WQ0045133_Academic_Complex_-_Law_and_Dental_Buildings_20240202

State of north carolima
DWR T Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FI'A 10-23 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
I. Applicant's name: High Point Universitecompany, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporations ❑ General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: Deborah McClintock per 15A NCAC 02T .0106(b)
Title: Vice President for Financial Affairs
❑ Privately -Owned Public Utility
❑ Other
i
4. Applicant's mailing address: One University Parkway r +
City: High Point "State: NC' %'
5. Applicant's contact information: \ h G
Phone number: (36) 841-9202 Ismail Address: debibahighpoint.cdu
[L PROJECT INFORMATION:
I. Project name: Academic Complex - Law and Dental Building$
2. Application/Project status: ® Proposed (New Permit) ❑ Ixisting Pennit/Project
If a modification, provide the existing permit number: W000_ and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 3,5,9675°� Longitude: -79 99791
5. Parcel ID (if applicable): 190041 (or Parcel ID to closest downstream sewer)
Ill. CONSULTANT INFORMATION:
I. Professional lingincer. Danicl W. Pritchcul iccnse Numbcr: NCI 1659
Firm: Jamestown En ing caring Group, Inca
Mailing address: 117 E. Main Street, PO Box 365
City: Jamestown State: NC Zip: 27282
i
Phone number: [phone]limail Address: clan r@iamestownengincerin .com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Eastsidc WWTP! Permit Number: NCO024210
Owner Name: City of Ili hg Point �
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
I. Permit Numbcr(s): WQ_
2. Downstream (Receiving) Sewer Information: 8 inches 0 Gravity ❑ Force Main
3. System Wide Collection System Pe it Number(s) (if applicable): WQCS� 1 O
9, 1 1 fpI taf�
Owner Name(s):
Fr)RM• FTA In -')I Noe 1 of 5

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VI. GENERAL REQUIREMENTS
I. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
[:]Yes ❑ No ® N/A�
2, if the Applicant is a Developer of lots to be sold, has a Develo er's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ®N/A'
3. If the Applicant is a I tome/Property Owncrs' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.01 15(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 ❑ Ilotel and/or Motels
® School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming PooUFiltcr Backwash
❑ Businesses / offices / factories ❑ Nursing I lomc ❑ Other (Explain in Attachment)
i
5. Nature of wastewater : 100 % Domestic _% Commercial _ % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Ycs® No
6. Has a flow reduction been approved under 15A NCAC 02T .01 14(D? ❑ Yes Z NO
D If yes, provide a copy of flow reduction apnroval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(Q)
Daily Design Flow 's
No. of Units
Flow
Classroom Scats
10 gayscat
1,080'
10,800 GPD
Employees
25 gal/person
116 '
2,900 GPD'
Planitarium/Auditorium
5 gal/seat
146/
730 GPD '
gall
GPD
gal/
GPI)
gal/
GPD
7oral
14,430 GPD
a See 15A NCAC 02T .01 14(b). (d). (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or cast of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in C.S. 42A4).
b Per ISA NCAC 02T.01 14(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01 14] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 1A430"GPD (per 15A NCAC 02T .01 14 and G.S. 143-215,1)
➢ 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 Dale:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
O'l ... I. I. 19 i)_ 9 ..rc

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"
357 i
DI
6"
135
DI
D 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 OFT] IIS PAGE FOR I.ACI I PUMP STATION INCLUDED IN TI IIS PROJ17CT
I. 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 (I'DI1)
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
MDCPSFM Section 2.01 C.I.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) _
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or ❑ Standby pump
D Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(13):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
D 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:
D Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
D 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 timcframcs, shall be provided
as part of this permit application in the case of a multiple station power outage.
F(1R AA- FrA to-,)'1 Vaor 7 of S

