WQCS00192_Other Correspondence_20221128

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
.11\I GS Town of Holly Springs
Utilities&Infrastructure
A P.O.Box 8 1128 S.Main St.
0 C3 Holly Springs,NC 27540
ti d(919)577-3150
®[e-mail]
4 G www.hollyspringsnc.gov
Nort''ti
October 20,2022
North Carolina Department of Environmental Quality
Division of Water Resources
Municipal Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1636
Re: Application for Local Program Sewer Delegation (Public Gravity Sewer and Public
Pump Stations &Force Mains)
Town of Holly Springs
Utley Creek Water Reclamation Facility
WWTF permit# -NC0063096
Collection System Permit # -WQCS000192
Dear Sir/Madam:
The Town of Holly Springs (Utley Creek Water Reclamation Facility) is requesting local
program sewer delegation approval for Public Gravity Sewer and Public Pump Stations &
Force Mains. Private and other non-standard requests, as outlined in the application, will
continue to be sent to the state for permitting.
Please find enclosed the following items in application for local program sewer delegation for
the Town of Holly Springs.
A. Cover Letter (this document)
B. No Application Fee Required for Local Delegation Request
Exhibit B1. Fee Schedule
C. Local Program Sewer Delegation Application
Exhibit C1. Application LSPD 11-21
D. Program Administration
Exhibit D1. Utilities and Infrastructure Organizational Chart
Exhibit D2. Development Services Organizational Chart
Exhibit D3. Town of Holly Springs Organizational Chart
Exhibit D4. Sewer Permitting Process Flow Chart
.......' .. ... _ _ -- -..•

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
E. Sewer Use Ordinance
Exhibit El. Town of Holly Springs Code of Ordinances Chapter 16 -
Revisions (submitted digitally)
Exhibit E2. Town of Holly Springs Code of Ordinances Chapter 16 -
Public Enterprises (submitted digitally)
F. Minimum Design Criteria
Exhibit Fl. Engineering Design and Construction Standards (submitted
digitally)
G. Local Program Permit Application
Exhibit Cl. Local Program Sanitary Sewer Extension Application
(Form: TOHS LPSSEA 06.22)
H. Local Program Permit Template
Exhibit H1. Authorization to Construct Template
I. Inspection and Certification Procedures
Exhibit I1. Inspection and Certification Procedures -Gravity Sewer
Inspection SOP
Exhibit I2. Inspection and Certification Procedures -Force Main&
Pump Station Inspection SOP
Exhibit I3. Inspection and Certification Procedures -Verification for
Certification
J. Downstream Capacity Assurance -Flow Tracking
Exhibit J1. Flow Tracking
Information was not included for Wastewater Treatment Authorization (K.) because it is not
applicable to the Town of Holly Springs.
Feel free to contact Rachel Ingham at [e-mail] or 919-567-3985 if
you have any questions or need additional information in order to process this application.
Sincerely,
�D9
D9wM: 2=
CO3C051389FC34440
Kendra D. Parrish, P.E., CFM Rachel Ingham
Executive Director of Utilities and Infrastructure utility Engineer
KP/tr
cc: Rachel Ingham;Engineering Manager
Seann Byrd; Deputy Director -Water Resources
Drew Johnson, Development Construction Manager
Project file/Correspondence #42000

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4 Hitting - Local Program Sewer Delegation
B.No Application Fee Required for Local Delegation Request
Exhibit 1-Fee Schedule
Town of
: HOLLY
49. 1
SPRINGS
North Carolina
Fee
Schedule
Exhibit B1 Page 1

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
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Exhibit B1 Page 2

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
} HOLLY
�1 SPRINGS Fee Schedule
North C.rolin ri—
Finance/Utility Fees
Description Approved Fee FY2022-23
Water/Sewer Rates- Recommended water and sewer rate changes would be effective August 1,2022
Water In-Town Rates(see below for access fee per meter size)
0-2,000 Gallons $4.03 per 1,000 Gallons
2,001-5,000 Gallons $5.24 per 1,000 Gallons
5,001-9,000 Gallons $6.45 per 1,000 Gallons
9,001-14,000 Gallons $7.66 per 1,000 Gallons
14,001 Gallons and over $8.87 per 1,000 Gallons
Water Out-of-Town Access Fees and Volume Rates ore Iwo times the In-Town Rates
Sewer In-Town Rates($12.66 Monthly access fee per unit)
0-2,000 Gallons $5.51 per 1,000 Gallons
2,001-5,000 Gallons $5.51 per 1,000 Gallons
5,001-9,000 Gallons $5.51 per 1,000 Gallons
9,001-14,000 Gallons $5.51 per 1,000 Gallons
14,001 Gallons and over $5.51 per 1,000 Gallons
Sewer Out-of-Town Access Fees and Volume Rates are two times the In-Town Rates
Meter Size(Inches) (Multi-Unit Dwellings will be charged the monthly access fee per unit)
3/4(Includes multi-unit dwellings) $12.14
1 $20.24
1 1/2 $40.48
2 $64.76
3 $129.50
4 $202.34
6 $404.68
8 $647.48
10 $1,699.60
Industrial Water/Sewer Rate(In-Town Rate for Monthly Access Fee per unit) In-Town 0-2,000 Gallons Rate
Government Rate(Internal only)Water/Sewer(In-Town Rate for Monthly Access Fee per unit) In-Town 0-2,000 Gallons Rate
All water users:$8.06 per 1,000 Gallons based on actual gallons used,plus a$12.14 monthly access fee
Residential/Commercial Reuse:$4.03 per 1,000 Gallons based on actual gallons used,plus a$6.07 monthly access fee
Bulk/Industrial Reuse:$2.69 per 1,000 Gallons based on actual gallons used,plus a$6.07 monthly access fee
Garbage fee $10.58
Recycling fee $4.74
Exhibit B1 Pa•e 3
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 187

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
.'tom r.•. .- _
i HOLLY
Fee Schedule J SPRINGS
Finance/Utility Fees (continued)
Description Approved Fee FY2022-23
Yard Waste Fee $4.50
Additional Monthly Yard Waste Cart Service(per cart) Additional Yard Waste Monthly Fee(Per Cart)+Actual Cart Cost
Additional Yard Waste Cart Delivery(per trip) $20
Bulk Yard Waste Fee(Based on estimated volume) Level I:$40,Level II:$80,Level III:$120
Residential(single family&townhomes) $5.20
Multi-Family Units $5.20 per unit
(0-10,000 sq.ft.of impervious surface) $5.20 per ERU
(10,001-75,000 sq.ft.of impervious surface) $5.20 per ERU
(75,001 and up of sq.ft.of impervious surface) $5.20 per ERU
Water Meter Deposit(with letter of intent to purchase or closing statement) $0
Water Meter Deposit(without letter of intent to purchase or closing statement) Owner.$45
Rental:$80
Commercial:$70
Same Day Water Service $75
Utility Set-up Administrative Fee $5
Meter Reading Fee S35 per trip if no fault of the Town
(Leak/Plumbing problem)
$0 if the problem is on the Tawn's side
Meter Data Reading $50
New Meter Installation Revisit $75 each additional trip
Hydrant Meter Rental $25/per day
$350/per month
Hydrant Meter Rental Deposit $1,500
Hydrant Meter Set-up Fee(initial or relocation) $75
Hydrant Meter Reading Fee $35
Hydrant Meter Damage Fee(plus actual repair or replacement cost) $55
Hydrant Meter Bill Late Payment Charge $10
Utility Bill Late Payment Charge $10.00
Water Meter"Cut Off Status"Delinquent Fee $35.00
Exhibit B1 Pa•e 4
188 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOIIYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
¢ HOLLY
SPRINGS Fee Schedule
Finance/Utility Fees (continued)
Description Approved Fee FY2022-23
Bulk Water Fee(no charge for reclaimed) $25+$8.06/1,000 gals
Late/No Show Fee $25
Reclaimed Bulk Account Setup(inc.up to 4 train/trans cards) $100
Reclaimed Bulk Training(per person) $50
Replacement Transaction Card Cif lost) $10
Line Flushing Fee/Reclaimed at 50% $25+$8.06/1,000 gals
$12.50+$4.03/1,000 gals
Water Meter(3/4") $355.00
Water Meter(1") $470.00
Water Meter(1 1/2") $945.00
Water Meter(2") $1,150.00
Water Meter 3"Octave w/Allegro Pit Mount $2,700.00
Water Meter 4"Octave w/Allegro Pit Mount $3,625.00
Water Meter 6"Octave w/Allegro Pit Mount $5,300.00
Water Meter 8"Octave w/Allegro Pit Mount $6,600.00
Water Meter 10"Octave w/Allegro Pit Mount $9,935.00
Water Meter 12"Octave w/Allegro Pit Mount $13,100.00
Allegro Register for Meter Only $250.00
Pit Mount Only $655.00
Water Meter Removal $25
Unauthorized Meter Connection Up to$1,000
Return Check Fee $25
Motor Vehicle Fee $25
Exhibit B1 Pa.e 5
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 189

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
eHOLLY
Fee Schedule SPRINGS
orh t'nrolina
Development Services Fees
Description Approved Fee FY2022-23
tund acreage to the uearest tenth;ex.(0.0 acres,
Zone Map Amendment $900+$10/acre*
(double fee for part parcel)
Zone Mop Amendment—Additional Public Hearing $350
PUD Master Plan—Major Amendment(fee includes 4 reviews $1500+$10/acre*
PUD Master Plan—Minor Amendment(fee includes 4 reviews) $500
•-dp``ent Pla ole:Fees include 3 reviews unless otherwise noted. _ •
Major Subdivision New&Major Amendment $700+$5/lot
Dev Plan for Multi-Family—New&Major Amendments(includes 3 reviews) $1,500+$5/lot(+each dwelling unit if multiple units on a single lot)
(double fee for part parcel)
Dev Plan—New or Major Amendment $1,000 +$5/acre*
Appeal of Adminisitrotive Decision /2 Original Fee
Final Plat $300+$10/lot
Exempt Plat $200
Minor Residential Plat $200
Amendment to Recorded Plat $200
Accessory Use/Building or Structure $75
Temporary Use/Building or Structure $75
Laying Hens $75
Wireless Telecom Facilities(plus Special Use permit fees when applicable) $1,000
Wireless Small Cell Telecom Co-Location on existing utility pole in Town Right-of-Way $100/each(first 5 in a batch)+
(Max.25 permits per batch) $50/each additional(max.20 additional)
+$500 technical consulting fee
Total fee not to exceed$2,500
UDO Permit-After the Fact Double Permit Fee
UDO Permit with Residential Bldg Permit Review $75
UDO Permit with Non-Residential Bldg Permit $100
Sign Permit(permanent/temporary) S75/$50
Temporary Family Healthcare Home $100
Temporary Family Healthcare Home Annual Renewal $50
Exhibit B1 Pa•e 6
190 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
et HOLLY
SPRINGS Fee Schedule
Vorrh Cu rulini
Development Services Fees (continued)
Description Approved Fee FY2022-23
Other Permits and Procedures ;
Special Use Permit or Quasi Judicial Cose $500+other required applications/fees
Special Use Permit After-the-Fact Double Fee
Minor Development Petition Amendment $200(includes 3 reviews)
additional review$200/each
Additional Review Fee(PUD,Subdivision,Development Plan,and Plotting) '/Original Fee
Master Sign Plon New or Amendment $200+applicable waiver and/or Variance Fees
Voluntary Annexation Petition Recording Fee Only
Historic Property Verification/Inspection Meeting—Capital Area Preservation(CAP) Actual CAP Cost
Home Occupation Registration $35
Zoning Verification Letter $100+Inspection Fee
ABC Permit Review/Inspection Fee $75
Planning Inspection/Re-Inspection Fee $75
Amendment to Comp Plan or UDO $700(double fee for part parcel)
Zoning Citation Fee As set forth in Town's UDO
Zoning Vested Rights $400
Development Agreement Public Hearing Fee Actual Cost
Incomplete Petition Processing Fee $50
UDO/DPM Waiver or Alternate Compliance $100
Development Petition Expiration Extension $100
Land Use Advisory Committee(LUAC)Request&Communications Item $100/$200 for each
subsequent meeting
Administrative Appeal $250
Variance of Development Standards $350
Variance—After the Fact $500
Variance of Development Standards—Town Council $100
Unified Development Ordinance Town's Reproduction Cost
Development Procedures Manuol Town's Reproduction Cost
Comprehensive Plan Town's Reproduction Cost
Exhibit B1 Pa•e 7
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 191

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
HOLLY
Fee Schedule �� SPRINGS
NOIFA Corolioo
Development Services Fees (continued)
Description Approved Fee FY2022-23
GIS Maps
8.5x11 $2 each
11x17 $3 each
18x24 $5 each
24x36 $10 each
30x42 $12 each
36x48 $15 each
Photographic Copies(B&W)
8.5x11 and 8.5x14 $0.10 per page
11x17 $0.20 per page
18x24 $4 per page
24x36 $8 per page
30x42 $10 per page
36x48 $12 per page
Photographic Copies(Color)
8.5x11 $2 per page
Files on Disk
Flash Drive or CD $10 each
Design R.Construction Standards Manual
Purchased $95 per copy
Mailed $110 per copy
Exhibit B1 Pase 8
i92 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOU

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DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
t HOLLY
SPRINGS Fee Schedule
North Col-ultra
Development Services Fees (continued)
Description Approved Fee FY2022-23
Construction Drawing Plan Review
Subdivision Covers 1st&2nd Reviews $650+$50/lot
Site Covers 1st&2nd Reviews 0-5 acres$1,000
5-20 acres$1,400
>20 acres$1,750
Major Plan Revisions(Covers 1st and 2nd review) $1,000
Other ex.Utility or Roadway(1st&2nd Review) $1,500
Subsequent Plan Review(includes utility plan review) $450
Minor Revisions Plan Review Covers 1st&2nd Reviews $450
Revisions Subsequent Plan Reviews(Per Rev after 2nd Rev) $450
Timbering Review Per Project $500
Irrigation Well Review $200
Preliminary Pump Station Site Plan review $650(covers 1st and 2nd review)
Construction Drawing Pump Station Review $1,000(covers 1st and 2nd review)
Construction As-built Review Fee $200
Subdivision/Site Covers 1st and 2nd Review $300/acre
Subsequent Plan Reviews&Plan Revision (Per Rev after 2nd) $450
Additional Reviews after 2nd Review $450/each additional review
Environmental Variance/Waiver Reviews Per Review $300
Environmental Variance/Waiver/Appeal Review After Fact Filing Fee Per Review $500
NPDES—Subdivision Covers 1st&2nd Reviews $500+$25/lot
NPDES—Stormwater Subsequent Reviews/Revisions(per rev) $500
NPDES-Site <20 acres$850
(covers 1st&2nd Reviews)
>20 acres$1,200
(covers 1st&2nd Reviews)
Stormwater As-built/Engineer Certification Administration $200
Annual Stormwater Storm Control Measure(SCM)Inspection&Administration <5 acres drainage$150 per BMP
Late Fee >5 acre drainage$200 per BMP
Water Permit Application Review(Delegated) $480
Sewer Permit Application Review(Delegated) $480
Reclaimed Water Distribution Line Extension Permit Application Review(Delegated) $480
Water Permit Processing $200
Wastewater Permit Processing $200
Reclaimed Water Permit Processing $200
Exhibit B1 Pa.e 9
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 193

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
rou,of
} HOLLY
Fee Schedule SPRINGS
Development Services Fees (continued)
Description Approved Fee FY2022-23
Special Study(Flood Study,Traffic Impact Analysis,Traffic Assessment Report,Sewer,Basin, $350 Plus Actual Cost
Fire Flaw/Hydraulic Analysis,Reclaimed Water Model Update,Pump Station,etc.)Covers 1st
8 2nd Reviews
Special Study Subsequent Reviews and Revisions $200 Plus Actual Cost
Special Study Verification Letter(Internal review only) $100
Environmental Development Permit $400 x acres
(yearly renewal required,fee based on remaining disturbed acreage)
• w
Storm drainage pipe $2.10 per if
Storm Control Measures(SCM) <5 acre drainage$300 each SCM
>5 acre drainage$500 each SCM
Neuse River Basin—Total fee-in-lieu=number of pounds/acre/year to be offset x acres in development x 30 yrs x$18.49 per pound
Cape Fear River Basin—Total fee-in-lieu=number of pounds/acre/year to be offset x acres in impervious surface x 30 yrs x$14 per pound
Infrastructure Surety Performance New—$350 ea.
Revised/Renewal-$300 ea.
Infrastructure Surety Warranty New—$350 ea.
Revised/Renewal-$300 ea.
Stormwater SCM Surety Performance New—$350 ea.
Revised/Renewal-$300 ea.
Stormwater SCM Surety Maintenance New—$350 ea.
Revised/Renewal-$300 ea.
Erosion Control Surety Performance New—$350 ea.
Revised/Renewal—$300 ea.
UDO Compliance Surety New—$350 ea.
Revised/Renewal—$300 ea.
Fees In Lieu Of Assessment
Payment in Lieu of Street Widening Per approved engineer's estimate
Payment in Lieu Infrastructure Improvements Per approved IRA by DOE
Payment in Lieu Street Light Installation $2,000 per light
Utility Inspection Fees
Water $2.10 per LF
Wastewater $2.10 per LF
Reclaimed $2.10 per LF
Pump Station Inspection $1,500 lump sum
Exhibit B1 Pa•e 10
194 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
Tat,n of _..
} HOLLY
�l SPRINGS Fee Schedule
North Cn ruling
Development Services Fees (continued)
Descriptjpp _...., Approved Fee FY2022-23
Utility Inspection Fees Continued
Streets/Fire lanes $2.10 per LF
Sidewalks $2.10 per LF
Greenway $2.10 per If
Fiber $2.10 per LF
Re-Inspection Fee $.25/LF for any after 1st or 2nd Inspection
Non-Residential System Development Fees-Based on Meter Size(due at issuance of building permit). Fee for Multi-Unit Dwellings will be
applied as the 3/4" residential meter rate per equivalent residential unit. All other fees will follow the Non-Residential fee schedule.
Water&Sewer <3,000 sq.ft. >3,001- >20,001 sq.ft. <3,000 sq.ft. >3,001- >20,001 sq.ft.
(charged separately) <20,000 sq.ft. <20,000 sq.ft.
Irrigation $3,200 $3,200 $3,200 $3,200 $3,200 $3,200
Irrigation (Reclaimed) $1,650 $1,650 $1,650 $1,650 $1,650 $1,650
3/4"meter Sewer $5,538 $6,701 $9,615 $6,701 $7,867 $10,781
3/4"meter Water $6,162 $7,459 $10,703 $7,459 $8,756 $11,999
1"meter Sewer $4,662 $7,866 $10,781 $7,284 $9,033 $11,947
1"meter Water $6,286 $8,756 $11,999 $8,108 $10,052 $13,296
1 '/4"meter Sewer $7,284 $9,032 $11,946 $9,032 S10,198 $13,112
11/4"meter Water $8,108 $10,054 $13,298 $10,054 $11,350 $14,594
11/2"meter Sewer $8,450 $10,197 $13,112 $10,197 $11,364 $14,278
1 'h"meter Water $9,406 $11,350 $14,594 $11,350 $12,647 $15,891
2"meter Sewer $9,617 $13,111 $15,443 $10,780 $14,278 $16,609
2"meter Water $10,703 $14,594 $17,189 $11,999 $15,889 $18,486
3"meter Sewer $10,781 $15,442 $17,774 $11,946 $16,609 $18,940 I
3"meter Water $12,001 $17,188 $19,784 $13,296 $18,484 $21,080 I
4"meter Sewer $11,947 $17,772 $20,105 $13,111 $18,940 $21,229
4"meter Water $13,298 $19,782 $22,379 $14,594 $21,079 $23,675
6"meter Sewer $23,602 $29,427 $35,255 $29,427 $35,258 $41,086
6"meter Water $26,271 $32,755 $39,244 $32,755 $39,238 $45,728
8"meter Sewer $35,258 $41,081 $46,909 $41,081 $46,912 $52,740
8"meter Water $39,245 $45,727 $52,218 $45,727 $52,210 $58,701
10"meter Sewer - - $54,745 - - $62,015
10"meter Water - - $60,941 - - $69,034
12"meter Sewer - - $64,722 - - $73,452
12"meter Water - - $72,047 - _ - $81,765
Exhibit B1 Pas 11
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 195

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
1 ,t>1
f HOLLY
Fee Schedule
SPRINGS
�� _
Development Services Fees (continued)
liter and Sewer Services-Village District Area Plan
Re:RaglitSystem Develcpment FeepseMetue at issce of buildin
Water&Sewer <5,000 sq.ft. 5001- 10,000- >20,001 sq.ft. <5,000 sq.ft. 5001- 10,000- >20,000 sq.ft.
(charged separately) 9999 sq.ft. 20,000 sq.ft. 9999 sq.ft. 20,000 sq.ft.
3/4"meter Sewer $4,021 $5,886 $7,284 $8,449 $4,487 $6,584 $8,159 $9,324
3/a"meter Water $4,475 $4,475 $8,108 $9,405 $4,993 $7,330 $9,081 $10,378
1"meter Sewer $4,487 $6,586 $8,159 $9,614 $4,953 $7,283 $9,033 $10,547
1"meter Water $4,993 $7,330 $9,081 $10,701 $5,512 $8,108 $10,054 $11,740
11/4"meter Sewer $4,953 $7,284 $9,032 $10,780 $5,419 $7,983 $9,907 $11,597
1 '/4"meter Water $5,513 $8,108 $10,054 $11,999 $6,032 $8,865 $11,027 $12,907
1 'h"meter Sewer $5,419 S7,984 $9,907 $11,944 $5,886 $8,681 $10,781 $12,529
11/2"meter Water $6,032 $8,886 $11,027 $13,296 $6,550 $9,665 $11,999 $13,945
2"meter Sewer $6,352 $9,383 $11,654 $13,694 $6,818 $10,080 $12,529 $14,860
2"meter Water $7,070 $10,443 $12,972 $15,242 $7,587 $11,221 $13,945 $16,540
3"meter Sewer $7,284 $10,781 $13,402 $16,023 $7,750 $11,478 $14,278 $16,608
3"meter Water $8,107 $12,001 $14,920 $17,837 $8,625 $12,778 $15,892 $18,486
4"meter Sewer $8,217 $12,180 $15,151 $17,772 $8,683 $12,877 $16,026 $18,939
4"meter Water $9,145 $13,558 $16,865 $19,782 $9,663 $14,336 $17,838 $21,079
6"meter Sewer $14,277 $21,269 $26,514 $31,749 $16,608 $24,764 $30,887 $36,419
6"meter Water $15,889 S23,677 $29,514 $35,349 $18,483 $27,568 S34,378 $40,537
8"meter Sewer $18,939 S28,262 $35,255 $42,244 $21,269 $31,756 $35,258 $46,909
8"meter Water $21,079 $31,461 $39,244 $47,024 $23,671 $35,352 $39,242 $52,212
10"meter Sewer - - - $49,273 - - - $55,175
10"meter Water - - - $54,852 - - - $61,413
12"meter Sewer - - - $58,271 - - - S65,378
•
12"meter Water - - - $64,869 - - - $72,770
Development Services Fees (continued)
Description Approved Fee FY2022-23
n a a ,c a,;.,ai l f.,, - IT, t.i..! ,e) qua a -..1,I... „ ( ,',1 a „,..s( rs •i�f -tom$ ral.cases,widerbts ng of way,
21
. ... .. ,...
Wastewater Town Installed (4"only) Non-Res-$1,500/lot/Res-$1,350
Water Town Installed(3/4"only) Nan-Res-$1,500/lot/Res-$1,350
Reclaimed Town Installed Non-Res-$1,500/lot/Res-$900
Water Developer Installed $150/unit
Wastewater Developer Installed $150/unit
Reclaimed Developer Installed $150/unit
Exhibit B1 Pa•e 12
196 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.60V

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
t HOLLY
SPRINGS Fee Schedule
North Cnralinu
Development Services Fees (continued)
Description Approved Fee FY2022-23
Irrigation Meter Top Fee 3/4"only $1,500
Street Cut $750 each
Curb&Gutter Crossing $250 each
Street Bore $500 each
Backflow Inspection Fee $25
Service Reconnection fee for lapse in annual backflow certification $50
Service Availability Verification $200
Utility Inspection Fees Same as Non-Residential Fees
Fee in Lieu of Assessment Same as Non-Residential Fees
System Development Fees—Water and Sewer Services
Irrigation Meters $0
3/4"Meter S$5,538;W$6,162
1"Meter S$6,119;W$6,811
1 3/4"Meter S$7,284;W$8,108
1 '/"Meter S$8,450;W$9,406
2"Meter S$9,617;W$10,703
3"Meter S$10,781;W$12,001
4"Meter S$11,947;W$13,298
6"Meter S$23,602;W$26,271
8"Meter S$35,258;W$39,245
Water/Wastewater/Reclaimed Town Installed Residential $900/unit
Water/Wastewater/Reclaimed Developer Installed $90/unit
Irrigation Meter Tap Fee $900
Service Reconnection fee for lapse in annual backflow $50
Driveways $125 each
Lot or Site Final(Prior to C.O.) $200 each
Reclaimed Irrigation Installation Inspection(Residential/Commercial) $100/$200 each
Utility Encroachment Permit without bore$50;with bore$100
Exhibit B1 Pa•e 13
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 197

