WQ0043269_Application (FTSE)_20220310

Engineers sr 4°v Surveying, Inc.
March 8, 2022
North Carolina Department of Environment and Natural Resources
Water Quality Section
NCDENR Winston-Salem Branch Office
Re: Fast -Track Application (FTA 04-16)
For Keystone at Penny Road — Phase 1
High Point, NC 27265
Environmental Department
y
Received
MAR 10 2022
Winston-Salem
Regional Office
On behalf Keystone at Penny Road, LLC, we are submitting herewith for your approval the following documents
relative to the above referenced project:
(1) Original Fast -Tract Application
(1) Copy of Fast -Tract Application (Completed by City of High Point)
(1) Check for $480 (Keystone at Penny Road, LLC)
Specifications for this project will be per the City of High Point standards and specifications. We respectfully request
your approval of these itemsy, If you have any questions or need any additional information, please give me a call.
Thank you for your assistance with this matter.
Sincerely,
CPT Engineering and Sytveying, Inc
D. ,.�/2
ToddD. Murphy, P.M.
Enclosures
4400 Tyning Sheet • High Point, NC 27265 Phone: [phone] • Fax: [phone]
www.cptengineerute.eom

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:
I. Applicant's name: Keystone at Penny Road, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: 0 Individual ❑ Corporation ❑ General Partnership 0 Privately -Owned Public Utility
0 Federal ❑ State/County ❑ Municipal ® Other
3. Signature authority's name: Scott Wallace per 15A NCAC 02T .0106(b)
Title: Manager
4. Applicant's mailing address: 3708 Alliance Dr.
City: Greensboro State: NC Zip: 27407-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Keystone at Penny Road — Phase I
2. Application/Project status: ® Proposed (New Permit) 0 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: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36d01'24.177" Longitude:-79d57'34.480"
5. Parcel ID (if applicable): 196580
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Chuck Trubv License Number: NC 14984
Firm: CPT Engineering and Surveying Inc.
Mailing address: 4400 Tyning Street
City: High Point State: NC Zip: 27265-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside Wastewater Plant Permit Number: NC0024210
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 Page 1 of 5

VI. GENERAL REQUIREMENTS
I. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑Yes ❑No ZN/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
Z Yes ❑No ❑N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
® Yes ❑No ❑N/A
4. Origin of wastewater: (check all that apply):
® Residential Owned
❑ Residential Leased
0 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
0 Nursing Home
5. Nature of wastewater : 100 % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
0 Car Wash
0 Hotel and/or Motels
0 Swimming Pool /Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
>Is there a Pretreatment Program in effect? ❑ Yes
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ❑ No
➢ If yes. provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
❑ No
Establishment Type (see 02T.0114(f))
Daily Design Flow a,h
No. of Units
Flow
Single -Family Subdivision
360 gal/3 bedroom
41
14,760 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
14,760 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.01 14] shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 14,760 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
0 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8"
2,040
PVC
8"
159
DIP
Total
2,204
> 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
VHI. 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:
2. Approximate Coordinates (Decimal Degrees): Latitude: . • Longitude: -
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 4 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(1) & (g)
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer system
Yes ❑ 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)
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 ❑ No
3. Does the project comply with all setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes ❑ 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.0 t05(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
➢ 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 (east 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 5 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A 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?
NYes ❑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.
2. Professional Engineer's Certification:
I Chuck Truby
(Professional Engineer's name from Application Item III.1.)
attest that this application for
Keystone at Penny Road - Phase 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. 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):
I,
Scott Wallace Mgr. attest that this application for
(Signature Authority's name & title from Application Item I.3.)
Keystone at Penny Road - Phase 1 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, 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 143-215.6B 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:
/' o-viC��I�li Date: 2-02Z
kL Stcrr- trio 11 a ce Nanusek-
FORM: FTA 04-16 Page 6 of 5

vly Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print an Amended a
annual Report form
Limited Liability Company
_egal Name
Keystone at Penny Road, LLC
Information
'Sosld: 1759960
'Status: Current -Active O
Date Formed: 10/11/2018
:itizenship: Domestic
4nnual Report Due Date: April 15th
CurrentAnnual Report Status:
Registered Agent: Wallace, W Scott
4ddresses
Mailing Principal Office Reg Office Reg Mailing
3708 Alliance Drive 3708 Alliance Drive 3708 Alliance Drive 3708 Alliance Drive
Greensboro, NC 27407 Greensboro, NC 27407 Greensboro, NC 27407 Greensboro, NC 27407
Company Officials
all LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Member
W. Scott Wallace
3708 Alliance Drive
Greensboro NC 27407

