WQ0038626_Regional Office Historical File Pre 2018

*No
Water Resources
ENV'WONM OCT AL QUALII Y
August 8, 2016
Mr. Andrea Surratt, Interim City Manager
City of Hickory
P.O Box 398
Hickory, NC 28603
74't
•
PAT MCCRORY
DONALD R. VAN DER VAART
,',ccrowy
S. JAY ZIMMERMAN
Subject: Permit No. WQ0038626
City of Hickory
Ashbury Lane Sewer Project
Wastewater Collection System Extension Permit
Catawba County
Dear Mr. Surratt:
In accordance with your application received August 4, 2016, we are forwarding herewith Permit No.
WQ0038626 dated August 8, 2016 to the City of Hickory (Peimittee) for the construction and operation
upon certification of the subject wastewater collection system extension. This permit shall be effective
from the date of issuance until rescinded and shall be subject to the conditions and limitations as specified
therein. This cover letter shall be considered a part of this permit and is therefore incorporated therein by
reference.
Please pay particular attention to the following conditions contained within this permit:
Condition II. I: This peimit shall not be automatically transferable; a request must be made and approved.
Condition 11.4: Requires that the wastewater collection facilities be properly operated and maintained in
accordance with I5A NCAC 2T .0403 or any individual system -wide collection system
permit issued to the Permittee.
It shall be the responsibility of the Permittee to ensure that the as -constructed project meets the appropriate
design criteria and rules. Failure to comply may result in penalties in accordance with North Carolina
General Statute §143-215.6A through §143-215.6C, construction of additional or replacement wastewater
collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to the licensing
board.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this pennit. This
request must be in the form of a written petition, conforming to Chapter 150B of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
State of North Carolina I Environmental Quality I Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 301 I Mooresville, North Carolina 28115
704 663 1699

If you need additional information concerning this matter, please contact Ori Tuvia at [phone] or
via e-mail at [e-mail].
Sincerely,
by W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
cc: Kevin Greer (E-copy)
Mooresville Regional Office Files
Water Resources Central Files
PERCS (E-copy)
Page 2 of 8

Environmental
Quaiiry
STATE OF NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
City of Hickory
Catawba County
for the construction and operation of approximately 1,200 linear feet of 8-inch gravity sewer ; a pump
station on -site equipped with audible and visual high water alarms, telemetry, and a permanent
generator with automatic transfer switch; as well as approximately 480 linear feet of 3-inch force
main to serve future development as part of Ashbury Lane Sewer Project, and the discharge of
16,373 gallons per day of collected wastewater into the City of Hickory's existing sewerage system,
pursuant to the application received August 4, 2016, and in conformity with 15A NCAC 2T; the
Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996, as applicable; the
Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
adopted June 1, 2000, as applicable; and other supporting data subsequently filed and approved by the
Department of Environment and Natural Resources and considered a part of this permit.
This permit shall be effective fro rn the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
by W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
By authority of the Environmental Management Commission
Permit Number: WQ0038626
Permit Issued: August 8, 2016
Page 3 of 8

SUPPLEMENT TO PERMIT COVER SHEET
City of Hickory is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the City of Hickory's Henry Fork
Regional Wastewater Treatment Facility in accordance with Permit Number NC0040797.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996, as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations
and Force Mains adopted June 1, 2000, as applicable, unless specifically mentioned herein. Division
approval is based on acceptance of the certification provided by a North Carolina -licensed Professional
Engineer in the application. It shall be the Permittee's responsibility to ensure that the as -constructed
project meets the appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below,
SPECIAL CONDI I IONS
1) No flow in excess of the quantity permitted herein, 16,373 GPD, shall be made tributary to
the subject sewer system until an application for permit modification for an increase in flow
has been submitted to and approved by the Division. [15A NCAC 02E0304 (b)]
II. STANDARD CONDITIONS
This permit is not transferable. In the event there is a desire for the wastewater collection facilities
to change ownership, or there is a name change of the Permittee, a foinial permit request shall be
submitted to the Division accompanied by documentation from the parties involved, and other
supporting materials as may be appropriate. The approval of this request shall be considered on its
merits and may or may not be approved. [15A NCAC 02T.0104; G.S 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 2T; the Division's Gravity Sewer
Minimum Design Criteria adopted February 12, 1996, as applicable; the Division's Minimum Design
Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000, as
applicable; and other supporting materials unless specifically mentioned herein. [15A NCAC
02T.0110]
This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .0110]
4, The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 2T .0403. If an individual
permit is not required, the following performance criteria shall be met: [15A NCAC 02T .0108(b)]:
Page 4 of S