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
P J
r ratn o/
HOLLY
Fee Schedule SPRINGS
Kurth l'a rotina
Development Services Fees (continued)
Description Approved Fee FY2022-23
i',`eral Fees: Refunds will be issued when requested,less any Administrative and/or Plan Review Fees for any permit,which has not
Building Code Fees
All permits are subject to a technology surcharge fee at 4%of permit fee. 4%of Code Enforcement Fees
Working w/o Permit Double permit fees,Max fee of$1,000
Reinspection Fees(Violations over 10;Not ready;Previous Violation(s)Not Corrected; $75
Violation of DPM)
Certificate of Occupancy C/O(same business day) $50
Stop Work Order $150
Add/Change Contractor(per permit/per trade) $50
Expired Permit Renewal 259'0 of permit cost
Conditional Power $150
Demolition Permit $150
After Hours Inspections(2 business day notice) $125/hr,min 2 hrs if directly after work hours;$125/hr,min 3 hrs if Inspector has
to leave home
Misc.Inspections $100/$150
Change of Occupancy or Use Permit $150
Stocking C/O $150
Temporary C/0(2 business day notice) $250
Temporary C/0(same business day) $400
Temporary C/O Renewal $200
Express Review Fee $500/hr,min.2 hr
Express Review(Re-review) $500/hr,min. 1 hr+
$125 per 15 minute increments
Express Review Cancellation(less than 3 business day notice) No Refund
Replacement Permit Card $10
Manufactured Homes(inc piers,tie-down,steps,decks 8 all trade inspections) $200
Modular Homes&Moved Dwellings Trade fees+$0.10 per sq.ft.
HVAC/Water Heater Change Out $75
Generator Install $75
Building $75
Electrical $75
Mechanical $75
Plumbing $75
Permit Revision $50
Exhibit B1 Pa.e 14
198 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
HOLLY SPRINGS Fee Schedule
Norrh Cn rulinu
Development Services Fees (continued)
Description Approved Fee FY2022-23
Residential New Dwellings
Up to 1,200 sq.ft. $450
Over 1,200 sq.ft. Add$0.30 per sq.ft.
Homeowner's Recovery Fee $10
Permit Revision $100
,Residentid Adct`iti "
0-500 sq.ft. $200
Over 500 sq.ft. Add$0.30 per sq.ft.
Permit Revision $50
Residenhaf jferaf oc's
0-500 sq.ft. $200
Over 500 sq.ft. Add$0.30 per sq.ft.
Permit Revision $50
Resr *11c'ess tfirtlefti ;a;
«
Building Trade $150
Electrical Trade $75
Mechanical Trade $75
Plumbing Trade $75
Permit Revision $50
lrV1omR0srdetr'aftcM � �
$0.00-$1,500 $250
$1,501-$2,500 $350
$2,501-$25,000 $425
525,001-550,000 $650
$50,001-$100,000 $1,200
$100,001-$200,000 $2,500
$200,001-$350,000 $4,500
$350,001-$500,000 $6,000
$500,001-$750,000 $8,000
$750,001-$1,000,000 $10,000
Over$1,000,000 $10,000+0.15%of each million
or portion thereof
Exhibit B1 Pa•e 15
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 199

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
> HOLLY
Fee Schedule ` ��1 SPRINGS
Nur1A Coro limn
Development Services Fees (continued)
Description Approved Fee FY2022-23
Non-Residential Plan Review Fee
0-5,000 sf $150
5,001-10,000 sf $200
10,001.25,000 sf $250
>25,000 sf $300
Permit Revision $150
Nan-Residential Permit Processing Fee
0.5,000 sf $75
5,001-10,000 sf $100
10,001-25,000 sf $125
>25,000 sf $150
Temporary Use Buildings(Construction/Sales)
Construction/Sales Trailer $150
Permit Processing $25
Plan Review $50
Permit Revision $50
Non-Residential Trade Fees
HVAC/Water Heater Change Out $150
Generator Install $150
Building $150
Electrical $150
Mechanical $150
Plumbing $150
Permit Revision $50
�i ��� {{ it ii i
..'+. �r:..li,.n t ,.. � -,_ .ten ..,...�<.ar. _z...,a....ev,.,sn�"-.3.,,�...._....,,._...._✓......,...�.....y......,
5 Facilities or Less $100 per Facility
Additional Facilities over 5 $50 per Facility
Technical Consulting Fee $500
+�! ,._ty£ f rY {� .-. .,s..s�..,n ...�..vr�.....,.e:O...,..
Code Enforcement Citation As set forth in Town's Municipal Code
Temporary Right-of-Way Signs
$25 per sign
Exhibit B1 Pa•e 16
200 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
HO
SPRINGS Fee Schedule
North Ca ralina
Parks & Recreation Department
Description Approved Fee FY2022-23
Park Land Dedication or Fees-in-Lieu Development Fees
Single Family Detached In lieu of land dedication a fee calculated pursuant to NCGS 160A-372(E)may be paid,
at the discretion of the Town Council
Single Family Attached In lieu of land dedication a fee calculated pursuant to NCGS 160A-372(E)maybe paid,
at the discretion of the Town Council
Multi-Family Attached In lieu of land dedication a fee calculated pursuant to NCGS 160A-372(E)may be paid,
at the discretion of the Town Council
Processing Fee for activity refunds and transfers.No refund if registration fee is below$15. $15
Town cancelled activities will not be assessed a processing fee.
Processing Fee for rental amendments or schedule changes unless due to Town weather $15 per occurrence
cancellations. Rentals must be rescheduled within 30 days of the original rental start date.
After-Hours Staffing Fee per hour for facility rentals(outside normal operating hours) $25/$38
Room Set Up Fee for facility rentals $25/$38
In Honor of/Memorial Tree Purchase with Personalized Plaque $200
In Honor of/Memorial Bench Purchase with Personalized Plaque $1,200
Annual Photography Permit(Valid 1 year) $100
To qualify for Non-profit facility rental fees,the organization must be physically located within the municipal town limits and provide o tax exempt certificate. Non-profit rates are
available Monday-Friday from 8 AM until 2 PM. Note Non-profit rates are not available at all facilities.
Youth Athletic Fee,except Football,per Individual/Non Res Fee $60/$90
Football Fee,per individual/Non Res Fee $80/$120
Athletics Activity Late Fee,per Individual/Non Res Fee $10/$15
Child Care Multi-child Fee Reduction $5
Scholarships(See Parks and Rec Policy-°/a dependent upon eligibility) 50°'0 Discount
Basketball Registration,per team (non res add$20 per individual) $400
Volleyball Registration,per team(non res add 515 per individual) $300
Softball Registration(non res add$22.50 per individual) $450
Ultimate Frisbee Registration (non res add$10 per individual) $200
Soccer Registration(non res add$18 per individual) $350
Dodgeball Registration(non res add$4 per individual) $75
Flag Football Registration (non res add$22.50 per individual) $450
Kickball Registration(non res add$5 per individual $150
Adult Athletics Late Fee,per team $25
Exhibit B1 Pa•e 17
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 201

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
> HOLLY
Fee Schedule S)" SPRINGS
UurfA Coro lino
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
After School Fee/Non Res Fee(per month) $120/$180
Track Out Fee/Non Res Fee(weekly rate) $150/$225
Track Out Session Rate/Non Res Fee $400/$600
Before School Fee/Non Res Fee(per month) $100/$150
Before and After School Fee/Non Res Fee(per month) $190/$285
Basic Camp/Non Res $100/$150
Non-refundable Registration Fee(After School,Before School&Track Out) $30
Late Payment/per day/per child(After school) $1
Late Pick Up Fee/per 15 minutes fime $10
Multi-child Fee Reduction $5
Daily Pass/Non Res Fee $10/$15
Monthly Pass/Non Res Fee $30/$45
3 Months(10%Discount) $81/$122
6 Months(20%Discount) $144/$216
Annual Pass/Non Res Fee $218/$327
Membership discount available to Youth(age 13-21),Seniors(age 55+)and Military 20%
Replacement Cards $5
Family Memberships receive a 10%discount(includes all 3/6/12 multi-month memberships)
Age 12 and under Daily Gym Pass/Non Res Fee $2/$3
Age 12 and under Gym 10 Visit Pass/Non Res Fee $10/$15
Exhibit B1 Pa.e 18
202 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNLGOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
1
r.,:,n ,
' W HOLLY
�1 SPRINGS Fee Schedule
.North Cn rulinu
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
Program Rooms(1-5)See Parks&Recreation Policy Manual for Equipment Available for Rental
Room Deposit $25
Rooms(1-5)Per Hour/Per Room $30/$45
Non-Profit Groups Per Hour/Per Room(only on weekdays) $23
Community Room and Multipurpose Room(Up/Down)
Room Deposit $50 _
Rental Per Hour/Non Res fee $40/$60
Non-Profit Groups Per Hour $30
Kitchen:Pots,pans and/or utensils ore not available.Refrigeration is not available.Must be rented in conjunction with the Community Room.
Per Hour/Non Res Fee $10/$15
Non-Profit Groups Per Hour $8
Gym:See Parks&Recreation Policy Manual for Gym equipment Available for Rental
Gym Deposit $100
Rental Per Hour/Non Res Fee $40/$60
Scoreboard/Clock Rental/Non Res Fee $25+$12/hr.for operator/
$38+$18/hr for operator
Picnic Shelters/Band Shell—Damage deposit of$25 is required
Half Day/Non Res Fee 40 max capacity:$40/$60
100 max capacity:$60/$90
Full Day/Non Res Fee 40 max capacity:$75/$113
100 max capacity:$110/$165
Athletic Fields—Natural Grass
Damage deposit for fields with portable mounds $50
Natural Grass Field Rental Per Hour/Non Res Fee $40/$60
Non-Peak Groups Per Hour(weekdays 8 am-5 pm) $25
Lights(where available)/Non Res Fee $20/$30
Baseball/Softball field prep(includes dragging,lining and laying out bases)/Non Res Fee $40/$60
Temporary fence install(baseball/softball fields,excluding Ting Stadium) $100/$150
Multipurpose field lining/Non Res Fee(excluding football) $50/$75
Football field lining(no numbers) $200/$300
Scoreboard/Clock Rental/Non Res Fee $25+$12/hr.for operator/
$38+$18/hr for operator
HSHS Baseball field-per hour/Non Res Fee(Games have a minimum rental of 3 hours) $35/53
Tournament Rentals—Baseball/Softball Fields:Damage deposit of$100 is required.EXCLUDES Ting BASEBALL STADIUM and HSHS Baseball
Full wheel(4 fields)- per day $850
Field Preparation(per application) $40 per field
Score Tower Daily/Weekend Rate $360/$120
Exhibit B1 Pase 19
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 203

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
Al HOLLY
Fee Schedule SPRINGS
North Coro llnn
Parks & Recreation Department (continued)
Description Approved Fee FY2022-,-• - ••
Tennis Courts(1-hour minimum)
Tennis Court Rental per hour/Non Res Fee $6/$9
Turf Soccer Field Rates—Womble and Ting—Damage deposit of$100 is required
Field Preparation per field(excluding football) $50/$75
Football field prep(no numbers) $200/$300
Hourly rental per quad/Non Res Fee $35/$53
Hourly Lighfing charge,per quad/per hour $15/$23
Turf Soccer Tournament Rates—Womble or Ting Turf Fields—Damage deposit of$100 is required
Whole Complex,per day $1,365
Field preparation per field $50/$75
Ting Baseball Stadium
Deposit $300
Rental Event held in the parking lot(Hourly rate not available for events) $250 per section per day/
$25 per section per hour
Stadium Rental
Early bird:Monday-Thursday prior to 12 PM Early bird:$72 per hour
Non-peak:Monday-Thursday 12 PM-5 PM Non-peak:$125 per hour
Peak:Monday-Thursday 5 PM and after,Friday-Sunday all day Peak:$200 per hour
Light Usage $50 per hour
Scoreboard(includes one staff member) $50 per hour
Additional Staff(Staffing Level Determined by HSPR Staff) $35/hour for FT staff;
$15/hour for PT staff
Clubhouse Rental(access available 1 hour prior and after rental time) Single Game:$150 per game
Daily Rate:$300 per day
Housekeeping Fee $50 per day
Cleaning Fee 3rd party fee
Exhibit B1 Pa.e 20
204 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
H
LLY
SPRINGSG Fee Schedule
No rrh Curuli�n__
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
Vendor Fee $100 per event
Electricity $30 per event
Vendor Fee $25-$75 per event
Electricity $30 per event
Commercial food vendor $125 per event
ONLY Holly Springs non-profit food vendor $75 per event
Electricity(food vendors only) $30 per event
Vendor Fee $75 per event
Holly Springs Non-profit non-food vendor(A Holly Springs Non-Profit must have a 501(c) (3) $0
certificate and be located within the corporate limits of Holly Springs)
Vendor Late Fee(HollyFest and July 5th) S15
Tree Fee(Tree Trail at Ting) Market Rate
Tier 1 $100
Tier 2 $250
Tier 3 $500
Tier 4 $1,000
Tier 5 $1,500
Tier 6 $2,000
Tier 7 $2,500
Tier 8 $3,000
Tier 9 $3,500
Tier 10 $5,000
Baseball/Softball(excludes Ting Stadium)
Field Advertisement Signs—per Field (4'x8') $500
Entrance Advertisement Signs—(4'x8') $750
Light Pole Banners—(72"x24') TBD based upon design,number,color etc
Soccer Complex(Womble Park and Ting)
Field Advertisement Signs—(4'x8') $500
Entrance Advertisement Signs—(4'x8') $750
Exhibit B1 Pa.e 21
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROUNA 205

