WQ0041754_Application (FTSE)_20200612

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: (to be completed by owe)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: K V Grandover Village. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ® Individual ❑ Corporation ® General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Richard Vanore per I SA NCAC 02T .0106(b)
R C Dapartment of
Title: Vice President Environmental Quality
4. Applicant's mailing address: 2275 Vanstory Street, Suite 200 Received _
City: Greensboro State: NC Zip: 27403-_ JUN 12 2020
5. Applicant's contact information:
Winston-Salem
Phone number: [phone] Email Address: rvanoreakourycorp.com Regional Office
11. PROJECT INFORMATION:
I. Project name: Grandover Village Phase 2
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: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.002209' Longitude:-79.905061°
5. Parcel ID (if applicable): 0226572
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
I. Professional Engineer: Anthony D. Lester License Number: 19773
Firm: Evans En ig neering Inc.
Mailing address: 4609 Dundas drive
City: Greensboro State: NC Zip: 27407-_
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: East Side WWTF Permit Number: NCO024210
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): W00038683 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00314
Owner Name(s): Town of Jamestown
FORM: FTA 04-16 Pagel 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: DEVI 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: % Domestic/Commercial 100 % 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(fl)
Daily Design Flow a•"
No. of Units
Flow
20,400 SF Retail
130 gal/1000 SF
20.4
2,652 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
2,652 GPD
a See I5A 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 ofthe 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: 0 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: W00038683
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: ETA 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
8" 580 DIP
➢ Section I1 & 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
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:
2. Approximate Coordinates (Decimal Degrees): Latitude: 0Longitude: - °
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
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(t)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f) & N) ® 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 11 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 swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpaee
➢ 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 02B .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 Permittin Branch
ranch
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?
10/�Mlm
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, ANTrtDN Y D • le sTfR 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, signatu e, and date: 0``0 S k CAR
�Q ESSl
��CQQ-pE ONE
j = SEAL
= 19773
;_ 3-18•�
3. Applicant's Certification per 15A NCAC 02T .01
91
�.lu.�•p� V,a►�lbp�,
p(Z�SInP�—G(
attest
(Signature Authority's name & title from Application Item I.3.)
J-
that this application for
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: 777 Date:
FORM: FTA 04-16 Page 5 of 5

I
valns
ngineering, Inca
—Since 1974—
1 Engineers Surveyors Planners
June 12, 2020
NC Department of
Environmental Quality
Received
Justin Henderson
Environmental Senior Specialist JUN 12 2020
Winston Salem Regional Office Winston-Salem
Division of Water Resources Regional Office
450 W. Hanes Mill Road
Winston Salem, NC 27105
Re: Fast Track Sanitary Sewer Application for Grandover Village Phase II
Justin,
Please find attached the completed application package and the $480 fee check. The flow
for this project was permitted in a previously approved permit (WQ0038683). Paul
Blanchard, Public Services Director for the Town of Jamestown, submitted this
application (a couple years ago). Please review and process for approval. Let me know
if you have any questions.
Sincerely,
Anthony D. Le t r, PE, PLS
Vice President
Evans Engineering, Inc.
M/Tony/630.266 Fast Track Sanitary Sewer Application

VR
011 - WN
tlivlsinr of Water ttrsone'ece
State of North Carolina
Department of > avh•onnicatal Qaality
Division of Water Resoat•ces
Flow Tracking for Server Extension Applications
(FTSE 10-18)
Application Number: 2020;I49
Entity Requesting Allocation: KV Grandover Village, LLC
Project Name for which flow is being requested: Grandover Village Phase 2
More Men one FTSR may be required for a single project ifthe oipner efthe WIM is not responsible for oll penip
stations along the ronte oflhe proposed wasten alerfloip.
1. Complete this section only if you are the owner of the wastewater heahnent plant.
a.
WWTP Facility name: EastsideWWTP
b.
W WTP Facility Permit #: NC-0024210
`:: All flmve are !n MC:D
c.
WWTP facility permitted flow:
26.0000
it.
Militated obligated flow not yet tributary to the WWTP:
0.7709
e.
W WTP facility's actual average flow:
16.3917
£
Total flow for this specifro request:
0.0027
g.
Total actual and obligated flows to the facility:
17.1652
h.
Percent of permitted flow used:
66.02%
11. Complete (his 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 W WTP.
(A)
(m)
(C)
(D)-(a+C)
(E}--(A-D)
Pump
pmnp
Fiml
Design
Approx.
Obligated,
Total Curren
Available
station
station
Capacity
Average
Cunent
Not Yet
Flow Plus
Capacity'
(Name or
Pemdl
Daily Flows
Avg. Wily
tributary
Obligated
Number)
Number
(Finn/po,
Flow,
Delly Flow,
flow
AM
A1GD
Mon
MGD
AIGD
Mine
atrndala
WQMS72
30.067
IIA$42
8.1996
OM14
9.1310
2Jan
-• aWA MIA AWA MIA MIA
IWA AN/A AWA AWA AWA 9WA
AWA AWA AWA IWA AWA MIA
AWA MIA AWA AWA IWA AMA
• The Fh•m Capaelty(design aov) ofmlypump 1Iai on Is defined ns d e maximum pmnped Dow Met
can he nchleved whit Ike largest pump Inken out ofservieo,
Design Average Flow Is the alma capacity of Ilse pump Mellon divided by the penldog factor (pq not
less Than 2.5, per Section 2.02(A)(4)(e) of the Minhnuns Design Criteria.
AAa A Planning ADtssmenl Addendum shall bo glinched for•ench pump slanun lacnied hehveen Ilia
project connection point and the WWTP where the Avnilable Capaelty 1990.
Downstream Facility Name (Sower):
Downstream Permit Number:
AWA AWA
ARIA AWA
MIA MIA
ARIA MIA
Page 1 of 0 FfS210.1 a

