WQ0035190_Regional Office Historical File Pre 2018

L i+µector
J
Mr. James R. Pietzak, Principal
Albemarle HCRE LLC
clo Smith Packett hit"ED-COrMM. LLC
4423 Pheasant Ridge Road SW, LJite 301
Roanoke, VA 24014
R
Subject: Permit No, WQ0035190
Albemarle Healthcare, LLC
rjVastewater Collection System E.
Stanly^ County. North Carolina
Dear Mr. Pietrzak,
!n accordance with your complete application received on January '1 3, 201 1 , we are forwarding
herewith Permit No. WQ0035190 dated January 21, 201 1 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until rescinded and shall be subject to the conditions and limitations as speroif0F.ad therein.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 waster
collection facilities be properly operated and maintained in accordance with 1 5A NCAC 2T .0403 or
individual system -wide collection system permit issued to the Perr7rittee_
Permitting of this project does not constitute an acceptance of any p °rr t of the project that does
.not meet 1) 15A NCAC 2T, 2) the Division of Water at n tj's (Division) Gravity Sewer Minimum Design
Criteria adopted February 12, 1996, as applicable,
the Fast -Track Permitting of Pump Stations and Force 5
unless specifically mentioned herein. Division approva
Division's Minimum Design Criteria for
adopted Jung 1, 2000, as applicable,
sed 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 -construct 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 additit nal or replacement wastewater collection
facilities, anchor referral of the North Carolina -licensed (Professional Engineer to the licensing board
Mooresville resville Regional Officie
O. Fat Center ,Ave,, suite 301
Phone: [phone]'y F 704) 563-6040 '.
He, NL 281 1
77- 2,3..

Fast Track Engineering Certification
Permit No. WQ0035190
January 21, 2011
OwnerMIQCS IMNTP/WQCS . • PE
James Pietrzak, Principal Raymond Allen, City Manager Matthew L. Mobley -
Albemarle HCRE, LLC City of Albemarle ' Design Resources Group
c/o Smith-Packett MED-COM, LLC PO Box 190 ' • .. 2459 Wilkinson Blvd, Ste 200
4423 Pheasant Ridge Rd, SW, Ste 301 Dunn, NC 28334 Charlotte, NC 26208
Roanoke, VA 24014'
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
❑ Partial ❑ Final
, as a duly registered Professional Engineer in the State of North Carolina, having been
authorized to observe (❑ periodically, ❑ weekly, ❑ full time) the construction of Albemarle Healthcare, LLC, a
Stanly 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 2T; 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 Engineer's
seal, -signature, and date:
SEND THIS FORM & SUPPORTING DOCUMENTATION
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS
MOORESVILLE REGIONAL OFFICE
SURFACE WATER PROTECTION
610 EAST CENTER AVENUE, SUITE 301
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
Engineer's Certification shall be considered a violation of the permit and shall subject the Permittee to appropriate
enforcement actions.

z
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Owner/Permittee:
la Albemarle HCRE, LLC
c/o Smith-Packett MED-COM, LLC'
1 b. .tames R. Pietrzak
igning Official Name and Title (Please
d.
Application Number:
(to be completed by DWQ)
5A NCAC 2T ,0106 (b) for authorized signing officials
The legal entity who will own this system is:
0 Individual ❑ Federal ❑ Municipality ❑ State/County ❑ Priv
g 4423 Pheasant Rid a Road SW, Suite 301,
Mailing Address
f. VA
e
1 h. 54©772 7762
Telephone
540,772,6470
Facsimile
2 Project (Facility) information:
Albemarle Healthcare, LLC
Brief Project Name (permit will refer to this name,
Contact Person:
.. Mobley, Resource Group, PA
Mathew L. Moble , P.E.; Design
Name and Affiliation of Someone Who Can Answer Questions About this Application
e Partnership 0 Corporation 0 0
DIVISION t tw;
Roanoke
City
lg. 24014
Zip Code
j. _.... _,lpiet ak
E-mail
3b. 704.343.0608_
Phone Number
1. Project is IXl' New
of an existing permit) I
2. Owner is ❑ Public (skip to Item B(3))
2a. If private, applicant will be:
Retaining Ownership (i.e, store, church, single office, etc
0 Leasing units (lots„ townhomes, etc. - skip to item B(3))
❑ Selling units (lots, townhomes, etc. - go to item B(2b))
3. Cif of Albemarle
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a, Long Creek Wastewater Treatment Plant
Name of WWTF
5a. Cit +oaf Albemarle 15b. 8" ® Gravity
wer Receiving Sewer Size ❑ Force Main
2b. Stan..__.
County Where Project is Located
3c. matthew €@dr rp.com
E-mail _.
cation, Permit No
Owner of Downstream
Private
The origin of this wastewater is (check all that apply):
❑ Residential Subdivision
❑ Apartments/Condominiums
0 Mobile Home Park
• School
0 Restaurant
O Office
go to
item 2(a))
b. If stld, facilities owned by a (must choose one
or ❑ Public Utility (Instruction C)
❑ Homeowner Assoc./Developer (Instruction D)
4be NC0024244
WWTF Permit No.
c,
Permit of Downstream Sewer (Instruction E)
Ej Retail (Stores, shopping centers)
El Institution
0 Hospital
❑ Church
Nursing Horne
0 Other (specify):
7. Volume of wastewater to be allocated or permitted for this particular project:
*Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
0 Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
• Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
00.00 % Domestic/Commercial
% Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify):
4 320 gallons per day
F`TAt`2/07 ver2