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
} HOLLY
Fee Schedule SPRINGS
YorfA Co,o lino
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
Bass Lake Park&Retreat Center
Conference Room
Deposit(Required)/Min.3 hour rental $300
Alcohol Deposit $300
Hourly Rental/Non Res Fee $77/$116
Holly Springs Non-Profit Groups hourly fee(weekdays from 8 AM until 2 PM only) $53
Evening Conference Room Rental
Deposit(Required) $100
M-TH conference room rental rate $185/$278
(includes room set up and A/V equipment for up to 3 hours of use)
Deck Rental
Deposit(Required) $100
Hourly Rental $30/$45
Holly Springs Non-Profit Groups hourly fee(weekdays from 8 AM until 2 PM only) $23
Packages
Bass Lake Birthday Party Package/Non Res Fee per hour($50 deposit) $154/$231
Weekend Wedding Package/Non Res Fee $2,200/$3,300
4 Hour Wedding Package/Non Res Fee($200 Deposit)Sunday-Thursday Only $325/$488
Weekday Business Package/Non Res Fee $275/$413
Weekday Business Package—Deck/Non Res Fee($25 deposit) $110/$165
Extra Fees
Daily Audio/Video Equipment/Non Res Fee $35/$53
Bass Lake Building and Deck Lights
Light set up for rentals prior to evening events $100/$150
Boats&Canoes
Canoe or Boat Hourly Rental $7
Hourly Motor Rental(in conjunction with a boat rental) $12
Summer Camp Fees
Specialty Camp per week I$115/$263
Exhibit B1 Pa•e 22
206 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
¢ HOLLY
� SPRINGS Fee Schedule
North Ca rolino
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
.Sugg Farm at Bass Lake
Event Deposit 20%of rental fee
General Event $2,500
General Event-Extra Day $825
Per Extra Day—Set-up or Breakdown $413
5K Race Rental(Includes one day for set up) $1,000
5K Race Rental Extra Day $330
5K Race Rental Extra Day for Set Up or Break Down $165
High School Cross Country Weekend Meet $500
High School Cross Country Team Charge for Practices and Weekday Meets $150
(Team who participate in 2 or more meets or practices per Fall season)
Greenway Fees(extra fees may apply depending upon need)
Womble Park(per event)rental/non-resident $250/$375 per event
5K-10K Race event(does not include park rental) $1,000
11K-20 K Race event(does not include park rental) $1,850
Half Marathon rental(12 month lead time required,does not include park rental) $2,500
Marathon rental(12 month lead time required,does not include park rental) $4,625
Portable Stage Rental
Deposit $50
Rental fee $200
Extra day fee $50
Hay Wagon Rental
Deposit(per wagon) $50
Hourly Rental fee(2 hour minimum) $150 per hour
Exhi.i B1 Pas e23
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 207

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
HOLLY
Fee Schedule SPRINGS
N�rlh Coro li rio
I •
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
Room Rental-2 hour minimum
Room Deposit(per room) $50
Hourly Fee per room/Non Res Fee $30/$45
Hourly Non-Profit Group Fee $23
Hourly Kitchen(Rm#126)/Non Res Fee $10/$15
Hourly Non-Profit Group Fee $8
Alcohol Deposit $100
Hourly Bartender Fee $25/$28
Theatre Rentals(Private Events)-3 hour minimum
Theater Deposit $100
Hourly Theatre Fee(private events,recitals,special events)/Non Res Fee $125/$188
Hourly Non-Profit Group Fee(weekdays from 8 AM until 2 PM only) $94
Hourly Technical Staffing Fee(per employee)/Non Res Fee $30/$45
Performance Groups/Rentals Ticketing Services 20%of net ticket sales(after taxes)
Dance Floor Rental/Non Res Fee(one setup/breakdown) $60/$90
Backline Equipment Usage Fee(set up/take down included) $75/$113
Cultural Center Outdoor Venue
Hourly Springs Outdoor Stage Fee/Non Res Fee $50/$60 per hour
Hourly Non-Profit Group Fee(weekdays from 8 AM until 2 PM only) $38
Daily Springs Outdoor Stage Package/Non Res Fee(8 hour block) $200/$300 per day(8 hour block)
Daily Non-Profit Groups(8 hour block) $150 per day(8 hour block)
Hourly Technical Staffing Fee(per employee)/Non Res Fee $30/$45
Daily Outdoor sound system rental fee(does not include Technical Staffing Fee)-Within Town Limits $400 per day
Exhibit B1 Pa•e 24
208 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
— -- --
' HOLLY
SPRINGS Fee Schedule
Parks & Recreation Department (continued)
Description Approved Fee FY2022-23
Vendor—Weekly $210
Vendor—Alternative A/B Week Schedule $150
Vendor—Daily/Substitute $20
Vendor—Seasonal Produce $60
Little Sprouts Vendor—Daily $25
Winter Vendor—Full Season $150
Winter Vendor—One Saturday per month $85
Winter Vendor—daily/substitute $20
Vendor—Extended Season Weekly $360
Vendor—Extended Season Alternative A/B Week Schedule $220
Electricity $25/season
Each Additional Booth Space or Produce/Meat Vendor Vehicle 50?c of regular booth fee/additional space
Night Market Vendor Fee $10
Exhibit B1 Pa•e 25
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 209

DocuSign Envelope ID: E8AB7BEA-014A-4263-B696-85A386C135D4
HOLLY
Fee Schedule SPRINGS
North Carolina
Water Quality Lab Fees
Any analysis that the Town's Environmental compliance Laboratory is not certified to perform will be billed to the business or industry at the Town's cost plus 10',6 handling fee.
Description Approved Fee FY2022-23
Permit Application $500
Permit Renewal $250
Permit Modification $250
Annual Administrative Fee $250
Biological Oxygen Demand(BOD) $35
Total Suspended Solids(TSS) $12
Ammonia $20
Total Phosphorus $35
Conductivity/pH $6 each
Fecal Coliform $40
Total Coliform $45
Dissolved Oxygen $6
Orthophosphorus $35
Total Nitrogen $40
Site Visit $100
Sampler Rental Fee $75 per day
• be ea t pen monthly repor d-vs g s ;• oncentration Limit)
Biological Oxygen Demand(BOD) $0.80 per lb.when exceeding 300 mg/1
Ammonia $2.00 per lb.when exceeding 25 mg/I
Total Suspended Solids(TSS) $0.60 per lb.when exceeding 300 mg/I
Total Nitrogen $1.35 per lb.when exceeding 45 mg/I
Total Phosphorus $3.09 per lb.when exceeding 6 mg/I
Grease Interceptor Not Maintained—Notice of Violation(NOV) $100
Grease Interceptor Missing Components—NOV $100
Food Serve Establishment with no Grease Interceptor/unapproved grease interceptor—NOV $100
Failure to implement expected action from NOV—Second NOV $250
Failure to implement expected action from second NOV(Third NOV) Utility Service suspended with
$500 reconnection fee
Exhibit B 1 Pa.a 26
210 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
HOLLY
SPRINGS Fee Schedule
:Yorrh Ca rosin r
Fire Department Fees
Description Approved Fee FY2022-23
,Fire Prevention and M►sCellaneous Permit/tnspection Fees
Fire Prevention/Misc $100
Commercial Bum $100
Blasting Permit $50
Fixed Fire Suppression Systems $50
Fuel Storage $75 per Tank
Water Supply(Hydrant Placement) $100
After Hours Inspections(2 business day notice) $125/hr,min 2 hrs if directly after work hours;$125/hr,min 3 hrs if Inspector has
to leave home
Reinspection Fee $75
•
0-5,000 SF $150
5,001-10,000 SF $200
10,001-25,000 SF $250
>25,001 SF $300
Foe pnl kir rialfnspedion Fees
0-5,000 SF $150
5,001-10,000 SF $200
10,001-25,000 SF $250
>25,001 SF $300
-ter
1F`eePrevefluono t! ISie us` iewewFes
Fire Prevention/Misc $50
Commercial Burn $100
Blasting Permit(30/90 Days) $100/$200
Fixed Fire Suppression Systems $100
Plan Review Revision $50
Fuel Storage $100
Residential Subdivision Site $100
Express Review $250
Express Re-Review $100
Exhibit B1 P-•- 27
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 211

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
HOLLY
Fee Schedule -%,p) SPRINGS
Nu rlh Carolina
Fire Department Fees (continued)
Description Approved Fee FY2022-23
Fire Prevention Plan Review Fees(Shell,New Building,Fit-up,Multifamily)
0-5,000 SF $150
5,001-10,000 SF $200
10,001-25,000 SF $250
>25,000 SF $300
Plan Review Revision $150
Fire Alarm R.Fire Sprinkler Plan Review Fees
0-5,000 SF $150+$2.00 per Device/Head
5,001-10,000 SF $200+$2.00 per Device/Head
10,001-25,000 SF $250+$2.00 per Device/Head
>25,000 SF $300+$2.00 per Device/Head
Plan Review Revision $150
rn royal.
Square Feet 1-2,500 2,501- 5,001- 10,001- 25,001- 50,001- 100,001- 500,001-
5,000 10,000 25,000 50,000 100,000 500,000 Plus
Inspection Fee $35 $50 $65 $80 $100 $125 $165 $250
1st Re-inspection No Fee No Fee No Fee No Fee No Fee No Fee No Fee No Fee
2nd Re-inspection $75 $75 $75 $75 $75 $75 $75 $75
3rd Re-inspection $100 $100 $100 $100 $100 $100 $100 $100
Subsequent 1st Offense $100 $100 $100 $100 $100 $100 $100 $100
Subsequent 2nd Offense $200 $200 $200 $200 $200 $200 $200 $200
3rd Subsequent Offense $500 $500 $500 $500 $500 $500 $500 $500
Police Department Fees
Description Approved Fee FY2022-23
Golf Cart Registration and Inspection Fee $50
Golf Cart Registration Renewal and Re-inspection Fee $20 Annually
Road Race Application Fee $150
Exhibit B1 P-•e 28
212 TOWN OF HOLLY SPRINGS,NORTH CAROLINA WWW.HOLLYSPRINGSNC.GOV
L

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
eToi n o/
t HOLLY
SPRINGS Fee Schedule
Miscellaneous Fees
Description Approved Fee FY2022-23
Backhoe $50
Pickup Truck $30
Dump Truck $45
Police Vehicle $25
Other Town Vehicles $15
Other Town Equipment $25
rairra-
U-Channel post 10' $30
U-Channel post 12' $33
Sign Brackets $6
Street sign 6"x 30" $35
Street sign 6"x 36" $35
Street sign 6"x 42" $35
Street sign 6"x 48" $35
Street sign 6"x 54" $35
Street sign 9"x 30" $40
Street sign 9"x 36" $40
Street sign 9"x 42" $40
Traffic signs 12"x 18" $42
Traffic signs 18"x 24" $52
Traffic signs 30"x 30"(Octagon) $85
Decorative Combo Assembly $930
Decorative Stop Assembly $565
Decorative Speed Limit Assembly $565
Department Head $50
Supervisor $40
Technician $30
Police Chief/Command Staff $75
Police Supervisor $55
Police Officer $35
Candidate Filing Fee $50
Solicitor/Peddler Permit $25
Irrigation Permit $50
Exhibit B1 Pa•e 29
ANNUAL BUDGET FOR 2022-2023 FISCAL YEAR TOWN OF HOLLY SPRINGS,NORTH CAROLINA 213

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
,A > HOLLY
Fee Schedule SPRINGS
Korth Carolina
Miscellaneous Fees (continued)
Description Approved Fee FY2022-23
Paper Copies.;:,
81/2 x 11 (per side) $.10 per page
81/2 x 14(one/two side) $.10 per page
11 x 17 (one/two side) $.20 per page
CD Rom or Flash Drive $10 each
_ r
E►ivePopes
Letter Size $.04 each
6 x 9 Kroft $.l0 each
9 x 12 Kraft $.14 each
10 x 13 Kraft $.16 each
Postage Actual Postage
4,7;1
Eligible Paper Documents Only $.35 per order,+cost of copies
Cemetery Plot-5 x 10 Plot -Resident $925 each
$1,375 for 2
$2,175 for 4
Cemetery Plot-5 x 10 Plot -Non Resident $1,115 each
$1,675 for 2
$3,175 for 4
Administrative Grave Opening Fee $75 per plot
Purchased TBD per project
Mailed TBD per project
Exhibit B1 Pa'e 30
214 TOWN OF HOLLY SPRINGS,NORTH CAROLINA 'WWW.HOL_fSFRINGStiC.GOV

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T.0306—LOCAL PROGRAMS SEWER DELEGATION
INSTRUCTIONS FOR FORM LPSD 11-21 &SUPPORTING DOCUMENTATION
Documents shall be prepared in accordance with 15A NCAC 02T .0306,and all relevant Division Policies. Failure
to submit all required items will necessitate additional processing and review time.
For more information, visit the Water Quality Permitting Section's Collection System website at:
https://deq.nc.gov/about/divisions/water-resources/water-quality-permitting/municipal-npdes-pretreatment-and-
collection-system/collection-systems
General—This application is for municipalities, counties, local boards or commissions, water and sewer authorities, or
groups of municipalities and counties applying for approval of local programs for permitting construction, modification,
and operation of public and private sewer systems in their utility service areas pursuant to G.S. 143-215.1(f). When
submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted.
The Applicant shall submit one original and two copies of the application and supporting documentation.
A. Cover Letter
® Submit a cover letter listing all items and attachments included in the permit application package,as well as a brief
description of the requested activities to be delegated.
® Include a list of any items required in these instructions that were not submitted, and include an explanation as to
why they were not relevant to the type of delegation being requested.
B. No Application Fee Required for Local Delegation Request
O Include the proposed fee structure the local program will utilize.
C. Local Program Sewer Delegation(FORM: LPSD 11-21)Application:
O Submit the completed and appropriately executed Local Programs for Sewer Systems (FORM: LPSD 11-21)
application. Any unauthorized content changes to this form shall result in the application package being returned.
If necessary for clarity or due to space restrictions, attachments to the application may be made, as long as the
attachments are numbered to correspond to the section and item to which they refer.
NOTE: The Authorized signing official listed in Section I.4 should match with that of the Applicant certification
page 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).
D. Program Administration(All Application Packages):
O Submit an organizational structure containing position types or contracts meeting the requirements of 15A NCAC
02T .0306 and adequately support the local program by providing, at a minimum the following:
0 Adequate administrative staff.
® A Professional Engineer on staff or retained as a consultant.
O Engineering/technical staff.
® Staff to inspection each project for compliance at least once during construction.
® Enforcement and compliance.
® Financial support for the delegated program.
0 Submit a description (flow chart) of the permitting process and the construction and inspection certification
program.
C. Local Program Sewer Delegation Form:LSPD 11-21)
INSTRUCTIONS FOR APPLICATION LPSD 11-21 &SUPPORTING DOCUMENTATION Page 1 of 6

