WQ0042779_Application (FTSE)_20210819

State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: (pK3e°q 27 (1(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Jones Estates Three R, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Jonathan Gindes per 15A NCAC 02T .0106(b)
Title: Manager
4. Applicant's mailing address: PO Box 14466
City: Durham State: NC Zip: 27709-
5. Applicant's contact information:
Phone number: [phone] Email Address: iegindes(a,gmail.com
II. PROJECT INFORMATION:
1. Project name: Three R Mobile Home Park
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000 and issued date:
If new construction but part of a master plan, provide the existing permit number: W000
3. County where project is located: Forsyth
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.00° Longitude: -80.21°
5. Parcel ID (if applicable): 6832-81-3240 & 6832-80-6604
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Timothy S. Kennerly License Number: 29317
Firm: Kennerly Engineering & Design, Inc.
Mailing address: 12133 N. NC HWY 150 STE F
City: Winston-Saelm State: NC Zip: 27127-
Phone number: [phone] Email Address: timothy.kennerly(Th,kennerlyengineering.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Lower Muddy Wastewater Treatment Plant Permit Number: NC0050342
Owner Name: Winston-Salem/Forsyth County Utilities
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 Page 1 of 5

VL GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ENo ZN/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ENo ZN/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ENo ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential Owned
Z Residential Leased
❑ School / preschool / day care
❑ Food and drink facilities
❑ Businesses / offices / factories
❑ Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
5. Nature of wastewater : 100 % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(201)
B•Is there a Pretreatment Program in effect?
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes
> If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
❑ Yes ® No
® No
Establishment Type (see 021'.0114(f)
Daily Design Flow a,b
No. of Units
Flow
2-3 Bedroom Residential
240 gal/unit
26
6,240 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
6,240 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 facifties located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 6,240 GPD (per 15A NCAC 02T .0114)
> Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16
Page 2 of 5

VH. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8
1215 PVC
> Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
> Section III contains information related to minimum slopes for gravity sewer(s)
> Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIH. 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: N/A
2. Approximate Coordinates (Decimal Degrees): Latitude: aLongitude: -
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B):
> Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
> Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
> It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
> If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 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(f) & (a)
➢ 15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
ZYes ❑No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
24 inches
Water mains (vertical -water over sewer including in benched trenches)
18 inches
Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical) P.
36 inches
> 15A NCAC 02T.0305(0) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Srteam 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) ® Yes ❑ No ❑ N/A
> See the Division's draft separation requirements for situations where separation cannot be meet
> No variance is required if the alternative design criteria specified is utilized in design and construction
> As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No ® N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or
individual permits or 401 Water Quality Certifications?
> Information can be obtained from the 401 & Buffer Permitting Branch
® Yes ❑ No
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ®No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
1, Does the submitted system comply with I5A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version) and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
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.
Professional Engineer's Certification:
I Timothy S. Kennedy, PE
(Professional Engineer's name from Application Item 111.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. 1 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):
Jonathan Gindes, Manager
(Signature Authority's name & title from Application Item 1.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 understand that if all required parts of'
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. 1 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 applicationpackage 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.
attest that this application for
Signature:
attest that this application far
Date: Ill / aJ
FORM: FTA 04-16 Page 5 of 5

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Jones Estates Three R, LLC
Project Name for which flow is being requested: Three R Mobile Home Park
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: MUDDY CREEK
b. WWTP Facility Permit #: NC0050342
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
£ Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
21.000000
3.022947
17.620000
0.006240
20.649187
98.3%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
*-Recent plant upgrades at Muddy Creek WWTP allows for excess flows from the Muddy Creek WWTP to be transferred to the Archie Elledge
WWTP for treatment to utilize excess capacity at the plant. Supporting document has been included with submittal with further information.
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pi) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** 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 < 0.
Downstream Facility Name (Sewer): Lower Muddy Creek
Downstream Permit Number: WQCS00003
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Courtney Driver, P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
�. eilete-Wnointafrp
-W
Signing Official Signature Date
5/12/21
Capital Projects Engineer
Title of Signing Official
Page 2 of 6
FTSE 10-18