III. Certification Statement
1, Terry Houk certify to the best of my knowledge that the addition of the volume of
wastewater to be permitted hr this project has been evaluated along the route to the receiving wastewater
treatment facility nod flint the flow from this project is not anticipated to cause any capacity related
sanitary sower 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 date. This certification applies to those Reins
listed above In Sections I and II plus all attached planning assessment addendums for which I mn 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 now wastewater.
Signing O,/JJc SS"nal'rle
1?ub1kC. Se-X/ecC� i7/�7dh
Title of Signing Official
Date
6/1 I/2020
Pane 2 of 0 FTSE 10.1a

Public Services Department
Terry L. Houk
DIRECTOR
NORTH CAROLINNS INTERNATIONAL CITr
June 11, 2020
NCDENR
Winston-Salem Regional Office
450 W. Hanes Mill Rd, Suite 300
Winston-Salem, NC 27105
Project: Grandover Village Phase 2
Applicant: KV Grandover Village, LLC
Dear Sir or Madam,
This is to acknowledge that the City of High Point will accept for treatment in the Eastside
Wastewater Treatment Plant (Permit #NC0024210), wastewater flow from the above referenced
project in the amount of 2,652 GPD. This flow will be discharged to facilities operated and
maintained by Jamestown and then to the City of High Point sanitary sewer system.
If further information is needed, please let me know.
Very truly yours,
/t A��
Terry L. I3 ik
Director of Public Services
TLH/tab
City of High Point, P.O. Box 230, 211 South Hamilton Street, High Point, NC 27261 USA
Fax:[phone] Phone:[phone] TDD:336.883.8517

State of North Carolina
Dft,�
R
Division of Water Resources
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: K V Grandover Village, LLC
Project Name for which flow is being requested: Grandover Village Phase 2
More than one FTSE 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
East Side WWTF
b. WWTP Facility Permit #: NCO024210
c. WWTP facility's permitted flow
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
h. Percent of permitted flow used
All flows are in MGD
0.002652
Il. 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,
Pump
Pump
Average
Approx.
Not Yet
Total Current
Station
Station
Firm Daily Flow**
Current
Tributary
Flow Plus
(Name or
Permit
Capacity, * (Firm / pf),
Avg. Daily
Daily Flow,
Obligated
Available
Number)
No.
MGD MGD
Flow, MGD
MGD
Flow
Capacity***
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped now
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): Grandover West
Downstream Permit Number: W00038683
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Paul R. Blanchard 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.
-PaL R. r?4J4 S? 4/3o/z,- .
Signing Official Signature Date
F061ic Se -vices Dirnc.A-vy-
Title of Signing Official
Page 2 of 6
FTSE 10-18

10
cSellled 17,52
ANAMESTOWN
ORTH CAROLINA
April 30, 2020
Mr. Terry L. Houk
City of High Point
P.O. Box 230
High Point, NC 27261
RE: K V Grandover Village, LLC
Grandover Village Parkway/Gate City Blvd
Jamestown, North Carolina
Dear Terry,
The Town of )amestown requests a FT/SE for the K V Grandover Village, LLC site in
)amestown. The flow from this project is part of the allocation from the previously
permitted Grandover West project. It was approved under permit WQ0038683. This site
is tributary to the gravity section of the Grandover West project, so it does not flow
through any Town of Jamestown pump stations. The flow from this project is 2,652 gpd
per the application.
The permitted versus allocated flows for the overall project are summarized below:
Grandover West Project Permitted Flow: 1 12,680 gpd
Millis &Main Apartments Allocated Flow: 43,200 gpd
Millis and Main Phase II Apts Allocated Flow: 34,900 gpd
Publix Allocated Flow: 6,500 gpd
K V Grandover West, LLC Design Flow: 2.652 gpd
Balance of Flow Not Allocated: 25,428 gpd
I hope this will help with the bookkeeping of the flows as the project develops.
I am enclosing scanned copies of the permit, required forms, and the Jamestown FT/SE.
Please feel free to contact me with any questions regarding this project.
Respectfully,
Paul R. Blanchard, PE
Public Services Director
C: Anthony D. Lester, Evans Engineering, Inc.
file
P.O. Box 848
Jamestown, NC 27282
www.jamestown-nc.gov
Tel:[phone]
Fax:[phone]