a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i,e, 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at least
once per week.
e. High -priority sewer lines shall be inspected at least once per every six months and inspections
documented.
g.
A general observation of the entire sewer system shall be conducted at least once per year.
Overflows and bypasses shall be reported to the appropriate Division regional office in
accordance with 15A NCAC 2B .0506(a), and public notice shall be provided as required by
North Carolina General Statute §143-215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3 Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
i. Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
Documentation shall be kept for Subparagraphs (a) through (i) of this Rule for a minimum of
three years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staffmember at the Mooresville Regional
Office, telephone number [phone], as soon as possible, but in no case more than 24 hours
following the occurrence or first knowledge of the occurrence of either of the following:
a. Any process unit failure, due to known or unknown reasons, that renders the facility
incapable of adequate wastewater transport., such as mechanical or electrical failures of
pumps, line blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Page 5 of 8

Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside noittial business hours may also be reported to
the Division of Emergency Management at telephone number [phone] or [phone].
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part 11 of Form CS-SSO (or the most current Division
approved form) can also be completed to show that the SSO was beyond control. [G.S. 143-
215.1C(a1)]
6. Constniction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State. [15A NCAC 02T.0108(b)]
7. Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form attached to this pei mit shall be submitted with the required supporting
documents to the address provided on the form. A complete certification is one where the form is
fully executed and the supporting documents are provided as applicable. Any wastewater flow made
tributary to the wastewater collection system extension prior to completion of this Engineer's
Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions.
If the permit is issued to a private entity with an Operational Agreement, then a copy of the
Articles of Incorporation, Declarations/Covenants/Restrictions, and Bylaws that have been
appropriately filed with the applicable County's Register of Deeds office shall be submitted
with the certification.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a One copy of the project construction record drawings (plan & profile views of sewer lines &
force mains) of the wastewater collection system extension. Final record drawings should be
clear on the plans or on digital media (CD or DVD disk) and are defined as the design drawings
that are marked up or annotated with after construction information and show required buffers,
separation distances, material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing,
velocity, pump cycle times, and level control settings, pump station buoyancy, wet well storage,
surge protection, detention time in the wet well, and force main, ability to flush low points in
force mains with a pump cycle, and downstream sewer capacity analysis. If a portable power
source or pump is dedicated to multiple stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, include travel
timeframes, shall be provided.
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including pipe length increases of 10% or greater, increased
flow, pump station design capacity design increases of 5% or greater, and increases in the
number/type of connections), regulations, or the Minimum Design Criteria. Requested modifications
Page 6 of 8

or variances to the Minimum Design Criteria will be reviewed on a case -by -case basis and each on
its own merit. Please note that variances to the Minimum Design Criteria should be requested and
approved during the permitting process prior to construction. After -construction requests are
discouraged by the Division and may not be approved, thus requiring replacement or repair prior to
certification & activation. [15A NCAC 02T .0116]
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident prior to completing and
submitting the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the construction record drawings shall be maintained on file by the Pennittee for the life
of the wastewater collection facilities, [15A NCAC 02T .0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996, as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted
June 1, 2000, as applicable; and other supporting materials may subject the Perrnittee to an
enforcement action by the Division, in accordance with North Carolina General Statutes §143-215.6A
through §143-215.6C, construction of additional or replacement wastewater collection facilities,
and/or referral of the North Carolina -licensed Professional Engineer to the licensing board. [15A
NCAC 02T .0104; 15A NCAC 02T .0108(b-c)]
11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Perrnittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities.
[15A NCAC 02T .0110; 15A NCAC 02T .0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and ail statutes,
rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or
Local government agencies which have jurisdiction or obtaining other permits which maybe required
by the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 8