B. PERMIT INFORMATION (CONTINUED)
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item B(7) ANDIOR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item B(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
Qdeslgn= 36 Units x lbed/Unit x 120 Gal/bedroom/day = 4,320 GPD
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
Length (feet)
New Gravity or Additional
Force Main
6"
282 ft.
Gravity
11. Summary of Pump Stations w! associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID NIA (self chosen - as shown on planslmap for reference)
Design Flow
(MGD)
Operational Point
GPM @TDH
Power Reliability Option
1 - permanent generator wIATS;
2 - portable generator w/MTS
Force Main Size
Force Main Length
Pump Station Location ID
(self chosen
- as shown on plans/map
for reference)
Design Flow
(MGD)
Operational Point
GPM @TDH
Power Reliability Option
1 - permanent generator w/ATS;
2 - portable generator wIMTS
Force Main Size
Force Main Length
Pump Station Location ID (self chosen - as shown on planslmap for reference)
Design Flow
(MGD)
Operational Point
GPM @TDH
Power Reliability Option
1 - permanent generator w1ATS;
2 - portable generator wlMTS
Force Main Size
Force Main Length
12.
•
Will
Yes
the
►.i
wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
No If Yes, permit number of 2nd treatment facility
(RO — if "yes" to 6,12 please contact the Central Office PERCS Unit)
13. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T as
applicable?
® Yes ❑ No If No, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
FTA 12/07_ver2

14. Have the following permits
s been submitted for approval for the system or project to be served?
Wetland/Stream Crossings - General Permit or 401Certifcation? ] Yes 0 No N/A
Sedimentation and Erosion Control Plan? Z Yes El No ❑ NIA
Stormwater? Fl Yes ❑ No fij N/A
15, Does this project includ
manholes)? These f(t1t
high priority lines,
tie cortsfderedh
Check if Yes:© and provide details
1a.
AC 02T .0402 (2)] involve aerial Ines, siphons, or interference
lnd m k _o every six ltoor�ttta
Owner/Pere ittee's Certification: (Signature of Signing Official and Project. Name)
1, James R, Pietrrak attest that this application for Albemarle Healthcare, LLC , 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 aro not
completed and that if all required supporting documentation and attachments are not included, this application package
i subject to being returned as incomplete. Note: In accordance with North Carolina General Statutes 143-215,6A and
143-215.68, any person who knowingly makes any false statement, representation, or cetiiification in any application
shall be guilty of a ,Gash 2 misdemeanor, which may include a fine not to exceed $1 0, 90© as well as civil penalties up to
$25, 000 per viola $on,
1 l
Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMI I I AL OF THIS
APPLICATION, THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
N TO OTHER UTILITIES, DESIGN CALCULATIONS, ETC. REFER TO 15A NCAC 02T .0305
Z
2, Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
M b attest that this application for AI ,e rnarte Healthcare. LLC has been reviewed by me and
isaccurate, complete aril consr""slant with the information in the 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 has
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 other
professionals may have developed certain portions of this submittal package, inclusion of those materials under my
signature and seat signifies that l 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, any 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,
2a. Matthew L. Mobley, P.E,
Prof
2b.
Engineer Name
n Resource Group. PA
Engineering Fir
2c, 2459 Wilkinson Blvd,, Suite 2
Mailing Address
2d. Charlotte
City
2e. NC 2
State
70 h�e
2g. 704.343.0608' 2h. 7iJ4.35B.309a ...__2i, matt
Telephone
Facsimile E-mail
20
Zip
drorp.co
n*r
NC PE Seal, Signature Date
A7 ver2

OF WA7'-9 State of North Carolina
O\-\� QG Department of Environment and Natural Resources
7 Division of Water Quality
-* Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE —10/07)
Project Applicant Name: Albemarle HCRE, LLC
Project Name for which flow is being requested: Albemarle Healthcare, LLC
More than one FTSE-10/07 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.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Long Creek Wastewater Treatment Plant
b. WWTP Facility Permit #: NC0024244
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f 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
16.0
0.132
5.229
0.00432
5.361
33.5%
II. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
List pump stations Iocated between the project connection point and the WWTP
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Firm/Design) Daily Flow, MGD
III. Certification Statement:
I, Ernest D. Borders, certify that, to the best of my knowledge, 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. 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 • 1 or which I am the responsible party. Signature of this form indicates acceptance of
this tew
Jan. 10, 2011
Signing Of cial Signature Date

