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HomeMy WebLinkAboutWQ0044800_Application (FTSE)_20231005_20231005VUI.UJ I IY.iI CI IVCIUytI IU. /IiCLU/1JV':JL.74"FLJ I-UFMO-�IU/OOCJz7CL/U �L'` SI Z `) State of North Carolina Department of Environmental Quality W, 1 Kmq k Division of Water Resources FAST TRACK SEWER SYSTEM EXTENSION APPLICATION Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION Application Number: O pt) 4 4 96L)(to be completed by oWtt) All: items must be completed or the application will be returned I. APPLICANT INFORMATION: L Applicant's name: City of Graham (company, municipality, HOA, utility, etc.) 2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Federal ❑ State/County ® Municipal 3. Signature authority's name: Aaron Holland per 15A NCAC 02T .0106(b1 Title: Assistant City Manama 4. Applicant's mailing address: 201 South Main Street City: Graham State: NC Zip: 27253- 5. Applicant's contact information: Phone number: (336) 570-6700 .Email Address: aholland@cityofgraham.com II. PROJECT INFORMATION: ❑ Privately -Owned Public Utility ❑ Other I. Project name: NCDOT U-6017 2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit(Project If a modification, provide the existing permit number: WQ00 and issued date: , For modifications, also attach a detailed narrative description as described in Item G of the checklist. If new construction, but part of aer,Imo; provide the existing permit number: WQ00 3. County where project is loca d: Alamance 4. Approximate Coordinates (Decimal Degrees): Latitude: 30.070934' Longitude:-79.393623° 5. Parcel ID (if applicable): (or Parcel ID to closest downstream sewer) III. CONSULTANT INFORMATION: 1. Professional Engineer: Clint L. Stevens License Number: 040370 Firm: Hinde Enaineering, Inc. Mailing address: 401 Harrison Oaks Blvd. City: Caty State: NC Zip: 27513- Phone number: (919) 653-0001 Email Address: cstevens@hindeengineeting.com IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION: 1. Facility Name: City of Graham WWT_P Permit Number: NC 002121 t Owner Name: City of Graham V. RECEIVING DOWNSTREAM SEWER INFORMATION: 1. Permit Number(s): WQ 2. Downstream (Receiving) Sewer Information: l0 inch ® Gravity 0 Force Main 3. System Wide Collection System PermitNumber(s) (if applicable): WQCS00065 Owner Name(s): City of Graham FORM: FTA 06-21 Page 1 of 5 UUI.UJIIY.II CI IVCIUyC IU. IIrCLVMJV-JL.7'-F-4LJ I-.71-Ho-.71U/OOCJ.7Cwo VI. GENERAL REQUIREMENTS 1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached? ❑ Yes ❑ No ® N/A 2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached? ❑ Yes ❑ No ® N/A 3. If the Applicant is a Home/Property Owners` Association, has an HOA/POA Operational Agreement (FORM: HOA} and supplementary documentation as required by 15A NCAC 02T.0115(c) been attached? []Yes ❑ No ® N/A 4. Origin of wastewater: (check all that apply): ® Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash ❑ Residential (Leased) ® Retail with food preparation/service ❑ Hotel and/or Motels ❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubliouse ❑ Food and drink facilities ® Church ❑ Swimming Pool/Filter Backwash ® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment) 5. Nature of wastewater: 60 % Domestic 40 % Commercial 0 % Industrial (See 15A NCAC 02T .0103(20)) If Industrial, is there a Pretreatment Program in effect? ❑ Yes ® No 6. Hasa flow reduction been approved under 15A NCAC 02T ,0114(1)? ❑ Yes ®No ➢ If yes provide a copy of flow reduction approval letter with this application 7. Summarize wastewater generated by project: Establishment Type (see 02T.0I l4(f)) Daily Design Flow °'' No. of Units Flow gal/ GPD gal/ GPD gal/ GPD gal/ GPD gal/ GPD gal/ GPD Total GPD a See 15A NCAC 02T 01 14(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 .0I14(c), design flow rates for establishments not identified [in table I5A NCAC 02T.01141 shall be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data. 3. Wastewater generated by project: 0 GPD (per 15A NCAC 021. 1114) y Do not include future flows or previously permitted allocations If permitted flow is zero, please indicate why: ❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line. Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow. ❑ Flow has already been allocated in Permit Number: Issuance Date: ❑ Rehabilitation or replacement of existing sewers with no new flow expected ® Other (Explain): Relocation only so flow already allocated in original permit FORM: ETA 06-2 l Page 2 of 5 UUUuolyl I CIIvviuyt: IL). /I.CLUFIJU-JLJ4-4GJ 1-m-Mo-.71 U 1000ouCU:1 VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers): 1. Summarize gravity sewer to be permitted: Size (inches) Length (feet) Material 8 466 DI, CLASS 50 10 424 DI, CLASS 50 ➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria ➢ Section III contains information related to minimum slopes for gravity sewer(s) ➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains): PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS .PROJECT 1. Pump station number or name: 2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - ° 3. Total number of pumps at the pump station: 3. Design flow of the pump station: millions gallons per day (firm capacity) ➢ This should reflect the total GPM for the pump station with the largest pump out of service. 4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total dynamic head (TDH) 5. Summarize the force main to be permitted (for this Pump Station): Size (inches) Length (feet) Material If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per MDCPSFIvi Section 2.01C. Lb, ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) 6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1): ❑ Standby power source or ❑ Standby pump ➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B); ➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day ➢ Must be permanent to facility and may not be portable Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C): ❑ Portable power source with manual activation, quick -connection receptacle and telemetry - or ❑ Portable pumping unit with plugged emergency pump connection and telemetry: ➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station. ➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided as part of this permit application in the case of a multiple station power outage. Pa FORlbi: FTA 06-21 Page 3 of 5 UuuuollJ.11 CIIVmUPt:ILJ. IIiCLVF1JV-JL.7Y'YLJ 1'.7 t-F10'J IU/OO�J�CU:J IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)): 1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(1) & (a)? ® Yes ❑ No ice A11-AP mT nI051f) rnntains minimun, separations that shall he provided for sewer systems: Setback Parameter* Separation Required Storm sewers and other utilities not listed below (vertical) 18 inches 'Water mains (vertical - water over sewer preferred, including in benched trenches) 18 inches 'Water mains (horizontal) 10 feet Reclaimed water lines (vertical - reclaimed over sewer) 18 inches Reclaimed water lines (horizontal - reclaimed over sewer) 2 feet **Any private or public water supply source, including any wells, WS-I waters of Class 1 or Class 11 impounded reservoirs used as a source of drinking water, and associated wetlands. 100 feet **Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal high water (or tide elevation) and wetlands associated with these waters (see item IX.2) 50 feet **Any other stream, lake, impoundment, or ground water lowering and surface drainage ditches, as well as wetlands associated with these waters or classified as MIL. 10 feet Any building foundation (horizontal) 5 feet Any basement (horizontal) 10 feet Top slope of embankment or cuts of 2 feet or more vertical height 10 feet Drainage systems and interceptor drains 5 feet Any swimming pools 10 feet Final earth grade (vertical) 36 inches ➢ If noncompliance with 02T.0305(f) or (s). see Section X.1 of this application * 15A NCAC 02T.0305(a) 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 webpaye 2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A ➢ If no, please refer to ISA NCAC 18C.0906(f) for documentation requirements and submit a separate document, signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule. 3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N/A ➢ Please provide supplementary information identifying the areas of non-conformance. ➢ See the Division's draft separation requirements for situations where separation cannot be met. ➢ No variance is required if the alternative design criteria specified is utilized in design and construction. 4. Is the project located in a river basin subject to any State buffer rules? ® Yes Basin name: Jordan ❑ No If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes [-]No ➢ This includes Trout Buffered Streams per I SA NCAC 2B.0202 5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No or 401 Water Quality Certifications? ➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required. 6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ❑ Yes ® No Per 15A NCAC 02T.0 I 05(c)(6), directly related environmental permits or certification applications must be being prepared, have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and sedimentation control plans, stormwater management plans, etc.). 7, Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters, siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer. Siphons and sewers suspended through interference/conflict boxes require a variance approval. ➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location). High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit. FORM: FTA 06-21 Page 4 of 5 UUI:U01Y1I CI Iv ClupC IL/. a 1 -ur-mo-U I of 0OCJz7CU'J Y. CERTIFICATIONS: 1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable? If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued concurrently with the approval of the permit, and proiects requiring a variance approval may be subject to longer review times. For projects requiring two or more variances or where the variance is determined by the Division to be a significant portion of the project, the full technical review is required. 2. Professional Engineer's Certification: 1, Clint L. Stevens, P.E. , attest that this application for (Professional Engineer's name from Application Item III, I.) NCDOT U-6017 (Project Name from Application item 11.1) has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this submittal package, inclusion of these materials under my signature and seal signifies that l have reviewed this material and have judged it to be consistent with the proposed design. NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701) North Carolina Professional Engineer's seal, signature, and date: °'`+cal CA PC�.; 040371) 9©6FUD777EB42Q'.._ 41 1Nfir- .' „ 1,10%31202 3. Applicant's Certification per 15A NCAC 02T .0106(b): 1, attest that this application for N6DO T lit— (00 17 (Slgna ire Authority a ie from Application ftem 1.3.) (Project Name from Application Item 11.1) attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge. i understand that if all required parts of this application are not completed and that if all required supporting documentation and attachments are not included, this application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated, i also understand that if all required parts of this application package are not completed and that if all required supporting information and attachments are not included, this application package will be returned to me as incomplete. NOTE — In accordance with General Statutes t43-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. i Signature: — Date: /t✓ FORM: FTA 06-21 Page 5 of 5 U-1-01U.S. 1AR INTOITHIINTIIIOR -To,p BURLINGTON QUADRANGLE MUSGS GEOLOGICAL SURVEYCAMINI 16 11 38 I9 o 43 MDRTH 7.540NUTE 15 ALRRIANCE COU- SERIES IR z HURIL11,147-ON PkiECT AREA91 92 f RS R7 11 IS BURLINGTON. M"I NC _ > o t • p 4 "�' :off"-:..+Y tip' tir u a , r 1,6�p� Y -k Yllmtei St ` n,..- _oVo J L v e i 4 Z � its a _ G y p h.7 u 2 .. q Q Walker Ave Walker AveIr AIL �} Cc v Oaf CT� ¢U q Flaniganl$t - ... C-) �n�i W r`r✓c. QS ._ y 4 z2 j v! _ . 1 m Ii E p 6if i ,r Z Q. N Melville st N Melville St N Melville St o m p jE Ef � U? N'MarshalL$t " "" p IMarshalllSt 4 i ; C J- O.. HINDS ENGINEERING 401 Harrison Oaks Blvd. Suite 220 Cary, NC 27513 Phone: (919) 653-0001 Fax: (704) 814-9042 LETTER OF TRANSMITTAL To: Winston-Salem Regional Office Water Quality Section 450 W. Hanes Mill Road, Suite 300 Winston-Salem, NC 27105 Re: U-6017 Alamance County. Gravity Sewer Line Relocations for City of Graham. NCDOT Project: U-6017 Intersection improvements at NC 54 & NC 49 I am sending you the following item(s): Date: NC Department of Environmental Quality Received OCT 0 5 2023 Winston-Salem octb gn2bfffte Job No.: A2021900.00 COPIES DATE NO. DESCRIPTION 1 10-4-2023 1 Sewer Permit Application 1 10-4-2023 1 8.5" x 11.5" Color Copy of USGS Topo Map (2 pages) 1 10-4-2023 1 Aerial View of Project 1 10-4-2023 1 Project Narrative 1 10-4-2023 1 Check for $480.00 1 1 10-4-2023 1 1 CD with digital copies These are transmitted as checked below: ❑ As requested ❑ For your use ® For approval ❑ For Signatures ❑ For review and comment ❑ Remarks: Copy to: File Signed: Jordan Chap an Designer HINDE ENGINEERING 401 Harrison Oaks Blvd., Suite 220, Cary, NC 27513 Office: 919-653-0001 October 4, 2023 Winston-Salem Regional Office Water Quality Section NC Division of Water Resources, DEQ (336) 776-9800 Subject: Fast Track Sewer Permit Narrative City of Graham — Relocation of Gravity Sewer Lines NCDOT Project: U-6017, Alamance County — Intersection Improvements at NC 54 (East Harden St) and NC 49 (East Elm St) in Graham The following gravity sewer lines will be relocated and replaced by the following proposed sewer lines along East Harden Street and East Elm Street. 