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE: CITY OF HICKORY
PERMIT #: WQ0038626
PROJECT: ASHBURY LANE SEWER PROJECT
ISSUE DATE: AUGUST 8, 20l6
This project shall not be considered complete nor allowed to operate in accordance with standard
Condition 7 of this permit until the Division has received this Certification and all required supporting
documentation. It should be submitted in a manner that documents the Division's receipt. Send the
required documentation to the Regional Supervisor, Water Quality Regional Operations Section at the
address noted in the page footer.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received by the Division. A Final Certification shall be a complete set of
record drawings and design calculations regardless of whether partials have been submitted.
PERNUTEE'S CERTIFICATION
1, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant to
the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain the
wastewater collection system permitted herein or portions thereof.
Printed Name, Title
Signature Date
ENGINEER'S CERTIFICATION
1, , as a duly registered Professional En neer in the State of North Carolina,
having been authorized to observe (fl periodically, D weekly, Li full time) the construction of the
project name and location as referenced above for the above Permittee hereby state that, to the best of my
abilities, due care and diligence was used in the observation of the construction such that the construction
was observed to be built within substantial compliance of this permit; 15A NCAC 02T; the Division of
Water Resources' (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996, as
applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000, as applicable; and other supporting materials.
North Carolina Professional Engineer's Seal wisigiature & date:
Final LI Partial (include description)
Certification Comments/Qualifiers (attach if necessary):
NC DWR — Water Quality Regional Operations Section 610 East Center Avenue, Suite 301, Mooresville, NC 28115
Mooresville Regional Office Phone: [phone] FAX: [phone]

Permit Number WQ0038626
Central Files: APS SWF'
8/812016
Permit Tracking Slip
Program Category Status Project Type
Non -discharge Active New Project
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
ortttMa
Coastal SINTRule
Permitted Flow
16,373
Facility
Version Permit Classification
1,00 Individual
Permit Contact Affiliation
Kevin B, Greer
Asst Director Public Services
3200 20th Ave SE
Newton
NC 28658
Facility Name
Astibury Lane Sewer Project
Location Address
Owner
MajoriMinor Region
Minor Mooresville
County
Catawba
Facility Contact Affiliation
Ovine( Name
City of Hick
Date Events
Owner Type
Government - Municipal
Owner Affiliation
Mick Berry
PO Box 398
Hickory
NC 28601039
Ong Issue Apo Received Draft Initiated
81812016 7725/2018
Regulated Activities
Scheduled
Issuance Public Notice Issue Effective
818/2018 8/8/2016
Requested /Received Events
Expiration
Retail Additional information requested 8/2118
Subdivision Additional information received 8/5116
Wastewater collection
Waterbody Name Streamindex Number Current Class Subbasin

TO THE
ORDER
OF
d.
THIS DOCUMENT CONTAINS A TRUE WATERMARK - HOLD TO LIGHT TO VERIFYWATERMARK
Fhls disbursement has beet
by the
CITY OF HICKORY
DATE
07/21/2016
HICKORY, NORTH CAROLINA
FOUR HUNDRED EIGHTY AND 00/100 DOLLARS
NCDEQ
DIVISION OF WATER QUALITY
MOORESVILLE REGIONAL OFFICE
610E CENTER AVENUE
M©ORFSVTLLF NC 2 €31 Z 5
I Act..
T 302124
Branch Banking and Trust Company
HICKORY, NC 28601
66-1 12/531
FYNANC€ QFFICER

City of Hickory
Post Office Box 398
Hickory, NC 28603
Phone: [phone]
Fax: [phone]
Email: [e-mail]
Public Utilities
July 28, 2016
NCDWR
610 E. Center Ave
Mooresville, NC 28 11 5
Attn: Ms. Dee Browder
RE: Ashbury Ln- Catawba Count- Sewer Line Extension Fast Track Permit Application
Dear Ms. Browder:
The purpose of this correspondence is to provide information relevant to the attached application.
This package is for submittal of the City of Hickory Ashbury Ln Lift Station and Collection
System. The application includes 1,000-ft of 8-inch gravity sanitary sewer and a Lift Station.
The improvements are being installed as a part of a development to include one fast food
restaurant, two potential outparcels, for small commercial and potentially a small Multi -family
development. The one fast food restaurant is the only thing committed at this time for
development.
Attached to this cover letter please find:
• Completed Application
• Fast -Track Form FTA 04-16
• Flow Tracking Form
• Site Maps
• Application Fee previously submitted
Thank you for your attention and cooperation. Should you have any questions please do not
hesitate contacting me.
Sincerely,
evin. B. Greer, PE
Assistant Public Services Director
Enclosures as listed
KBG/dc

