WQ0045379_Smith_Warehouse_Private_FTSSE_Permit_App_2nd_Submission_20240514_20240514

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dlvlslon of Water Resources FTA 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: KG Land Development. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
i
3. Signature authority's name: Greg Smith per 15A NCAC 02T .0106(b)
Title: Managing Partner
4. Applicant's maili g address:)530 Kirkpatrick Road
i
City: Burlinnton State: NC Zip: 27215
5. Applicant's contact information:
Phone number. 336 314-0866 Email Address: sg [e-mail]
11. PROJECT INFORMATION:
1. Project name: Smith Warehouso
2. Application/Project status: ❑ Proposed (New Permit) ❑ Existing Permit(Project
If a modification, provide the existing pemtit number: W00015113 and issued date: 2-2-2024,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but pan of a master plan, provide the existing permit number: W000_
3. County where project is located: Alamance I/
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0149' Longitude:-79.4895'
5. Parcel ID (if applicable): 112119 (or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer: Kent E. Bamev License Number: 19275
Firm: Landmark Builders, Inc
Mailing address: 3520 Triad Court
City: Winston-Salem` State: NC Zip: 27107
Phone number. 3( 36) 784-2000 Email Address: kbameyAlandmarkbuilders.eom
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: South Burlington Permit Number: NCO02387�
Owner Name: City of Burlington
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ(Not available)
2. Downstream (Receiving) Sewer Information: 8 inch ` ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00008
Owner Name(s): Cry of Burlington
FORM: FTA 10-23 Page I of 5

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: HP -Al 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/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
® Businesses /offices /factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic 100 % Commercial _ % Industrial (See 15A NCAC 02T .0103(20))
[f Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .01 14(f1? ❑ Yes ®No
➢ if yes provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow',b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0l 14(b). (d). (c)(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 east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T 0114 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 Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
® Other (Explain): (_Flow is currenity allocated under permit WO0045113
FORM: FTA 10-23 Page 2 of 5

Second submission of this page with updated PS firm capacity and number of pumps.
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
➢ 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: 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.0490' Longitude:-79.4891 °
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station:.0648 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): 45 gallons per minute (GPM) at24 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
290
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C. 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.
FORM: FTA 10-23 Page 3 of 5

1st submission of this page with simplex PS.
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
➢ 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: 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.04900 Longitude:-79,4891'
3. Total number of pumps at the pump station: 1 `
3. Design flow of the pump station:.0006 millions gallons per day (firm capacity)•fl!��
This should reflect the total GPM for the pump station with the largest pump out of service. (O"
4. Operational point(s) per pump(s): 60 gallons per minute (GPM) at 15 feet total dynamic head (TDH) k
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
290
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C. 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
Y Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B);
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
® Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 3 of 5

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(f) & IRV
c A NTC A C 02T ninon "":a;..� m;pimum emnmtinnQ that shall he provided for sewer systems:
i
® Yes ❑ No
.......�.._ __.._'_- ' --------
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 I or
Class 11 impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
"Waters classified WS (except WS-I or WS-V), B, SA, ORW, HOW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (a), see Section X.1 of this application
' 15A NCAC 02T.0305(rt) contains alternatives where separations in 02T.0305 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 webpaee
2. Does this project comply with the minimum separation requirements for water mains? ® des ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ Seethe Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alterative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer niles? ® Yes Basin name: Cave Fear River ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yis ❑ 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, storinwater 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 i5A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pamn Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
11
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
2. Professional Engineer's Certification: y
L. Kewr E o 3�t e� t� jf' k attest that this application for s^ �{� �4rCAVVI.&
(Professional Engineer's name from Application Item III.I.) (Project Name Prom 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 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 $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:
SEAL
19275
3. Applicant)ACertification peA5A NCAC OJT .0106(b):
r I, � p 4� S e.` • �'h a, attest that this application for 15A13h a1r ho ws t
( mlre(y l�JamdSlicafio„ a.m t 1) (Project Name from Application Item E.I)
attest th t th' application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 understan that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.611, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: _ Date: y ! V 2-
FORM: FTA 10-23 Page 5 of 5

