons per minute at 55.1 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2"
1,072
Schedule 40 PVC
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B).
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
® Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be
provided in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f) & (g)
® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains horizontal
10 feet
Reclaimed water lines vertical - reclaimed over sewer
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water or ride elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(f) or (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ®Yes [—]No ❑ N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 0213.0200? ®Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ® No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes [:]No
Per 15A NCAC 02T.0 105 (c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents
for review. Approval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification:
I Aden R. Stoltzfus, PE attest that this application for
(Professional Engineer's name from Application Item III.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1 Andrew Dreyfuss, Manager attest that this application for
(Signature Authority's name & title from Application Item I.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a
condition of this permit be violated. I also understand that if all required parts of this application package are not completed
and that if all required supporting information and attachments are not included, this application package will be returned to
me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceV$10,000 as well as civil penalties up to $25,000 per violation.
Signature: 1 iu AA Date: A06oz elf eotq
FORM: FTA 04-16
Page 5 of 5

D VT
Oivision of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Nova Harmon, LLC
Project Name for which flow is being requested: 12408 Courtyards at Harmon Mill
More Chun one FTSE luny be required for a single project if the owner of the WWTP is not responsible for all ptaup
stations along the route of the proposed wastewaterJlow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Archie Elledge
b. WWTP Facility Permit #: NCO037834
Al! flows are in MGD
c. WWTP facility's permitted flow 30.000000
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
It. Percent of permitted flow used
1.820579
19.630000
0.008400
21.458979
71.5% v'
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow,
List pump stations located between the project connection point and the WWTP:
t
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Design
Average
Approx.
Obligated,
Total
Pump
Daily
Current
Not Yet
Current
Pump Station Station
Firm Flow**
Avg. Daily
Tributary
Flow Plus
(Name or Permit
Capacity, * (Firm / pf),
Flow,
Daily Flow,
Obligated
Available
Number) No.
MGD MGD
MOD
MGD
Flow
Capacity***
KernersMill
6.33600 2.184828
1.627754
0.049094
1.676848
0.507980
South Fork
14.400000 14.400000
6.733753
0.176744
6.910497
7.489503
The South Fork Lift Station operates as a basin transfer station. Staff is capable of allowing peak flows to bypass the station and flow to the Lower
Muddy Creek W WTP by gravity. Therefore, no peaking factor Is used when determining design average daily Flow.
* The Firm Canacitv (design flow) of anv numb station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Archie Elledge
Downstream Permit Number: WQCS00003
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Courtney Driver, P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing
Page 2 of 6
FTSE 10-18

o
y.
y
)y 16
l rv� Gw >%aii
l flx a iNp "�
� Y
� 4
a
L
(l
�
1 4 .s k
• A� y�j"�k
yyry may-
9n �eXaF�lll9f.�� R � ��` '� '" �•2�
Y
fy%w
It
,y,,,.
FIR tl
�.y
3�143J1 A
ilk
ee£ I
7
l5
�.,,IV—
•
T
A„V ,:'
j

TIMMONS GROUP
Check Date: 9/23/2019
0E
86549
Invoice Number
Date
Voucher
Amount
Discounts
Previous Pay
Net Amount
92019-35148.057.
9/20/2019
1000000143022
$480.00
$480.00
NC DEQ - TOTAL
Operating Account 1 1525
$480.00
$480.00
a av\cL CDLk. n4,u\
ONSGROUP

Division of Water Resources
Fast Track Application for Sewer Systems— Review Checklist
Project Name: F Application Number: S'
Application Completeness Review
Project is located in a County currently covered by the regional office
Application and supporting documentation submitted in duplicate?
One original and One Copy
Correct application fee submitted? See G.S. 143-215.31)
Ensure that a check for $480 is submitted and made out to NC DEQ.
All new projects and major modifications to existing projects
includes any changes to permitted flow volumes, changes in pipe
of the originally permitted length, changes in operating points of
Office.
Application package is complete?
Current application version (See website)
Brief project narrative (per Section B of F`.
Certification of Public Convenience and N
(if applicable)
Operational Agreements, signed and dated
(if applicable)
Flow Tracking / Acceptance Fo
Flow Tracking / Acceptance PI
(if applicable)
Site Map and Street ap(per Se
PE Certification signed,
Applicant Ce is si d dated
If any portion of the U
return of an application
the deficief
n fee has not
is not c etc, or %
it, the f ' g steps
be
the
provided
it as well.
taken:
❑YI's- ❑No
es ❑No ❑N/A
cation fee. A major modification
es in pipe length greater than 10%
etc. If unclear, contact the Central
❑No
❑No
❑No XIA
❑No ❑N/A
o ❑N/A
[]No ❑N/A
s jLJNo
❑Y ❑No.
have been omitted, and the
email for very minor completeness deficiencies.
this completeness review, fill out a checklist that
applicant with a copy to the consultant. If the
Any projects tha to be returned be re prior to accepting the application (i.e., before logging in the
application and de _ the check er a oject has been accepted, any information that is found to be
incorrect and/or lac ' t be reque via an Additional Information Request in accordance with 15A NCAC
02T .0107.

