WQ0042308_Application (FTSE)_20210121

Coulter Jewell Thames, PA
ENGINEERING LAND SURVEYING LANDSCAPE ARCHITECTURE
LETTER OF TRANSMITTAL
Date: 1/19/2021
To: NCDWR
Attn: Water Quality Section
40 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
WE TRANSMIT TO YOU HEREWITH:
Csi
Project: TROSA
1931 Union Cross Road.
!' NC D^nartment of .1
EnvironniE::ntal Quality
Received
JAN 2 2021
Winston-Salem
Regional Office
Job # 1964
# Copies Sheet No. Date Description
2 Sewer system extension application
1 $480 review
2 Flow tracking/acceptance form
2 Site maps
2 Construction Plans
Remarks:
Request for a private sewer permit that will tie into the Winston-Salem public sewer.
The permit is for a Congregate living/Substance abuse trament facility.
The estimate daily flow is 6,600 GPD. A flow acceptance letter has been provided by
Winston-Salem.
Copies To:
Daniel A. Jewell, ASLA, RLA
Jeffrey P. Williams, PLS
From: Kevin Burke
Main Office: 111 West Main Street, Durham, NC 27701
Phone: [phone] Fax: [phone]
Email: andrew.porter(U7citoa.com

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
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC or and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, ISA
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineering nraetices.
While no upfront engineering design documentsare required for submittal, in accordance. with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would includeplans, design
calculations, and project specifications referenced in I5A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in I5A NCAC 02T,0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC 1C .0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General - When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):.
El List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
• If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
Ez Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
f J Submit the completed and appropriately executed application.
• If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
f4] The Project Name in Item IL I shall be consistent with the project name on the flow acceptance letters, agreements, etc.
p The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with I5A NCAC 02T .0I06(6).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
fl Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
> Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
> The flow acceptance indicated in form FTSE 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 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 a project -specific FTSE.
F. Site Maps (All Application Packages):
ZI Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
> Location of the project (gravity sewer, pump stations & force main)
> Downstream connection points and permit number (if known) for the receiving sewer
Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
n/a G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
n/a H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per I5A NCAC 02T .0305(h)( I ), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
> It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
n/a I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per ISA NCAC 02T .0115(a)( I) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
n/a
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per I5A NCAC 02T .0115(c), submit the properly executed Operational Atneement (FORM:IIOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

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 he completed or the application will be returned
L APPLICANT INFORMATION:
1. Applicant's name: TROSA, Inc. (company, municipality, HOA, utility, etc.).
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership
❑Privately-Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal 0 Other
3. Signature authority's name: Keith Artin per 15A NCAC 02T.0106(b)
Title: CEO
4. Applicant's mailing address: 1820 James Street
City: Durham State: N.C.. ' Zip: 27707-
5. Applicant's contact information:
Phone number: (919) 411 -1059 Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: TROSA - Triad
2. Application/Project status: ® Proposed (New Permit) 0 Existing Permit/Project
If a modification, provide the existing permit number: WQ00_ and issued date:
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Forsyth County
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.045468° Longitude: -80.136918°
5. Parcel ID (if applicable): 6863378175000
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Peston B. Royster License Number: 35003
Firm: Coulter Jewell Thames. P.A.
Mailing address: 111 Wcst Main Street
City: Durham State: N.C.. Zip: 27701-_
Phone number: [phone] Email Address: uroysteracitpa,com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. FacilityName:Archie Elledge Permit Number: NC0037834
Owner Name: Winston-Salem/Forsyth County Utility Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQCS00003 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Numbers) (if applicable): WQCS 00003
OwnerName(s): WS/FC Utility Commission
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 ZN/A
3. If the Applicant is a home/Property Owners' Association. has an Operational __greentent (FORM: DOA) been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
® Residential Owned
❑ Residential Leased
❑ School / preschool / day care
® Food and drink facilities
® Businesses / offices / factories
0 Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
❑Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool /Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic/Commercial % Commercial
_% Industrial (See I5A NCAC 02T.0103(20))
)Is there a Pretreatment Program in effect? ❑Yes ® No
6. Has a flow reduction been approved under 15ANCAC 02T Al urn? ❑ Yes 0 No
> If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.01 t4(0)
Daily Design Flow a'b
No. of Units
Flow
Residential Care
60 gal/person
110
6,600 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
6,600 GPD
a See I5A NCAC on- A I 14(b), (d). (e)(1) and (0)(2) for caveats to wastewater deign 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 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: 6,600 GPD (per I A 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:
0 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
628
DI
> Section D & III of the MDC for Permitting of Gravity Sewers contains information relatedto design criteria
> Section III contains infomiation related to minimum slopes for gravitysewer(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 (Pmnn 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 pings) of the pump(s): gallons per minute at feet total dynamic head (TDB)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6. Power reliability in accordance with I5A NCAC 02T .0305(11111]:
❑ 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 1 SA 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 sourceor 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: PTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations found in 15A NCAC 02T.0305f) & (g)
➢ 15A NCAC 02T.0305lfa contains minimum separatious that shall be mvided fot
0 Yes ❑ No
p .
Setback Parameter*
.7.7...,,,..
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 swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ I5A NCAC 02T.0305(g) contains alternatives whereseparations in 02T.0305(f1 cannot be achieved.
**Stream classifications can be identified using the Division's NC Surface Water Class' icmlons webpage
> If noncompliance with 02T.0305(flor(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 028 .0200? 0 Yes 0 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
individual permits or 401 Water Quality Certifications?
> Information can be obtained from the 401 & Buffer Permitting Branch
❑Yes ®No
5. Does project comply with I5A NCAC 02T.0I05(c)(6){additional permits/certifications)? ® Yes 0 No
Per I5A NCAC 02TA 105(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 projectinclude 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