of Water Resources
RECEIVENNCDENR/DWR State of North Carolina
Department of Environmental Quality
AUG 0 4 Z01,1 Division of Water Resources
aaata
15A NCAC 0 .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
mooR,srim 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 02T 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 practice.
While no upfront engineering design documents are 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 include plans, design
calculations, and project specifications referenced in 15A 'NCAC ,02T .03.05 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 15A NCAC 0210303.
Projects riot 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):
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):
Submit a check or money order in the amount of S480.00 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):
Submit the completed and appropriately executed application.
> If necessary for clarity or due to space restrictions, attachments to the application may be made.
O If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretani of State,
O 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.
The Project Name in Item 11.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
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 15A NCAC 02T .0106(b).
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 TrackinglAcceptance Fonn (Form: FTSE 04-16) (If Applicable):
Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
A Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
A 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.
A Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143:
21 5,67(a).
• Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
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)
A Downstream connection points and permit number (if known) for the receiving sewer
Include a street level map showing general project area.
G. Existing Permit (All Modification Packages):
O Submit the most recently issued existing permit.
D Provide la list of any items within the permit the Applicant would like the Division to address during the permit
modification .e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
0 Per 15A NCAC 02T .030511-W1), submit documentation of power reliability for pumping stations.
A 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 ease of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
El Per 15A NCAC 02T .0115(a)(U 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
El 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.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be Id):
O Home/Property Owners' Associations
El Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORIvl: HOA).
0 Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws,
O Developers of lots to be sold
El Per 15A NCAC 02T ,0115(b), submit the properly executed Qperational Agreement (FORM: DE \D.
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 0416 & SUPPORTING DOCUMENTATION
Page 2 of 3

THE COWLETED APPLICATION PACKAGE INCLDKNG ALL SUPPORTING INFORMATION AND
NIATERL4,LS,8HO0LD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
Asheville Regional Office
Water Quality Section
FaVettmviUeRegional Office
Water Quality Section
Mooresville Regional
Water Quality Section
ADDRESS
| COUNTIES SERVED
2U0UUSHighway 70
Svmnnanoa,North Carolina 28778
(82E)296-4500
(O20)2S8-7043Fax
Avery, Buncombe, Burke, Caldwell, Cherokee,
C|ay, Braham, Meywocd, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
225 Green Street Suite 714
Fayetteville,North Carolina 20301'5094
(91Q)480-O707Fax
Anson, Bladen.Cumberland, Harnett, Hoke,
Montgpmery, NYomre, Rubeeon, Riohmond,
Sampson, Scotland
G1OE.Center Avenue
Mooresville, North Carolina 28115
[phone]
(7D4)0]3-8{40Fax
!Raleigh Regional Offic
Water ua|itvGectioo
/ Office -WashingtonRegional
Water Quality Section
Wilminciton Regional Office
Water Quality Section
'Inuton-Sal.emRegional Office
| Water Quality Section
Alexander, Cabanuu.Catawba, Cleveland,
Gaston, |redel|'Lincoln, Mecklenburg, Rowan,
Stanly, Union
1G28Mail Service Center
Raleigh, North Carolina 27689'1028
[phone]
(91Q)7B8-715QFax
� `
S43Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone]Fax
127Cardinal Drive Extension
Wilmington, North Cwnd|nm 28405
<910796'7215
Chatham, Durham, Edgecombm.Franklin,
Gcunx6he, Halifax, Johnston, Lee, Namb,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Beaufort, Bertie.Camden, Ch,owmn.Craven,
Currbudk.Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pnm|ico.Pmsquotank.
Perquimans, Pitt, Tyrrell, Washington, Wayne
Brunswick, Carteret, Columbus, Duplim,New
Hanover, Onslow, Fender
45ON1Hanes Mill Road
Sudm3OO
vWnston-Salem.North Carolina 271Q5
[phone]
/Uamanoa.AJleghany.Ashe.Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Sumy,Watauga, uN|keo,Yadkin
INSTRUCTIONS fORFODA4, FTA 04-l6&SOPPORTrNGDOCUMENTATION
Page 3 of 3

