WQ0036166_Application_20120928

OF \NA7-F9 DENR—FRO State of North Carolina
OG Department of Environment and Natural Resources
v) y SEP Z $ 2012 Division of Water Quality
> DWa
Owo FAST -TRACK APPLICATION
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(FTA 12/07 very)
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included/addressed the following list of required application package items by
checking the space provided next to each applicable item. Failure to submit all required items will lead to your application
being returned as incomplete. Forms are available from the web site or by calling the Regional Office serving your county:
httpJ/h2o. enr. state. nc. us/peres/Collection % 20SystemsICollectionSystemApplications. html
® A. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. The application should include a project narrative describing the final build -out design (i.e. system and/or
pump station to ultimately serve 500 homes, but flow for only 100 homes being requested now). For modifications,
clearly explain the reason for the modification (i.e. adding another phase, changing line size/length, etc.). Only
include the modified information in this permit application - do not duplicate project information that has already
been included in the original permit.
Any changes to this form will result in the application being returned. The Division of Water Quality (Division) will
only accept application packages that have been fully completed with all applicable items addressed. You do not
need to submit detailed plans and specifications unless you respond NO to Item 1303).
Separate aDDlications should be made for non-contiauous sewer systems
® B. Application Fee - Submit a check in the amount of $480 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ C. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2)a of this application.
❑ D. Operational Agreements — Submit one original and two copies of a properly executed operational agreement, as
per 15A NCAC 02T .0115, if the application is submitted by a private applicant and will be serving residential or
commercial lots (e.g., houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If
the applicant is a home or property owner's association, use Form HOA 02/03. If the applicant is a developer,
use Form DEV 02/03. EVEN IF THE PROJECT MAY BE TURNED OVER TO A MUNICIPALITY UPON
COMPLETION, FORM DEV 02/03 IS REQUIRED.
® E. Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance — FORM FTSE 10/07 (Flow
Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant
(and owners of downstream sewers, pump stations and/or treatment facilities submitting FORM FTSE-10/07)
certifies that the addition of the volume of wastewater to be permitted in this project has been evaluated along the
route to the receiving treatment plant, and that the flow from this project will not cause capacity related sanitary
sewer overflows or overburden any downstream pump station en route to the receiving wastewater treatment
plant. Where the applicant is not the owner of the downstream sewer, submit two copies of FORM FTSE 10/07
from the owner of the downstream sewer and owner of the WWTF, if different. The flow acceptance indicated in
FORM FTSE-10/07 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-10/07 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 project -specific FTSE 10/07.
® F Map — Submit an 8.5-inch by 11-inch COLOR copy of a USGS Topographic Map of sufficient scale to identify the
entire project area and the closest surface waters. Each map or maps must show the location of the sewer line
and pump stations and be of reproducible quality. Include a street level map showing the downstream connection
point, and the permit number for the downstream sewer, if known.
FTA 1 ?/07

® Ca. Stream Classifications — Watershed Classification Attachment (Form WSCAS-12/07) If any portion of the
sewer system project is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment
may need to be completed. A variance must be requested for encroachment within required setbacks or buffers
pursuant to 2T .0305 (f) and be indicated in Item B-13 with supporting documentation/justification provided.
❑ H Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application cannot be used. Send the project application on the most current version of Form
PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications
cannot be accepted until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS)
has been issued. A copy is to be submitted with that permit application.
❑ I. Flow Direction — Many wastewater treatment systems are entering into agreements for regionalization efforts
and emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be directed
to more than one treatment facility. If this is the case with this project, please indicate in 13(12) and give the permit
number of the second treatment facility.
® J. Certifications — Section C
The application must be certified by both the applicant and the design engineer who is a North Carolina
Registered Professional Engineer (PE). The applicant signature must match the signing official listed in Item
A(1 b). The PE should NOT certify the application if he/she is unfamiliar with 15A NCAC Chapter 2T, the Gravity
Sewer Minimum Design Criteria (most recent version) and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (most recent version), as applicable to the project.
THE COMPLETED FTA 12/07 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
DOCUMENTS AND $480 FEE, 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,
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,
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,
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,
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,
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
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell, Davidson,
Winston-Salem, North Carolina 27107
Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone]
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at.
http://h2o.enr.state.nc.uslperesICollection%2OSystemsICollectionSystemsHome.htmi
or contact the Regional Office serving your county.
FTA 12/07

