WQ0023049_Regional Office Historical File Pre 2018

'NAT Michael F, Easley, Governor
William G. Ross Jr,, Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
Coleen h. Sullins, Deputy Director
Division of Water Quality
September 8, 2003
Mr. Daniel Patton
Gaston Christian School
200 Mercy Drive
Belmont Campus
Belmont, North Carolina 28012
Subject: Permit No. WQ0023049
Gaston Christian School
Gaston Christian School Gym
Wastewater Collection System Extension
Gaston County
Dear Mr. Patton:
In accordance with your application received on September 3, 2003, we are forwarding herewith
Permit No. WQ0023049, dated September 8, 2003, to Gaston Christian School for the construction and
operation 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date of issuance until rescinded, and shall be subject to the conditions and limitations as specified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 Permit Condition 3 which requires that the wastewater
collection facilities be properly operated and maintained in accordance with 15A NCAC 2H .0227 or any
individual system -wide collection system permit issued to the Permittee.
Permitting of this project does not constitute an acceptance of any part of the project that does
not meet 1)15A NCAC 2H .0200; 2) the Division of Water Quality's (Division) Gravity Sewer Minimum
Design Criteria adopted February 12, 1996, as applicable; 3) 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. 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.
Mooresville Regional Office
919 N. Main Street, MooresvIlle, NC 28115
Internet http:ilh2oenr state nc,us/
Telephone [phone] Fax (704) 40
ISITC15ENR
DENR Customer Service Center
Telephone [phone]

Mr. Daniel Patton
Page 2
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 Gaston Christian School for the construction and operation of approximately 1,283 linear feet
of 8-inch gravity sewer to serve a 400 seat gym as part of the Gaston Christian School Gym project,
and the discharge of 4,800 gallons per day of collected domestic wastewater into the City of Lowell's
WWTP (NPDES No NC0025861) existing sewerage system, pursuant to the application received
September 3, 2003 and in conformity with 15A NCAC 2H .0200; 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 become voidable unless the agreement between Gaston Christian School and
the City of Lowell far the collection and final treatment of wastewater is in full force and effect,
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing upon mitten request within 30 days following receipt of this
permit. 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.
If you need additional information concerning this matter, please contact Sonja Williams at (704)
663-1699.
Sincerely,
.for Alan W. Klimek, P.E.
cc: Gaston County Health Department
Mooresville Regional Office, Water Quality Section (WVVTF Permit No. NC002586
Franklin Craig, Carolinas Design Group, PLLC
Water Quality Central Files
NDPU Files

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
This permit shall be effective from the date of issuance until rescinded and shall be subject to the
following specified conditions and limitations:
1. This permit shall became voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 2H .0200; the Division of Water Quality's
(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 unless specifically
mentioned herein.
2. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data.
3. The wastewater collection facilities shall be properly maintained and operated at all times. The
Perrnittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 2H .0227. If an individual
permit is not required, the following performance criteria shall be met as provided in 15A NCAC 2H
.0227:
a. The sewer system shall be effectively maintained and operated at all times to prevent
discharge to land or surface waters, and any contravention of the groundwater standards in
15A NCAC 2L .0200 or the surface water standards in 15A NCAC 28 .0200.
b. A map of the sewer system shall be developed prior to January 1, 2004 and shall be actively
maintained.
c. An operation and maintenance plan shall be 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 fines shall be inspected at least once per every six-month period of time.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Inspection and maintenance records shall be maintained for a period of at least three years.
h. Overflows and bypasses shall be reported to the appropriate Division regional office in
accordance with 15A NCAC 28 .0506(a), and public notice shall be provided as required by
North Carolina General Statute §143-215,1C.