0 424 LF of new 10" DI Sewer Line. This will replace the existing 10" Clay Sewer Line along East Elm Street that is in conflict and be placed in a permanent utility easement adjacent to the NCDOT Right -of -Way. • 306 LF of new 8" DI Sewer Line. This will replace the existing 8" Clay Sewer Line along East Harden Street that is in conflict and tie into the relocated 10" sewer line on East Elm Street (mentioned above). The sewer line will be placed in a permanent utility easement adjacent to the NCDOT Right -of -Way. • 160 LF of new 8" DI Sewer. This will replace the existing 6" Clay Sewer Line coming from Walker Street to tie into the relocated 10" sewer line on East Elm Street (mentioned above). The City of Graham requested to upsize this line for expected future capacity increase, not related or impacted under this project. This sewer line will be placed in a permanent utility easement adjacent to the NCDOT Right -of -Way. All the sewer lines being proposed are replacing existing sewer lines and there are no additional connections with this project and there will be no additional flows. The sewer permit submittal also includes the sewer permit application, site maps (topo and aerial) and $480.00 permit fee. Sincerely, ou- -J • �X�— Clint L. Stevens, PE Cary Branch Manager Cc: Josh Johnson, PE osjohnson@cityofgraham.com) City Engineer LJUUUJIYI IF-[ Ivtnupu ILJ. / I..CLVFIJ V-:JL.7'4-4LJ I-Vr/10-.7 I V / OOOJuCL/u State of North Carolina Department of Environmental Quality Division of Water Resources FAST TRACK SEWER SYSTEM EXTENSION APPLICATION Division of Water Resources INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been certified by a professional engineer and the applicant that the project meets the requirements of I5A NCAC 02T and the Division's Minimum Design Criteria (Gravi Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300, Division policies, and goad engineering practices. While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These documents shall be immediately available upon request by the Division. Projects that are deemed permitted (do not require a permit fi•om the Division) are explained in ISA NCAC 02T.0303. Projects not eligible for review via the fast track process (must be submitted for full technical review): ➢ Projects that do not meet any part of the minimum design criteria (11dDC) documents; ➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T; ➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps; ➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains); ➢ Vacuum sewer systems. General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of requested additional information. Failure to submit all required items will necessitate additional processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of the application and supporting documentation. A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents ® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures. Please do not submit engineering design plans with the application unless specifically requested. B. Cover Letter/Narrative Description (Required for All Application Packages): ® List all items included in the application package, as well as a brief description of the requested permitting action. ➢ Be specific as to the system type, number of homes served, flow allocation required, etc. ➢ Include the permit number/status of any other required sewer permits (downstream/upstream) ➢ If necessary for clarity, include attachments to the application form. C. Application Fee (Ali New and Modification Application Packages): ® Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal. ➢ Payable to North Carolina Department of Environmental Quality (NCDEQ) D. Fast Track Application (Required for All Application Packages, Form FTA 05-21): ® Submit the completed and appropriately executed application. ➢ If necessary for clarity or due to space restrictions, attachments to the application may be made. ❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the North Carolina Secretary of State. ❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in the county of business. ® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc. G1 The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina licensed Professional Engineer. ® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0 t06(b). Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A NCAC 02T .0106(b). INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3 UUL,U01 11 CI IVCIUr1C IU. l IiCLVl1JV':JL.7Y-YLJ I-Urmo-u I V / OOOJyCUJ E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable): ❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility. ➢ Nultiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different. ➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year prior to the application date. ➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a). ➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE. F. Site Maps (All Application Packages): ® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area, including the closest surface waters. ➢ General location of the project components (gravity sewer, pump stations, & force main) ➢ Downstream connection points and permit number (if known) for the receiving sewer ® Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff can easily locate it in the field. G. Existing Permit (Application Packages- for Modifications to an Existing Permit): ❑ Submit a copy of the most recently issued existing permit. ❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be added, and/or items to be modified (the application form itself should include only include items to be added/modified). The narrative should also include whether any previously permitted items have been certified. ❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in the final permit. H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station): ❑ Per 15A NCAC 02T .0305(h)(I ), submit documentation of power reliability for pumping stations. ➢ This alternative is only available for average daily flows less than 15,000 gallons per day ➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0 t06(b)) or proposed contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances and personnel are available for distribution and operation of this pump station." ➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification) I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities): ❑ Per 15A NCAC 02T .0 I t 5(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer extension, or ❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval is expected. J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold): ❑ Home/Property Owners' Associations ❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA). ❑ Per 15A NCAC 02T .01 15(c), submit a copy of the Articles of Incorporation, Declarations and By-laws. ❑ Developers of lots to be sold ❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV). For more information, visit the Division's collection systems website INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3 UuwalylI CI IvCIupty IW. / I'C4UM0U-J4U•4-V1J I-.71-MO-.N IU/OODOUCUZ) THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE: REGIONAL OFFICE ADDRESS COUNTIES SERVED Asheville Regional Office 2090 US Highway 70 Avery, Buncombe, Burke, Caldwell, Cherokee, Water Quality Section Swannanoa, North Carolina 28778-8211 Clay, Graham, Haywood, Henderson, Jackson, (828) 296-4500 Macon, Madison, McDowell, Mitchell, Palk, (828) 299-7043 Fax Rutherford, Swain, Transylvania, Yancey Fayetteville Regional Office 225 Green Street Suite 714 Anson, Bladen, Cumberland, Harnett, Hoke, Water Quality Section Fayetteville, North Carolina 28301-5095 Montgomery, Moore, Robeson, Richmond, (910) 433-3300 Sampson, Scotland (910) 486-0707 Fax Mooresville Regional Office 610 E. Center Avenue Alexander, Cabarrus, Catawba, Cleveland, Water Quality Section Mooresville, North Carolina 28115 Gaston, Iredell, Lincoln, Mecklenburg, Rowan, (704) 663-1699 Stanly, Union (704) 663-6040 Fax Raleigh Regional Office 3800 Barrett Drive Chatham, Durham, Edgecombe, Franklin, Water Quality Section Raleigh, North Carolina 27609 Granville, Halifax, Johnston, Lee, Nash, (919) 791-4200 Northampton, Orange, Person, Vance, Wake, (919) 5714718 Fax Warren, Wilson Washington Regional Office 943 Washington Square Mall Beaufort, Bertie, Camden, Chowan, Craven, Water Quality Section Washington, North Carolina 27889 Currituck, Dare, Gates, Greene, Hertford, Hyde, (252) 946-6481 Jones, Lenoir, Martin, Pamlico, Pasquotank, (252) 975-3716 Fax Perquimans, Pitt, Tyrrell, Washington, Wayne Wilmington Regional Office 127 Cardinal Drive Extension Brunswick, Carteret, Columbus, Duplin, New Water Quality Section Wilmington, North Carolina 28405 Hanover, Onslow, Pender (910) 796-7215 (910) 350-2004 Fax Winston-Salem Regional Office 450 W. Hanes Mill Road Alamance, Alleghany, Ashe, Caswell, Davidson, Water Quality Section Suite 300 Davie, Forsyth, Guilford, Rockingham, Randolph, Winston-Salem, North Carolina 27105 Stokes, Surry, Watauga, Wilkes, Yadkin (336) 776-9800 (336) 776-9797 Fax INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3