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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)
1. Owner/Permittee:
1 a. Town of Biscoe
Full Legal Name (company, municipality, HOA, utility, etc.)
1 b. Sam R. Stewart
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
1 c. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1 d. P. O. Box 1228 1 e. Town of Biscoe
Mailing Address City
1 f. NC 1 g. 27209
State Zip Code
1 h. 910-428-4112 1 i. 910-428-3975 1j. sam.stewartatownofbiscoe.com
Telephone Facsimile E-mail
2. Proiect (Facility) Information:
2a. Myrick Property Pump Station and Force Main 2b. Montgomery
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. Wes Carter
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 704-334-5348 3c. [e-mail]
Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one)
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3. Town of Biscoe
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Town of Biscoe WWTP 4b. NPDES Permit No. NCO021504
Name of WWTF WWTF Permit No.
5a. Town of Biscoe 5b. 18" ® Gravity 5c. WQCS00167
Owner of Downstream Sewer Receiving Sewer Size ❑ Force Main Permit # of Downstream Sewer (Instruction E)
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
❑ Retail (Stores, shopping centers)
❑ Institution
❑ Hospital
❑ Church
❑ Nursing Home
® Other (specify): Commercial
100 % Domestic/Commercial
% Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify):
7. Volume of wastewater to be allocated or permitted for this particular project: 50,000 gallons per day
*Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA 12/07

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9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item B(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item 13(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
Non -Residential development with use and occupancy unknown at this date — 50 Ac @ 1,000 GPD/AC = 50,000 GPD
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) New Gravity or Additional
Force Main
8" 8,080 Gravity
181, 276 Gravity
8" 16,800 Force Main
11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID Myrick Property (self chosen - as shown on plans/map
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
400 e,pA4 &_ 177 1 8" 16,800 ft
Pump Station Location ID,
(self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
Pump Station Location ID
Design Flow
(MGD)
(self chosen - as shown on plans/map for reference)
Operational Point Power Reliability Option
GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
❑ Yes ® No If Yes, permit number of 2"d treatment facility
(RO — if "yes" to B,12 please contact the Central Office PERCS Unit)
13. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T as
applicable?
❑ Yes ® No If No, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
Minimum Design Criteria V.6.2 - Wetland and stream buffers encroached. Watermain standard pipe and sealed manholes
are specified within the encroached areas.
FTA 12/07

• 14. Have the following permits/certifications been submitted for approval for the system or project to be served?
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Wetland/Stream Crossings - General Permit or 401 Certification? ® Yes ❑ No ❑ N/A
Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A
Stormwater? ❑ Yes ❑ No ® N/A
15. Does this project include any high priority lines, [see 15A NCAC 02T .0402 (2)] involve aerial lines, siphons, or interference
manholes)? These lines will be considered high priority and must be checked once every six months
Check if Yes: ❑ and provide details
1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
la.
1, Sam R, Stewart, attest that this application for the Town of Biscoe 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. Note: In accordance with North Carolina General Statutes 143-215.6A and 143-215.6B,
any person who knowingly makes any false statement, representation, or certification in any application 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.
Signing&lfficial Signature
-3/-!
Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
1, Charles R. Froneberger , attest that this application for WK Dickson Co.. Inc. has been reviewed by me and is
accurate, complete and consistent with the information in the engineering plans, calculations, and all other supporting
documentation to the best of my knowledge. 1 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
adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force
Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance. 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 NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application 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.
Professional Engineer Name ���`0�� �ARolz �•,,�
..••• •..
2b. WK Dickson Co., Inc. :�DF_SS IO / .�q'�.�
Engineering Firm ? 9
2c. 616 Colonnade Drive = �.
Mailing Address
2d. Charlotte
City
2g. 704-334-5348
Telephone
2h. 704-334-0078
Facsimile
y; 8802 •�,,;
2e. NC 2f. 28205 �'.�9�F•.;�NGIVV;.:
State Zip
2i. [e-mail]
E-mail NC PE Seal, Signature & Date
FTA 12/07