CERTIFICATIONS:
1. Does the submitted system comply with I5A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version) and the Gravity Sewer Minimum Dcsien Criteria (latest version) as applicable?
®Yes El No
If No, complete and submit the Variance/AltemativeDesign 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:
1Ke5I o^r TraYsttic attest that this application for
(Professional Engineer's name from Appllcation Item 111. 1.)
has been reviewed by me and isaccurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all othersupporting 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 143-215.6B, any person who knowingly makes any false
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation.
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may )4,
North Carolina Professional Engineer's seal, signature, and date: ,,\V ...CAR®r�i/
gS/O)
3. Applicant's Certification per 15A NCAC 02T .0106(1,):
1,
lee,(h4 A rb',n , CEO f Ptee;derk
(Signature Authority's name & title from Application Item I.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 applicationpackage 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.
i•
SEAL
35003 —
'O/' `TO1. N tBi B. l`
Ili/
•
attest that this application for
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 packageshall 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:
Date:
tz fsslzo
FORM: PTA 04-16 Page 5 of 5

Winston-Salem
/ Forsyth County
Utilities
Water • Wastewater • Solid Waste
Administration, P.O. Box 2511, Winston-Salem, NC 27102
0: 336-727-8000, F: 336-727-8432, wsfcutilities.org
December 30, 2020
TROSA, Inc.
1820 James Street
Durham, NC 27707
Attn: Keith Artin
Re: Public Water and Sewer Availability
TROSA, Triad
Dear Mr. Artin,
This letter is to inform you that Winston-Salem/Forsyth County water & sewer services are
available to serve the proposed site referenced above. The proposed development is located at
parcel identification number 6863-37-8175, and the plan is to construct a 110-unit residential
care complex with anticipated sewer flow of 6,600 gpd.
Water Service:
According to our records, an 8" water main exists along Union Cross Road. This line should
provide adequate service to the property.
Sanitary Sewer Service:
According to our records, an 8" sewer main exists at the southem edge of this property. This line
should provide adequate service to the property.
Sincerely,
Todd Lewis, P.E.
Senior Civil Engineer
City Council: Mayor Allen Joines; Vivian H. Burke, Mayor Pro Tempore, Northeast Ward; Denise D. Adams, North Ward; Dan Besse, Southwest Ward; Robert C. Clark,
West Ward; John C. Larson, South Ward; Jeff Macintosh, Northwest Ward; Annette sclpplo, East Ward;James Taylor,Jr., Southeast Ward; City Manager; Lee D. Garrity
County Commissioners: David R. Plyler, Chair; Don Martin, Vice Chair; Fleming El -Amin; Ted Kaplan; Richard V. Linville; Tanya McDaniel; Gloria D. Whlsenhunt; County
Call 311 or 336-727-8000 Manager: Dudley Watts, Jr.
Winstomsalem/Forsyth County Utility Commission: Randall 5. Tuttle, Chair; L. Wesley Curesdr., Vice Chair; Harold E. Day; Tom Griffin:Yvonne H. Hines; Duane Long;
[e-mail] Hugh W.Jernigan; Chris Parker; James Ruffin; Donald R. Stewart; Allan Younger