IX. SETBACKS & SEPARATIO14S—(02B.0200 & 15A NCAC 02T.0305(Q):
I. Does the project comply with all scparations/altemativcs found in 15A NCAC 02T .0305(f) & (e)? O'Yes ❑ No
15A NCAC 02T.0305(I) contains minimum cenamlions that chall he nrnvidnd fnr cru n�
Setback Parameter*
.... .........
SeparationRequired '
Storm sewers and other utilities not listed below (vertical)
18 inches
ZWater mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 foci
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizon(al - reclaimed over sewer)
2 feet
"Any private or public water supply source, including any wells, WS-1 waters of Class 1 or
Class 11 impounded reservoirs used as a source of drinking water, and associated wetlands.
100 foci
**Waters classified WS (except WS-1 or WS-V),13, SA, ORW, IIQW, 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 WI..
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
"fop slope of embankment or cuts of 2 feel 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 or W. sec Section X.I of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "ycs"
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 weboage
2. Does this project comply with the minimum separation requirements for water mains? ®'%es ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC I8C.0906(Q for documentation requirements and submit a separate document,
signcd/sealed by an NC licensed Pr, 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: Randleman ❑ No
If ycs, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Ycs ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stornwatcr management plans, etc.).
7. Does this project include any sewer collection lines that arc deemed "high-priorityT' ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to strcambanks that arc 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 permtttee 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.
rnUM- r. rA t n_rt Pape 4 of 5

X. CERTIFICATIONS:
Does the submitted system comply with I5A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes r ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the reQuest will be issued
concurrently with the approval of the permit, and nroiccts reauirine 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 proicet, the full technical review is required.
2. Professional Engineer's Certification:
I, DQnreL U.Prite/y.t. � __, attest that this application for
(Professional Engincer's name from Application Item 111.1.) (Project Name from ation Item 11.1) )3Ut Id 1A9!9
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 Pumn 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 1 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 S25,000 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 NCA&&Q 1)
North Carolina Professional Engineer's seal, signature, and date: , ' ' t+ ;'{.', .s_
EAL } {
e^
P
Q
Applicant's Certification per ISA NCAC 02T.0106(b):
i n
attest that this application for RW�t /�C' _.LQm IIM) tSl
(Signature Auamrity Name from Application Item 1.3.) (Projca Nnme from A lication Item II. q eliwdiTs
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 understand that if all required pans 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. 1 understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE. - In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:. , 9 ------ ---- Date: 11 Z�2
FORM: FfA 10-23 Page 5 of 5

I
Divi�;Iuri nl \itater kesources
State ofNo at Carolina
Department of Environmental Quality
Division of WaterResom•ces
Ilowllacldi% for Sewer Extension Applications
"E 10-23)
FntityRegrrstingAlhcatiDMff )PointNC'
Project Nanie for which flow is being requested: Acadeneo Conplex - Law and Dental-'
More than one ME may be requiredfor a single project if the owner of the WWIP is ool responsiblefor allpionp stallons along the
mule of the proposed wastenvatei flow
I. Corplete Offs section only ifyou are die owner of an wastewater heatnent plant.
a. W WTP Facility neat;: Fastside VWVIP
b, W WTP Facility Pennit #: NC0024210/
All floss are In MGD
c. W WIP faciliVs Pemirtted Sow
26 '
d. Mulled obligded flow not yet tributary to the WWI?
4.5703 '
e. W W1P faolit}ls actual average flow
14.92
f. Total flow for Us specific request
0.0144 '
g. Total actual and obligated flows to die facr7ay,
19.5047 '
In Percent ofperrnilted flow reed
75.02°A ,
R. Complete tM section for each pu np station your ate respowtile for along die route ofOta proposed wastewater now
List pulp station located belmen the project connection point and the W WIP.
(A) (B) (C) (D)-(B+C) (E)-(A-D)
Pulp Pump Design Approx Obligated IblidCunrert
Station Station Flat Average Daily Cully t Not Yet Flow Plus Available
(Nan>r or Pemit Capacity, + Flow" Avg, Daily 71flntay, Obligated Capacity"**
Nmr$er) No. MGD (Fam/pl) Flow Daily Flow Flow MGD
MGD MGD MGD MGD
Riverdale WO0008572 30,0887 11,4842 ' 8.3901 / 1,6212 10.0113 IA729
* Tine Ittm Capacity of ally pure station is delbied as the maxinum pooped flowtlut can be
acideved tdth the largest punp taken out of so -Ace.
"Design Average Daly howls the firm capacity of the pimp station divided by a pealing factor (po
not less than 2.5, perSectlou 2.02(A)(4)(c) of the Mlnbnu iDesign Criteria.
***A Planning Assessment AddendumsiuO be attached for each pump station located between tee
project connection point and the NV WIP where the Available Capacity Is < 0.
Dow»sheamFacililyNarrm(Sewer): EoslsideWWDP
DbtmtshcmiiPe»rit Nmixr (Sewer): NC0024210
Page 1 of 8
FTSE 10.23