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
E. Sewer Use Ordinance(All Application Packages):
El Submit a properly executed and signed sewer use ordinance or local law.
® The requirements of the ordinance or local law shall be compatible with the requirements imposed by G.S. 143-
215.1. The requirements established in the ordinance or local law shall include at a minimum,the following:
® The authority to issue and enforce permits.
® The authority to assess penalties as a result of enforcement action.
® The authority to inspect facilities.
® Clearly defined appeal process of local decisions(e.g.permit denial).
® Provides that the Division and appropriate Division Regional Office receive a report of all permitting actions on
a quarterly basis.
® Provides that plans and specifications shall be prepared by or under the direct supervision of a licensed North
Carolina Professional Engineer when required by G.S. 89C.
® Provides for adequate administrative organization,engineering staff,financial and other necessary resources.
® Design criteria for sewer systems consistent with 15A NCAC 02T. The ordinance or local law my reference a
separate document(e.g.minimum design criteria document)for providing detailed requirements. The ordinance
or local law shall provide the title of the separate document and provide information on how it will be maintained.
F. Minimum Design Criteria(i.e.Specifications)(All Application Packages):
® Submit minimum design criteria for construction of sewer systems to be permitted. Minimum design criteria shall
meet or exceed all State requirements established in 15A NCAC 02T,Division Minimum Design Criteria and any
other applicable state rules:
® 15A NCAC 02T
® Minimum Design Criteria for Gravity Sewers
® Minimum Design Criteria for Pump Stations and Force Mains
® Alternative Design Criteria for Minimum Separation of Sewer Systems to Wetlands
G. Local Program Permit Application Forms(All Application Packages):
® Submit the local program's proposed permit application form for the type of sewer system(s)the local program is
requesting for delegation.
H. Local Program Permit Template(All Application Packages):
® Submit a permit template or template(s)addressing all activities proposed for delegation meeting the requirements
of 15A NCAC 02T.
I. Inspection and Certification Procedures(All Application Packages):
• Submit the inspection and certification procedures (SOPs,checklists,etc.) to be utilized for each project permitted
by the local program.
❑ Submit a template of the certification document(s)placing the project into operation after construction.
J. Downstream capacity assurance(All Application Packages):
® Submit the method for tracking the downstream capacity for each project permitted by the local sewer system
program.This documentation may mirror the Flow Tracking for Sewer Extensions form as issued by the Division.
K. Wastewater Treatment Authorization(Programs discharging to separate jurisdiction):
❑ Submit a written statement from that local unit of government that the proposed program complies with all its
requirements and that the applicant has entered into a satisfactory contract which assures continued compliance.
> NOTE: Only required if the treatment and disposal system receiving the waste is under the jurisdiction of another
local unit of government.
C. Local Program Sewer Delegation Form:LSPD 11-21)
INSTRUCTIONS FOR APPLICATION LPSD 11-21&SUPPORTING DOCUMENTATION Page 2 of 5

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
L. Summary of Attachments Required:
® Instruction A: Cover Letter
® Instruction C: Application
❑ Instruction C: Delegation Letter(If necessary for signing official)
® Instruction D: Program Administration Documents
® Instruction E: Sewer Use Ordinance or Local Law
El Instruction F: Design Criteria(e.g.Specifications)
® Instruction G: Permit Application Forms
® Instruction H: Permit Template(s)
® Instruction I: Inspection and Certification Documents
® Instruction J: Downstream Capacity Assurance Method
❑ Instruction K: Wastewater Treatment Authorization(If necessary)
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS AND TWO COPIES,SHOULD BE SENT TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
MUNICIPAL PERMITTING UNIT
By U.S.Postal Service: By Courier/Special Delivery:
Attn:Municipal Permitting Unit Supervisor Attn:Municipal Permitting Unit Supervisor
1617 MAIL SERVICE CENTER 512 N.SALISBURY ST.Suite 925
RALEIGH,NORTH CAROLINA 27699-1636 RALEIGH,NORTH CAROLINA 27604
TELEPHONE NUMBER:[phone]
C. Local Program Sewer Delegation Form:LSPD 11-21)
INSTRUCTIONS FOR APPLICATION LPSD 11-21 &SUPPORTING DOCUMENTATION Page 3 of 5

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
I. APPLICANT INFORMATION:
1. Applicants name (Municipality, Public Utility, etc): Town of Holly Springs
2. Facility Information: Name: Utley Creek Water Reclamation Facility
Collection System Permit No.: WQCS00192
3. Applicant type: ® Munici al County Local Board or Commission
❑ Group of Municipalities ❑ Group of Counties ❑ Water and Sewer Authority
4. Signature authority's name: Kendra D. Parrish, PE per 15A NCAC 02T .0106(b)
Title: Executive Director of Utilities & Infrastructure Services
5. Applicant's mailing address: PO Box 8
City: Holly Springs State:
NC Zip:
: 27540-
6. Applicant's contact information:
Phone number: [phone] Fax number: ( )_-
Email address: Kendra.parrish(a�hollyspringsnc.gov
II. PR
OFESSIONAL ENGINEER ON STAFF OR RETAI
NED ENGINEER'S INFORMATION:
1. Engineer's Name: Rachel A. Ingham License Number: 044502
2. Affiliation: ® On Staff: [' Retained (Firm:
3. Engineer's mailing address: PO Box 8
4. City: Holly Springs State: NC Zip: 27540-
5. Engineer's contact information:
Phone number: [phone] Fax number: ( ) -
Email address: Rachel.inghamAhollyspringsnc.gov
III. GENERAL REQUIREMENTS:
1. County system is located in: Wake County
2. Owner& Name of Wastewater Treatment Facility(ies) receiving wastewater from this collection system:
Owner(s) & Name(s): Town of Holly Springs, Utley Creek Water Reclamation Facility
3. WWTF Permit Number(s): NC0063096
IV. DELEGATION REQUEST:
1. Select which activities are requested for delegation:
® Gravity Sewers (Public) ❑ Gravity Sewers (Private)
C. Local Program Sewer Delegation Form:LSPD 11-21)
APPLICATION LPSD 11-21 Page 4 of 5

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
® Pump Stations & Force Mains (Public) ❑ Pump Stations & Force Mains (Private)
V. Rules and Minimum Design Criteria:
1. Do the specifications and Minimum Design Criteria (MDC) equal or exceed the rules and MDC of the
Division?
® Yes ❑ No
If not, explain which criteria are not met and why (attach additional sheets as needed):
VI. APPLICANT'S CERTIFICATION per 15A NCAC 02T .0106(b) & 15A NCAC 02T.0306(3):
I, Kendra D. Parrish, Executive Director of Utilities& Infrastructure Services attest that this application for
(Signature Authority's Name & Title)
Town of Holly Springs— Local Program Sanitary Sewer Extension
(Local Program Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I certify that the proposed
permit review process, design criteria, inspection and certification procedures, and appeal process proposed for
local program delegation and submitted with this application are compatible with all requirements and rules of
the Division of Water Resources, specifically but no limited to 15A NCAC 02T, or the Division's Minimum Design
Criteria. I understand that if all required parts of this application 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 NC General Statutes 143-215.6A and 143-215.6B, 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.
p—DocuSigned by:
Signature: Date: 11/4/2022
'—uauuot,oarL4444kr
C. Local Program Sewer Delegation Form:LSPD 11-21)
APPLICATION LPSD 11-21 Page 5 of 5

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Updated 072071

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4'r r lily Springs Utility Permitting — Local Program Sewer Delegation
D.Program Administration
03NGs Exhibit 2-Development Services Organization Chart
a 1g
1- ....,.z......97— ,o
o-
NortYL
Development Services
Director
I I ,
I
Land Development Customer Service and Chief Building Official
Division Manager Compliance Division Division Manager
t PE) Manager
I I I I i
Engineering
Planning Manager Development Zoning Compliance Development Building inspection
Manager Construction Manager Officer Technician Manager Buildi M Manager
Review
(PE)
1 I l
Transportation Planner Planner II—Long Range Development Plan Development Plan Development Development Code Compliance/ PlanningTech BuildingInspector BuildingPlans
Reviewer Reviewer Supervisor Supervisor Safety Officer P _ Building inspector
Reviewer
Senior Planner Development Plan Development Plan Central Permitting Development Business
Development Inspector Development Inspector p Coordinator Building Inspector II Budding InspectorReviewer Reviewer Supervisor
Planner 11 Development Review Development Inspector Development Ins
Engineer p P P Inspector Development Review Permit Assistant Building Inspector —_ Building Inspector I
Coordinator
I I
Planner) Development Plan Development Inspector Development Inspector Administrative Permit Assistant Building Inspector I Building Inspector
Reviewer
Specialist
I
Development Inspector Administrative
Assistant
Orange highlights indicate
positions in the Development
Services Department that are
involved in the utility permitting
process.
updated July 2022

TEAO1 of 263-B6 6-85A3r6c I I+ilifi/ permitting — Local Program Sewer Delegation
DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
D.Program Administration
Exhibit 3-Town of Holly Springs Organization Chart
Organization Chart
Full-Time Positions
Green highlights indicate f
Departments in the Town of Residents of
Holly Springs that are
involved in the utility permitting Holly Springs
process. \ 1
I
Mayor
and Council
1
Town Boards \ 6 Members f
and
Commissions J
I I
1
*Town Clerk's \ / *Town 1 1*Town Attorney's,
Office - - - Manager's Office - - . Office
2 Employees , 4 Employees 3 Employees J
Office of Budget, / Office of
Innovation, & Strategy-- — Customer Care
4 Employees 2 Employees**j
Operations ) (Development & Infrastructure)
( I
Economic Communications Development
Development & Marketing Services
2 Employees 4 Employees .149 Employees
I I
/ \ r \
Public
Fire/Rescue Finance Works
71 Employees 20 Employees 42 Employees
\ J
1 1
Information / Human Utilities & \
Technology Resources Infrastructure
10 Employees 4 Employees .1 \.. 66 Employees J
Parks &
Recreation
39 Employees J
1
l \
Police } HOLLY
93 Employees � 9� SPRINGS
I `- .' Norlh Carolina
*The Town Manager,Town Clerk,and Town Attorney are appointed by Town Council.
Rev 07/2022

DocuSlgn Envelope ID.E8AB7BEA-014A-4263-0696-85A386C135D4 Town of Holly Springs Utility Permitting - Local Program Sewer Delegation
D.Program Administration
Exhibit 4-Permitting Process Flow Chart
Local Program Management
Engineering Manager-
(PE)
Permitting Process -4 Construction&Inspection Certification
6.Permit
4.Permit Review Approval D.Cert Approval
Engineer 1/11/IIIEngineering Engineering
Manage
Manager
(D/PE) (PE) (Pt)
1.Pro ec[Intake 2.Plan Review 3.Utility Permit _ 6.Permit Approval C.Cert D.Cert Approval E.Data
i Intake 4.Permit Review S.Permit 7.Data A.Cert Intake B.Cert Review Processing Management
Development (aria DevelopmentUtilities PermittingProcessing Executive Director of Management Executive Directoro pntrn Development Develo merit f
1 —► Development I. Utilities&Infrastructure p —y p Utilities Utilities& Utilities
Review Division Manager Specialist Utilities Permitting Utilities Permitting Review Supervisor Permitting Review Services
Coordinator Specialist 5 g Infrastructure Services Permitting
(PE) Coordinator (PE)
pectaltst Coordinator Specialist (PE)
Specialist
I i
2.Plan Review 4.Permit Review B.Cert Review Z,,rwmr.wn.,w.prx
6.Permit r
Engineering
Manager Development Approval Development
Pion Reviewer Inspector DAVebprmme
(aEl Development eliit Xiiii.
I Construction
Manager I Mangler
2.Plan Review B.Cert Review
Development
Development
Construction Inspector
Manager
I Permitting Process )
2.Plan Review 1. Project Intake—Communicate with applicants,receive/log project and fee submittals,and route for review. B.Cert Review
Development 2. Plan Review—Ensure Construction Drawings(CDs)meet current Town of Holly Springs Engineering Design& Development
Plan Reviewer Construction Standards(Town Standards). Make comments,and repeat steps#1 and#2 until all comments have Inspector
I been addressed sufficiently. I
3. Utility Permit Intake—Communicate with applicants,receive/log utility permit applications,and route for review.
z.Plan Review 4. Permit Review—Ensure completeness and accuracy of sewer permit applications based on instructions and B.Cert Review
Plan Development approved CDs. Ensure adequate sewer capacity is available. Make comments,and repeat steps#3 and#4 until all Development
Plan Reviewer PP q P tY P P Inspector
comments have been addressed sufficiently.
I 5. Permit Processing—Prepare permit application packages to route for required signatures I
2.Plan Review 6. Permit Approval—Review and sign application packages.
B.Cert Review
Development 7. Data Management—Issue approved permits,maintain database,and communicate with applicants as necessary. Development
P/on Reviewer Inspector
Construction&Inspection Certification Process:
I A. Cert Intake—Communicate with applicants,receive/log project submittals,and route for review. I
2.Plan Review B. Cert Review—Review certifications and as-builts to ensure project has been constructed in accordance with B.art Review
Development approved permits and CDs,based on inspection reports. Make comments,and repeat steps A and B until all Development
Pion Reviewer Inspector
comments have been addressed sufficiently.
C. Cert Processing—Prepare certifications and as-built packages to route for required signatures.
D. Cert Approval—Review and sign application packages. I
E. Data Management—Issue approved certifications,maintain database,and communicate with applicants as B.Cert Review
Updated 07/2022 necessary. Development