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
App i is
ion Number:
Ali items
APPLICANT INFORMATION:
1. Applicant's name: City of Hicko.
2. Applicant tyre: © Individual
© Federal
Signature authority's name: And
Title: interim City Manager
4. Applicant's mailing address: PO. Box 398
City: Hickory State: NC Zip: 28603-
5. Applicant's contact information:
Phone number: [phone] Email Address: ttsura
PROJECT INFORMATION:
1. Project name: Ashbury Ln Sewer Project
2. Application/Project status: Proposed (New Permit) Ej Existing Pe' :Project
If a modification, provide the existing permit number: WQOil and issued date:
If new construction but part of a master plan, provide the existing perrnit number: WQ©d
3. County, where project is located:: Catawba
4, Approximate Coordinates (Decimal Degrees): Latitude: 3 ,69' Longitude:-81.35°
5. Parcel ID (if applicable): 3701-13-04-9669
(or Parcel ID to closest downstream sewer)
ust be completed or th
comp y, municipalit
Ej Corporation
[� State/County
(to be completed by DWR)
ptallcation
11 be returned
I1:OA, utility, etc.)
[j General Partnership El Privately -Owned Public Utility
Municipal 0 Other
tt per 15A NCAC 02T .0106
korvnc, uov
LII. CONSULTANT INFORMATION;:
1. Professional Engineer: Kevin B„ Greer License Number: 02693'7
Firm: City of Hickory
Mailing address: PO Box 398
City: Hickory State: SIC Zip: 28603-
Phone number: [phone] Email Address: kareer�a'?,hickorync.gov
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Henry Fork WWTF Permit Number: NC0040797
Owner Name: City of Hickory
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: 10 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS04020
Owner Name(s): City of Hickory
FORM: F"i'A 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?
1 Yes ON° N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEVI been attached?
Yes EN° N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
fl Yes EINo N/A
4. Origin ofwastewater: (check all that apply):
Residential Owned
0 Residential Leased
El School / preschool / day care
0 Food and drink facilities.
Ej Businesses/ offices / factories
0 Retail (stores, centers, malls)
Retail with food ,preparation/service
LI Medical / dental / veterinary facilities.
O Church
Nursing Horne
Car Wash
Hotel andlor Motels
0 Swimming Pool /Clubhouse
Swimming Pool/Filter Backwash
O Other (Explain in Attachment)
5. Nature of wastevvater : 60 % Domestic/Commercial 40 °A) Commercial
% Industrial (See 15A NCAC 02T .01031201)
>Is there a Pretreatment Program in effect? 0 Yes El No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? E: Yes No
yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type s e 02T.0114(f))
Residential Multi- Family
Commercial
Retail/Restaurant
120 gaLtedroom
120 ga1/1000 sqft
40 gaL'15 sqft
80 bedroom
12,000 sqft
2000 sqft
Total
16,373 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) 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 021' ,0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T,0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project 16,373 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
El Flow has already been allocated in Permit Number:
0 Rehabilitation or replacement of existing sewer with no new flow expected
El Other (Explain):
FORM: FTA 04-16
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Ap bl ) - 02T .0305 & MDC (Gravity Sewe
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
1200
PVC
• Section 11 & U1 of the MDC for Permitting of Gravity Sewers contains information related to design criteria
Section HI 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
VIII. .PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION :INCLUDED IN THIS PROJECT
1. Pump station number or name: Asbury Ln
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.69° Longitude: -81,35'
3. Design flow of the pump station: 59.597 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 62, gallons per minute at 45 feet total dynamic head (TD1-)
5. Summarize the force main to be permitted (for this Plump Station):
Size (inches)
Length (feet)
480
Material
PVC
6. Power reliability in accordance with 15A NCAC 02T .0305(11)(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:
E] Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
ID Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
i> 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 04-16
Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(t)):
1,
Does the project comply with all separations found in 15A NCAC 02T .0305(0 &
• I5A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter* Separation Required
Storm sewers and other utilities riot listed below (vertical)
Water mains (vertical -water over sewer including in benched trenches)
Water mains (horizontal)
Reclaimed water lines (vertical - reclaimed over sewer)
Reclaimed water lines (horizontal - reclaimed over sewer)
**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
24 inches
18 inches
10 feet
18 inches
2 feet
100 feet
Waters classitied WS (except WS-I or WS-V), B, SA, ORW, HOW, 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
Any_building foundation
10 fee
5 feet
mbanknaent or cuts of 2 feet or more vertical height
and interceptor drains
Any swimming pools
Hnal earth grade (vertical)
10 feet
10 feet
fe
10 feet
36 inches,
• 15A NCAC 02T0305(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 webpage
• It -noncompliance with 02T,0305 o see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation)
); See the Division's draft separation requirements for situations where separation cannot be meet
.A No variance is required if the alternative design criteria specified is utilized in design and construe
• As built documents should reference the location of areas effected
3. Does the project comply with all setbacks found in the river basin rules per 5A NCAC 02B .0200?
• This would include Trout Buffered Streams per 15A NCAC 2B.0202
[Z1 Yes ENo
No
Yes 1 INo
4. Does the project comply with an individual 404 Permit or any 401 Certifications? Yes El No
• Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
)0 Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T,0105(c)(6) (additional permits/certifications)? Yes LI No
Per 15A NCAC 02'1'1)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 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,
D Yes No
▪ If yes, include an attachment with details for each line, including type (aeriai 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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permittin ofPum Stations
and Force Mains (latest versiorA and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
VA Yes L1No
If No, complete and submit the Variance/Alternative Design 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'
I, kc,1,& C
(Professional Engineer's name from Application Item III, I .
attest that this application for
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 143-215,6B, 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):
rc- r'‘ riAt4 A (2-
(Signature Authority's name & title from Application Item L3.)
at this application for
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, andlor 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 143-215.6B, 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,
Signature:
Date:
FORM: FTA 04-16
Page 5 of 5