4, This permit shall not be 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 formal 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.
5. Construction 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.
6. Upon completion of construction and prior to operation of these permitted facilities, a certification, a
copy of the construction record drawings, as well as supporting design calculations for any pump
stations permitted as part of this project shall be received from a North Carolina -licensed
Professional Engineer certifying that the facilities have been installed in accordance with this
permit; 15A NCAC 2H .0200; 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 Main adopted June 1, 2000 as applicable; and other supporting materials. If this
project is to be completed in phases and partially certified, you shall retain the responsibility to
track further construction approved under the same permit, and shall provide a final certificate of
completion once the entire project has been completed. A copy of the construction record
drawings, indicating the facilities constructed in the phase being certified, shall be submitted with
each partial certification. Mail the Engineer's Certification, one copy of the "Construction Record
Drawings,' and one copy of the supporting design calculations to the Non -Discharge Permitting
Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617.
7. A copy of the construction record drawings shall be maintained on file by the Permittee for the Iife
of the wastewater collection facilities.
Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2H .0200; 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 Permittee to an
enforcement action by the Division, in accordance with North Carolina General Statutes §143-
215.6A through §143-215.6C.
9. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including
those as may be required by this Division, such as the construction of additional or replacement
facilities.
10. The issuance of this permit shall not exempt the Permittee from complying with any and all
statutes, rules, regulations, or ordinances that may be imposed by other government agencies
(local, state and federal) which have jurisdiction, including but not limited to applicable river buffer
rules in 15A NCAC 2B .0200, erosion and sedimentation control requirements in 15A NCAC Ch. 4
and under the Division's General Permit NCG010000, and any requirements pertaining to wetlands
under 15A NCAC 2B .0200 and 15A NCAC 2H .0500.

11. Noncompliance Notification:
The Permittee shall report by telephone to the Mooresville Regional Office, telephone number
[phone], as soon as possible, but in no case more than 24 hours or on the next working
day, 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 failure of a pumping station or sewer line resulting in a by-pass directly to receiving waters
without treatment of all or any portion of the influent to such station or facility.
Persons reporting such occurrences by telephone shall also file a written report in letter 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.
Permit issued this the 8th day of September, 2003,
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Alan W. Klima PE, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0023049

East Track Engineering Certification
Permit No. WQ0023049
September 8, 2003
Complete and submit this form to the permit issuing regional office with the following:
• One copy of the project record drawings (plan & profile views of sewer lines) of the wastewater collection
system extension
• supporting design calculations (selected pumps, system curve, operating point, available storage if portable
generator(s) or storage greater than longest past three year outage reliability option selected) for any pump
stations permitted as part of this project
• Changes to the project should be clearly identified on the record drawings or in written summary form. Permit
modifications are required for any changes resulting in non-compliance with this permit, regulations or
minimum design criteria.
This project shall not be considered complete nor allowed to operate until this Engineer's Certification and all
required supporting documentation have been received by the Division, Therefore, it is highly recommended
that this certification be sent in a manner that provides proof of receipt by the Division.
ENGINEER'S CERTIFICATION
LJ Partial E Final
, as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observe (E] periodically, fl weekly, Elfull time) the construction of the Gaston Christian
School Gym, Gaston County project for the 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 2H ,0200: the Division of Water Quality's (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 Engin€
seal, signature, and date:
SEND THIS FORM & SUPPORTING DOCUMENTATION
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS
MOORESVILLE REGIONAL OFFICE
919 N. MAIN STREET
MOORESVILLE NC 28115
The Permittee is responsible for tracking all partial certifications up until a final certification is received. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion of this
Engineers Certification shall be considered a violation of the permit and shall subject the Permittee to appropriate
enforcement actions.

09108/03
Permit Number W(30023049
Permit Tracking Slip
Program Category
Nen-discharge
Permit Type PaSt -'racK
Gravity Sewer Extension, Pump Stations, & Pressure Sewer
Extensions
Primary Reviewer
sonja,williams
Permitted Flow
4800
Facility
Facility Name
Gaston Christian School Gym
Location Address
Owner
Owner Name
Gaston Christian School
Status Project Type
in review New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Dates/Events
Ong issue
Major/Minor
Minor
Region
Mooresville
County
Gaston
Facility Contact Affiliation
Owner Type
Non-Govemment
Owner Affiliation
Daniel Patton
200 Mercy Drive
Belmont
Scheduled
App Received Draft Initiated Issuance
09/03/03
Regulated Activities
Public fitotioe
D ic, other
Sehrstri
Duffel! \JULE
Issue
/JO/Da
Requested/Raceived Events
Additional information requested
Additional Infoimation received
Water y Name Stream index Number
Current Class
Stitibasirt
NC 2 012
Effective Expiration