UNITED STATES
DEPARTMENT OF THE INTERIOR
GEOLOGICAL SURVEY
STATE Of NORTH CAROLINA
DEPARTMENT or ENVIRONMENT, HEALTH
AND NATURAL RESOURCES
RALEIGH. NORTH CAROLINA
CONTOUR INTERVAL t® FEET
NATIONAL aFat}F.'TlC VERTICAL DATUM 4F 1929
�+o$ AS' („e1M1t IFS w r F 1f,yNAJ MAP ACCURACY STA1 L) W S
FOR SALE 13Y U.S. GEOLOGICAL SURVEY
DENVER, COLORADO R0225, OR RESTON, VIRGINIA 2 092
A FOLDER DESCRIBING ToPOGRAP* C MAPS AND SYMBOLS IS AVAILACE ON REQUEST
ALBEMARLE QUADRANOLE
NORTH CAROLINA—STANLY CO,
7.5 MINUTE SERIES (TOPOGRAPHIC)
Produced the Lk ted States ,tie ! Sulr y
�tr c methods tram imagery dated 1977
edited 1981
North Arnenicars Datum of 1927 INAD 27). ProtetCtWcen and
10 Q00foot ticks: North Carolina coordinate system
CL embed conformal coned
11300rtiter IA 'warm] transverse Mercator grid, awns 17
North American Daum of 1983 tNAC 831 rs shown by dashed
comer 1kksr, The values of the shift between ?IAD 27' and NAD 83
far 7.5-minute Intersections are esbtainable horn Notional tae<tdetrc
Spey filikDCON software

, North Carolina Secretary of State Page 1 of 1
North Carolina
Elaine F. Marshall DEPARTMENT OFrHE
Secretary SECRETARY OF STATE
PO Box 29622 Raleigh, NC 27626-0622 [phone]
Date: 1/19/2011
Click here to:
View Document Filings I Sign Up for E-Notifications
JPre -populated Annual Report Filiable PDF Form i File an Annual Report 1
Corporation Names
Name Name Type
NC ALBEMARLE HCRE, LEGAL
LLC
Limited Liability Company Information
SOSID: 1122020
Status: Current -Active
Effective Date: 10/29/2009
Dissolution Date:
Annual Report Due Date:
Citizenship: DOMESTIC
State of Inc.: NC
Duration: PERPETUAL
Registered Agent
Agent Name:
Office Address:
WARNER, S. ROGERS, JR.
401 SOUTH TRYON STREET SUITE 3000
CHARLOTTE NC 28202
Mailing Address: 401 SOUTH TRYON STREET SUITE 3000
CHARLOTTE NC 28202
Principal Office
Office Address: 4423 PHEASANT RIDGE ROAD SUITE 301
ROANOKE VA 24014
Mailing Address: 4423 PHEASANT RIDGE ROAD SUITE 301
ROANOKE VA 24014
Officers
This website is provided to the public as a part of the Secretary of State Knowledge Base (SOSKB) system. Version:
2708
http://www.secretary.state.nc.us/corporations/Corp.aspx?PitemId=9241819 1 /19/2011

de
or°ur
4
January 17„ 2011
North Carolina Department of Environment and Natural R ources
Division of Water Quality
Fat 0 E. Center Avenue
Mooresville, North Carolina 281
Reference:
r` u p
Fast -Track Application or Gravity Sewers„ Pump Stations,
and Force Mains
rska: 31 -- 0 1. - Woodhaven Court xpansion
Enclosed you .ill fond the following infrarmanon for your review:
C0Ples Description of items
1
Completed Application Form (Original)
Completed Application Form (Copy)
FTSE 1 f1/U7 Acceptance from the City of
Albemarle Utility Department
.5"xI 1" Color USGS Togo Map
NCDENR Application Fee ( S0,0
1f any additional information is required tc«complete your revieti of these
plans„ feel free to contact me at (70) 343-0608 x318.
Sinceriy;
esi
water t. oraiey,
associate
F.A.
3

Permit Number WQ0035190
Central Files: APS, SWP_
01/21/11
Permit Tracking Slip
Program Category
Non -discharge
Permit Type F ss- _rack Version Permit Classification
Gravity Sewer Extension, Pump Stations, & Pressure Sewer 1.00 individual
Extensions
Primary Reviewer Perrnit Contact Affiliation
dee.browder
Coastal SW Rule
Permitted Flow
4320
Facility
Facility Name
Albemarle Healthcare, LLC
Location Address
Owner
Status Project Type
Active New Project
Major/Minor Region
Minor Mooresville
County '
Stanly
Facility Contact Affiliation
Owner Name Owner Type
Albemarle Hcre LLC Non -Government
Owner Affiliation
James Pietrzak
Dates/Events
Orig issue
01/21/11
App Received
01/18/11
Draft Initiated
Scheduled
Issuance
4423 Pheasant Rdg Rd SW
Roanoke VA 24014
Public Notice Issue
01/21/11 01/21/11
Effective
Regulated Activities Re. uestedlReceived Events
Additional information received
Additional information requested
Nursing Home
Wastewater collection
Expiration
Outfall NULL
Waterbody Narne Stream index Number Current Class Subbasin