Public Services Department
Terry L. Houk
DIRECTOR
NORTH CAROLINA'S INTERNATIONAL CITY"'
August 27, 2021
NCDENR
Winston-Salem Regional Office
450 W. Hanes Mill Rd, Suite 300
Winston-Salem, NC 27105
Keystone at Penny Road.
Phase 1 Private Sewer
Applicant: Keystone at Penny Road, LLC
Greensboro, NC
Dear Sir or Madam:
This is to acknowledge that the City of High Point will accept for treatment in the Eastside
Wastewater Treatment Plant (Permit #NC 0024210), wastewater flow from the above referenced
project in the amount of 14,760 GPD, which will be discharged to facilities operated and
maintained by the City of High Point.
If further information is needed, pleaselet me know.
Very truly yours,4I
Terry L. auk
Director of Public Services
City of High Point, P.O. Box 230, 211 South Hamilton Street, High Point, NC 27261 USA
Fax: [phone] Phone: [phone] TDD: 336.883.8517

Division of Water Resources
Application Number:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
2 2 : ........
0
Entity Requesting Allocation: Keystone at Penny Rd LLC
Project Name for which flow is being requested: .Keystone at Penny Rd Phase 1
More than one FTSE may be required fora single project Oho owner of the 111PTP is not responsible for all pump
stations along the route of l/re proposed waslelvales•flow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility name: Eastside WWTP
b. WWTP Facility Permit it: NC-0024210
c. WWTP facility permitted,flow:
d. Estimated obligated flow not yet tributary to the WWTP:
e. WWTP facility's actual average flow:
f. Total flow'for this specific request:
g. Total actual and obligated flows to the facility:
h. Percent of pertnitted flow used:
oAVS:YrY.e:Ilt. MOP.
26.0000
3.0240
16.1917
0.0148
19.2304
73.96%
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) (a) (C) (D)=(E+C) (E)`(A-D)
Pump Finn Design Approx. Obligated, Total Current Available
Station Capacilyt Average Current Not Yet Flow Phis Capacity'
Permit Daily Flovl Avg. Daily Tributary Obligated
Number (p;milpf), Flow, Daily Flow, Flow
MGD MCD MOD MGD MOD
Pump
Station
(Name or
Number)
MGD
Rivadalo %0000857243.3270. 16.5370 8.3996 1.6794 10.0790. 6A580
aN/A
*NIA
MNIA
pNIA
*NIA
DNA
KVA *NIA MIA nNIA 6NIA aN/A
H33IA
*'NM 8N/A
pNIA
MNIA pNIA
.*NIA MNIA NNIA OVA qN/A RNIA
MIA .MNIA pNIA pNIA
MNIA
* The Ph•In Capacity (design now) of any Pmnp station Is defined as the maximum pumped flow that
can he achieved with the largest pump taken out of service.
** Design Average Flow Is the firm. capacity of the pump station divided by the peaking factor (pf) not
less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
•0* 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 5 0.
Downstream Facility Name (Sewer);
Downstream Permit Number:
0NA eN/A
Page 1 of 6
FTSE 10-16

III, Certification Statement
I, Terry Houk 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 codification applies to those items
listed above in Sections 1 and 1I 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.
Signing Official attire Date
Ptl ac S4 2✓445 .4iRf carc
Title of Signing Official
8/26/2021
Page 2ot 8 PISS 10.16