Smith Warehouse Private Sewer Pump Station and Force Main
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COUNTY
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2nd submission of this page with project narrative.
T A X TT11% /r A Tl TT
I.H1viJ1v�HR[�
We Build Confidence.
May 13, 2024
Private sewer pump station and force main for Smith Warehouse
Enclosed please find the executed FTA 06-23, color USGS map and aerial location map for the project
named "Smith Warehouse". This project consists of a proposed private sewer pump station and 290 If
of 2" force main, which will tie into the 180 If of new 8" public gravity sewer that was previously
permitted and installed under permit no. WQ0045113 and named "Smith Warehouse" as well.
Landmark Builders 1 3520 Triad Court I Winston-Salem, NC 27107
p.336.784.2000 I www.landmarkbuilders.com

1st submission of this page with project narrative.
LO
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We Build Confidence.
April 12, 2024
Private sewer pump station and force main for Smith Warehouse
Enclosed please find the executed FTA 06-23 (Modification to WQ0045113), color USGS map and
aerial location map for the referenced Smith Warehouse Project. The project consists of a proposed
private sewer pump station and 290 If of 2" force main. The existing permit included a 180 If of new
public gravity line. This portion has not been certified.
Landmark Builders 1 3520 Triad Court I Winston-Salem. NC 27107
p.336.784.2000 II www.landmarkbuilders.com

KG Land Development, LLC
4-12-2024
1530 Kirkpatrick Road
Burlington, NC 27215
Attn: Ron C. Boone, Environmental Program Specialist, NCDEQ
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Dear Mr Boone,
Pursuant to section 15A NCAC 02T .0305(h)(1) of the Division's Minimum Design
Criteria of Gravity Sewer & Pump Stations/Force Mains, the portable power
generation unit or portable, independently - powered pumping units, associated
appurtenances and personnel are available for distribution and operation of the
pump station associated with 1530 Kirkpatrick Road, Burlington, NC 27215.
Sincerely,
Greg SmManaging Partner— KG Land Development, LLC
1530 KIRKPATRICK ROAD, BURLINGTON, NC 27215
T. 336-314-0866 ENTAIL: GSMI'[e-mail]

tmmv
NAME OF LIMITED LIABILITY COMPANY:
North Carolina Secretary of State
KG Land Development, LLC CA2024 023 00104
SECRETARY OF STATE ID NUMBER: 2655839 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2024
SECTION A: REGISTERED AGENTS INFORMATION
1. NAME OF REGISTERED AGENT: Folmar, Natalie C.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTIMES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS 8 COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
400 Bellemeade Street, Suite 800 400 Bellemeade Street, Suite 800
Greensboro, NC 27401 Guilford County Greensboro, NC 27401
SECTION B:
1. DESCRIPTION OF NATURE OF BUSINESS: Land Development
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] x_ 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
1530 Kirkpatrick Road 1530 Kirkpatrick Road
Burlington, NC 27215 Burlington, NC 27215
6. Select one of the following If applicable. (Optional see Instructions)
❑ The company Is a veteran -owned small business
❑ The company Is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials In Section E.)
NAME: Gregory P Smith NAME:
TITLE: Manager TITLE:
ADDRESS: ADDRESS:
1530 Kirkpatrick Road
NAME:
TITLE:
ADDRESS:
Burlington, NC 27215
SECTION D: CERTIFICATION OF ANNUAL REPORT, Section D must be completed in Its entirety by a persoillbusiness entity.
Gregory P Smith 1/3/2024
S=IGNASIGD RE DATE
Farm must be signed by a Company under Section C of This form.
GregoryP Smith Manager
Print or Type Name of Company Official Print or Type Title of Company Official
SUBMIT THIS ANNUAL REPORT WITH THE'REQUIRED FILING FEE OF $200.00
MAIL TO: Secretary of Slate, Business Registration Division, Post Office Box 29525. Raleigh, NC 276264525