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
Town of Holly Springs
Utilities&Infrastructure
I HOLLY OP P.O.Box 8 I 128 S.Main St.
SPRINGS Holly Springs, )5 27540
d(919)577 3150
�� Utilities & Infrastructure ®[e-mail]
■www.hollyspringsnc.gov
Local Program Sanitary Sewer Extension Application
(Form: TOHS LPSSEA 06.22)
This application is for public gravity sewer,public pump station,and/or public force main sewer extensions in the
Town of Holly Springs(Town),North Carolina. Prior to the submittal of a Local Program Sanitary Sewer Extension
Application(LPSSEA)package,the engineering plans and specifications shall be approved through the appropriate
technical review process as required by the Executive Director of Utilities&Infrastructure Services and defined by
the Town of Holly Springs Development Ordinance(s). Plans, specifications and supporting documents must be
prepared in accordance with the requirements of 15A NCAC 02T,the North Carolina Department of Environmental
Quality Division of Water Resource(Division)'s Minimum Design Criteria(Gravity Sewer&Pump Stations/Force
Mains), the Town of Holly Springs Engineering Design and Construction Standards, and good engineering
practices.
Projects not eligible for review via the Town of Holly Springs' Local Program process(must be submitted for full
J g
technical review to the Division)include but are not limited to:
>Private sanitary sewer extensions
Projects that do not meet any part of the minimum design criteria(MDC)documents;
>Projects that involve any 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.
The Town of Holly Springs will not accept this application unless all of the instructions listed below are followed.
Failure to submit all required items will necessitate additional processing and review time,and may result in
return of the application.
A. Cover Letter/Narrative Description:
❑ 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 Authorization to Construct (ATC) number/status of any other required sewer permits
(downstream/upstream)
• If necessary,include attachments to the application form. Such attachments will be considered part of
the application package and should be numbered corresponding to the section to which they refer.
B. Application Fee:
Each application shall be subject to fees in accordance with the current Town of Holly Springs Fee Schedule
(viewable on the Town of Holly Springs website at www.hollyspringsnc.gov).
❑ Submit a check or money order in the amount of $480.00 for Sewer Permit Application Review
(Delegated),dated no more than 90 days prior to application submittal.(Payable to Town of Holly Springs)
❑ Submit a check or money order in the amount of$200.00 for Wastewater Permit Processing,dated no
more than 90 days prior to application submittal.(Payable to Town of Holly Springs)
2008 TOHS LPSSEA 06.22
INSTRUCTIONS FOR FORM:TOHS LPSSEA 06.22&SUPPORTING DOCUMENTATION Page 1 of 2

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
Q P.O.Box 8 128 S.Main St.
HOLLY Holly Springs,NC 27540
e
SPRINGS d(919)577-3150
®[e-mail]
Utilities&Infrastructure a www.hollyspringsnc.gov
C. Local Program Sanitary Sewer Extension Application (Form: TOHS LPSSEA 06.22):
❑ Submit the completed and appropriately executed application.
❑ The Project Name in Item II.1 shall be consistent with the project name on the cover letter,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.
D. Site Maps:
❑ 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 ATC number(if known)for the receiving sewer
❑ Include an aerial location map showing general project area(such as street names or latitude/longitude).
E. Digital copy of the plans:
❑ Submit one digital copy of the complete design drawings in PDF format.
F. Existing ATC (Application Packages for Modifications to an Existing Permit):
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the
ATC, items to be added, and/or items to be 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 ATC.
G. 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(GPD)
> 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)
For more information, visit the Town of Holly Springs webs ite
THE COMPLETED APPLICATION PACKAGE (INCLDING ALL
SUPPORTING INFORMATION AND MATERIALS) SHOULD BE RETURNED
TO THE TOWN OF HOLLY SPRINGS UTILITIES & INFRASTRUCTURE
SERVICES DEPARTMENT
VIA THE CITYVIEW PORTAL
® email questions to:utilities-infrastructure(a,hollysprinasnc.2ov
2008 TOHS LPSSEA 06.22
INSTRUCTIONS FOR FORM:TOHS LPSSEA 06.22&SUPPORTING DOCUMENTATION Page 2 of 2

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
J P.O.Box 8 1128 S.Main St.
er
HOLLY Holly Springs,NC 27540
LQ [phone]
SPRINGS ®utilities-infrastructure®hollyspringsnc.gov
Utilities&Infrastructure s www.hollyspringsnc.gov
.___-_,9)
For Town of Holly Springs'Use Only _
Received Date: _
ATC#:
ATC Date:
1. Name of Petitioner:
2. Petitioner's Title:
w Name of Petitioner's Company: (as defined in property
zp 3. records and/or as listed in the NC Secretary of State
E Corporation filings)
o., Via) Petitioner's Address: (Street)
•
4. Petitioner's Address: (City, State,Zip Code)
(b)
Petitioner's I6. Petitioner's
5. Phone: Email address:
7. Project Title: (as shown on approved CDs)
8. Description of Project Location:
w 9. Description of Facility to be Served:
C Parcel Area:
cam, 10. PIN#: 11.
(ac)
:; #Lots/ 13 Commercial
12. #Units: Building: (ft2)
14. Additional Project Description:
15. Name of North Carolina Professional Engineer:
a
w 16. North Carolina PE License#:
z
z 17. Engineering Firm Name:
18 cil ( ) Engineering Firm's Address: (Street.)
U
18.
) Engineering Firm's Address: (City,State,Zip Code)
E (b)
Engineer's I20 Engineer's I
Email Phone: address:
2l.
Proposed(New)Authorization to Construct(ATC)
Project
ow, Status: Modification of an Existing ATC
ATC#: Issue Date:
2008 TOHS LPSSEA 06.22 Page 1 of 6 „

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
P.O.Box 8 I 128 S.Main St.
HOLLY Holly Springs,NC 27540
SPRINGS d(919)577-3150
®[e-mail]
Utilities&Infrastructure 111 www.hollyspringsnc.gov
22.11117
Receiving Sewer 23. Receiving Sewer Size:
z dProject Name:
pReceiving Sewer Type:
A to 24 Receiving Sewer 25. (gravity/force main/
ATC#:
pump station)
The Origin of this Wastewater is:(check all that apply) Nature of Wastewater:
Residential Medical/dental/
Domestic
(Single Family Home) veterinary facilities (%)
Residential School/Preschool/
(Multi-family) Daycare Commercial(%)
26. Businesses/offices/ Service Station/ 27. Industrial(%)
factories Car Wash
Church Retail(stores, Other(%)
centers,malls) Specify:
Food/drink facilities Retail with food Is Pretreatment Required?
z preparation/service
0 Hotel and/or Motels Other(Explain in Yes No
Attachment) _
Volume of Wastewater to be Allocated for this Project: (GPD) *Wastewater discharge
28, volume shall be calculated in accordance with values defined in Title 15A NCAC 2T.0114.
(Do not include future wastewater discharge projections that are outside of the scope of the
project or previously allocated wastewater flow.)
If Wastewater Flow is 0,Indicate Why?
Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent ATCs that
connect to this line.
29. Flow has already been allocated in ATC Number: Issue Date:
Rehabilitation or replacement of existing sewers with no new flow expected
Other(Explain):
Q Summarize Wastewater Generated by Project:
Establishment Type Design flow Units Flow
(See 02T.0114(f)) (GPD)—[a,b] (#) (GPD)
30.
Total
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.
2008 TOHS LPSSEA 06.22 Page 2 of 6

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
CP P.O.Box 8 128 S.Main St.
6p, HOLLY Holly Springs,NC 27540
o(919)577-3150
� SPRINGS [e-mail]
Utilities&Infrastructure •www.hollyspringsnc.gov
Summarize gravity sewer to be permitted:
Diameter Length Manholes
(inches) (linear feet) Material Number Diameter(ft)
w 31.
• 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
Pump Station Name:
Approximate Coordinates(Decimal Degrees): Latitude: Longitude:
Total number of pumps at the pump station:
32. Design flow of the pump station,firm capacity:
(million gallons per day—MGD)
gallons per minute(GPM)
Operational point(s)per pump(s): feet total dynamic head(TDH)
Summarize the force main to be permitted(for this Pump Station):
Diameter Length Air-relief Manholes
Material
(inches) (linear feet) Number Diameter(ft)
a,
33.
34. 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).:
35. Power reliability in accordance with 15A NCAC 02T.0305(h)(1):
36. Does this project include any high priority lines,siphons,and/or sewers suspended
through interference/conflict boxes? 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. If yes, include an attachment with details for each line, including
type (aerial line, size, material, and location).
2008 TOHS LPSSEA 06.22 Page 3 of 6

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
OP P.O.Box 8 1128 S.Main St.
4UtffiefraTrucre
[e-mail]
a www.hollyspringsnc.gov
Does the project comply with all separations / alternatives found in 15A NCAC 02T
.0305(f)& (g)?
Setback Parameter* Separation
Required
18 inches
Storm sewers and other utilities not listed below(vertical)
Water mains(vertical-water over sewer preferred,including in benched trenches) 18 inches
va
Water mains(horizontal) 10 feet
C£ Reclaimed water lines(vertical-reclaimed over sewer) 18 inches
" Reclaimed water lines(horizontal-reclaimed over sewer) 2 feet
gg Any private or public water supply source,including any wells,WS-I waters of Class I or Class II impounded 100 feet
a. reservoirs used as a source of drinking water,and associated wetlands.
(A r 37• Waters classified WS(except WS-I or WS-V),B,SA,ORW,HQW,or SB from normal high water(or tide
Q23 elevation)and wetlands associated with these waters(see item IX.2) 50 feet
vi
i Any other stream,lake,impoundment,or ground water lowering and surface drainage ditches,as well as 10 feet
Vd` wetlands associated with these waters or classified as WL.
cci
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
40 ,
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.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
Complete the stream classification for the closest down slope surface waters. Include all points that
traverse over or are near different waterbodies (or counties, basins, etc.). A variance must be requested for
Z
., encroachment within required setbacks or bufferspursuant to 2T .0305 and be submitted bythe Town of
q (fl
Holly Springs to NCDEQ DWR with supporting documentation/justification provided.
Q 38.
G Name of Waterbody River Basin
rn
Have the following permits/certifications been submitted for approval for the proposed project?
If`yes',submit a copy of all applicable permits.
=4 gN a). US Army Corp 404 or NCDEQ 401 wetland permit?
.a a 39. b). Sedimentation&Erosion Control Plan?
z a, c). Stormwater Management Permit?
X d). NCDOT Utility Encroachment?
e). Environmental Assessment?
Does the submitted project comply with 15A NCAC 02T,the Minimum Design Criteria for
40. the Permitting of Pump Stations and Force Mains (latest version), and the Gravity Sewer
Minimum Design Criteria(latest version) as applicable?
2008 TOHS LPSSEA 06.22 Page 4 of 6

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
0 P.O.Box 8 1128 S.Main St.
HOLLY Holly Springs,NC 27540
et
go(919)577-3150
SPRINGS ®[e-mail]
Utilities&Infrastructure Al www.hollyspringsnc.gov
IX. CERTIFICATIONS:
1. PROFESSIONAL ENGINEER'S ICATION
I, ,attest that this application for
has been reviewed by me and is accurate, complete and consistent with the information supplied 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 and subject to
the Town of Holly Springs Engineering Design and Construction Standards; the Town of Holly Springs'
ordinances,policies,and standard details;and the North Carolina Administrative Code for wastewater collection.
In the event of conflict between the Holly Springs Engineering Design and Construction Standards;the Town of
Holly Springs'ordinances,policies,and standard specifications,or the North Carolina Administrative Code,the
more restrictive requirements shall apply. 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 NC General
Statutes 143-215.6A and 143-215.6B,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.
North Carolina Professional Engineer's seal,signature,and date:
2. PETITIONER'S CERTIFICATION PER 15A NCAC 02T .0106(B):
I, ,attest that this application for
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 information and
attachments are not included, this application package will be returned to me as incomplete. Any application
package determined incomplete by the Executive Director of Utilities and Infrastructure Services shall be
returned to the petitioner. Revised engineering plans and specifications shall constitute a re-submittal, shall be
accompanied by a new fee,and shall require additional time for review. Note: In accordance with NC General
Statutes 143-215.6A and 143-215.6B,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.
Signature: Date:
2008 TOHS LPSSEA 06.22 Page 5 of 6

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
ErP P.O.Box 8 1128 S.Main St.
HOLLY Holly Springs,NC 27540
d(919)577-3150
SPRINGS ®[e-mail]
Utilities&Infrastructure
a www.hollyspringsncgov
3. TOWN OF HOLLY SPRINGS' CERTIFICATION(TO BE COMPLETED BY THE TOWN OF
HOLLY SPRINGS)
I, attest that this application for
has been reviewed by me and contains sufficient information to ascertain reasonable grounds to believe the
application package and its contents meet all applicable standards of Subchapter 15A NCAC 2T,the State
of North Carolina's Administrative Code,the Town of Holly Springs Engineering Design and Construction
Standards and the Town of Holly Springs' ordinances,policies and details as presented.The denial of the
issuance of an ATC, subject to the provisions in Chapter 16, Article 1, Division 2 of the Town of Holly
Springs Code of Ordinances shall be made in writing and shall contain the reasons for the denial and the
Town's estimate of the general changes in the petitioner's proposed activities or plans which will be
required in order that the petitioner may obtain an ATC. Nothing in such estimate shall preclude or
otherwise bar the Town from denying an ATC, which incorporates such changes, based upon changed
circumstances or information not previously known by the Executive Director of Utilities and Infrastructure
or the petitioner.
Signature: Date:
2008 TOHS LPSSEA 06.22 Page 6 of 6

