WQ0042107_Application (FTSE)_20201106

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: \dQwA)- Jol (to be completed by DWR)
All items must be completed or the sonlication will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: City of Burlington (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: Hardin Watkins per
Title: City Manager - NC Department of
Environmental QUal1tY
4. Applicant's mailing address: 425 S. Lexington Avenue Received
City: Burlington State: NC Zip: 27215-_ NOV O 6 2020
5. Applicant's contact information:
Phone number: (a36) 222-5050 Email Address: en ing eerinp4burlingtonnc.go_v t Winston-Salem
Regional Office
U. PROJECT INFORMATION:
I. Project name: Alamance Co. Health Building
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: N36.100° Longitude:-W.79.4030
5. Parcel ID (if applicable): 147811
(or Parcel ID to closest downstream sewer)
II1. CONSULTANT INFORMATION:
I. Professional Engineer: John D. Lipka License Number: 026494
Firm: MLA Design Group. PA
Mailing address: 120 Club Oaks Ct., Suite 100
City: Winston-Salem State: NC Zip: 271 4-_
Phone number: 3( 36) 7M.122 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: City of Burlingotn East Plant
Owner Name: CIty of Burlington
Permit Number: 23868
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than W WTF):
1. Permit Number(s): WQ Unknown Downstream (Receiving) Sewer Size: 8" inch
System Wide Collection System Permit Number(s) (if applicable): WQCS—
Owner Name(s): City of Burlington - Rudd Street Outfall
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/Prooerty 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: ]QU/o 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(t)? [-]Yes ®No
D If yes, provide a copy of flow reduction avoroval letter
7. Summarize wastewater generated by project:
Establishment Type (see 021.0114(fl)
Daily Design Flow 0.b
No. of Units
Flow
Medical Facilities
250 gaVpractitioner/shift
14
3500 GPD
Medical (Residential Care Facilities)
60 gal/person
48
2880 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
6380 GPD
a See 15A NCAC 02T 0114(b) (d) (e)(l) 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 I SA NCAC 02T .0114(c), design flow rates for establishments not identified [in table I SA 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: �M GPD (per 15A NCAC 02T .01 l4)
D 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
8 114 DI
D Section 11 & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
D 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
VIH. PUMP STATION DESIGN CRITERIA (if Applicable) — 02T .030E & MDC (Pum D 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
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(I):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(hxl)(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 - I5A 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.
D 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

DI. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in I5A NCAC 02T.0305(f) & (2) ® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be orovided 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 swimmirip vools
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 weboaze
➢ If noncompliance with 02T.0305(n or (a). 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 I5A 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)( (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(ax5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
I. Does the submitted system comply with 115A NCAC 021, the \1inimum Design Criteria r the Pemtinin� ofPumo Stations
and Force Mainsdlatest versioni and the Gravity Sewer Minimum Design Criteria i 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. Annrovalofthe reauestisrequired prior tosubmittalofthe FastTrackApi2licationandsupportingdacuments,
2. Professional Enginecrs Certification:
C. Aq D. .. /ca,. _ attest that this application for
(Professional Engineer' 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 143-215.68, 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.
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Hardtn Vt(a'�'k'ws5 t_ Crk Nlwna �! _ _attest that this application for
(Signature Authority's name & tit) from Applidiation 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 141215.6A and I43-21,5.0, 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.
r
Signature: A -- Date:
FORM: FTA 04.16 Page 5 of 5

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE 10-18)
Enity Requesting Allocation City of Burlington
Project Name for which flow is being requested: Alamance County Health Building
More than am FTSE nary be required far a single project if the owner of the IMP is not responsible for all pump stations along
the route ofthe proposed wastewaterflow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: East Burlington WWTP
b. WWTP Facility Permit M NC 0023868
A11flows are in MCD
e. WWTP facility's permitted flow 12.00
d. Estimated obligated flow not yet tributary to the WWTP 1.910073
e. WWTP facility's actual avg. flow 5.0740
f. Total flow for this specific request 0.006380
g. Total actual and obligated flows to the facility 6,990453
h. Percent of permitted flow used 58.3%
U. 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 : None
(A)
(B)
(C)
(D)=(B+C) (E)=(A-D)
Obligated,
Total
Design
Approx.
Not Yet
Current Flow
Firm Average Daily
Current Avg.
Tributary
Plus
Pump Station Capacity, • Flow"
Daily Flow,
Daily Flow,
Obligated Available
Name GPD (Firmlico, 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 lase 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:; 0.
Downstream Facility Name (Sewer) : NaKwwr`
Downstream Permit Number:
Not Known
Page 1 of 2 FTSE 10-18

Certification Statement:
I, W. Todd Lambert, 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 asssemmenl 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 addendutns 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.
t/j-. 0 � l0 2$-1GZ0
Signing Official Signature
City Engineer
Title of Signing Official
Date
Page 2 of 2 FTSE 10-18

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November 5, 2020
State of North Carolina
Department of Environmental Quality
Division of Water Resources
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
[phone]
INC Department of
Environmental Quality
Received
Re: Alamance County Health Building — Fast Track Sewer System Extension Application
To Whom it May Concern,
NOV 0 6 2020
Winston-Salem
Regional Office
On behalf of the City of Burlington, find attached herein completed Fast Track Application and supporting plans for the
referenced project. Included with this submittal:
• Fast Track Application (one original and one copy)
• USGS Topographic Map (8-1/2 x 11)
• Approved (City of Burlington) Plans (2 sets)
• Application fee of $480 (check #004703)
Permitting actions inside of the Rudd Street Right of Way (R.O.W.) include the installation of one (1) four foot diameter
concrete manhole, approximately 114 linear feet of 8" ductile iron pipe (DIP), one 8" DIP outside drop, core and connection to
existing public manhole and concrete cradle crossing of existing storm sewer pipe. The system public extension is necessary
to provide a service connection from the new Alamance County Health Building (Anne Petree Ivey Building) which is under
construction. The Anne Petree Ivey Building will house public health office and clinic space producing approximately 6,380
GPD of flow
We trust the enclosed information is sufficient for Fast Track review and approval process. Should you require additional or
supplemental information please contact our office.
Best R� /--Z—
John D. Lipka, P.E.
Director of Civil Engineering (C-3999)
HUB/MWBE CERTIFIED
MLA Design Group, Inc.
120 Club Oaks Ct., Suite 100
Winston-Salem, NC-27104
T-336.765.1923
F-336.765.5023
c: Perry Peterson, Peterson Gordon Architects
Hardin Watkins, City Manager (City of Burlington)
Todd Lambert, City Engineer (City of Burlington)
LA Design Group, Inc.