GASTON 1 TIA SCHOOL, INC.
PLANT FUND
200 MERCY DRIVE
FJFrm1 MON I', NC 280I1
NCDENR
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CITIZENS SOUTH
2245 WEST MAIN AVENUE
['AST ONVA, Nu ;:00)5
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CHECK DATE
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IANSCHOOL IN

LC
Land Surveying
Land Planning
Civil Engineering.
Geo Technical Engi
er
August 25
Ms. Dee Browder
NCDENR,
919 North Main Street
Mooresville, NC 28115
Re: Fast Track permit Gaston Christian School Gym - Sewer Extension,
Dear Ms. Browder:
Gerald. M.. Sosele, PLS
Michael L. Clo:ningcr.
Franklin S, Craig, PE
Jerry W, Cook, PE
Enclosed you will find the application for the sewer extension for the Gaston Christian School Gym -
sewer extension in Lowell, NC, Two applications, flow acceptance letter from the Town of Lowell and
the $400.0O application fee submitted with this application.
Please contact this office if you have any questions or coments,
Sincerely,
Franklin S. Craig, PE
201 West Second Avenue Gastonia, NC 28052
Phone [phone] Fax [phone]

August 26, 2003
NCUENR
919 N. Main Street
Mooresville, NC 28115
Attn: Sonja Williams
Re: Gaston Christian School
Dear Ms. Williams,
The City of Lowell agrees to accept the flow of 4,800 gallons of waste -water per
day (gpd) for the proposed Gaston Christian School compound. The waste -water will
be treated by the City ofLowell Waste Treatment Plant facility.
If you should have further questions concerning this matter, please do not hesitate
to call on me. I remain,
Respectft 11
Ben T. Blackburn.,.
B B/
City of Lowell
101 W. Furst Street • Lowell, North Carol na 28098 • Phone: [phone] • Fax: [phone]

TOR0r map printed on 07/14/03 from "Nortii Carolnavo" and "UnttedJpg"
91°07.000W 81°06,000' W WGSB4 131°05,000'
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_ IMO 4E1 4c,r AACIPIS
Punted trona TOPOI (021301 Net)onmil Grovaphsc Holdings (www top° tom)
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State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
eat€ sewer systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included the following list of required application package items by checking the
space provided next to each item. Failure to submit all required items will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
Application Form - Submit one original and one copy of the completed and appropriately executed application
form. Any changes to this form will result in the application being returned. The Division of Water Quality
(Division) will only accept application packages that have been fully completed with all applicable items
addressed. You do not need to submit detailed plans and specifications unlessyou respond NO to Item)(12).
'II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
III. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2a) of this application.
Ell IV. Operational Agreements — Submit one original and two copies of a properly executed operational agreement if
the sewer extension will be serving residential or commercial lots (e.g., houses, condominiums, townhomes,
outparcels, etc.) that will be owned by a homeowners° association or developer (Item B(2b)), If the applicant is a
homeowners° association, use Form HOA 02/03, If the applicant is a developer, use Form DEV 02/03. EVEN IF
THE PROJECT WILL BE TURNED OVER TO A MUNICIPALITY, FORM DEV 02/03 iS REQUIRED,
I- V.
Flow Acceptance Letters — If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and name and permit number of the receiving sewers/V VU' T The flow acceptance must not
expire prior to permit issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
Vi. Map — Submit an 8.5-inch by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map along with this
form. The map should identify the entire project area location as well as the closest downslope surface waters as
clearly as possible. Each map portion must be labeled with the map name and number, the identified location,
and be of clear and reproducible quality, For instance, if the project involves 4 miles of interceptor sewer that
traverses over or near several different waterbodies (or counties, basins, etc.), the map should have location ID's
for each different waterbody (where the sewer line is within 100 feet of such waterbody - see Instruction VII).
Vll. Watershed Classifications — Section C
• If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)' available from http://h2o.enr.state.nc.us/ndpu or by contacting the appropriate regional
office.
INSTRUCTIONS FOR FORM FTA 02/03

II. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) j1SA NCAC
01C .0500], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
processed until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS) has been
issued. A copy is to be submitted with that permit application.
Certifications — Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE).. The applicant signature must match the signing official listed in Item A(1 b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, the Gravity Sewer Minimum Design Criteria (most
recent version) and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
(most recent version), as applicable to the project. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral,
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
REGIONAL OFFICE
ADDRESS
sheville Regional 0
Fayetteville Regional Office
59 Woodfin Place
Asheville, North Carolina 28801
[phone]
[phone] Fax
COUNTIES SERVED
Avery, Buncombe, Burke, Caldwell,
Cherokee, Clay, Graham, Haywood,
Henderson, Jackson, Macon, Madison,
McDowell, Mitchell, Polk, Rutherford, Swain,
Transylvania, Yancey
225 Green Street Suite 714
Fayetteville, North Carolina 28301
[phone]
[phone] Fax
ooriesville Regional
eigh Regional
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson„ Scotland
919 N Main Street
Mooresville, North Carolina 28115
[phone]
[phone] Fax
hincgton Regional Office
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, Orange, Person, Vance, Wake,
Warren, Wilson
943 Washington Square 1
Washington, North Carol.'
[phone]
[phone] Fax
n+gton Regional Office
Winston
Ofh ce
alem Regional
27889
127 Cardinal Drive Extension
VVimington, North Carolina 28405
[phone]
[phone] Fax
585 Waughtown Street
Winston-Salem, North Carolina
27107
[phone]
[phone] Fax
Beaufort, Bettie, 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, Onslow, Pender
Alamance, Allegheny, Ashe, Caswell,
Davidson, David, Forsyth, Guilford,
Rockingham, Randolph, Stokes, Surry,
Watauga, Wilkes, Yadkin
For more information, visit our web site at: http•//h20.enr.state.nc.us/ndpu/
INSTRUCTIONS FOR FORM
A 02/03

CK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
1 Owner:
1 a„
Full Legal Name
z 1 b
O Signing (...5ffl
2
ld
O Street Address
z
z
O h
— J
11. Brief Project Name (per
'CC 3. Contact Person:
PAGE I.
Application Number:
(to be completed by DWQ) iki .00 304-9
Please review 15A NCAC 2H 02
b) for authorized sigrAng offcasI)
lc„ The legal entity who will own this system is:
O Individual 0 Federal 0 Municipality 0 State/County 0 Private Partnership 0 Corporatio
M Dr; V e
if, Niel "I'61 624PlieLet_
ete_m goo 1i
Telephone Facs
2 Project Facility) information:
2a Cta
Net
y
1g
4 ij
Ci
Zip Code
E-mail
2b (zia
County Where Project is Located
3a W1&( thwLki& 1ILJ_Cr
Name and liation of Someone W*dJan Answer s ions About this Applieation
3b,
ne Number
Oooi 3c.
1, Project is Er/New 0 Modification (of an existing permit)
reivitt e etvo
If Modification, Permit No.:
2 Owner is 0 Public (skip to Item B(3)) IBvate (go to Item 2(a))
2a If private, applicant will be:
EWRetaining Ownership (Le. store, church, single office, etc.)
O Leasing units (lots, townhomes, etc. - skip to Item Bp)
O Selling units (lots, townhomes, etc. - go to 'tern B(2b))
O 3
LL
z
th
d
peci
.rc. Co
2b. If sold, facilities owned by a (must choose one)
01 Public Utility (Instruction III)
0 Homeowner AssociDeveloper (instruction IV)
ater Treatment Facility (WVVTF) Treating Wastewater From This Proj
Wir 4b ocZ5e3.6_1
5b.
_
Receiving Sewer Size
The origin of this wastewater is (check all that apply):
O Residential Subdivision
0 Apartments/Condominiums
El Mobile Horne Park
School
1:j Restaurant
O Office
Li Car Wash
0 Institution
D Hospital
0 Church
0 Nursing Home
0 Other (specify):
7 Volume of wastewater to be permitted in this proj
5c.
WWTF Permit No
Permit Nu be
lions per day
of Downst ea
Sewer
Domestic/Commercial
% Industrial
% Other (specify):
B. If the permitted flow is zero, indicate why:
0 Interceptor Line - Flow will be permitted is subsequent permits that connect to this line
Li Flow has already been allocated in Permit No.
0 Rehabilitation or replacement of existing sewer with no new flow expected