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
CP P.O.Box 8 1128 S.Main St.
HOLLY Holly Springs,NC 27540
2Q,[phone]
SPRINGS ®utilities-infrastructureoOhollyspringsnc.goy
Ut tities&Infrastructure www.hollyspringsnc.gov
ATC Date
Petitioner's name
Petitioner's title
Name of Petitioner's Company
Petitioner's address (Street)
Petitioner's address (City, State, Zip)
Subject: Authorization to Construct (ATC)
Town of Holly Springs ATC #: ATC #/Permit#
Project Title
Sanitary Sewer System Extension
Utley Creek Water Reclamation Facility NC0063096
Town of Holly Springs System Wide Collection System WQCS00192
Wake County, North Carolina
Dear Petition
er's name:
In accordance with the Town of Holly Springs' approved local wastewater collection system
extension and/or modification permitting program, we herewith issue to the Petitioner,
Petitioner's Company, the wastewater collection system extension Authorization to Construct
(ATC) Number (ATC #) dated (ATC date) for the CONSTRUCTION of the subject wastewater
collection system extension/modification. This ATC shall be effective from the date of issuance
until rescinded and shall be subject to the conditions and limitations as specified in the permits
for the project described herein:
The Project Title engineering plans and specifications,as prepared and sealed by Name of North
Carolina Professional Engineer with Engineering Firm Name, for the wastewater collection
system extension consisting of Gravity Sewer to be permitted, Pump Station Name, Design flow
of the pump station, Force Main to be permitted, to serve Origin of this Wastewater with Volume
of Wastewater to be Allocated for this Project.
Construction of this project shall be in accordance with 15A NCAC 02T; the Division of Water
Quality's Minimum Design Criteria (MDC) for the Permitting of Gravity Sewers adopted February
12, 1996 and/or the Division of Water Quality's MDC for the Permitting of Pump Stations and
Force Mains adopted June 1, 2000, as applicable; the Town of Holly Springs Engineering Design
and Construction Standards (Town Standards); the Town of Holly Springs' ordinances, policies,
and standard details; the approved plans; and other supporting data. Permitting of this project
20XX TORS Sanitary Sewer System Extension Permit 06.22-Cover Letter
Permit#/Application #, Issue Date Page 1
:!

DocuSign Envelope ID:E8AB7BEA-014A-4263-6696-85A386C135D4
does not constitute an acceptance of any part of the project that does not meet 15A NCAC
02T; MDC for the Permitting of Gravity Sewers; MDC for the Permitting of Pump Stations and
Force Mains; Town Standards; and Town ordinances, policies, and standard details; unless
specifically mentioned herein. Failure to comply may result in penalties in accordance with
North Carolina General Statute 143-215.6A through 143-215.6C and the Town of Holly Springs
ordinances, construction of additional or replacement wastewater collection facilities, and/or
referral of the North Carolina-licensed Professional Engineer to the licensing board.
In the event that construction does not commence within 12-months of the issuance of the
Authorization to Construct(ATC) permit, the ATC permit shall expire and a new ATC permit must
be applied for and obtained by the petitioner. An active ATC permit must be maintained until
full final approval has been issued for the infrastructure defined in the ATC permit. Written
requests for an extension of time received prior to expiration of the ATC permit may be granted
by the Executive Director of Utilities & Infrastructure Services (Director)for good cause shown.
The Director reserves the right to deny the ATC permit, subject to the provisions in the Town of
Holly Springs Code of Ordinances, Chapter 16 - Public Enterprises. A denial shall be made in
writing and shall contain the reasons for the denial and the Towns' estimate of the general
changes in the petitioner's proposed activities or plan which will be required, in order that the
petitioner may obtain the ATC permit. Nothing in such estimate shall preclude or otherwise bar
the Director from denying a permit, which incorporates such changes, based upon changed
circumstances or information not previously known by the Director or the petitioner. The Director
reserves the right to modify or revoke the ATC upon not less than 14-days written notice to any
person affected. In the event of a developed or developing threat to public health or safety,
revocation and/or disconnection may occur immediately without notice. Notice to affected
persons shall occur as soon as practicable thereafter.
This cover letter shall be considered a part of this ATC and is therefore incorporated therein by
reference. If any parts, requirements, or limitations contained in this permit are unacceptable,
you have the right to request an adjudicatory hearing upon written request within 30-days
following receipt of this permit. This request must be in the form of a written petition, conforming
to Town Code of Ordinances, Chapter 16, Article 1, Division 2, Section 16-27, and filed with the:
Town of Holly Springs Utilities and Infrastructure Services Department
128 South Main Street, PO Box 8
Holly Springs, NC, 27540
[e-mail]
Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this matter, please contact Rachel Ingham via
email at [e-mail] or telephone at 919-567-3985.
20XX TOHS Sanitary Sewer System Extension Permit 06.22- Cover Letter
Permit#/Application #, Issue Date Page 2
_
_._� -... .._.. 4 F✓

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
Sincerely,
Kendra D. Parrish, PE, CFM
Executive Director, Utilities and Infrastructure Services
Town of Holly Springs
cc: Name of North Carolina Professional Engineer; Engineering Firm Name
Seann Byrd; Deputy Director, Water Quality;Town of Holly Springs
Rachel Ingham, PE; Engineering Manager; Town of Holly Springs
Town of Holly Springs Office files
20XX TORS Sanitary Sewer System Extension Permit 06.22- Cover Letter
Permit #/Application #, Issue Date Page 3

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
'fO4�. P.O.Box 8 1128 S.Main St.
c� ia7s '''�,
�ti* •;�:, Holly Springs,NC 27540
if 2Q.,[phone]
n ®[e-mail]
••�_ www.hollyspringsnc.gov
"F.
°62V
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
WASTEWATER COLLECTION SYSTEM EXTENSION AND/OR MODIFICATION PERMIT
In accordance with the provisions of Article 215 of Chapter 143, General Statutes of North
Carolina-as amended, the Town of Holly Springs delegated permitting program, and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO THE PETITIONER
Name of Petitioner's Company
Wake County
FOR THE
Construction, operation, and maintenance of the Project Title wastewater collection system
extension consisting of Gravity Sewer to be permitted, Pump Station Name, Design flow of the
pump station, Fore Main to be permitted, to serve Origin of this Wastewater with Volume of
Wastewater to be Allocated for this Project to the Utley Creek Water Reclamation Facility Permit
#NC0063096 pursuant to the application received (received date) and in conformity with the
project plans, specifications, and other supporting data subsequently filed and approved by
the Town of Holly Springs Utilities and Infrastructure Services Department and considered a part
of this permit.
This permit shall be effective from the date of issuance DATE OF ISSUANCE and shall be subject
to the following specified conditions and limitations:
1. In the event that construction does not commence within 12-months of the issuance of
the Authorization to Construct (ATC) permit, the ATC permit shall expire and a new ATC
permit must be applied for and obtained by the petitioner. An active ATC permit must
be maintained until full final approval has been issued for the infrastructure defined in the
ATC permit. Written requests for an extension of time received prior to expiration of the
ATC permit may be granted by the Executive Director of Utilities & Infrastructure Services
(Director) for good cause shown.
2. This permit shall become voidable unless the facilities are constructed in accordance
with the conditions of this permit; 15A NCAC 02T; the Division of Water Quality's Minimum
Design Criteria (MDC) for the Permitting of Gravity Sewers adopted February 12, 1996
and/or the Division of Water Quality's MDC for the Permitting of Pump Stations and Force
Mains adopted June 1, 2000, as applicable; the Town of Holly Springs Engineering Design
and Construction Standards (Town Standards); the Town of Holly Springs' ordinances,
policies, and standard details; the approved plans; and other supporting data. If a
modification to the approved plan is needed, the Petitioner shall request a permit
modification in writing. Permit modifications shall be subject to current design standards.
Page 1

DocuSign Envelope ID:E8AB7BEA-014A-4263-8696-85A386C135D4
.,,c Nou.),, EP P.O.Box 8 1128 S.Main St.
. A
*, 1s7sy Holly Springs,NC 27540.' d(919)577-3150
•.o nMI�]o n • ®[e-mail]
• ., www.hollyspringsnc.gov
F
%`Y NO3
3. This permit shall be effective only with respect to the project scope, nature and volume
of wastes described in the LPSSEA for Project Title.
4. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so
as not to interrupt service by the existing utilities nor result in an overflow or bypass
discharge of wastewater to the surface waters of the State. Prior to initiating any work
on an active sanitary sewer system, the Petitioner's contractor must provide the Town of
Holly Springs Development Construction Manager and the Petitioner's engineer with a
construction work plan for review and documentation. The construction work plan must
clearly detail how the existing sanitary sewer system will be maintained during the
construction process, including but not limited to any temporary losses of service, system
draining, bypass systems, temporary pumps, temporary in-system storage and/or parallel
systems. The Petitioner's engineer will need to review and approve the Contractor's work
plan and submit adequate documentation to the Town of Holly Springs' Development
Construction Manager.
5. Deviations from the approved plans and specifications or site conditions affecting
capacity, hydraulic conditions, or any provisos stipulated in this ATC permit must be
approved prior to further construction or installation. An ATC permit application
package, consisting of the revised engineering drawings and the supporting
documentation, must be submitted to the Executive Director of Utility & Infrastructure
Services (Director) for approval and issuance of a new ATC permit, before any
construction work affected by such deviations is initiated. All proposed deviations shall
be required to comply with 15A NCAC 02T, the Division's MDC (Gravity Sewer & Pump
Stations/Force Mains), Town Standards, Town of Holly Springs ordinances, policies, and
standard details; the approved plans; and other supporting data.
6. Upon completion of construction and prior to the operation of these permitted facilities,
the executed Engineering Certification form attached to this permit; sealed record
drawings in PDF and ACAD formats; copies of the legal documentation regarding the
transfer of all utility easements to the Town of Holly Springs, by recorded plat or deed;
and sealed pump station as-built calculations, as applicable, must be submitted to the
Town of Holly Springs. The certification must be completed and sealed by a professional ii
engineer, certifying that the permitted facility has been installed in accordance with this
permit,the approved plans and specifications, and any other supporting materials. If the
project is to be completed in phases and partially certified, the Petitioner shall retain the
responsibility to track further construction approved under this permit, and shall acquire
a final certificate of completions once the entire project has been completed. Sealed
record drawings in PDF and ACAD formats;copies of the legal documentation regarding
the transfer of all utility easements to the Town of Holly Springs, by recorded plat or deed;
and sealed pump station as-built calculations, as applicable, indicating the facilities
constructed in the phase being certified, shall be submitted for approval to the Town of
Holly Springs.
20XX TOHS Sanitary Sewer System Extension Permit 06.22
Permit #/Application #, Issue Date Page 2

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
��R•i876 Y.s,9 0]P.O.Box 8 1128 S.Main St.
Holly Springs,NC 27540
it~ �• go(919)577-3150
p Ilsl p1. ®[e-mail]
.. Wi hr
www.hollyspringsnc.gov
� o
rrG�'Y N
7. In the event that the wastewater collection facilities fail to perform satisfactorily, including
the creation of nuisance conditions, immediate corrective actions, such as the addition
or replacement of facilities, shall be taken by the Petitioner.
8. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T;
the Division's MDC for Gravity Sewer adopted February 12, 1996, as applicable; the
Division's MDC for the Fast-Track Permitting of Pump Station and Force Mains adopted
June 1, 2000, as applicable; Town Standards; Town ordinances, policies, and standard
details; and other supporting materials may subject the Petitioner to an enforcement
action by the Town of Holly Springs, NCDEQ and other applicable agencies, in
accordance with Federal, State, and Local regulations and as stipulated in Chapter 16
of the Town of Holly Springs Code of Ordinances.
9. Any wastewater flow made tributary to the sanitary sewer wastewater collection system
extension prior to completion of this Engineering Certification shall be considered a
violation of the permit and shall subject the Petitioner to appropriate enforcement
actions.
10.The issuance of this permit shall not exempt the Petitioner from:
a. Complying with any and all statutes, rules, regulations, or ordinances that may be
imposed by government agencies (Local, State, and Federal) that have
jurisdiction, or
b. Obtaining other permits which may be required by the Town, Division,or any other
Federal, State, or Local Government agencies (including but not limited to
applicable river buffer rules in 15A NCAC 2B .0200, erosion and sedimentation
control requirements in 15A NCAC Ch. 4 and under the Division's General Permit
NCG0100000, and any requirements pertaining to wetlands under 15A NCAC 2B
.0200 and 15A NCAC 2H .0500.)
11.This permit shall not be transferable. In the event there is a desire for the wastewater
collection facilities to change ownership, or there is a name change of the Petitioner, a
formal ATC request must be submitted to the Director accompanied by an application
fee, documentation from the parties involved, and other supporting materials as may be
appropriate. The Director reserves the right to approve or disapprove the request based
on the format ATC merits.
20XX TORS Sanitary Sewer System Extension Permit 06.22
Permit #/Application #, Issue Date Page 3

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
orioc��r� CP P.O.Box 8 1128 S.Main St.
la�s' ,•?% Holly Springs,NC 27540
/i*
2L,[phone]
[e-mail]
*1•406411.c
www.hollyspringsnc.gov
N)K ``!
Permit issued ATC Date.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Kendra D. Parrish, PE, CFM
Executive Director, Utilities and Infrastructure Services
Town of Holly Springs
By Authority of the Environmental Management Commission
ATC Permit Number:Permit#/Application #
20XX TORS Sanitary Sewer System Extension Permit 06.22
Permit #/Application #, Issue Date Page 4

