WQ0041306_Application_20191115

,0*00
5410 Trinity Road
i-IMMONS GROUP Suite102
YOUR VISION ACHIEVED THROUGH OURS. Raleigh, NC 27607
TRANSMITTAL
NCDEQ
TO: Date:
450 W Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Project:
Reference:
Copies Sent To:
P 919.866.4951
F 919.859.5663
www.timmons.com
Job#: 36148.057
Lidl #1418 - Burlington
Fast Track Sewer System Application
DESCRIPTION
rack Sewer S stem Extension A lication
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A lication Feerack
A lication Form: FTA 04-16Trackin
/Acce tance Form Form: FTSE 04-16aStreet
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level map showing aerial
...�..� •r'low— I ICU.
If enclosures are not as noted, please notify us at once. Fee will be paid at time of submittal by Credit
Card.
COMMENTS:
Attached is our Fast Track Sewer System application. Please review and approve this
project. If you have any questions or concerns, then please contact me at
stephen.ballentine(otmmons com
Thank You,
Stephen J Ballentine, PE
Project Manager
Timmons Group
a �nne;,q
Environmental Quality
Received
Winston-Salem
Recional
CIVIL ENGINEERING I ENVIRONMENTAL I SURVEYING I GIS I LANDSCAPE ARCHITECTURE I CONSTRUCTION SERVICES

• f•0000
• 0 5410 Trinity Road
TIMMONS GROUP Suite102
YOUR VISION ACHIEVED THROUGH OURS. Raleigh, NC 27607
September 27, 2019
NCDEQ — Winston-Salem Regional Office Water Quality Section
450 W Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
RE: 35148.057 LIDL Burlington
NCDEQ — Fast Track Sewer System Extension Application
To whom it may concern:
P 919.866.4951
F 919.859.5663
www.timmons.com
Environmental Quality
Received
Winston-Salem
Fegional Office
Please see the attached Fast Track Sewer System Application for the LIDL-Burlington project. A 29,140
square foot grocery store is being proposed on a 3.46 acre lot. The project proposes that an existing six
inch private gravity sanitary sewer main going through an adjacent property to the east is to be extended
to the LIDL-Burlington site. This existing private sewer main connects to an existing public sanitary sewer
main along Holly Hill Outfall. There is 106 feet of six inch DIP and seven feet of six inch PVC private
gravity sewer to be permitted at the southeast corner of the site.
This application includes the following:
➢ One original and one copy of application and supporting documents
➢ Cover letter
➢ $480.00 check payable to NCDEQ
➢ Signed Fast Track (Form: FTA 04-16) Application
➢ Documentation showing LIDL registered with Secretary of State
➢ Signed Flow Tracking/Acceptance Form (Form: FTSE 04-16)
➢ Site map (USGS) identifying project area and sewer network
➢ Street level map of project area
Please contact Stephen Ballentine(stephen.ballentinena.timmons.com) for any further questions.
Thank you,
Stephen Ballentine, PE
CIVIL ENGINEERING I ENVIRONMENTAL I SURVEYING I CIS I LANDSCAPE ARCHITECTURE I CONSTRUCTION SERVICES

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 INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T 15A NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ 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 (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 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.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for Ali Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (Ali New and Major Modification Application Packages):
ID Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for AB Application Packages):
U Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
® If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Pagel of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-
215.67 a .
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (Ali Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an -
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