III. Cetificalloa�statenent
I, Dcn' .k Boot ., certify to the bast ofr y knowledge that the addtion ofthe %clone of
wastewater to be permitted in this project has been evaluated along the route to the receivirgwaslewater
treatment facility and that Ile flow fiom this project is trot u&ipated to cause arty capacdy related sanitary
seuer overflows or overburden anydownsheampru p station en route to the receiving heahnent plant
under nontal chcunatances, given the inpler entation ofthe planned hrprover ents identified in On
planning assesstrent where applicable, This analysis bas been perfomed in accordance with local
established policies and procedures using the best available data. This certification applies to those item
Wed above in Sections I and II plus all attached planning assesstrent addenduars for which I am die
responsible party. Sigalure of this form hdieates acceptance ofthis wastewater flow.
M
Tale of Sigting Ofrr.W
123 2ozy'
Dafe
Page 2 of 8
FfSE 10-23

C I 1 Y OF
PUBLIC SERVICES h"i
�h
Derrick Boone point,
Public Services Assistant Director
January 23, 2024
NCDENR
Winston-Salem Regional Office
450 W. Hanes Mill Rd, Suite 300
Winston-Salem, NC 27105
Project: HPU Academic Complex- Law & Dental
Applicant: High Point University
High Point, NC
Dear Sir or Madam:
This is to acknowledge that the City of High Point will accept for treatment in the
Eastside Wastewater Treatment Plant (Permit #NC0024210), wasterwater flow from the
above referenced project in the amount of 14,430 GPD, which will be discharged to
facilities operated and maintained by the City of High Point.
If further information is needed, please let me know.
Sincerely,
Derrick Q. Boone
Assistant Public Services Director
DQB/tab
9 211 South Hamilton St. High Point, NC 27260 t. 336.883.3111 1: HighPointNC.gov 0

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JAMESTOWN ENGINEERING GROUP, INC.
L CIVIL ENGINEERS & SURVEYORS
LAND PLANNING • MUNICIPAL CONSULTING
r ins 117 East Main Street • P.O. Box 365 • Jamestown, N.C. 27282
Telephone [phone] Fax [phone]
www Jamestownengineering.com
January 29, 2024
Re: Sewer Line Extensions to Serve the
Academic Complex — Law and Dental Buildings
High Point University
High Point, NC
JEG File No. 23006 NC Dep:irtm Y.
Environrlr
NC Department of Environmental Quality Roc`_
Division of Water Resources FEB 0 2 20?4
Winston Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Dear Sir or Madam:
With regards to the referenced project, and on behalf of High Point University, we are
requesting your reviewiapproval of the attached private sewer extension applications
required to service the Academic Complex. The Academic Complex includes two new
buildings to house the School of Dentistry and the School of Law. 8-inch sewer mains
and 6-inch sewer service lines are proposed to tie into 8-inch public sewer lines owned
and maintained by the City of High Point.
On this basis, we have enclosed private application package in support of the sewer line
extensions, inci! (ding the following:
- One original and one copy of the Fast Track Sewer Application (FTA 10-23)
- $600.00 Application Fee
- Two copies of Form FTSE 10-23 completed by the City of High Point
- Letter of Flow Acceptance from the City of High Point
- 8.5" X 11" color USGS topographic map
If there are any questions or additional information required, please call.
Yours very truly,
JAM�E WN ENGI ERING GROUP, INC.
a6 niel W. 1, E & PLS
DWP/cp
Enclosures
Cc: Mr. Derrick Boone, City of High Point
Ms. Dana Ruth, City of High Point
Mr. Jasun Sweet, High Point University
Ms. Deborah McC!intock, High Point University