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
lwuys CIP P.O.Box 8 1128 S.Main St.
.�f Holly Springs,NC 27540
• c,[phone]
41:111th n 6 [e-mail]
y!, *www.hollyspringsnc.gov
NOW
SANITARY SEWER ENGINEERING CERTIFICATION
Petitioner: (Petitioner's Name)
Project Title: (Project Title)
Permit#: (ATC #)
Issue Date: (ATC Date)
This project shall not be considered complete until the Town of Holly Springs has received this Certification and all
required supporting documentation. Required documents for partial and final approval are:
One (1) original and one (1) digital copy of the Engineering Certification form executed by the
Engineer
One (1) printed copy and one (1) digital copy of the sealed Record Drawings in PDF and ACAD
format (24 x 36-inch sheets)
One (1) printed copy and one (1) digital copy of the recorded Record Plats, Easements, and
Deeds, as applicable, in black and white pdfs.
Sealed Pump Station As-built Calculations, as applicable
Town of Holly Springs- Design Variances Request with supporting documentation
ENGINEER'S CERTIFICATION
I, , as a duly registered Professional Engineer in the State of North
Carolina, having been authorized to observe or a representative under my supervision having been authorized to
observe (❑periodically,❑weekly,❑full time) the construction of the project:
Project Title
For the Petitioner 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 and intent
of this permit; 15A NCAC 02T; 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; the Town of Holly Springs (Town) Engineering
Design and Construction Standards; the Town's ordinances, policies, and standard details; the approved plans;
and other supporting materials.
North Carolina Professional Engineer's Seal with signature and date:
❑ Final ❑ Partial
Provide the constructed system summary pertaining to this certification
and any other Certification comments:
I ;
20XX TOHS Sanitary Sewer System Engineering Certification 06.22 Page 1

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
CP P.O.Box 8 1128 S.Main St.
Holly Springs,NC 27540
7 qm(919)577-3150
n G ®utilities-infraslructure@holly(919)5 nc.gov
• ;. I:I .;' www.hollyspringsnc.gov
-`1Y NO5 A
Date
Petitioner's name
Petitioner's title
Name of Petitioner's Company
Petitioner's address (Street)
Petitioner's address (City, State, Zip)
Subject: Complete Application Package Receipt
Wastewater Collection System Extension/Modification
Project Title
Receipt Date:
Utley Creek Water Reclamation Facility NC0063096
Town of Holly Springs System Wide Collection System WQCS00192
Wake County, North Carolina
Dear Petitioner's name:
In accordance with The Town of Holly Springs' approved local permitting program for
wastewater collection system extensions and the Town of Holly Springs' Code of Ordinances,
Chapter 16, Article I, Division 2, Section 16-25, this letter is to confirm that the submitted
application package consisting of the Project Title engineering plans and specifications, as
prepared and sealed by Name of North Carolina Professional Engineer with Engineering Firm
Name, for the wastewater collection system extension consisting of Gravity Sewer to be
permitted, Pump Station Name, Design flow of the pump station, Force Main to be permitted, to
serve Origin of this Wastewater with Volume of Wastewater to be Allocated for this Project has
been deemed substantially complete.
Please note that application review can take up to 90-days from the receipt of a complete
application package. If you need additional information concerning this matter, please
contact Rachel Ingham via email at [e-mail] or telephone at 919-
567-3985.
Sincerely,
Kendra D. Parrish, PE, CFM
Executive Director, Utilities and Infrastructure Services
Town of Holly Springs
cc: Name of North Carolina Professional Engineer; Engineering Firm Name
Seann Byrd; Deputy Director, Water Quality; Town of Holly Springs
Rachel Ingham, PE; Engineering Manager; Town of Holly Springs
Town of Holly Springs Office files
Page 1

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
�IN Gs Town of Holly Springs
Utilities&Infrastructure
} OP P.O.Box 8 1128 S.Main St.
a cS Holly Springs,NC 27540
0 d(919)577-3150
`i• {� [e-mail]
• G IR www.hollyspringsnc.gov
North
I. Inspection and Certification Procedures
Exhibit 1—Gravity Sanitary Sewer Inspection
Standard Operating Procedures
• Inspect the installation of the mains, manholes and services,verifying that the material meets Town of
Holly Springs Engineering Design and Construction Standards(Town Standards)and approved
Construction Drawings(CDs)criteria.
• After installation,witness air testing of sewer mains.
• After the sewer mains have been installed for 30 days,witness mandrel being pulled through the main.
• After all manholes frames have been bolted to the manhole cones on outfalls or after pavement has
been placed around manholes, allow the contractor to have the sewer main CCTV'ed.
o Review the CCTV video to ensure:
• The pipe is clean,and
• There are no sags or damaged pipe/fittings.
• Receive as-builts and PE Certification and verify that pipe slopes and as-builts meet Town Standards.
o If criteria is met—submit as-builts and PE Certification to Utilities& Infrastructure Services to be
processed.
o If criteria is not met—work with contractor,engineer and Utilities& Infrastructure Services to
remedy situation.
11. Force Main& Pump Station Inspection SOP

DocuSign Envelope ID:E8AB7BEA-014A-4263-8696-85A386C135D4
Town of Holly Springs
Cis Utilities&Infrastructure
/ CP P.O.Box 8 1128 S.Main St.
Holly Springs,NC 27540
5 D(919)577-3150
O [e-mail]
• 0a www.hollyspringsnc.gov
North
I. Inspection and Certification Procedures
Exhibit 1—Gravity Sanitary Sewer Inspection
Standard Operating Procedures
• Inspect the installation of the mains, manholes and services,verifying that the material meets Town of
(Town Standards) and approved
Holly Springs Engineering Design and Construction Standards pp
Construction Drawings(CDs) criteria.
• After installation,witness air testing of sewer mains.
• After the sewer mains have been installed for 30 days,witness mandrel being pulled through the main.
• After all manholes frames have been bolted to the manhole cones on outfalls or after pavement has
been placed around manholes, allow the contractor to have the sewer main CCTV'ed.
o Review the CCTV video to ensure:
• The pipe is clean,and
• There are no sags or damaged pipe/fittings.
• Receive as-builts and PE Certification and verify that pipe slopes and as-builts meet Town Standards.
o If criteria is met—submit as-builts and PE Certification to Utilities&Infrastructure Services to be
processed.
o If criteria is not met—work with contractor,engineer and Utilities&Infrastructure Services to
remedy situation.
11. Force Main& Pump Station Inspection SOP

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
GS Town of Holly Springs
Utilities&Infrastructure
,J Jo1 P.O.Box 8 1128 S.Main St.
ti Holly Springs,NC 27540
o 6(919)577-3150
'I`— ®[e-mail]
• G www.hollyspringsnc.gov
NortYt
INSPECTOR VERIFICATION FOR SEWER CERTIFICATION
Permit#: Design Professional Contact:
❑ Partial
❑ Final
I certify that the sewer infrastructure (lines, manholes, pump stations, and other appurtenances) for
(Project Name),
Phase/Section have been installed and inspected per the approved plans
and the Town of Holly Springs Engineering Design Standards and Specifications. I have approved the
attached as-builts, the PE certification, and summary with accompanying highlighted 8.5 x 11 map, and:
❑ Changes are clearly noted on the as-builts, however, no permit modification was
required.
❑ No changes were made.
In addition, I reviewed any Priority Sewer for this project and verified that an enhanced vicinity map has
been provided and the Infrastructure Table on the cover notes this information. This project:
❑ Has High Priority Sewer(as defined by the state)
❑ Has Town Priority Sewer Infrastructure
❑ Does not have High Priority Sewer lines.
Inspector Signature Date
Utilities and Infrastructure Services
P.O.Box 8 • 128 S.Main Street • Holly Springs,NC 27540 • www.hollyspringsnc.gov
2007 Inspector Verification for Sewer Certification
01.14.21 ?

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
J. Downstream Capacity Assurance
Exhibit 1 - Flow Tracking
..of HOLt,Y
gt nfTflo .
y *rings
THE TOWN OF
(TOHS USE ONLY) Project Name
Section 1. Wastewater Treatment Plant (WWTP) Information
a. WWTP Facility Name: Utley Creek Wastewater Treatment Plant
b. WWTP Facility Permit#: NC0063096
c. WWTP facility's permitted flow(MGD): 6.000
d. Estimated obligated flow not yet tributary to the WWTP(MGD):
e. WWTP facility's actual average flow(MGD):
f. Total Flow for this specific request(MGD):
g. Total actual and obligated flows to the facility(MGD):
h. Percent of permitted flow used:
Section II. Pump Stations located between the project connection point and the WWTP
(C) (D)=(B+C) a D
(A) �) Obli ated Not Total Current �)=( )
Pump Firm Design Average Approx.Current g Available
Pump Station Station Capacity* Daily Flow** Average Daily Yet Tributary Flow Plus Capacity***
Permit# [MGD] Dailty Flow Obligated Flow 1IGDi
(firm/pi)[MGD] Flow[MGD] [MGD] [MGD]
ill
*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 pioint and the WWTP where Available Capacity is<0.
Section 111. Certification Statement:
,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 from the connection to the collection system to the receiving wastewater treatment plant 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 assesment 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
Section I and Section II plus all attached planning assessment addendums for which I am the responsible party. Signature of this form indicates the Town of Holly
Springs'(TOHS)guarantee of capaity for this wastewater treatment flow. Notwithstanding the guarantee of capacity,TOHS does not make a commitment to
service this wastewater flow until a building permit is requested through the TOHS Development Services Department and TOHS receives payment of all
applicable fees.
TORS Signing Official Signature Date
TORS Signing Official Title
Utilities and Infrastructure Services
P.O.Box 8 128 S.Main Street Holly Springs,NC 27540 www.hollyspringsnc.gov
J1. Downstream Capacity Assurance Page 1

DocuSign Envelope ID:E8AB7BEA-014A-4263-B696-85A386C135D4
Ili v�N of Nort,y s�
nr_rl,o1 Springs
• o ) .os "J` THE TOWN OF
Planning Assessment and Addendum (PAA)
Submit a planning assessment addendum where each pump station listed in Section II where Available Capacity is<0.
Pump Station Name:
Pump Station Permit#:
Given that:
a.The proportion and amount of Obligated,Not Yet Tributary Daily Flow(C)accounts for
%and MGD of the Available Capacity(E)in Pump Station
,and that
b. The rate of activation of this obligated,not yet tributary capacity is currently approximately
MGD per year,and that
c. A funded Capital Project that will provide the required planned capacity,namely
is in design or under construction with planned
completion in ;and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information,there is sufficient justification to allow this flow
to be permitted,without a significant likelihood of over-allocating capacity in the system infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-215.67(a)which
prohibits the introduction of any waste in excess of the capacity of the waste disposal system.
TORS Signing Official Signature Date
Utilities and Infrastructure Services
P.O.Box 8 128 S.Main Street Holly Springs,NC 27540 www.hollyspringsnc.gov
J1. Downstream Capacity Assurance Page 2

DocuSign
Certificate Of Completion
Envelope Id:E8AB7BEA014A4263B69685A386C135D4 Status:Completed
Subject:Complete with DocuSign:Sewer Permit Application to State
Source Envelope:
Document Pages:63 Signatures:2 Envelope Originator:
Certificate Pages:5 Initials: 1 Emily Koncz
AutoNav:Enabled PO Box 8
Envelopeld Stamping:Enabled Holly Springs,NC 27540
Time Zone:(UTC-05:00)Eastern Time(US&Canada) [e-mail]
IP Address:204.84.166.2
•
Record Tracking
Status:Original Holder:Emily Koncz Location:DocuSign
11/4/2022 3:06:32 PM [e-mail]
Signer Events Signature Timestamp
Rachel Ingham °S Sent: 11/4/2022 4:18:04 PM
[e-mail] (R= Viewed:11/4/2022 4:58:52 PM
Utility Engineer Signed:11/4/2022 5:01:22 PM
Security Level:Email,Account Authentication
(None) Signature Adoption:Pre-selected Style
Using IP Address:65.191.132.203
Electronic Record and Signature Disclosure:
Accepted:11/16/2020 9:41:26 AM
ID:0c7f672d-8bab-496f-91 f1-115266328d46
Company Name:Town of Holly Springs
Kendra Parrish _°`, nftl°Y Sent: 11/4/2022 5:01:27 PM
[e-mail]�°-^ Viewed: 11/4/2022 5:37:29 PM
`-03C05B89FC34440... Signed:11/4/2022 5:37:53 PM
Exec Director of Utilities and Infrastructure 9
Holly Springs
Signature Adoption:Drawn on Device
Security Level:Email,Account Authentication
(None) Using IP Address:64.98.124.55
Signed using mobile
Electronic Record and Signature Disclosure:
Accepted:4/6/2021 7:18:46 PM
ID:6cbf2406-2f8d-46a2-8e81-c6f600daf744
Company Name:Town of Holly Springs
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps

Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 11/4/2022 4:18:04 PM
Certified Delivered Security Checked 11/4/2022 5:37:29 PM
Signing Complete Security Checked 11/4/2022 5:37:53 PM
Completed Security Checked 11/4/2022 5:37:53 PM
Payment Events ` Status Timestamps
Electronic Record and Signature Disclosure

Electronic Record and Signature Disclosure created on:11/12/2020 9:42:57 PM
Parties agreed to:Rachel Ingham,Kendra Parrish
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