WQ0043546_Application (FTSE)_20220606

IE
T A X TTIA /E A Tl TT
Lti1 r J J[V f H r` I\
We Build Confidence.
June 20, 2022
Mr. Alex Lowe
Environmental Specialist
Division of Water Resources
Winston Salem Regional Office
RE: Cover Letter for Sanitary Sewer Extension Permit
Prepac 2 - 90,000 Square Foot Warehouse Building
To Whom It May Concern:
Please let this cover letter serve as an introduction to our application for the extension of the
sanitary sewer for our proposed construction of a 90,000 square foot warehouse facility for
Prepac Manufacturing on Hendren Road in Whitsett, NC.
The purpose of this project is to provide additional storage, shipping, and office space for Prepac
manufacturing. The facility will be utilized for minor storage and minor office space, it will be used
in conjunction with their existing facility next door. This facility will be on a forced main (pump
station) sewer exiting the building and run to a gravity fed sewer that will connect to the existing
sewer manhole located on this property. Please review the application for all details.
Sincerely,
LANDMARK BUILDERS, INC.
Avery Hale
Associate Project Development Manager
Landmark Builders 13520 Triad Court I Winston-Salem, NC 27107
p.336.784.2000 I www.landmarkbuilders.com

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300, Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 05-21):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
® If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1 F418D462A3
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 28778-8211
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
Water Quality Section
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301-5095
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
Water Quality Section
Mooresville Regional Office
610 E. Center Avenue
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Water Quality Section
Raleigh Regional Office
3800 Barrett Drive
Raleigh, North Carolina 27609
[phone]
[phone] Fax
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Water Quality Section
Washinqton Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
Beaufort, Bertie, Camden, Chowan, Craven,
Currituck, Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington, Wayne
Water Quality Section
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pender
Water Quality Section
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, North Carolina 27105
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
Water Quality Section
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & 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: Landmark Builders, Inc. (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: Avery Hale per 15A NCAC 02T .0106(b)
Title: Associate PDM
4. Applicant's mailing address: 3520 Triad Court
City: Winston Salem State: NC Zip: 27107-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Prepac 2
2. Application/Project status:
® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.05836° Longitude: -79.59213°
5. Parcel ID (if applicable): 230662 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Ryan Thompson License Number: 048858
Firm: Landmark Builders, Inc.
Mailing address: 3520 Triad Court
City: Winston Salem State: NC Zip: 27107-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: TZ Osborn Water Permit Number: NC0047384
Owner Name: City of Greensboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream (Receiving) Sewer Information: 21 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 06-21
Page 1 of 5

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls)
❑ Residential (Leased) ❑ Retail with food preparation/service
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities
❑ Food and drink facilities ❑ Church
® Businesses / offices / factories ❑ Nursing Home
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : % Domestic 100 % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
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 with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
Warehouse
100 gal/loading bay
1
100 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
100 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.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 60 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21
Page 2 of 5

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
6"
960'
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 requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Pump Station #1
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.05836° Longitude: -79.59213°
3. Total number of pumps at the pump station: 1
3. Design flow of the pump station: .0432 millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 30 gallons per minute (GPM) at 1,550 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2"
1,550'
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. ® Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or El Standby pump
➢ Must have 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 and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant 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
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (g)? ® Yes ❑ No
15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water 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, and associated wetlands.
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 associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
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
➢ If noncompliance with 02T.0305(f) or (g), see Section X.1 of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ® Yes Basin name: Lake Mackintosh ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. 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 must be 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.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ 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 permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
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?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
p- DocuSigned by:
I, jtr.v ? onip .t. , attest that this application for Prepac 2
(Profes i�E,dagyasgEmpee from Application Item III.1.) (Project Name from Application Item II.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,
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. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
4
JI�r
grllliiRM."—
, attest that this application for Prepac 2
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II.1)
attest that this application 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
FORM: FTA 06-21 Page 5 of 5

DocuSign Envelope ID: 7B330348-214B-4809-A6CO-A1F418D462A3
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:
Date: 6/1/2022
FORM: FTA 06-21 Page 6 of 5