FkWK
DICKSON
community infrastructure consultants
September 27, 2012
Ms. Belinda Henson
North Carolina Department of Environment and Natural Resources
Division of Water Quality
225 Green Street, Suite 714
Fayetteville, North Carolina 28301-5094
Re: Town of Biscoe
Myrick Property Pump Station and Force Main
WK Dickson Project No. 20110151.00.CL
Dear Ms. Henson:
DENR-FRO
SEP 2 8 2012
(M)
Enclosed are the following documents in support of the Town of Biscoe Myrick Property Pumps
Station and Force Main Project:
• One (1) original and one (1) copies of the "Fast -Track Application for Gravity Sewers, Pump
Stations, and Force Mains (DENR Form FTA 12107).
• Application Fee - Town of Biscoe Check #32617 for the $480.00.
• Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance (DENR Form FTSE
10/07).
• One (1) copy of an 8.5-inch x 11-inch USGS Topographic Map showing the project area.
• Project Narrative
• Two (2) copies of plans and specifications pertinent to the variance due to the installation
of pipe and manholes within the 50 foot offset for wetlands. The pipe in the area complies
with watermain standards and manholes are sealed.
Should you have any questions or need additional information, please contact me @ 704-227-3403
or by email at [e-mail].
Sincerely,
W.K. Dickson & Co., Inc.
Charles R. Froneberger, P.E.
Project Manager
cc: Mr. Brooks Lockhart, Town of Biscoe
616 Colonnade Drive
Charlotte, NC 28205
Tel: [phone]
Fax: [phone]
www.wkdickson.com Transportation 9 Water Resources • Urban Development • Geomatics

PROJECT NARRATIVE
TOWN OF BISCOE
MYRICK PUMP STATION, FORCE MAIN AND GRAVITY SEWERS
FAST TRACK APPLICATION (FTA 12/07)
The Town of Biscoe proposes to install new gravity sewers, sewage pump station and force main
providing sewer service for the future development of a general service area along Highway 27-23
east of Interstate 1-73-74 in Montgomery County.
The proposed gravity sewer will include approximately 8,080 If of 8-inch gravity sewer in two
separate lines. One gravity sewer will include approximately 3035 If of 8-inch gravity sewer
extending adjacent to Lick Creek to provide service to the "Myrick Property" located north of
Highway 27-23 on the east side of Interstate Highway 1-73-74. The second gravity sewer will
include approximately 5045 If of 8-inch gravity sewer extending along an unnamed tributary of
Lick Creek to a point near Cotton Creek Road providing future sewer service to the initial
development of a proposed Montgomery County "Mega Site". The projected wastewater flow from
these service areas was based upon the initial development of approximately 50 acres as non-
residential with use and occupancy unknown and an average wastewater generation of 1000
gallons per day per acre or an initial flow of 50,000 gpd.
The two gravity sewers will discharge into a new pump station located at the confluence of Lick
Creek and the unnamed tributary to Lick Creek. The proposed pump station is designed to serve a
future service area with an average daily flow of approximately 230,400 gpd and a peak daily flow
of 576,000 gpd based upon a peaking factor of 2.5. The pump station is proposed to include the
following features:
• Duplex submersible pumps with each pump designed for a pumping capacity of 400 gpm @
176 feet total dynamic head.
• Backup emergency power provided by a diesel fueled generator with automatic transfer upon
loss of primary power.
• Chemical feed system and 1500 gallon bulk storage for control of hydrogen sulfide and related
odor generation within the force main system.
• All-weather gravel access road.
• Potable water supply with backflow preventer from Montgomery County water line.
Transfer of wastewater to the Town of Biscoe WWTP is proposed through an approximate 16,800
If of new 8-inch force main extending to a connection point immediately up stream of the WWTP.
The design pumping rate of 400 gpm will provide an average force main velocity of 2.56 fps. The
force main design includes provisions for air/vacuum relief at high points within the force main,
isolation valves at key locations, and a flushing connection at the low point within the force main.
The new force main will connect into a new manhole installed over the Town's existing 12-inch
gravity sewer immediately up -stream of the WWTP. Approximately 276 If of new 18-inch gravity
sewer is to extend from this manhole to a point immediately up -stream of the WWTP's influent bar -
screen structure where it will connect back into the existing 12-inch incoming plant sewer.
Provisions are included within the new sewer to permit the future diversion of influent flow into a
new mechanical screening system to be installed during a planned WWTP upgrade.