i
Permit Information
ew Permit ❑Permit Modification
If the project is a modification to an existing permit, be sure to enter the application imo'BIMS as it permit
modification (i.e. "renew/modify application" and not "create new project"). BIMS will Pull the previous signing
official and affiliations information. Modify all tabs. and enter updated information.
Does the project require a permit for the activity? E h' s []No
See Permittingby Regulation (15A NCAC 02T.0303) for projects deemed permitted
If No, return fee and application package
Is the project eligible for the Fast Track Program? es ❑No
Projects not permitted through the fast track program:
➢ Projects that require an environmental assessment in accordance with 15A NCAC 1C .0100;
➢ Projects that do not meet any part of the minimum design criteria WC) document;
➢ Projects that involve a variance fromthe requirements of 15ANCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ . STEP or simplex grinder pumps connecting to pressurized systems (e.g, force mains);
➢ Vacuum sewer systems.
IfNo, return fee and application package and advise applicant what to do
Information entered into BIMS? (Project details, affiliations, etc)
Applicant (Owner/Permittee) signature meets requirement of 15A NCAC .0106(b)7
If No, request revised application with an appropriate official, or a letter from an
appropriate official that indicates the person in question is delegated to sign the
application on the applicant's behalf. If a new delegated signing official is listed,
add the person to BIMS
Is the applicant is a public entity (county, city, sanitary district, etc.)?
If Yes, move to Wastewater Flow Information Section
is the applicant is a private entity and intends to retain ownership (store, church, etc.)?
if Yes, move to Wastewater Flow Information Section
Is the applicant is a private entity (private utility)?
If Yes, Applicant has been designated as a public utility by the NC Utilities Commission
Has submitted a Certificate of Public Convenience and Necessity (CPCN)
or Letter from the Public Staff of the NC Utilities Commission (contact Central Office)
The project name on the application and CPCN must match
❑Yes
❑No
yes
❑No
oyes
EV
❑Yes
EW"
[]Yes
ENO
❑Yes
❑No
❑Yes
❑No
Is the applicant is a private entity (Developer) that will be selling units? ET Y
If Yes, Applicant has submitted an executed Operational Agreement (DEV) es
A developer may be responsible for the system for an interim period until the HOA is formed,
at which time a name change / change of ownership form is required to transfer the permit to the HOA
The operational agreement should be attached to the permit and incorporated into the language of the permit.
[]NO
❑No
Is the applicant is a Homeowner's or Property Owner's Association selling units? []No
If Yes, Applicant has submitted an executed Operational Agreement (HOA) a ❑leo
and, Copy of the Articles of Incorporation, Declarations and By-laws ❑Yes ENO -
The operational agreement should be attached to the permit and incorporated into the language of the permit.