STATE OF NORTH CAROLINA
COUNTY OF Ct u71-FozD Permit No.
OPERATIONAL AGREEMENT
This AGREEMENT made pursuant to G.S. 143-215.1 (d1) and entered into this Z- day of
Mg 20 2.z , by and between the North Carolina Environmental Management
Commission, an agency of the State of North Carolina, hereinafter known as the COMMISSION; and
i 11Z- o-T pi- polwY Roki) /4L0141E1>wnoz.$ 455o0nr'u4, a non-profit corporation organized
and existing under and by virtue of the laws of the State of North Carolina, hereinafter known as the
ASSOCIATION.
WITNESSETH:
1. The ASSOCIATION was formed for the purpose, among others, of handling the property, affairs and
business of the development known as Ket5Tot4 PT PEN/41' & kb , PhA-sE L
(hereinafter the Development); of operating, maintaining, re -constructing and repairing the common
elements of the lands and improvements subject to unit ownership, including the wastewater collection
system with pumps, wastewater treatment works, and/or disposal facilities (hereinafter Disposal System);
and of collecting dues and assessment to provide funds for such operation, maintenance, re -construction
and repair.
2. The ASSOCIATION desires, to construct and/or operate a Disposal System to provide sanitary sewage
disposal to serve the Development on said lands.
3. The ASSOCIATION has applied to the COMMISSION for the issuance of a permit pursuant to G.S. 143-
215.1 to construct, maintain, and/or operate the Disposal System.
4. The Development was created subject to unit ownership in the dwellings units, other improvements and
lands through filing of a Declaration of Unit Ownership (hereinafter Declaration), pursuant to Chapter
47C of the North Carolina General Statutes.
5. The COMMISSION desires to assure that the Disposal System of the Development is properly
constructed, maintained and operated in accordance with law and permit provisions in order to protect the
quality of the waters of the State and the public interest therein.
NOW, THEREFORE, in consideration of the promises and the benefits to be derived by each of the parties
hereto, the COMMISSION and ASSOCIATION do hereby mutually agree as follows:
1. The ASSOCIATION shall construct the Disposal System and/or make any additions or modifications to
the Disposal System in accordance with the permit and plans and specifications hereafter issued and
approved by the COMMISSION, and shall thereafter properly operate and maintain such systems and
facilities in accordance with applicable permit provisions and law.
2. The ASSOCIATION shall provide in the Declaration and Association Bylaws that the Disposal System
and appurtenances thereto are part of the common elements and shall thereafter be properly maintained
and operated in conformity with law and the provisions of the permit for construction, operation, repair,
and maintenance of the system and facilities. The Declaration and Bylaws shall identify the entire
wastewater treatment, collection and disposal system as a common element, which will receive the highest
priority for expenditures by the Association except for Federal, State, and local taxes and insurance.
FORM: HOA 01-15 Page 1 of 2

3. The ASSOCIATION shall provide in the Declaration. and Association Bylaws that the Disposal System
will be maintained out of the common expenses. In order to assure that there shall be funds readily
available to repair, maintain, or construct the Disposal System beyond the routine operation and
maintenance expenses, the Declaration and Association Bylaws shall provide that a fund be created out of
the common expenses. Such fund shall be separate from the routine maintenance fund allocated for the
facility and shall be part of the yearly budget.
4. In the event the common expense allocation and separate fund(s) are not adequate for the construction,
repair, and maintenance of the Disposal System, the Declaration and Association Bylaws shall provide for
special assessments to cover such necessary costs. There shall be no limit on the amount of such
assessments, and the Declaration and Bylaws shall be provided such that special assessments can be made
as necessary at any time.
5. If a wastewater collection system and wastewater treatment and/or disposal facility provided by any city,
town, village, county, water and sewer authorities, or other unit of government shall hereinafter become
available to serve the Development, the ASSOCIATION shall take such action as is necessary to cause the
existing and future wastewater of the Development to be accepted and discharged into said governmental
system, and shall convey or transfer as much of the Disposal System and such necessary easements as the
governmental unit may require as condition of accepting the Development's wastewater.
6. Recognizing that it would be contrary to the public interest and to the public health, safety and welfare for
the ASSOCIATION to enter into voluntary dissolution without having made adequate provision for the
continued proper maintenance, repair and operation of its Disposal System, the ASSOCIATION shall
provide in the ASSOCIATION Bylaws that the ASSOCIATION shall not enter into voluntary dissolution
without first having transferred its said system and facilities to some person, corporation or other entity
acceptable to and approved by the COMMISSION by the issuance of a permit.
7. The ASSOCIATION shall not transfer, convey, assign or otherwise relinquish or release its responsibility
for the operation and maintenance of its Disposal System until a permit has been reissued to the
ASSOCIATION's successor.
8. The agreements set forth in numbered paragraphs 1, 2, 3, 4, 5, 6, and 7 above shall be conditions of any
permit issued by the COMMISSION to the ASSOCIATION for the construction, maintenance, repair and
operation of the Disposal System.
9. A copy of this agreement shall be filed at the Register of Deeds in the County(ies) where the Declaration
is filed and in the offices of the Secretary of State of North Carolina with the Articles of Incorporation of
the Association.
IN WITNESS WHEREOF, this agreement was executed in duplicate originals by the duly authorized
representative of the parties hereto on the day and year written as indicated by each of the parties named below:
FOR THE ENVIRONMENTAL le�¢,T ter P wKr f2oa-a ll4#eownag 4-55ocrahn,.znc,
MANAGEMENT COMMISSION Name of ASSOCIATION
By:
( ' g
S. Jay Zimmerman, Director (Signature)
Division of Water Resources
(Date)
FORM: HOA 01-15
G/. `tt Via i (R r Le
Print Name and Title - W , S r wrr w A-u "CF
3/2-12„. 2—Z
(Date)
Page 2 of 2