Geospatial
Information Services
Real Estate Search
lin=600ft
Parcel: 370113144926, 2175 ASHBURY LN HICKORY, 28602
Owners: SHARPE LARRY WILLIAM, SHARPE WAYNE LOUIS
Owner Address: 1072 ZION CHURCH RD
Values - Building(s): $8,800, Land: $26,700, Total: $35,500
This map/report product was prepared from the Catawba County, NC Geospatial Information Services, Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained on this map or data on this report. Catawba County promotes and recommends
the independent verification of any data contained on this map/report product by the user, The County of Catawba, its employees, agents, and
personnel, disclaim, and shall not be held liable for any and all damages, loss or liability, whether direct, indirect or consequential which arises or may
arise from this map/report product or the use thereof by any person or entty,
Copyright 2014 Catawba County NC
07/08/2016

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 08-13)
Project Applicant Name: City of Hickory
Project Name for which flow is being requested: Ashbury Lane Sewer Project
More than one FT5'E may: be required for a single project if the owner of the *1'4"7P is not responsible
stations along the route nf'the proposed wastewater flow.
0
pump
Complete this section only if you are the owner of the wa
a. WWTP Facility Name; Henry Fork WWTP
b. WWTP Facility Permit #: NC0040797
atr ent p
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary .
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the faci.li
h. Percent of permitted flow used
All flows are in D�
9.0.
the WWTP 1.69762
2.67
0.016373
4.383993
48.7%
Il. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
ist 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. Firm Flow** Current Avg, Tributary Flow Plus
(Name or Capacity„* (Firm / pf), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
* The Firm Capacity ofany pump station is defined as the maximum pumped flow
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.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < O.
hat
Page 1 of 6
FISE08-13

eriit cation Stater n
IAndrea Surratt, Interim City certify tco the best of my knowledge that the addition of
11i1 a.ger
the volume of wastewater to be pet.fitted in this project has been evaluated along the rcoute 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 treat eat plant under normal circumstances, given the implementation
entation
of the pl ed 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 l
plus all attached planning assessment addendums for which I am the responsible party.
Signature of this form indicates acceptance of this wastewater flow:
Pag of

rvto„),
P/ovvo
AUG 0 4 2016
o atter tOck wm°S INSTRUCTIONS
.14:9,;j510A7AC 02T .0300 —
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
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 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(1),
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans,
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria,
documents shall be available upon request by the Division.
Projects that are deemed Remained (do not require a permit from the Division) are explained in 15A 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 NC AC IC .0100;
> Projects that do not meet any part of the minmum deskscriteria (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.
design
design
These
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):
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):
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):
Submit the completed and appropriately executed application.
• If necessary for clarity or due to space restrictions, attachments to the application may be made.
O 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.
Q 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.
The Project Name in Item 11. I shall be consistent with the project name on the flow acceptance letters, agreements, etc.
The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina lic n ed Professional En Meer.
O The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b),
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 & SIJPPORTING DOCUMENTATION
Page 1 of 3

E. Flow Tracking/Acceptance Form (Form FTSE 04-16) (11' Applicable):
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 r other contracts will not be accepted in lieu of a project -specific VISE.
F. Site Maps (All Application Packages):
Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identi
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 showing general project area.
ie entire project
G. Existing Permit (All Modification Packages):
O Submit the most recently issued existing permit.
O 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.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
0 Per 15A NCAC 02T .0305(h)(1), 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)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
0 Per 15A 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
D 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.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
O Home/Property Owners' Associations
O Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORNI: HOA).
El Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
O Developers of lots to be sold
El Per 1.5A NCAC 02T .01I5(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
II'STRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
Water Quality Section
2090 US Highway 70
Swannanoa, North Caroli
[phone]
[phone] Fax
28778
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
Water Quality Section
225 Green Street Suite 714
Fayetteville, North Carolina 28301-5094
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
IViooresville Regional Office
Water Quality Section
Raleigh Regional Office
Water Quality Section
610 E. Center Avenue
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
[phone]
[phone] Fax
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee,Nash,
Northampton, ©range, Person, Vance, Wake,
Warren, Wilson
hington Regional
ater Quality Section
ce
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
ington Regional Office
er Quality Section
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Beaufort, Bertie, Camden, Chowan, Craven,.
Currituck, Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington, Wayne
Brunswick, Carteret, Columbus, Duplin, New
Hanover, ©nslow, Fender
alem Regional Office
ity Section
450 W. Hanes Mill Road
Suite 300
Winston -Salem, -North Carolina 27105.
[phone]
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
TRUCTION Ft R FORi'vt: FTA 04-16 SUPP©RTING DOCU1v NTATION Page 3 of 3

