WQ0042344_Application (FTSE)_20210219

"A TOWN IN PROGRESS"
February 18, 2021
NV Department of
Subject: Town of Yadkinville Environmental Quality
McClesky Street Sewer Extension Application Received
Gentlemen, QED 19 2921
Winston-Salem
Please find enclosed the following items: Regional Office
1. Check in the amount of $480 payable to NCDEQ
2. 1 original and 1 copy FTA 04-16 fully completed and fully executed
3. 1 original and 1 copy FTSE 04-16 fully completed and fully executed
4. 1 original and 1 copy 8.5-inch x 11-inch color annotated USGS Topographic Map for the project
5. 1 original and 1 copy street level map for the project
Project Description:
The application is for the construction of approximately 195 of additional 8-inch sewer along McClesky
Street in Yadkinville. The extension will connect into an existing manhole located at which has a plugged
opening for this purpose and will include the addition of a new terminal manhole. The extension is
necessary to allow the connection, by gravity, of two new 3-bedroom homes under construction at the
intersection of McClesky Street and Taylor Street with a flow allocation of 720 gallons per day for the
two homes.
Sincerely,
,_ 2)/, -z-
Michael R. Koser, P.E.
Town Manager
213 Van Buren Street
Post Office Drawer 816 Telephone [phone]
Yadkinville, North Carolina 27055-0816 Fax [phone]

State of North Carolina
Department of Environmental Quality
DWK Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
i
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
i
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: Town of Yadkinville (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: Michael R. Koser per 15A NCAC 02T .0I06(b)
Title: Town Manager NO Department
l Quality
of
Environmental Quality
4. Applicant's mailing address: P.O. Box 816 Recel led
City: Yadkinville State: NC Zip: 27055- FEB 19 2021
5. Applicant's contact information:
Winston-Salem
Phone number: [phone] Email Address: mkoser(cavadkinville.ore Regional Office
lI. PROJECT INFORMATION:
1. Project name: McClesky Street Sewer Extension
2. Application/Project status: ®IProposed (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: Yadkin
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.131057' Longitude:-80.645142'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer: Michael R. Koser License Number: 033427
Firm: Town of Yadkinville
Mailing address: P.O. Box 816
City: Yadkinville State: NC Zip: 27055
Phone number: 336 679-8732 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Yadkinville WWTP Permit Number: NCO020338
Owner Name: Town of Yadkinville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
I
1. Permit Number(s): WQ' Downstream (Receiving) Sewer Size: — inch
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System Wide Collection System PermitNumber(s) (if applicable): WQCS_
Owner Name(s):
FORM: FTA 04-16 Page I of 5

VL GENERAL REQUIREMENTS
I'. 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/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
FI Businesses / offices /factories ❑ Nursing Home El Other (Explain in Attachment)
5. Nature of wastewater: 100 %Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ® Yes ❑ No
6. Has a 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:
8.
Establishment Type (see 02T.0 I 14(f)
Daily Design Flow',b
No. of Units
Flow,
Residential Single Family 3 bedroom
360 gal/day
2
720 GPD
gaV
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
721 GPD
a See 15A NCAC 02T 0114(b), (d),'(e)(U 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 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.
Wastewater generated by project: 720 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:
❑ Rehabilitation or replacement of existing lsewer with no new flow expected
❑ Other (Explain):
FORM: ETA 04-16
Page of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
i
1. Summarize gravity sewer to be permitted:
➢ Section 11 & 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
VIIL PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pum o 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):
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:
I
❑ 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 104-16 Page 3 of 5

SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (a)
�. 1 CA wrn A n nnm nanein «.,.:«.. ..,. :..,....... o...,..a:,.«.. ♦6«t �6n11 l.o ....,.,4Aod 4, enarPr m.eteme
®Yes ❑No
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 waterlines 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
36inches
➢ "15A NCAC 02T,0305(0 contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ * *Stream classifications can be identified using the Division's NC Surface Water Classifications weboage
➢ 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 0 No
individual permits or 401 Water Quality Certifications?
Information can be obtained from the 401 & "Buffer Pennittine Branch
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 of 5

X. CERTIFICATIONS:
i
I . 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 Minimun Design Criteria (latest version) as applicable?
®IYes ❑No'
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) andksupportingdocuments 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, M I C (4Ati_ L IF— 1< OSt attest that this application for
(Professional Engineer's name from Application Item 111.1.)
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 m 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
aa'odi:-waaF4ap
North Carolina Professional Engineer's seal, signature, and date
a
SEAL
Wti ba 2y
Yy L ry C4aae.
8/
' 3. Applicant's Certification per ISA NCAC 02T .0106(b): OZ/ 1 2. Z(
1, 1 CH d EZ ('Z. P'-o &-)?- ' F0 V // ( 114 A yV 4 Getz attest that this application for
(Signature Authority's name & title from Application 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 143-215.6A and 143-215.613any 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: ��� �G�<< ( fL, ��� Date: OZI
FORM: ETA 04-16 Page 5 of 5

State of North Carolina
Department of Environmental Quality
A Division of Water Resources
f.
DNWon of water Resources Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Town of Yadkinville
Project Name for which flow is being requested: McClesky Street Sewer Extension
More than one FTSE pray be required for a single project /f1he owner ofthe'WWTP is not responsible for all pump
stations along the route ofthe proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: ! Yadkinville WWTP
b. WWTP Facility Permit #: NCO020338
All flows are in MGD
c. WWTP facility's permitted flow 2.5
d. Estimated obligated flow not yet tributary to the WWTP 0.207
e. WWTP facility's actual avg. flow 0.834
f. Total flow for this specific request 0.00072
g. Total actual and obligated flows to the facility 1.04172
h. Percent of permitted flow used 42%
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:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Finn Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm / pf , Daily Flow, Daily Flow, Obligated Available'
Number) MODMOD MOD MOD Flow Capacity***
* The Firm Capacity ofany 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 pump station divided by a peaking
factor (pf) not less than 2.5.
*** APlanning 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): Haw Branch Outfall Sewer
Downstream Permit Number: WQCS00130
Page 1 of 6
FTSE 04-16

I1I. Certification Statement:
I Jacob Swaim 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 indicates acceptance of this wastewater flow.
Sign g is n ignature Date
' I
I
I
I
i
4
Page 2 of 6
FTSE 04-16

McCleskyStreet Sewer Extension
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Mapping information is a representation of various data sources and is not a substitute for information that would result from an accurate
land survey. In no event shall Yadkin County Planning Department or Yadkin County, NC be liable for any damages, direct or consequential,
from the use of the information contained on this mao.