STATE OF NORTH CAROLINA
COUNTY OF 41)11-Foiab Permit No.
DEVELOPER'S OPERATIONAL AGREEMENT
This AGREEMENT made pursuant to G.S. 143-215.1 (di) and entered into this Z S day of
f eBgt teY , Zo 12_ , by and between the North Carolina Environmental Management
Commission, an agency of the State of North Carolina, hereinafter known as the COMMISSION; and
kiSTohi 1k l FGXiMY RoA-D LC.0 , a corporation/general partnership registered/licensed to do
business in the State of North Carolina, hereinafter known as the DEVELOPER.
WITNESSETH:
1. The DEVELOPER is the owner of the certain lands lying in GU I LFm Tab County, upon
which it is erecting and will erect dwelling units and other improvements, said development to be known
as kGYSrolvc: Ai FE-Alxi Rom:)- P'W4 C .1 (hereinafter the Development).
2. The DEVELOPER desires, to construct a wastewater collection system with pumps, wastewater treatment
works, and/or disposal facilities (hereinafter Disposal System) to provide sanitary sewage disposal to serve
the Development on said lands.
3. The DEVELOPER has applied to the COMMISSION for the issuance of a permit pursuant to G.S. 143-
215.1 to construct, maintain, and operate the Disposal System.
4. The DEVELOPER has created or shall create unit ownership in said dwellings units, other improvements
and lands through filing of a Declaration of Unit Ownership (hereinafter Declaration), pursuant to Chapter
47C or 47F of the North Carolina General Statutes.
5. The DEVELOPER has caused to be formed or will cause to be formed at the time of filing of the
Declaration, RE`12C7kr N'r. PE Ng K /2-40AO m ICOW P,e' 4%o4a�ion ANC (hereinafter
Association), a non-profit corporation organized and existing under and by the virtue of the laws of the State
of North Carolina, for the purpose, among others, of handling the property, affairs and business of the
Development; of operating, maintaining, re -constructing and repairing the common elements of the lands
and improvements subject to unit ownership, including the Disposal System; and of collecting dues and
assessments to provide funds for such operation, maintenance, re -construction and repair.
6. The COMMISSION desires to assure that the Disposal System of the Development is properly constructed,
maintained and operated in accordance with law and permit provisions in order to protect the quality of the
waters of the State and the public interest therein.
NOW, THEREFORE, in consideration of the promises and the benefits to be derived by each of the parties
hereto, the COMMISSION and DEVELOPER do hereby mutually agree as follows:
1. The DEVELOPER shall construct the Disposal System in accordance with the permit and plans and
specifications hereafter issued and approved by the COMMISSION, and shall thereafter properly operate
and maintain such systems and facilities in accordance with applicable permit provisions andlaw.
2. The DEVELOPER shall not transfer ownership and/or control of the Disposal System to the Association
until construction has been completed in accordance with the permit and approved plans, and the staff of
the Division of Water Resources has inspected and approved of the facilities. In order to change the name
of the permit holder, the DEVELOPER must request that the permit be reissued to the Association. The
request must include a copy of the Association Bylaws andDeclaration.
3. The DEVELOPER shall not transfer, convey, assign or otherwise relinquish or release its responsibility for
the operation and maintenance of its Disposal System until a permit has been reissued to the DEVELOPER'
successor.
FORM: DEV 03-19 Page 1 of 2

4. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System and
appurtenances thereto are part of the common elements and shall thereafter be properly maintained and
operated in conformity with law and the provisions of the permit for construction, operation, repair, and
maintenance of the system and facilities. The Declaration and Bylaws shall identify the entire wastewater
treatment, collection and disposal system as a common element which will receive the highest priority for
expenditures by the Association except for Federal, State, and local taxes and insurance.
5. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System will
be maintained out of the common expenses. In order to assure that there shall be funds readily available to
repair, maintain or construct the Disposal System, beyond the routine operation and maintenance expenses,
the Declaration and Association Bylaws shall provide that a fund be created out of the common expenses.
Such fund shall be separate from the routine maintenance funds allocated for the facility and shall be part
of the yearly budget.
6. In the event the common expense allocation and separate fund are not adequate for the construction, repair,
and maintenance of the Disposal System, the Declaration and Association Bylaws shall provide for special
assessments to cover such necessary costs. There shall be no limit on the amount of such assessments, and
the Declaration and Bylaws shall provide that such special assessments can be made as necessary at any
time.
7. If a wastewater collection system and wastewater treatment and/or disposal facility provided by any city,
town, village, county, water and sewer authorities, or other unit of government shall hereinafter become
available to serve the Development, the DEVELOPER shall take such action as is necessary to cause the
existing and future wastewater of the Development to be accepted and discharged into said governmental
system, and shall convey,pr transfer as much of the Disposal System and such necessary easements as the
governmental unit mayrequire as condition of accepting the Development's wastewater.
8. Recognizing that it would be contrary to the public interest and to the public health, safety and welfare for
the Association to enter into voluntary dissolution without having made adequate provision for the continued
proper maintenance, repair and operation of its Disposal System, the DEVELOPER shall provide in the
Association Bylaws that the Association shall not enter into voluntary dissolution without first having
transferred its said system and facilities to some person, corporation or other entity acceptable to and
approved by the COMMISSION by the issuance of apermit.
9. The agreements set forth in numbered paragraphs 1, 2, 3, 4, 5, 6, 7, and 8 above shall be conditions of any
permit issued by the COMMISSION to the DEVELOPER for the construction, maintenance, repair and
operation of the Disposal System.
10. A copy of this agreement shall be filed at the Register of Deeds in the County(ies) where the Declaration is
filed and in the offices of the Secretary of State of North Carolina with the Articles of Incorporation of the
Association.
IN WITNESS WHEREOF, this agreement was executed in duplicate originals by the duly authorized
representative of the parties hereto on the day and year written as indicated by each of the parties named below:
FOR THE ENVIRONMENTAL 10TDAIE �`r I EtlY f2_0A.b
MANAGEMENT COMMISSION Name of DEVELOPER
By: 71cL --Pier?, ry.-eiY
Linda Culpepper (Signature) //
IA/ 'S�TW
T a -A-LC 1 14nave-✓
Director, Division of Water Resources
Print Name and Title
(Date) (Date)
FORM: DEV 03-19 Page 2 of 2

ROY.COOPER
GOVERNOR
Guilford County
Subject:
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
J. ERIC BOYETFE
SECRETARY
Commercial Driveway Permit for: Keystone at Penny Rd., LLC — SR 1536
(Penny Rd.) & SR 1544 (Florence School Rd.) - DP210406
(D072-041-21-00003)
Mr. Todd Murphy
CPT Engineering & Surveying, Inc.
4400 Tyning Street
High Point, NC 27265
Dear Mr. Murphy:
This of office has received and approves the commercial driveway permit application with plans
attached for Keystone at Penny Rd. subject to the following comments`
1. Keystone at Penny Road, LLC or their authorized representatives shall comply with all
applicable federal, state, and local environmental regulations and shall obtain all necessary
federal, state, and local environmental permits including but not limited to those related to
sediment control, stormwater, wetlands, streams, endangered species and historical sites.
2. The access locations are approved as shown on the plan attached with the permit.
3. Any utilities (water and sanitary sewer) in the right of way on SR 1536 (Penny Rd.) shall
be reviewed, inspected, and approved under a 16.6 Encroachment Agreement with
Keystone at Penny Road, LLC: being the second party and the City of High Point being the
third party on the agreement.
4. Proposed roadway improvements on SR 1536 (Penny Rd.) shall be reviewed, inspected,
and approved under a 16.1B Encroachment Agreement. Please provide this office with a
cost estimate to determine the amount of the required bond.
5. Contact Mr. James Marley with this office (336-487-0100 or [e-mail]) 48
business hours prior to beginning work in the right of way on this state -maintained road.
Th15 b) 020 At4012(2170
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3184
.
Sincerely,
B.L. Norris, P.E.
District Engineer
ion Engineer
LLC
Telephone: [phone] Location:
Fax: [phone] YANCEYVILLE STREET
Customer Service: 1-877-368-4968 GREENSBORO,.NC 27405
Website: ncdot.gov