0 WATF
FORM WSCAS-03/2012 ,off 00
WATERSHED CLASSIFICATION ATTACHMENT
FOR SEWER SYSTEMS
Applicant Name
Project Name
Town of Biscoe
Myrick Property Pump Station and Force Main
Professional Engineer Name
Engineering Firm Name
Charles R. Froneberger, P.E.
W.K. Dickson & Co., Inc.
Location
ID
Name of
Waterbody'
County
River Basin
Waterbody Stream
Index No.
Waterbody
Classification
#1
Unnamed Tributary
to Lick Creek
Mont
Cape Fear
17-26-5-3-2
Lick Creek
WS-III
#2
Unnamed Tributary
to Lick Creek
Mont
Cape Fear
17-26-5-3-2
Lick Creek
WS-III
#3
Unnamed Tributary
to Lick Creek
Mont
Cape Fear
17-26-5-3-2
Lick Creek
WS-III
Unnamed Tributary
to Lick Creek
Mont
Cape Fear
17-26-5-3-2
Lick Creek
WS-III
#5
Hickory Branch
Mont
Yadkin
Pee -Dee
13-25-22-3
White Oak Creek
C
#6
Unnamed Tributary
to Lick Creek
Mont
Cape Fear
17-26-5-3-2
Lick Creek
WS-III
' If unnamed, indicate "unnamed tributary to X", where X is the named waterbody to which the unnamed tributary joins.
1 certify that as a Registered Professional Engineer in the State of
North Carolina that I have diligently followed the Division's instructions
for classifying waterbodies and that the above classifications are
inclusive of the stated project, complete and correct to the best of my
knowledge and belief.
PE Seal, Signature and Date
*** END OF FORM WSCAS-03/2012 ***
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FORM: WSCAS-03/2012
Page 1 of 1

OF W A TFR State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE—10/07)
Project Applicant Name: Town of Biscoe
Project Name for which flow is being requested: Myrick Property PS and Force Main
More than one FTSE-10/07 may be required for a single project if the owner of the WWTP is not responsible for all
pump stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Town of Biscoe
b. WWTP Facility Permit #: NCO021504
All flows are in MGD
c. WWTP facility's permitted flow 0.500
d. Estimated obligated flow not yet tributary to the WWTP N/A
e. WWTP facility's actual avg. flow 0.199
f. Total flow for this specific request 0.050
g. Total actual and obligated flows to the facility 0.249
h. Percent of permitted flow used 49.8%
11. 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
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Finn/Design — WK Dickson) Daily Flow, MGD
Mvrick Pronertv Pumn Station 0.23 MGD 0 (new pump station)
III. Certification Statement:
I, Sam R. Stewart, certify that, to the best of my knowledge, 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. 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 for which I am the responsible party. Signature of this form indicates acceptance of this
Sign ingaff Signature
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Date

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community infrastructure consultants FXIST PS PROP

OENR-SRC'
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Application Number:
(to be completed by DWQ) �I�'2
g 2
1. Owner/Permittee:
1a. Town of Biscoe
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Full Legal Name (company, municipality, HOA, utility, etc.)
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1b. Sam R. Stewart
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Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
1 c. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
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1 d. P. O. Box 1228
1 e. Town of Biscoe
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Mailing Address
City
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1 f. NC
1 g. 27209
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State
Zip Code
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1 h. 910-428-4112 1 i. 910-428-3975
1j. sam.stewart(o)townofbiscoe.com
Telephone Facsimile
E-mail
U2.
Project (Facility) Information:
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2a. Myrick Property Pump Station and Force Main
2b. Montgomery
a-
Brief Project Name (permit will refer to this name)
County Where Project is Located
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3. Contact Person:
Q3a.
Wes Carter
Name and Affiliation of Someone Who Can Answer Questions
About this Application
3b. 704-334-5348
3c. [e-mail] _
Phone Number
E-mail
1. Project is ® New ❑ Modification (of an existing permit)
If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3)) ❑ Private
(go to Item 2(a))
2a. If private, applicant will be:
2b. If sold, facilities owned by a (must choose one)
❑ Retaining Ownership (i.e. store, church, single office, etc.)
or ❑ Public Utility (Instruction C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Homeowner Assoc./Developer (Instruction D)
F1 Sellino units (lots. townhomes. etc - ae) to Item R19htt
32617
FIDELITY BANK
TOWN OF BISCOE
23RIGHT
1 E. CHUU YOURCH ST
CENTRAL DEPOSITORY
MARTINSVILLE, VA 24112
This Disbursement Has Been Approved As Required By
66-358-531
The Local Government Budget And Fiscal Control Act
a
32617
Four Hundred Eighty Dollars and 00 Cents
DATE AMOUNT
m
o
m
08/31/2012 $480.00
d
z
m
PAY
TO THE
DER
NCDENR
8
OF
DIVISION OF WATER QUALITY
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1617 MAIL SERVICE CENTER
RALEIGH NC 27699-
AUTHORIZED SIGNATURE
11100032617119
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❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA 12/07