WQ0042200_application revision_20210104

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Keystone Group. Inc. (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: W. Scott Wallace per 15A NCAC 02T .0106(b)
Title: President
4. Applicant's mailing address: 3708 Alliance Drive
City: Greensboro State: NC Zip: 27407-
5. Applicant's contact information:
Phone number: Q 36) 856-0111 Email Address: swallace(&,gokevstone.com
❑ Privately -Owned Public Utility
❑ Other
H. PROJECT INFORMATION:
1. Project name: Mebane Towne Center Phase T2, T3, T4, A2, A3 &A4
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date:
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Alamance
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0700 Longitude:-79.280.
5. Parcel ID (if applicable): 164152, 164335 & 164338
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Charles P. Truby, Jr. License Number: NC 14984
Firm: CPT Engineering and Surveying, Inc.
Mailing address: 4400 Tynin Street
City: High Point State: NC Zip: 27265
Phone number: 3( 36) 812-8800 Email Address: chuckt(a),cotengineering.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Mebane Wastewater Treatment Plant Permit Number: NCO021474
Owner Name: Citv of Mebane
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0040602 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS0021474
Owner Name(s): City of Mebane
FORM: FTA 04-16 Page 1 of 5