DER
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: Landmark Builders
Project Name for which flow is being requested: Prepac 2
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: T.Z. Osborne Water Reclamation Facility
b. WWTP Facility Permit #: NC 0047384
All flows are in MGD
c. WWTP facility's permitted flow 56.0
d. Estimated obligated flow not yet tributary to the WWTP 0.3100
e. WWTP facility's actual avg. flow 33.93
f. Total flow for this specific request 0.0001
g. Total actual and obligated flows to the facility 35.6624
h. Percent of permitted flow used 63.68
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
Average Approx. Obligated,
Pump Pump Daily Current Not Yet Total Current
Station Station Firm Flow** Avg. Daily Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pf), Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
Rock WQ0028972 4.13 1.652 0.519 0.408 0.927 0.725
Stewart WQ0038555 10.224 4.626 1.419 0.292 1.778 2.848
* 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
(pf) 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): City of Greensboro T.Z. Osborne
Downstream Permit Number: NC0047384
Page 1 of 6
FTSE :10-18

III. Certification Statement:
I Wendy Messer 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.
/..:(-1Z4fdt
Signing Official nature
da-61.JW? O
Title of Sigingfficial
abi/to_altce
a 2-( .
Date
Page 2 of 6
FTSE 10-18

* Y or Se Jr •ll 0
BUSINESS CORPORATION ANNUAL REPORT
1/6/2022
NAME OF BUSINESS CORPORATION:
Landmark Builders, Inc.
•
SECRETARY OF STATE ID NUMBER: 0083367
REPORT FOR THE FISCAL YEAR END:
SECTION A: REGISTERED AGENT'S INFORMATION
STATE OF FORMATION: NC
1. NAME OF REGISTERED AGENT: Paul M Stephens , III
2. SIGNATURE OF THE NEW REGISTERED AGENT:
Filing Office Use Only
❑X Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
3520 Triad Court
Winston Salem, NC 27107-4571 Forsyth
SECTION B: PRINCIPAL OFFICE INFORMATION
3520 Triad Court
Winston Salem, NC 27107-4571 Forsyth
1. DESCRIPTION OF NATURE OF BUSINESS: Commercial general construction
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] x 3. PRINCIPAL OFFICE EMAIL: [e-mail]
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
3520 Triad Ct 3520 Triad Ct
Winston Salem, NC 27107-4571 Forsyth Winston Salem, NC 27107-4571 Forsyth
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: OFFICERS (Enter additional officers in Section E.)
NAME: David F Bohlmann NAME: William Joseph Burgess , Ill NAME: Patricia L. Cortes
TITLE: Senior Vice President TITLE: Secretary TITLE: Treasurer
ADDRESS:
3520 Triad Court
ADDRESS: ADDRESS:
3520 Triad Court 3520 Triad Court
Winston-Salem, NC 27107 Forsyth Winston Salem, NC 27103 Forsyth Winston-Salem, NC 27107 Forsyth
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business
entity.
SIGNATURE DATE
Form must be signed by an officer listed under Section C of this form.
Print or Type Name of Officer Print or Type Title of Officer
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $25
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

SECTION E: ADDITIONAL OFFICERS
NAME: Randall W Elliott
TITLE: Senior Vice President
ADDRESS:
3520 Triad Court
NAME: PAUL M STEPHENS , III
TITLE: President
NAME: Samuel G. Stephens
TITLE: President
ADDRESS: ADDRESS:
3520 Triad Court 3520 Triad Court
Winston-Salem, NC 27107 Forsyth Winston-salem, NC 27107 Forsyth Winston-Salem, NC 27107 Forsyth
NAME: Wrenn C Wells
TITLE: Vice President
ADDRESS:
3520 Triad Court
Winston Salem, NC 27107 Forsyth
NAME: NAME:
TITLE: TITLE:
ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME: NAME:
TITLE: TITLE:
ADDRESS: ADDRESS:
NAME: NAME: Name:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME:
TITLE:
NAME: NAME:
TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:

North Carolina Department of the Secretary of State
Elaine F. Marshall, Secretary
BELOW IS THE CHECK LIST FOR BUSINESS CORPORATION ANNUAL REPORT. Please take a few minutes and read the
information provided. The Business Corporation's Annual Report is due by the 15th of the 4th month after the end of the
Business Corporation's fiscal year, with the filing fee of $20.00 if filed online, if filed in paper form the fee is $25.00.
Each Business Corporation filing an annual report with the North Carolina Department of Secretary of State must
provide the following information:
1. NAME OF BUSINESS CORPORATION
2. STATE OF FORMATION
3. ANNUAL REPORT FILING YEAR
4. THE REGISTERED AGENT STREET ADDRESS AND MAILING ADDRESS IF DIFFERENT
5. THE REGISTERED AGENT'S NAME AND SIGNATURE IF CHANGED
6. THE PRINCIPAL OFFICE ADDRESS, COUNTY AND TELEPHONE NUMBER
7. THE NAMES, TITLES AND BUSINESS ADDRESS OF THE PRINCIPAL OFFICERS
8. A BRIEF DESCRIPTION OF THE NATURE OF BUSINESS
IF THE INFORMATION REQUIRED TO BE ENTERED IN SECTION A THROUGH SECTION C HAS NOT CHANGED SINCE THE MOST
RECENTLY FILED ANNUAL REPORT, COMPLETE HEADER SECTION AND SECTION D TO CERTIFY THE ANNUAL REPORT.
SECTION A: REGISTERED AGENT'S INFORMATION
1. The name of the registered agent must be typed or printed.
2. If the registered agent has changed, the new registered agent MUST SIGN CONSENT to the appointment in the space provided. If the registered agent's
name has changed due to marriage, or by any other legal means, the business corporation must indicate such change in the space provided and have the
agent sign consent to the appointment under their new name. If the new registered agent is a business entity, then the appropriate representative of that
entity must sign and print their name and title. The registered agent must reside in NC.
3. If the street address of the registered office has changed, indicate the change. The address of the registered office must be a Street Address and NOT a
Post Office Box Address. The street address of the registered office must be a North Carolina address.
4. If the mailing address of the registered office has changed it should be indicated in this item. The registered offices mailing address may be a Post Office
Box. The registered office mailing address must be a NORTH CAROLINA ADDRESS.
SECTION B: PRINCIPAL OFFICE INFORMATION
1. Provide a brief description of the nature of the Business Corporation's business.
2. Enter the principal office telephone number.
3. Enter the principal office E-mail address.
4. The principal office address should reveal the Business Corporation's physical location. The principal office street address must be a street address and
NOT a Post Office Box Address.
5. The principal office mailing address may be a Post Office Box.
6. You may voluntarily report whether the company qualifies as a service -disabled veteran -owned or veteran -owned small business. The annual net receipts
cannot exceed one million dollars ($1,000,000) to report as either veteran -owned small business designation. Choose the designation of a service -disabled
veteran -owned small business if one or more service -disabled veterans owns more than 50% of the business. Choose the designation of veteran -owned small
business if one or more veteran owns more than 50% of the business. For further definitions see N.C.G.S. §55-1-40; §57D-1-03; or §59-32.
SECTION C: OFFICERS
Provide the names and addresses of each officer. Use Section E or a plain 8 1/2 X 11 sheet of paper if more space is needed. A person listed in this section
must sign the annual report and is then authorized to sign on other documents filed with this office.
SECTION D: CERTIFICATION OF ANNUAL REPORT
Check the annual report carefully to ensure all information required for filing has been provided. Only an officer listed on this report or past completed and
filed report may sign. Complete the signature, date, title and typed or printed name in the space provided on the form to certify that the information is accurate
and current. If the Officer of the business corporation is another business entity then the appropriate representative of that business entity must certify the
annual report.
SECTION E: ADDITIONAL OFFICERS
Provide the names and addresses of each additional officer. A person listed in this section is then authorized to sign on other documents filed with this
office.
Mail the annual report to: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525. For information or assistance, contact
the Business Registration Division at [phone] or Toll Free 1-888-246-7636. The url address is http://www.sosnc.gov. (Revised 10/2017)

Far Sez--la.,
Po
10
rm l•
� /�(• U.S. DES.. EOLGEOLOGICAL SURVEY qR
NT OF THE INTER
U.S. G
mom w.+..0nodal
J
Pr*.Mthe YtS Uaa 0ook.F.ism
�w1
n lE
►:: US Topo
n
SCALE 1:110E0
ale f77
i � Y
9 Y�_.-.N
y
_111 Y.
GI•SONVILLE QUADRANGLE
7.5M011.fEE SEAMS
1,50
Po
•
•
Y
1E1.-N
CAP
a.
•......s a O 0_r
men
e-�
=a
GISSONVLLLE, NC is#g
2011

MCC
NELL RD
PINEY RD
BURLINGT N RD\�^.
INTERSTATE DR
FRI'£ PKWY
WINNERS
1 \
L . J ROCKLEDGE RD
/4W
Little .4/u»ru»(•F, if,e
O,