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RJCHARD E. ROGERS, JR.
Director
Craig Honeycutt, City Manager
Email: enaineering(fturlinetonnc.eov
City of Burlington
425 South Lexington Avenue
Burlington, NC 27215
NORTH CAROLINA
Environmental Quality
February 2, 2024
Subject: Permit No. WQ0045113
City of Burlington
Smith Warehouse
Wastewater Collection System Extension Permit
Alamance County
Dear Mr. Honeycutt:
In accordance with your application received January 18, 2024, and additional information received on
February 1, 2024, we are forwarding herewith Permit No. WQ0045113 dated February 2, 2024 to the City
of Burlington (Permittee) for the construction and operation upon certification of the subject wastewater
collection system extension. This permit shall be effective from the date of issuance until rescinded and
shall be subject to the conditions and limitations as specified therein. This cover letter shall be considered
a part of this permit and is therefore incorporated therein by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 11.1: This permit shall not be automatically transferable; a request must be made and
approved.
Condition 11.4: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 02T .0403 or any individual system -wide collection system
permit issued to the Permittee.
Condition 11.7: Upon completion of construction and prior to operation of these permitted facilities, the
completed Engineering Certification form with checklist attached to this permit shall be
submitted with the required supporting documents to the address provided on the form.
Permit modifications are required for any changes resulting in non-compliance with
this permit, regulations, or the Minimum Design Criteria. (15A NCAC 02T.01161
It shall be the responsibility of the Permittee to ensure that the as -constructed project meets the
appropriate design criteria and rules. Failure to comply may result in penalties in accordance with North
Carolina General Statute §143-215.6A through §143-215.6C, construction of additional or replacement
wastewater collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to
the licensing board.
North Carolina Department of Environmental Quality I Division of Water Resources
��
f' Winston-Salem Regional Office 450 West Hanes Mill Road. Suite 300 Winston-Salem. North Carolina 27105
736.776.9800

City of Burlington
Permit No. WQD045113
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 Chapter 150E of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this matter, please contact Jenny Graznak at (336) 776-
9695 or via e-mail at iennv.araznakC�deg.nc.eov.
Sincerely,
DOCUSIOned Er:
C ,4W
OD2D3CE3F197�SE...
Jennifer F. Graznak, Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: Kent E. Barney, Landmark Builders, Inc., [e-mail]
Page 2 of 7

NORTH CAROLINA
Environmental Quality
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
City of Burlington
Alamance County
for the construction and operation of approximately 180 linear feet of 8-inch gravity sewer to serve a new
warehouse with two loading bays and a general business facility which will employ 15 employees daily on
a single shift, as part of the Smith Warehouse project, and the discharge of 575 gallons per day of collected
commercial wastewater into the City of Burlington's existing sewerage system, pursuant to the application
received January 18, 2024, and additional information received on February 1, 2024, and in conformity
with 15A NCAC 02T; the Division's 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; and other supporting data subsequently filed and
approved by the Department of Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
CaocuSigned by: u
rNru�rn 4.
OD203CE3F187458_. t�
Jennifer F. Graznak, Assistant Regional Supervisor
Water Quality Regional Operations Section, Winston-Salem Regional Office
Division of Water Resources, NCDEQ
Permit Number: WQ0045113
Permit Issued: February 2, 2024
Page 3 of 7

SUPPLEMENT TO PERMIT COVER SHEET
City of Burlington is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the City of Burlington's South
Wastewater Treatment Facility in accordance with Permit Number NC0023876.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000 as applicable, unless specifically mentioned herein. Division approval
is based on acceptance of the certification provided by a North Carolina -licensed Professional Engineer in
the application. It shall be the Permittee's responsibility to ensure that the as -constructed project meets
the appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
I. SPECIAL CONDITIONS
1. No flow in excess of the quantity permitted herein, 575 GPD, shall be made tributary to the subject
sewer system until an application for permit modification for an increase in flow has been submitted
to and approved by the Division. [I5A NCAC 02T.0304(b)]
II. STANDARD CONDITIONS
1. 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 Permittee, a formal permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be considered
on its merits and may or may not be approved. [15A NCAC 02T.0116; G.S 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 02T; the Division's 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; and
other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. 115A NCAC 02T .0110]
4. The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 02T .0403. If an individual
permit is not required, the following performance criteria shall be met:
Page 4 of 7

a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at
least once per week.
e. High -priority sewer lines shall be inspected at least once per every six -months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance
with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina
General Statute §143-215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
i. Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept for Subparagraphs (a) through (i) of this Rule for a minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staff member at the Winston-Salem
Regional Office, telephone number [phone], as soon as possible, but in no case more than 24
hours, following the occurrence or first knowledge of the occurrence of either of the following:
a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line
blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Page 5 of 7

Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside normal business hours may also be reported to
the Division of Emergency Management at telephone number [phone] or [phone].
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part 11 of Form CS-SSO (or the most current Division approved
form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)]
6. 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. [15A NCAC 02T.0108(b)]
Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form with checklist attached to this permit shall be submitted with the
required supporting documents to the address provided on the form. A complete certification is one
where the form is fully executed and the supporting documents are provided as applicable. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Engineer's Certification shall be considered a violation of the permit and shall subject the
Permittee to appropriate enforcement actions.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings (plan & profile views of sewer lines & force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media and are defined as the design drawings that are marked up or
annotated with after construction information and show required buffers, separation distances,
material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing, velocity,
pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge
protection, detention time in the wet well, and force main, ability to flush low points in force
mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or
pump is dedicated to multiple stations, an evaluation of all the pump stations' storage capacities
and the rotation schedule of the portable power source or pump, include travel timeframes, shall
be provided.
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including but not limited to pipe length changes of 10% or
greater, increased flow, pump station design capacity design increases of 5% or greater, and
increases in the number/type of connections), regulations, or the Minimum Design Criteria.
Requested modifications or variances to the Minimum Design Criteria will be reviewed on a case -by -
case basis and each on its own merit. Please note that variances to the Minimum Design Criteria
should be requested and approved during the permitting process prior to construction. After -
Page 6 of 7

construction requests are discouraged by the Division and may not be approved, thus requiring
replacement or repair prior to certification & activation. [15A NCAC 02T .0116]
8. Gravity sewers installed greaterthan ten percent below the minimum required slope perthe Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident priorto completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the individual permit and construction record drawings shall be maintained on file by the
Permittee for the life of the wastewater collection facilities. [15A NCAC 02T .0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted June
1, 2000 as applicable; and other supporting materials may subject the Permittee to an enforcement
action bythe Division, in accordance with North Carolina General Statutes §143-215.6Athrough §343-
215.6C, construction of additional or replacement wastewater collection facilities, and/or referral of
the North Carolina -licensed Professional Engineer to the licensing board. [15A NCAC 02T .0108(b-c)]
11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities.
[15A NCAC 02T .0110; 15A NCAC 02T .0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or Local
government agencies which have jurisdiction or obtaining other permits which may be required by
the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 7

CERTIFICATION CHECKLIST
To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116.
Certifying Engineer:
Certification Review Date:
Project: Smith Warehouse
Permit No. WQ0045113 Project County: Alamance County
1) Has permittee information changed since the permit was issued (or last modified): change of mailing address,
change of ownership, transfer from developer to HOA/POA, etc. ❑ Yes ❑ No
• If yes, please provide either a change of ownership form or new contact information. Note that transfer of
permits from the developer to the HOA/POA must occur with the first certification.
2) Have the as -built drawings have been signed, sealed, and dated by an N.C. PE? ❑ Yes ❑ No
3) Final Engineering certification? ❑ Yes ❑ No
If Partial Engineering certification, provide detailed narrative including what is being certified in the current
phase, what was previously certified (if applicable), and what is left to be certified.
4) Adequate information related to sewer lines: ❑ Yes ❑ No ❑ N/A
• Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed.
• Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines.
• Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all
intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches).
5) Adequate information related to pump stations: ❑ Yes ❑ No ❑ N/A
• Ensure power reliability option was selected per 15A NCAC 02T.0305(h).
6) Was project construction completed in accordance with all of the following: ❑ Yes ❑ No ❑ N/A
• 15A NCAC 02T. Minimum Design Criteria (MDC) for the permitting of Gravity Sewers (latest version), and MDC
for the Permitting of Pump Stations and Force Mains (latest version)?
If not, a variance approval is required in accordance with 15A NCAC 02T.0105(b). prior to certification and operation.
• Contact the Central Office to discuss the variance to determine a course of action.
• Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other
pertinent information to the Central Office (one hard copy, one digital copy).
• The central office will review the variance request, and if approvable, specific language regarding the variance
will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the
reissued permit with variance language or the variance letter must be maintained with the original documents.
7) Does the project contains high priority lines (15A NCAC 02T .0402(2))? ❑ Yes ❑ No
• If yes, ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC
02T.0403 (a)(5). If the permit does not include this language, the Fast Track reviewer will reissue the permit with
the appropriate language.
8) Are Permit modifications are required for any changes resulting in non-compliance with this permit (including but not
limited to pipe length changes of 10%or greater, change in flow, pump station design capacity design change of 5%or
greater, and/or change in the number/type of connections)? ❑ Yes ❑ No
• If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified
permit with revised certification must be issued prior to certification and operation.
NC DWR— Water Quality Regional Operations Section 450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE:
City of Burlington
PERMITff:
WQ0045113
PROJECT:
Smith Warehouse
ISSUE DATE:
February 2, 2024
COUNTY:
Alamance County
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
to the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMITTEE'S CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name, Title Signature Date
ENGINEER'S CERTIFICATION
I, . as a duI registered Professional En ineer in the State of North Carolina,
having been authorized to observe (periodically, ❑ weekly, L] full time) the construction of the
project referenced above for the above Permittee, and hereby state that, to the best of my abilities, due
care and diligence was used in the observation of the following construction:
approximately 180 linear feet of 8-inch gravity sewer to serve a new warehouse with two loading bays
and a general business facility which will employ 15 employees daily on a single shift, as part of the Smith
Warehouse project, and the discharge of 575 gallons per day of collected commercial wastewater into the
City of Burlington's existing sewerage system, pursuant to the application received January 18, 2024, and
additional information received on February 1, 2024, such that the construction was observed to be built
within substantial compliance of this permit; 15A NCAC 02T; the Division of Water Resources' (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; and other supporting materials. ,
North Carolina Professional Engineers Seal w/signature & date:
❑ Final ❑ Partial (include description)
Certification Comments/Qualifiers (attach if necessary):
NC DWR- Water Quality Regional Operations Section 450 West Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