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
ApplicationNumber:W QOOg 13Up(to becompletedbyDWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: LIDL US OPERATIONS, LLC (company, municipality, FICA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: JENNIFER DURU PERRY per 15A NCAC 02T .0106(b)
Title: i, .' O'jpartnieot of
4. Applicant's mailing address: 3815 SENATOR RALPH SCOTT PARKWAY Environmental Quality
Received
City: MEBANE State: NC Zip: 27302-
5. Applicant's contact information: E•. 9i % nGOt`�
Phone number: 703 254-9073 Email Address: JENNIFER.DURU[7aLIDL.US Winston-Salem
Regional Offi:-e
II. PROJECT INFORMATION:
1. Project name: LIDL #1418 - BURLINGTON
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: ALAMANCE
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.079645' Longitude:-79.491966°
5. Parcel ID (if applicable): 113301
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: STEPHEN BALLENTINE, PE License Number: 26493
Firm: TIMMONS GROUP
Mailing address: 5410 TRINITY ROAD, SUITE 102
City: RALEIGH State: NC Zip: 27607-_
Phone number: (2M) 255-2367 Email Address: STEPHEN BALLENTINE(&,,TIMMONS.COM
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: SOUTH BURLINGTON WASTEWATER TREATMENT PLANT Permit Number:
WC0023TI(p
Owner Name: CITY OF BURLINGTON
V. RECEIVING DOWNSTREAM SEWER IN. OTI TION (if different V han WWTF):
Tln; i a lit 1 "� unler�wn.
1. PermitNumber(s�: WQ_ Downstream7Receiving) Sewer Size: 9 inch
System Wide Collection System Permit Number(s)((if applicable): WQCS 00 00 8 /�
(c o11¢.�-�:n Jm t.+nSl-fLo Wr. ut- r:�fa%F. Stw er ¢k �tnS�an)
Owner Name(s):� >( Gi�i;b. 1'
FORM: FTA 04-16 Page 1 of 5

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

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/Property 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))
I,Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ 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
BAKERY
10 gal/100 SF
570 SF
57 GPD
SHOPPING CTR WITH FOOD SVC
130 gal/1000 SF
28,530 SF
3,709 GPD
gal/
GPD
gal/
GPD
gall
GPD
gall
GPD
Total
3,766 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 near 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: 3 766 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
6
106
DIP
6
7
PVC
➢ 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 MDC
VHI. 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:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude:
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
I�
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(i)):
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 Drovided 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 tide 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 swimmin ools
10 feet
Final earth: rade` v . tta
36 inches
➢ 15A NCAC 0210365(@ contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢'' **Stream classifications 4an be identified using the Division's NC Surface Water Classifications webpage
➢ uIf noncompliance with 02T.0305( or (g), see Section X of this application
2. Does the project comply withSeparation requirements for wetlands? (50 feet of separation) ® Yes ❑ No ❑ N/A
➢ -. See the Division's draftseparation requirements for situations where separation cannot be meet
➢ No variance is requiredif the alternative design criteria specified is utilized in design and construction
➢ As built documgnts'should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.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.0105(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 reauired prior to submittal of the Fast Track Application and supporting documents.
2. Professional Engineer's Certification:
J , 8 oA t k nC- 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 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 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: o„" ""N
26493
Uo • 19
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Je v s attest that this application for
(Signature Authority's name title from Application Item 1.3.)
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, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: AM4M'�)6� /// /
Date: d
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
Department of Environment and Natural Resources
wo- Division of Water Resources
oivislnn of. Water Resources Plow Tracking/Acceptance for Server Extension Permit Applications
(FTSE 10-18)
Enity Requesting Allocation City of Burlington
Project Name for which flow is being requested: LIDL #1418 - Burlington
More than one FTSE-10107 may be required for a single project if the owner of the WIM is not responsible for al! pump
stations along the route of the proposed wastewater flow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: South Burlington WWTP
b. WWTP Facility Permit #: NC0023878
All flows are in GPD
c, WWTP facility's permitted flow 12,000,000
d. Estimated obligated flow not yet tributary to the WWTP 1,620,111
e, WWTP facility's actual avg. flow 9,065,000
f, Total flow for this specific request 3,766
g, Total actual and obligated flows to the facility 10,688,877
h. Percent of permitted flow used 89.1 %
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
(A)
(B) (C) (D)=(B+C) (E)°(A-D)
Design
Obligated,
Average Daily
Approx. Not Yet Total Current
Pump Station Firm
Flow"
Current Avg. Tributary Flow Plus
(Name or Capacity, "
(Firm/pt),
Daily Flow, Daily Flow, Obligated Available
Number) GPD
GPD
GPD GPD Flow Capacity'""
NONE
" The Firm Capacity of any pump 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 pumpstation divided by a
peaking factor (pf) not less than 2.6.
""" A Planning Assessment Addendum shall be attached for each pump station
located between the project connection point and the WWTP where the Available
Capacity s 0.
Downstream Facility Name (Sewer) : HOLLY HILL OUTFALL
Downstream Permit Number: unknown
t of 2 FTSE 10.18