Three R Mobile Home Park
170 Jones Road, Winston-Salem, NC
Frienclyacres.tcr

12/5/2020, 3:21:25 PM
State Capitol Buildings
m Post Offices
— Local Connecting Roads
— Secondary Highways
— Controlled -access Highways
In Airport Runways
Three R MHP Expansion
Airports
▪ International Airport
▪ Military
T Municipal Airstrip / Airport
* Private Airstrip / Airport
* Regional Airport
Unknown
1:9,028
0 335 670 1,340 ft
I / i r r r II
0 100 200 400 m
USGS The National Map: 3D Elevation Program. Data Refreshed October,
2020., USGS TNM — National Structures Dataset. Data Refeshed October,
2020., USGS TNM — National Hydrography Dataset. Data Refreshed
October, 2020., USGS The National Map: National Transportation Dataset;
USGS
USGS The National Map: National Boundaries Dataset, 3DEP Elevation Program, Geographic Names Information System, National Hydrography Dataset, National Land Cover Database, National

Winston-Salem / Forsyth County
Utilities
Water • Wastewater • Solid Waste
Administration, P.O. Box 2511, Winston-Salem, NC 27102
0: 336-727-8000, F: 336-727-8432, wsfcutlllties.org
December 20, 2019
Jenny Graznak, Assistant Regional Supervisor
North Carolina Department of Environmental Quality
Division of Water Resources
450 West Hanes Mill Road, Suite 300
Winston Salem, NC 27105
Dear Ms. Graznak,
Please allow this letter to serve as documentation that Winston-Salem/Forsyth County Utilities is
currently engaged in a project at the Muddy Creek Wastewater Treatment plant to address future
wastewater capacity needs. Upgrades to the plant are expected to be completed by December 2020.
The project was originally scheduled to be completed in July 2017, however significant unforeseen
delays have caused the construction to be extended longer than anticipated: The upgrades include
replacement of the existing headworks, grit removal and influent pumping facilities, 3.75 million gallons
of storm equalization storage, and 2 million gallons of diurnal equalization storage. The equalization
storage will reduce treatment impacts due to heavy wet weather events and provide for a more uniform
flow to the plant. The project will also allow excess flows from the Muddy Creek WWTP to be
transferred to the Archie Elledge WWTP for treatment to utilize excess capacity at that plant. This
opportunity is unique and provides our system the ability to optimize efficiency at both plants by setting
a baseline flow at the Muddy Creek WWTP, based off of hydraulic and financial considerations, and send
any remaining flow to either the Archie Elledge WWTP or the storm equalization facilities. The
integrated influent system and flow storage provides significant reliability, allows us to balance flows
between plants, and provides optimum treatment performance during dry and wet weather.
Please let this letter serve as justification to continue permitting wastewater flows to the Muddy Creek
Wastewater Treatment Plant.
gards, _
Courtney Driv , P.E.
Utilities Director
City Mayor AaonSnas;VrH.ourkacMay Pr Tampn.,;heaelWmdp Denise
D. Adams,
North Ward; Dan 6euss, uthweil Ward;Robet C.Clark,West Ward;lohno Larson,out Wad; fMe, NorthwestWWard; Annelle a,East Ward;lamas
Tayl d a u tWa d Maaer: Lee Garri
Cityty
County Commissioners: David RPlylar,Chalo Don Mrtin, Vice Chair; Fleming El -Amin; Ted Kaplan; Richard V. Linville;Tonya Mcoanlel;Gloria D. Whlsenhunt; County
CalI 311 or 336-727-8000 Manger. DudleyWalts,Jr.
Winston-Salem/Forsyth County Utility CommIsslon: Randall S. Tuttle, Chair; L. Wesley Curt%Jr., Vice Chair; Harold E. Day; Tom Griffin; Yvonne H..Hines; Duane Long;
[e-mail] Hugh W. Jernigan; Chris Parkeames Ruffin; Donald R. Stewart; Allan Younger

KENNERLY
ENGINEERING & DESIGN, INC.
CITY/COUNTY UTILITIES
100 EAST FIRST STREET, STE 235
WINSTON-SALEM, NC 27101
THREE R MOBILE HOME PARK EXPANSION
SANITARY SEWER EXTENSION
APPLICATION
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August 18th, 2021