WQ0036419_Application_20130311

W A T State of North Carolina
F
p ,F RQG C E V Department of Environment and Natural Resources
MAR 1 1 2013 Division of Water Quality
FAST -TRACK APPLICATION
DENR-FAYETTEVILLE REGIONAL OFFICE (FTA 12/07 ver5)
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:
http://Portal.ncdenr.org/web/wq/swp/ps/cs/apps
® 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 B(13).
Separate applications should be made for non -continuous 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 12/07

❑ G. 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:
ht0://portal. ncdenr. orp/web/wg/swp/ps/cs
or contact the Regional Office serving your county.
FTA 12/07

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Application Number. UO
(to be completed by DWQ)
1. Owner/Permittee:
1 a. Citv of Clinton
Full Legal Name (company, municipality, HOA, utility, etc.)
1b. Mr. John Connet, City Manager
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. PO Box 199 — 221 Lisbon St
Mailing Address
1f. North Carolina
'USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
le. Clinton
City
1 g. 28329-0199
State Zip Code
1 h. 910-299-4900 1 i. 910-592-3825 1j. Vreugdenhil@city
Telephone Facsimile E-mail
2. Project (Facility) Information:
us
2a. Clinton Ward, LDS Church 2b. Sampson
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. Charles P. Koch
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-563-9041 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. City of Clinton. North Carolina
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Norman H. Larkins WWTP 4b. NCO020117
Name of WWTF WWTF Permit No.
5a. City of Clinton 5b. 12"
Owner of Downstream Sewer lReceiving Sewer Size
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
Gravity 5c. Collection systems permit # WQCS00079
Force Main I Permit # of Downstream Sewer (Instruction E)
❑ Retail (Stores, shopping centers)
❑ Institution
❑ Hospital
® Church
❑ Nursing Home
❑ Other (specify):
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: 1,035 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).
207 seat church x 5 gallons / seat / day = 1,035 gallons / day
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
8" Ductile Iron
12" Ductile Iron
Length (feet) New Gravity or Additional
Force Main
129' Gravity
101, Gravity
11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID
Design Flow
(MGD)
Pump Station Location ID
Design Flow
(MGD)
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
(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
(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 2nd treatment facility
(RO — if "yes" to 13,12 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
FTA 12/07

14. Have the following permits/certifications been submitted for approval for the system or project to be served?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
.+,
Sedimentation and Erosion Control Plan?
Stormwater?
❑ Yes ❑ No ® N/A
❑ 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)
1 a.
1, attest that this application for Clinton Ward, LDS Church has been
reviewed by me and is accurate and complete to the best of my knowledge. 1 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
dwell as civil penalties up to $25, 000 per violation.
Sigr)Kfg1O*rcial S
3-C�-I
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
Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
1, Charles P. Koch , attest that this application for Clinton Ward, LDS Church 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. 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 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 1 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 143-215.68, 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.
2a. Charles P. Koch
Professional Engineer Name
2b. EarthCentric Engineering Inc.
Engineering Firm
2c. 204 West Clay Street
Mailing Address
2d. Mebane
City
2g. 919-563-9041
Telephone
2h. 919-304-3234
Facsimile
2e. NC 2f. 27302
State Zip
2i. [e-mail]
E-mail
9?41fSF;
NC PE Seal. Signature & Date
FTA 12/07

Shawn C. Sidener 12-028 — Clinton Ward, Sewer Extension
204 West Clay Street
Mebane, NC 27302
Phone: [phone]
Fax: [phone]
Page 1 of 1
Wastewater flow calculations and project narrative for NCDENR — DWQ Fast -Track
Application for Gravity Sewers, Pump Stations, and Force Mains.
Project Narrative:
207 seat Church with Kitchen
5 gallons / Day / Seat
207 Seats X 5 gallons / seat / day = 1,035 gallons / day
Total Wastewater Flow = 1,035 gallons / day

OF WATF9 State of North Carolina
\O� QG Department of Environment and Natural Resources
v� Division of Water Quality
o Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE—10/07)
Project Applicant Name: City of Clinton
Project Name for which flow is being requested: Clinton Ward, LDS Church
More than one FTSE-10107 maybe 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: Norman H. Larkins WWTP
b. WWTP Facility Permit #: NCO020117
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
5.00
2.6193
0.001035
2.620335
52.4%
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
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Finn/Design) Daily Flow, MGD
There is no pump station alonz this line. This is an extension of a zravity feed line.
HEUEIVED
MAR 1 1 2013
DENR-FAYETTEVILLE REGIONAL OFHCE
III. Certification/Statement:
I, 'Sokn f COnne'�" , 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 J 1m the responsible party. Signature of this form indicates
accentattce of this wastewater flow. j
Signing Vfcial Signature
Date

USGS Topographic Map - 12-028 - Clinton Ward, LDS Church
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12-028 01inton Ward, LDS Church
1610 Boykin Bridge Road, Clinton NC
Fast -Track Gravity Sewer Extension
dinton nc - Google Maps
Ge't Google Maps on yotw phorn
Text the word "GMAPS" to466453
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§1
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)
1. Owner/Permittee:
1 a. City of Clinton
Full Legal Name (company, municipality, HOA, utility, etc.)
Z 1 b. Mr. John Connet, City Manager
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
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1c. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corp f B lC5M �fpe,jfSy):
1 d. PO Box 199 — 221 Lisbon St le. Clinton CC �,// �� G�V
Mailing Address
1f. North Carolina
State
1 h. 910-299-4900 1 i. 910-592-3825
Telephone Facsimile
2. Proiect (Facility) Information:
2a. Clinton Ward, LDS Church
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Charles P. Koch
City
1 g. 28329-0199
1j.
MAR 1 12013
Zip Code pENR-FAYETTEVILLEREGIONAL OFFICE
[e-mail]
E-mail
2b. Sampson
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-563-9041 3c. Phil. [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
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
MICHAEL R. MCLEOD, ARCHITECT, P.A.
13A HAMPSTEAD VILLAGE
HAMPSTEAD, NORTH CAROLINA 28443
910-270-9778
PAY TO THE NCDENR
ORDER OF
❑ Public Utility (Instruction C)
❑ Homeowner Assoc./Developer (Instruction D)
FIRST CITIZENS
BANK & TRUST COMPANY
66-30/531/353
2/27/2013
s **480.00
Four Hundred Eighty and
NCDENR
MEMO
LDS Clinton Sewer 1 � �� � C-
15264
0
I �J
DOLLARS
s
❑ 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

Central Files: APS_ SWP_
03/20/13
Permit Number WQ0036419 Permit Tracking Slip
Program Category Status Project Type
Non -discharge Active New Project
Permit Type Fast Track Version Permit Classification
Gravity Sewer Extension, Pump Stations, & Pressure Sewer 1.00 Individual
Extensions
Primary Reviewer Permit Contact Affiliation
trent.allen
Coastal SW Rule
Permitted Flow
1035
Facility
Facility Name
Clinton Ward, LDS Church
Location Address
Owner
Major/Minor Region
Minor Fayetteville
County
Sampson
Facility Contact Affiliation
Owner Name Owner Type
City of Clinton Government - Municipal
Owner Affiliation
John F. Connet
PO Box 199
Clinton NC 283290199
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective
03/20/13 03/11/13 03/20/13 03/20/13
Regulated Activities Requested/Received Events
Wastewater collection Additional information requested
Additional information received
Outfall NULL
Expiration
Waterbody Name Stream Index Number Current Class Subbasin