WQ0043211_Application (FTSE)_20220218

DWR
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 Number: (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Wilkesboro (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Ken Noland per 15A NCAC 02T .0106(b)
Title: Town Manager
4. Applicant's mailing address: PO Box 1056
City: Wilkesboro State: NC Zip: 28697-
5. Applicant's contact information:
Phone number: [phone] Email Address: townmanager@,wilkesboronc.org
❑ Other
II. PROJECT INFORMATION:
1. Project name: NCDOT Bridge 960733 Aerial Sewer Relocation
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/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: Wilkes
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.1333° Longitude: -81.1552°
5. Parcel ID (if applicable): 2202448
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Tucker Martin License Number: 039117
Firm: KCI Associates of North Carolina, P.A.
Mailing address: 4505 Falls of Neuse Road, Suite 400
City: Raleigh State: NC Zip: 27609-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Town of Wilkesboro WWTP Permit Number: NC0021717
Owner Name: Town of Wilkesboro
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