III. Certification Statement:
1, W, Todd Lambert, RE, certify to the best of my knoi
volume of wastewater to --Fe permitted in this project has been
receiving wastewater treatment facility and that the flow from thi
cause any capacity related sanitary sewer overflows or overburden a
route to the receiving treatment plant under normal circumstance
the planned improvements identified in the planning asssessr
analysis has been performed in accordance with local established pc
best available data. This certification applies to those items listed
all attached planning assessment addendums for which I am 11
of this form certifies that the receiving collection system or treatment
transport and treat the proposed new wastewater.
Signing Official Signature
City Enaineer
Title of Signing Official
FLOW ACCEPTED YI'K0UURY PROPERTIES CENTRE LL
SIGNATURE: A SIGN T ���i"r"�
DATE: 9• q. Z019.
FLOW ACCEPTED BY FLOW
SIGNATURE:
DATE: / _ '�> —
CHURCH LLd:
;dge that the addition of the
aluated along the route to the
project is not, anticipated to
downstream pump station en
given the implementation of
nt where applicable. This
,ies and procedures using the
bove in Sections I and 11 plus
responsible party. Signature
arks has adequate capacity to
0
Date
2 of 2 FTSE 10.18

TIMMONS GROUP
fOUR Vii!ON fYCH'iLD TNk6UCH OUR'.
Sanitary Sewer Flow Acceptance:
The LIDL project will discharge the below estimated wastewater flows into the
existing private gravity sanitary sewer main, which runs across the neighboring
properties.
Bakery: 570 SF X 10 gal/100 SF = 57 Gal/Day
Shopping Center with Food Service: 28,530 SF X 130 gal/1,000 SF = 3,709 Gal/Day
Total Wastewater: 3,766 Gal/Day
Koury Properties Centre LLC hereby accepts the wastewater flows into the private
sanitary sewer main on their property.
Sanitary Sewer Flow Accented By:
Koury Properties Centre LLC
Alamance Parcel ID: 113490
Property Address: 2950 S Church Street, Burlington
Mailing Address: 2316 Tucker Street Ext, Burlington, NC 27215
Print Name
Print Job Title
Signature
Date

TIMMONS GROUP
YOUR VISION ACHIEVED THROUGH OURS.
Sanitary Sewer Flow Acceptance:
The LIDL project will discharge the below estimated wastewater flows into the
existing private gravity sanitary sewer main, which runs across the neighboring
properties.
Bakery: 570 SF X 10 gal/100 SF = 57 Gal/Day
Shopping Center with Food Service: 28,530 SF X 130 gal/1,000 SF = 3,709 Gal/Day
Total Wastewater: 3,766 Gal/Day
Flow 2920 South Church LLC hereby accepts the wastewater flows into the private
sanitary sewer main on their property.
Sanitary Sewer Flow Accepted By:
Flow 2920 South Church LLC
Alamance Parcel ID: 113493
Property Address: 2920 S Church Street, Burlington
Mailing Address: 1425 Plaza Drive, Winston Salem, NC 27103
Print Narfe
Print Job Title
Signature
'iL_30_ zo t9
Date

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Legal Name
1.1 USOpemdms, ILC
Information
SosM: 1481375
Status: CummtAttve
Annual Report Status Cumenl
Cltinsmshlp Fa q
Date Formed: IIII7R015
State of Incorporation,
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Reglstered Agent CarpAadonSwtte Compm�
Addresses
Reg ONIw
2626 Dbnciood Awmmu Sure 550
Rabaul; NC 27609
Reg Melling
26260bnwood Awmal,Sube 50
Rasilt, NC 27606
Malting
3500Souh C"Sher
Adlirglan, VA W024045

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