Route/Road: Drive
2 (Florence School Dr)
Exact Distance 515 LF/966 LF ❑ Miles N S E W
Z Feet ❑ EM O
From the Intersection of Route No. Horney Rd and Route No. SR1536 Toward SR1620 Sunnyvale
Property. Will Be Used For. ® Residential/Subdivision 0 Commercial 0 Educational Facilities ❑ TND ❑ Emergency Services 0 Other
Pro•e ®Is ■ is not within ,• • i P•'t C2onin• Area.
• I, the undersigned property owner,request access and permission to construct driveways) or street(s) on public right-
of-way at the above location:
• 1 agree to construct and maintain driveway(s) or street entrance(s) in absolute conformance with the current "Policy on
Street and Driveway Access to North Carolina Highways" as adopted by the North Carolina Department of
Transportation.
• I agree that no signs or objects will be placed on or over the public right-of-way other than those approved by NCDOT.
• I agree that the driveway(s) or street(s) will be constructed as shown on the attached plans.
• I agree that that driveway(s) or street(s) as used in this agreement include any approach tapers, storage lanes or
speed change lanes as deemed necessary.
• I agree that if any future improvements to the roadway become necessary, the portion of driveway(s) or street(s)
located on public right-of-way will be considered the property of the North Carolina Department of Transportation, and 1
will not be entitled to reimbursement or have any claim for present expenditures for driveway or street construction.
e I agree that this permit becomes void if construction of driveway(s) or street(s) is not completed within the time
specified by the "Policy on Street and Driveway Access to North Carolina Highways".
• I agree to pay a $50 construction inspection fee: Make checks payable to NCDOT. This fee will be reimbursed if
application is denied.
• I agree to construct and maintain the driveway(s) or street(s) in a safe manner so as not to Interfere with or endanger
the public travel.
• I agree to provide during construction proper signs, signal lights, flaggers and other warning devices for the protection
of traffic in conformance with the current "Manual on Uniform TrafficControLDevlces for Streets and Highways" and
Amendments or Supplements thereto. Information as to the above rules and regulations may be obtained from the
District Engineer.
• I agree to indemnify and save harmless the North Carolina Department of Transportation from all damages and claims
for damage that may arise by reason of this construction.
• 1 agree that the North Carolina Department of Transportation will assume no responsibility for any damages that may
be caused to such facilities, within the highway right-of-way limits, in carrying out Its construction.
• I agree to provide a Performance and indemnity Bond In the amount specified by the Division of Highways for any
construction proposed on the State Highway system.
• The granting of this permit is subject to the regulatory powers of the NC Department of Transportation as provided by
law and as set forth in the N.C. Policy on Driveways and shall not be construed as a contract access point.
• I AGREE TO NOTIFY THE DISTRICT ENGINEER WHEN THE PROPOSED WORK BEGINS AND WHEN IT IS
COMPLETED.
2004-01 NOTE: Submit Four Copies of Application to Local District Engineer, N.C. Department of Transportation TEB 65-04rev.
61-03419