Wastewater Flow Information
Has submitted Flow TrackineAcceptance Form (FTSE Form)
❑Xes ❑No ❑NIA
Ensure form is complete with all required information and that the owner
has accepted the. entire volume of flow listed
r
Proper certification per 15A NCAC 02T .0106 (b)
Form is dated within one year of receipt of application package
[Yes [:]No
©Xis []No
❑No ®N/�
Is FTSE Planning Assessment Addendum Required?
Required only for projects where available pump station capacity is < 0.
(Contact Central Office if needed)
Additional forms (FTSE 06-13) required?
N ©N1A%
❑Yes o
Required only if the owner of downstream sewer different then owner of W WTF
es ❑No
Receiving W WTF and downstream sewers have adequate capacity
Ensure no compliance issues (SSOs or W WTF compliance issues)
Wastewater domestic in nature
Elles ❑No
If item B.6 indicates industrial wastewater, notify the regional pretreatment coordinator or
contact the Central Office to determine if a pretreatment permit is needed or if it is in
place and compliant
Has the wastewater flow volume been calculated correctly (section II.7 of FTA)?
EJ es ❑No
Flow is calculated per 15A NCAC 02T.0114
or
if daily design flow is not based on regulations ensure that the applicant has an approved flow reduction of daily
design flow rate on file with the Division.
or
If other than 2T.0114, values must be supported with flow data per 15A NCAC 02T.0I14(fl
(Contact Central Office if this is the case)
Design Information
YNo
Adequate information related to sewer lines (Section VII of FTA) ®-es ❑ ❑N/A
Note that per the 2T and MDC, there is a minimum 8" for public gravity or
minimum 6" for private gravity /
Adequate information related to pump stations (Section VIII of FTA) []No ❑N/A
Ensure power reliability option is selected (see 15A NCAC 02T 0305(h))
Has Setbacks & Separations Section been completed? t❑Yes ❑No ❑N/A
Required if any portion of project is within 100 feet of any surface water or wetlands
Note, 15A NCAC 02T .0305 (f) contains minimum separations required for sewer
A variance is required if minimum separations cannot be attained (see below)
Is Project design is in accordance with (see section X of FTA) ®Yes ❑No
15A NCAC 02T
Gravity Sewer Minimum Desian Criteria (latest version)
n..;o ('riterin fnr Permitting of Purim Stations and Force Mains (latest version)
If no, a variance approval is required per the requirements of 15A NCAC 02T.0105(b)
• Applicant must submit TWO copies of the plans, specifications, and calculations
• Contact the Central Office to discuss the variance request to determine a course of action. The central
office will review the variance request, and if approvable, specific language regarding the variance will be
forwarded to the Regional Office reviewer to incorporate into the permit. A copy of the variance letter (or
email correspondence) should be kept with the application file.
Project contains high priority lines (15A NCAC 02T .0402(2)) []Yes EINi
If Yes, insure that the permit contains the necessary condition related to high priority lines
15A NCAC 02T.0403 (a)(5)

Application Certification
Has a N.C. PE stamped, signed, and dated the application? LI�e ❑No
PE with active license in North Carolina? Ej es ❑No
Check the NCBELS to ensure Engineer is currently registered to practice
NCBELS License Lookup
If the owner is a corporation, is the corporation registered in N.C.? ❑Yes ❑No
N.C. Secretary of State (Corporation Search)
Applicant should be registered to conduct business as a corporation in NC (Private Owners; Developers; HOAs, etc.)
If No, see return application guidance
Inning a Permit
Most current version of the Fast -Track permit shell used?
es []No
❑Yes ❑No
Special conditions utilized within permit?
t'
High Priority Lines (Aerials)
Variance Language (Approved by the Central Office)
Regional. Conditions (i.e. Stormwater Plans for Coastal Counties)
Construction Only Language ("Dry Lines')
Other instances (contact the central office if required)
If permit modification:
❑Yes ❑No @M '
Include Permit History
Void Previously Issued Permit in language
❑No
Permit signed only by those delegated to sign for the Director
es
Permit distributed as follows: ❑Yes ❑No
• Original to-Permittee
Copy to Consulting Engineer
• Copy to County Health Department (if applicable)
• Copy to Mecklenburg County Department of Environmental Protections
(only for projects located in Mecklenburg County)
• Copy to the applicable Building Inspections Authority (if applicable)
Copy(ies) to the owner of the W WTF and owner of the downstream sewers
(Only if different than the Permittee)
• Copy to Regional Office Files
• Copy to Water Quality Central Files.(see Central Files Permit Package below)
• Electronic copy to PERCS unit
Electronic version shall preferably a signed, scanned copy of the permit in pdf format.
If not, the electronicversion can be a final version of the permit in word format. Regardless,
the permit should follow the framing convention of W000� - YY.MM.DD.
Electronic copies should be forwarded to the PERCS unit contact on a frequent basis (once a month is fine).
• Signed Operational Agreements should be distributed with the permit (if applicable)
Finalizing BIMS
Permit issued in BIMS? ❑Yes ❑No
All relevant Event Dates Entered? ❑Yes ❑No
(add info request, add info received, variance granted, variance denied, etc)
Central Files Permit Package
Complete package forwarded to Central Files
• Finalized Tracking Slip (BIMS Report)
• Copy of signed, issued permit (with operational agreements, if applicable)
• Copy of permit application package (application, supporting documentation, etc.)
• Review comments, calculations, notes, review checklist, etc.
• All other correspondence (email, phone logs, cover sheets, etc.)
All material in the permit package should be stapled together. Plans and specifications should not
be included in the permit package sent to central tiles.
❑Yes ❑No