Technical Information
GRP 19/3
4 RAJ..? � EN MIT
SYSTEM
Operating data
Flow 30 US g.p.m.
Head 34 ft
Shaft power P2 1.75 hp
Pump efficiency 26.5 %
Required pump NPSH
Pumpe type Single pump
No. of pumps 1
Fluid Water
Pump
Pump Code GRP19/3
Impeller Vane impeller with cutter sys
Impeller size 59/16"
Solid size
Discharge port 1 '/<" - 11 '/: NPT
Suction port
Motor
Rated voltage 230/ 460 V
Frequency 60 Hz
Rated power P2 2.0 hp
Rated speed 3450 rpm
Number of poles 2
Efficiency 75 %
Rated current 5.8 / 2,9A
Degree of protection IP 68
Materials
Motor housng Cast Iron ASTM A48;CI.40B
Motor bearing cover Cast Iron ASTM A48;CI.40B
Pump housng Cast Iron ASTM A48;CI.40B
Impeller Cast Iron ASTM A48;CI.40B
Cutting system Hardened Stainless Steil HRC55
Motor shaft AIS1430 F Stainless Steel
0-Rings Nitrite Rubber
Bolts AISI 304 Stainless Steel
Mechanical seal on medium side SiC / SiC
Shaft seal (motor side) Nitrite Rubber
Lower Bearing Double row angular ball bearing
Upper Bearing Deep Groove Ball Bearing
[ft]
100
90
80
70
60
50
40
30
20
10
0
Testnorm: HI Standard Sect. 11.6.5.4
Head
A79/0
ff.
[%] _ Efficiency
2 ]_
15=
10=
RP 19/3
0
[hp]
1.5.
0.5=
0=
0
Shaft power P2 eRP49/3 (P2)
5 10 15 20 25 30 35 40 45 50 55 60 [US g.p.m.]
Table Dimensions
(inch )
Project
Project no.:
Created by:
Page:
Date:
1
2021-12-27
- 17.01.2017 (Build 147)

Performance Curve
GRP19/3
HOMA
PUMPEN MIT SYSTEM
Impeller type:
Vane impeller with cuttersys.
Solid size
0:
Max. 0:
59/16"
Min. 0:
47/18
Sel. 0:
5s/16°
Operating data
Speed:
3450 rpm
Frequency:
60 Hz
Duty point:
Q =30 US g.p.m. H =34 ft
Shaft power P2:
1.75 hp
Discharge port:
11/."-111/2NPT
Power data referred to:
Water, clean [100%] ; 68°F; 62.322Ib/ft'; 1.0818E-5ft'/s
Testnorrn: HI Standard Sect. 11.6.5.4
[ft] = Head
105=
100_
95=
90.
85=
80-
75.
70=
65-
60=
55=
50=
45=
40.
35-
30-'
25-
20-
15=
10.-
5
[%]-
24-
20:
16:
12=
8=
4-
0
[hp]'
1.6-
1.2-
0.
0.4-
Eff.
2.. °0
Shaft pow er P2
GRP19/3 (P2)
0 4 8 12 16 20 24 28 32 36 40 44
48 52 56 60
64
[US g.p.m.]
Project
Project no.:
Created by:
Page:
Date:
2
2021-12-27
2.0.1 - 17.01.2017 (Build 147)

Technical Data
GRP19/3
HOMA
PUMPEN MIT SYSTEM
Operating data
Flow
30 US g.p.n41S g.p.m.
Head
34 ft ft
Shaft power P2
1.8 hp
Static head
10 ft
Pump efficiency
26.5 %
Required pump NPSH
ft
Pumpe type
Single pump
No. of pumps
1
Fluid
Water
Temperature
68 °F
Density
62.31 Ib/ft3
Kin. viscosity
1.077E-5 ft2/s
Pump Code
GRP19/3
Speed
3450
rpm
Suction port
Head
Max.
101.7
ft
Discharge port
1 '/4 -11 '/z NPT
Min.
3.0
ft
Impeller type
Vane impeller with cuttersys
Flow
Max.
60.2
US g.p.m.
Solid size
inch
Pump efficiency max.
26.5
ok
Impeller0
5.59 inch
Required rated power max. P2
1.9
hp
Motor design
Submersible motor
Insulation class
H
Motor name
AM120TM.2,4/2/3
Degree of protection
IP 68
Frequency
60 Hz
Temperature class
T4
Rated power P1
2.7 hp
NEMA code
F
Rated power P2
2.0 hp
Explosion protection
Rated aoeed
3450 rpm
100%
75.0 %
Rated voltage
230 / 460 V 3-
Efficiency 75%
at %rated power
o
/0
Rated current
5.8 / 2,9 A
50%
Starting current, direct starting
23.4 / 11,7 A
100%
0.83
Starting current, star -delta
7. A
cos phi
75%
at % rated power
Starting mode
Directly
50%
Power cable
6G1,5
Control cable
Type of power cable
HO7RN8-F PLUS
Type of control cable
Cable length
32.809 ft
Service factor
1.15
Shaft seal
Mechanical seal on medium side SiC / SiC
Shaft seal (motor side) Nitrite Rubber
Bearing
Lower Bearing Double row angular ball bearing
Upper Bearing Deep Groove Ball Bearing
Remarks
Materials / Weight
AMotor
housing
Cast Iron ASTM A48;CI.408
Motor shaft
AISI 430 F Stainless Steel
Pump housing
Cast Iron ASTM A48;CI.40B
Bolts
AISI 304 Stainless Steel
Motor bearing cover
Cast Iron ASTM A48;C1.40B
0-Rings
Nitrite Rubber
Impeller
Cast Iron ASTM A48;CI.40B
Cutting system
Hardened StainlessSteil HRC55
Weight aggregat
57.319 lb
Project
Project no.:
Created by:
Page:
Date:
4
2021-12-27
2.0.1 - 17.01.2017 (Build 147)