PROPERTY OWNER (APPLICANT)
COMPANY Keystone at Penny Road, LLC NAME ToddMufor CPT Enpinserinq& Surveying
SIGNATURE 4,124 i �-friar SIGNATURE ' 1
ADDRESS 3708 Alliance Dr., Greensboro NC 27407 ADDRESS 44001ynine Streef%li i Point, NC 27285
Scott Wallace, Mgr. Phone No. 3368560111
WITNESS
338-812.8800 ext. 909
AUTHORIZED AGENT
COMPANY NAME
SIGNATURE SIGNATURE
ADDRESS ADDRESS
Phone No.
WITNESS
fi4PPLICATION RECEIVED BY DISTRICT ENGINEER
OP,tc401At-.
SIGNATURE
DATE
\PPLICATION APPROVED BY LOCAL GOVERNMENTAL AUTHORITY (when required)
ob"m"rmi"Matt Car entexwmwim.wrm"mmw‘
,mriiwp"°""""" Traffic Operations Engineer
SIGNATURE TITLE
3/11/2021
DATE
1PPLICATION APPROVED SY DISTRICT ENGINEER
L t•love-am I rc 5
SIGNATURE
4115) 2 24
DATE
NSPECTION SY NC00T
SIGNATURE
TITLE DATE
MMENTS:
ce. aAractexcia 1c and a 4it'pLan.

NARRATIVE
FOR
Keystone At Penny Road — Phase 1
Single -Family Subdivision
GUILFORD COUNTY
HIGH POINT, NORTH CAROLINA
March 3, 2022
DEVELOPER:
Keystone At Penny Road LLC
3708 Alliance Drive
Greensboro, NC 27407
[phone]
FINAL OWNER:
Keystone At Penny Road LLC
3708 Alliance Drive
Greensboro, NC 27407
[phone]
ENGINEER:
CPT Engineering and Surveying, Inc.
4400 Typing Street High Point, NC 27265
Phone [phone] • Fax [phone]

PROJECT DESCRIPTION
The project is located on an approximately 37.63 acre tract in Guilford County, High
Point, NC. The purpose of the project is to construct 41 single-family lots on 8.28 acres
being Phase 1, with associated paved drives including private water and sewer service.
SITE DESCRIPTION
The site consists of 8.28 acres being Phase 1 more or less and is currently field/wooded
and vacant.
ADJACENT PROPERTY
Land use in the vicinity is single-family residential. The site will access the public street
network by new driveway entrance Drive #2, which is located 966 LF south of Homey
Road at the intersection of SR1536 Penny Road and Florence School Road.
SOILS INFORMATION
The soil in the project area is mapped as ApB — Appling sandy loam, 2 to 6 percent
slopes; ApC — Appling sandy loam, 6 to 10 percent slopes; CcB — Cecil sandy loam, 2 to
6 percent slopes; VaD — Vance sandy loam, 10-15 percent slopes.
The existing site slopes northwest to southeast at approximately 2.63% average slope.
OWNERSHIP
Keystone at Penny Road, LLC plans to retain ownership of the subject property with NO
plans to sell subject property upon completion.

REF: USGS QUAD MAPS
GUILFORD, N.C.
NAD83; NAVD 1988
WGSB4
//� ENGINEERING AND SURVEYING, INC.
pri
LANDDEVELOPMENTI51LICENSE
CONSULTING
WWI 5 FIRM LIG@FE Na C.13f5
4400 WNIN6 STREET
HIGH POINT, NORTH CAROLINA 27265
PHONE, [phone] -- FAX1 (336) 8I2-S1SO
SURFACE WATER CLASSIFICATION
STREAM INDEX: 17-2-(0.7)
STREAM NAME: East Fork Deep River (High
Point Lake)
DESCRIPTION: From a point 0.4 ride
downstream of Guilford County SR 1541 to High
Point Lake, Deep River
CLASSIFICATION: WS-IV:'
CLASSIFICATION DATE: 8 / 3 / 92
RIVER BASIN: Cape Fear
NIT
-CD EXISTING SANITARY SEY82
SASE 1
KEYSTONE AT PENNY RD.
USGS TOPO MAP - ENLARGED
HIGH POINT, NC
SCALE: I1=200'

R $ Q AND SURVEYING, INC:,
\
4400
SIRE-FM 2a
v -F: ) Sv
STREET MAP
HIGH POINT, C
IL 2.

ENGINEERING AND SURVEYING, INC.
LAND DEVELOPMENT C/ONSUL_TIN-S
IX 15 FIR -I LIGua kJ. G4375
4400 TYNIY.o STREET
HIGH POINT, NORTH CAROLINA 21265
'HONE: (330) 6i2-8B00 - FAX: (330) D12-61P,0
PHASE 2
MULTI -FAMILY
APARTMENTS
FUTURE
PHASE 3
MULTI -FAMILY
APARTMENTS
F14 1
KEYST A Y
STREET MAP
HIGH POINT, NC
SCALE: I- = 200