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 Numb (to be completed by DWR)
Al] items must be completed or the application will be returned
APPLICANT INFORMATION:
1. Applicant's name: City of Hickory (company, municipality, HOA, utility, etc.)
2. Applicant type: Individual. 0 Corporation 0 General Partnership 0 Privately -Owned Public Utility
0 Federal
0 State/County Municipal 0 Other
3. Signature authority's name: Andrea Surratt per 15A NCAC 02T ..01.06(b)
Title: Interim City Manager
4., Applicant's mailing address: PO Box 398
City: Hickory State: NC Zip: 28603-
5. Applicant's contact information:
Phone number: [phone] Email Address: asaraickoync,gov
IL PROJECT INFORMATION:
1. Project name; Ashbury Ln Sewer Project
2. Application/Project status: Proposed (New Permit) 0 Existing Penn-tit/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: WQ00
3. County where project is located: Catawba
4. Approximate Coordinates (Decimal Degrees); Latitude: 35.69* Longitude: -81.35'
5. Parcel ID (if applicable): 3701-13-04-9669
(or Parcel ID to closest downstream sewer)
HI. CONSULTANT INFORMATION:
1. Professional Engineer: Kevin. B. Greer License Number: 02.6937
Firm: City of 1-fickory
Mailing address: PO Box 398
City: Hickoa. State: NC Zip: 28603-
Phone number: [phone] Email Address: kgreer(ylickorync...gov
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Henry Fork WWTF Permit Number: NC0040797
Owner Name: City of Hickory
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWII):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: 10 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS000.20
Owner .Name(s): City of Hickory
FORM: FTA 04-16 Page 1 of 5

GENERAL REQUIREMENTS
If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
the Applicant is a Developer o
0 Yes
be sold, has a Devel
0 Yes 0No
No
N/A
ationa
N/A
n
FORM: DEY) been attached?
3. If the Applicant is a ome/Property OwnersAssociation, has an Operational Agreement (FORM: HOA) been attached?
0 Yes 0No N/A
4, Origin of wastewater (check all that apply):
Residential Owned
0 Residential Leased
0 School / preschool / day care
Food and drink facilities
0 Businesses / offices / factories
0 Retail (stores, centers, malls)
Retail with food preparation/service
D Medical / dental / veterinary facilities
0 Church
D Nursing Home
5. Nature of wastewater : 60 % Domestic/Commercial 40 % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
>-Is there a Pretreatment Program in effect?
6. Has a flow reduction been approved under I5A NCAC 02T .0114(f)? 0 Yes
if yes, provide a copy of flow reduction approval letter
7, Summarize wastewater generated by project:
Car Wash
0 Hotel and/or Motels
D Swimming Pool /Clubhouse
Swimming Pool/Filter Backwash
0 Other (Explain in Attachment)
Yes 0 No
No
Establishment Type 02T.0114(f)
Residential Multi- Family
Commercial
Dailv Design Flow a,b
120 gal/bedroom
Retail/Restaurant
120 gal/1000 sqft
No. of Units
Flow
80 bedroom 9600 GPD
12,000 sqft
1440 GPD
40 ga1/15 sqft
2000 sqft
5333 GPD
gal/
gal/
gali
GPD
GPD
Total
GPD
16,373 GPD
a See 15A NCAC 02T .0114(b), (d),,(e)(1) 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.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data,
8. Wastewater generated by project: 16,373 GPD (per 15A NCAC 02T .0114)
> Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
0 Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
0 Flow has already been allocated in Permit Number:
Rehabilitation or replacement of existing sewer with no new flow expected
0 Other (Expiain)
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)
8
Length (feet)
1200
Material
PVC
A Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
A 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
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains:
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Asbury Ln
2. Approximate Coordinates (Decimal Degrees): Latitude: 35,69' Longitude: -81„35'
3. Design flow of the pump station: 59,597 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 62 gallons per minute at 45 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet)
3 480
Material
PVC
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)(13)1
A Required for all pump stations with an average daily flow eater than or equal to 15,000 gallons per day
A Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
El Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
„0305(h)(1)(C)
Or
El Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02-r .030
X
XC):
> 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.
A 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