NOTE MEASUREMENTS OF BASINS ARE ALL I.D.,
NOT OTHERWISE SPECIFIED
■4**DACKFILL INSTRUCTIONS TO BE FOLLOWED
FOR AK IND, TO WARRANTY BASINsnesi■
120'
I.D.
1
(2) 2' SS COUPLINGS
(LOCATED AT 6100)
SS DUPLEX FLOAT BRACKET
(LOCATED AT 900)
4' ADAPT —A —FLEX
SCH 40
(SHIPPING LOOSE)
(2) CP-10SS LIFTING CHAINS
(SHIPPING LOOSE)
(4) 2900-20W FLOAT SWITCHES
(SHIPPING LOOSE)
ROUND FIBERGLASS
HEAVY DUTY
ANTI —FLOAT (-200)�
0
36'
42'
41
4
it
2' MUSHROOM VENT
(SHIPPING LOOSE)
(4) LIFTING LUGS
1/8' X 1' X 12'
SS SUPPORT BRACKET
3/8' SS EXTENSION HANDLE RODS
7777—
1/4' ALUMINUM
UPPER GUIDE PLATES
(2) 2' BRASS GATE VALVES
�2' SS TEE
2' SS UNION
2' SS DISCHARGE COUPLING
(LOCATED AT 12100)
(FLUSH WELD)
1(2) 2' SS 90' ELBOWS
(2) 1 1/4' X 2' AK
ADJUST —A —RAIL SYSTEMS
(NON —SPARKING)
(2) 1 1/4' SS STREET ELBOWS
(2) 1 1/4' CI
BALL CHECK VALVES
1 1/4' SS DISCHARGE PIPE
3/4' SS GUIDE RAILS
1/4' ALUMINUM
LOWER GUIDE PLATES
(2) 1 1/4' SS CONDUIT NUTS
POLY LOWER BASE PLATE
TO CUSTOMER'
EXAMINE THIS DRAWING CAREFULLY, VERIFY ALL DIMENSIONS, LOCATIONS, AND ELEVATIONS FOR ACCURACY. SIGN
AND DATE AT LINE. ANY MODIFICATIONS OR CHANGES TO THIS DRAWING OR FINISHED PRODUCT, AFTER IT HAS BEEN
SIGNED, MAY RESULT IN ADDITIONAL CHARGES AND SHIPPING DELAYS. NO JOB WILL BE STARTED UN 1 CONFIRMATION
THROUGH SIGNATURE. I 7.29.21
(REQUESTED SIGNATURE $. DATE PE E)
CONFIRMATI❑N THROUGH SIGNATURE RELEASES ORDER FOR PR❑DU
84"
,PRAWN FOR.
THE 419 GROUP
Poi 5457
DISCONNECTS: AKD 125—ADJ—NS
SHEET
1
OF 2
Revision 0
oUOTE / 75791
PUMPS: UBERTY LSG202
.UI REFE Ek* E / Notes.
UNION CITY
DASDs DESCAWTDH
36 X 120-200
CHECKED DY. / DATE CHECKED
"THE REST AROUND UNDERGROUND"
[OVER DESCRVTOH
1/4' ALUMINUM FROG MOUTH HDC
1E1: (574)-936-6022 FX: (574)-936-5811
WWW.AKI DUSTREES.COM