CK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
1 Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02/03
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
o necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
regional office (see instructions for addresses) OR indicate the following:
El A Watershed Classification is not needed because all parts of the project are at least 100 feet away from any down
O slope waterbody, AND,
El A Watershed Classification is not needed because the design does not depend on wet well storage as a power
reliability option for any pump station near a Class C down slope waterbody
WATERSHED
0
Location ID
on Map
Name of
Waterbody
14104i
Nak
Waterbody Stream Waterbody
County River Basin Index Classification
Ck4-etiAktAl I (4
Submit the 8.5" x 11" topographic map as required in Instruction VI regardless of whether a classification is providedf
1. Applicant's Certification:
/ attest that this application for 64erk 1fJTi1.,CeLfftL
1 a
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 ail required supporting documentation and attachments are not included, this application package is subject to
being returned as incomplete, Note: In accordance with North Caroline General Statutes 143-215,6A and 143-215.6B,
any person Wh knowingly makes any false statement, representation, or certification in any application shall be guilty of
a Class 2 or which may Include a fine not to exceed $/0, 000 as well as civil penalties up to $25,000 per
violation.
Signing Official Signatur
2 Professional Engineer's Certification
/ attest that this application fo A,44te 514,44, A44^"
has been reviewed by me and is accurate, complete
2
2b,
2c
2d
and consistent with the inform
he engineering plans, calculations, and all other supporting documentation to the
best of my knowledge. I further attest that to the best of my knowledge the proposed design hes been prepared in
accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February
12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June
1, 2000 and the watershed classification in accordance with Division guidance. Although certein portions of this submittal
package may have been developed by other professionals, 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 NC General Statutes 143-215,6A and 143-215 68, eny person who knowingly makes any false statement,
representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed $10, 000 as well as civil penalties up to $25, 000 per violation.
IL.. 5
Professional Engineer Name
_C-aefo boit afaf
Engineering Firm
Ad
ity
Oqt
11:16
*facsimile
elephone
2i.
2e WC- 2f2--
State Zip
144_0144t r
Seal, Signature & Date

CK APPLICATION to - GRAVITY SE ERS, P '1 P STATIONS, AND FORCE MAi'NS PAGE 2.
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
0219(i) for Item B(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that in 15A NCAC 2H .0219(IX1-2) must be approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality, Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(1)(3).
400 6(4-1/574/5,41( iffcr
10 Summary of
Size (inches)
Z
z
0
0
nes to be Permitted (attach additional sheets if necessary)
Length (feet)
12-g3
ENTER TOTAL LiNE LENGTH IN MILES
0
'H 11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
it Location ID Design Flow Operational Point
0 (as shown on plans) (MGD)
tl.
GPM g TDH
Gravity or Force Main
(pull down menu)
Gravity
Gravity
Gravity
Gravity
Gravity
Gravity
Power Reliability Option
(dual line feed, permanent generator w/ATS,
portable generator wlautodialer, wet well storage)
12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
(j Maps -(latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
ITW"Ves © No if no, please reference the pertinent minimum design criteria or regulation and indicate why a
ararlance is requested.
SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ©l Yes © No N/A
Sedimentation and Erosion Control Plan? g3 res © No © N/A
Stormwater? [r es ❑ No © N/A