` State of North Carolina
Depat•tment of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTLtM EXTENSION APPLICATION'
Division of Water Resources INSTRUCTIONS FOR FORM: FI•A 10-23 & SUPPORTING DOCUMENTATION
This application is for server 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 nnects the requirements of I5A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with ISA NCAC 02T. I5A NCAC 02T.0300 Division policies, and Qood engineering practices.
While no upfront engineering design documents are required I'or 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 'I5A 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 it permit from the Division) are explained in I5A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
]'rejects that do not meet any part of the minimum design crilcria (M DC) dpettm en is;
`r Projects that involve more than one variance from the requirements of 15A NCAC 02
i Pressure sewer systenns utilizing simples septic lank -effluent pumps (S'TITs) or simplex grinder pumps;
Simplex STEP or simple grinder pumps connecting to pressurized systems (c.g. force mains);
p 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 he digital) of Application and Supporting Documents
® Required unless otherwise notch. Signatures on original must be "wet ink" or secure digital signatures.
Please do notsubmit 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.
`r 13c specific as to the system type, number of homes served, Ilow allocation required, etc.
i Include the permit number/status of any other required sewer permits ((iownstr•cant/upsu'cann)
i If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
Z Submit a check or money ord'cr in the amount of'S000.00, dated no more than 90 days prior to application submittal.
D Payable to North Carolina Department of Environmental Ouality (NCIA"M
D. Fast Track Application (Required for All Application Packages, Form FrA 10-23);
® Submit the completed and appropriately executed application.
i If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is It corporation or company, provide documentation it is registered for business with the
North Carolina Secretory or State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate riled with the Register of Uccds in
the county of business.
® The Project Name in Ilea IL I shall be consistent with the project name on the now acceptance fetters, agreements, etc.
® 'rho professional Enaineca's Certification on Page 5 of the application shall he signed, scaled and dated by a North Carolina
licensed Professional Engineer.
(D The Applicant's Certification on Page 5 of the application shall he signed in accordance with 15A NCAC 02T .0106(b . Per
15A NCAC 02T.0106(c), an alternate person may be designated as tile Signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .010C(b).
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPOR'17NG DOCUMENTATION Page 1 Ol'3

E. Flow Tracking/Acceptance Form (Form: FTSF. 10-23) (If Applicable):
® Submit -the completed and executed FTSI? form from the owners of the downstream sewers and treatment facility.
D Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
D 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.
D Submittal ofthis application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
D Intergovernmental agreements or other contracts will not be accepted in lieu of a projcct-specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x I 1-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters,
D General location of the project components (gravity sewer, pump stations, & force main)
D 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).111e
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
D This alternative is only available for average daily (lows less than 15,000 gallons per day
D It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump station."
D 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)
1. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T.0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
fora 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 .01 15(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .01 15(b), submit the properly executed Operational Agreement (FORM: DEV).
ror more information, visit the Division's collection systems website
MSTRTI(:Tft1NS FOR FORM: FTA 10-73 k.. Rl1PPORTINt) DOMWENTATION Paec 2 of

THE COMPLETED APPLICATION PACKAGE, INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SIIOULD BE SENT TO TIE 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,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] 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,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Curriluck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] 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, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Allegheny, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: PTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3