LX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) &
15A NCAC 02T.0305(f) containsseparations that shallbe provided for sewer ystems:
tback P er*
Storm sewers and other utilities not listed below (vertical)
Water mains (vertical -water over sewer including in benched trenches)
Water mains
ical reclairned over sewer
Reclaimed water lines orizont reclaimed over sewe
Yes El No
Separation Required
24 inches
18 inches
0
2 feet
Any private or public water supply source, including any wells, WS-I waters of Class I or
Class 11 impounded reservoirs used as a source of . g water
aters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
ater (or tide elevation) and wetlands (see item IX.2)
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
Any building foundation
Any basement
Top slope of embankment or cuts of 2 feet or more verticalhei
ge
y
d intercevtor draiii
Any swimming pools
Final earth grade (vertical)
00 feet
5
10 feet
5 feet
0 feet
10 feet
5 feet
e
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 webpage
> 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)
> 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
Yes El No
3. Does the project comply with all setbacks found in the river basin rules per 15A NCAC 02B .020 Yes No
> This would include Trout Buffered Streams per 15A NCAC 2B4O202
4, Does the project comply with an individual 404 Permit or any 401 Certifications? 4 Yes El No
> Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
> Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? Yes E] No
Per 15A NCAC 02T.0105(e)(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,
E] Yes No
> 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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Desi Criteria for the Permitting, of Pump Stations
and Force Mains (latest version), and the Gravity Sewer MitliM11113 Desi Criteria 'latest versio as applicable?
Yes El No
If No, co u dete and submit the Variance/Alternative Design Request application (V ADC 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:
(ProfessionalEngineer's name from Application Ite
attest that this application for
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 Pemiitting
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.
NO1E, — 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 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'
workoviii"
eal, signature, and date: F.?
- .0 '•
3. Applicant's Certification per 15A NCAC 02T ,0106(b):
1, fri 31.2 A Sc, g_ A tirmzi in A r4 A 1'2_ attest that t is applicationor
(Signature Authority's name & title ffom Application Item .
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if ail 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 143-215.613, 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.
Signature:
Date:
FORM: FTA 04-16
Page 5 of 5

AA Geospatial
information Services
Real Estate Search
1 in=600ft
Parcel: 370113144926, 2175 ASHBURY LN HICKORY, 28602
Owners: SHARPE LARRY WILLIAM, SHARPE WAYNE LOUIS
Owner Address: 1072 ZION CHURCH RD
Values - Building(s): $8,800, Land: $26,700, Total: $3 n
5 5©0
This map/report product was prepared from the Catawba County, NC Geospatial Information Services. Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained on this map or data on this report, Catawba County promotes and recommends
the independent verification of any data contained on this map/report product by the user, The County of Catawba, its employees, agents, and
personnel, disclaim, and shall not be held liable for any and all damages, loss or liability, whether direct, indirect or consequential which arises or may
arise from this map/report product or the use thereof by any person or entity.
Copyright 2014 Catawba County NC
/08/2016

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
r t R„„„ Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 08-13)
Project Applicant Name: City of Hickory
Project Name for which flow is being requested: Ashbury Lane Sewer Project
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for ail pump
stations along the route oftheproposedwastewarcrflow.
I. Compiete this section only if you are the owner of the wastewater treatment plant.
a, WWTP Facility Name: Henry Fork WWTP
b. WWTP Facility Permit #: NC0040797
Alt flows are in MGJi
c. WWTP facility's permitted flow 9.0
d. Estimated obligated flow not yet tributary to the WWTP 1.69762
e. WWTP facility's actual avg. flow 2.67
f. Total flow for this specific request 0.016373 •
g. Total actual and obligated flows to the facility 4383993
h. Percent of pennitted flow used 48.7°%©
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
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current -Avg., Tributary Flow Plus
Name or Capacity,* (Firm/ pt), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
* The Firm Capacity of any pump station is defined as the maximum pumped flow
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 (pt) not less than 2.5.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < O.
Page 1. of 6
FTSE 08-13

111. Certification Statement:
I Andrea Surratt, Interim City certify to the best of my knowledge that the addition of
Manager
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 overlauden any downstream pump station
en route to the receiving treatment plant under no *sal circumstances, given the implementation
of the planned improvements identified in the planning assessinent 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 adderidtmls for which I am the responsible party.
Sigriature of this form indicates acceptan.ec of this 'wastewater flow,
Signing Official Signature
Page 2 of 6
Date
FTSE 08-13