T A 'N TT1A X A Tl TT
L.1-�1V L1V1L-iIVi1
We Build Confidence.
NC Department of
Environmental quality
Received
Letter of transmittal APR 19 2024
Date: 4/22/2024 Job No.: AH-22176 Winston-Salem
Regional OffiCe
To: NCDEQ From: Kent E. Barney, PE
450 West Hanes Mill Road 3520 Triad Court
Winston-Salem, NC 27105 Winston-Salem, NC 27107
Attn: Ron Boone,
Environmental Program Consultant
Re: Smith Warehouse
We are sending you (x)Attached ( )Under separate cover via the following items:
( )Shop Drawings ( )Prints (x)Plans ( )Samples ( )Specifications
( )Copy of Letter ( )Change Order(s)
Copies
Date
Description
1
Fast Track Sewer Extension FTA 06-21 package
1
Fast Track Sewer Extension FTA 06-21 package co
1
Check for $600 payable to NCDEQ
These are transmitted as checked below:
For approval
)Approved as submitted
Resubmit )copies for approval
For your use
)Approved as noted
Submit copies for distribution
As requested
Returned for corrections
Return corrected prints
For review and comment
Remarks:
Ron,
Please call me at 336-784-2000 with any questions.
Thanks,
Kent E. Barney, PE
to:
Signed:
Landmark Builders 1 3520 Triad Court I Winston-Salem, NC 27107
p.336.784.2000 I www.landmarkbuilders.com

NC Department of
Environmental Quality
a.,- Received State of North Carolina
DWR APR 2 9 2024 Department of Environmental Quality
Division of Water Resources
WlflrX4YhWVR SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIOi8g?0ff4QWW,8FTA 10-23 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pumn Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300, Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy maybe 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):
N List all items included in the application package, as well as a brief description of the requested permitting action.
D Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $600.00, 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 10-23):
® 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 1.2 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 1.2 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 11.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with I SA NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page I of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
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 ]mown) 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):
0 Submit a copy of the most recently issued existing permit.
Jl Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
® Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
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."
➢ 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)
Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115 submit the properly executed Operational Agreement (FORM: DEW
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 3

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,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Hamett, 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, Berlie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gales, 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, Fender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Burry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

Landmark Builders, Inc.
3520 Triad Court PNC Bank
Winston-Salem, NC 27107 2150 Country Club Road
336-784-2000 Winston-Salem, NC 27104
PAY 0 0
ONLY °
PAY ***************Six Hundred and 00/100 Dollars
TO
THE
ORDER
OF
NC DEQ
lie L0920L711' 1:0540000301:5322327LL3ov
1092017
DATE 04/24/2024
$********600.00

ENDORSE CHECK HERE
❑CHECK HERE IF MOBILE DEPOSIT
DO NOT SIGN /WRITE / STAMP BELOW THIS LINE
FOR FINANCIAL INSTITUTION USAGE ONLY
SECURITY FEATURES include -
0' Microline Printed
Border
N' High Security
"VOID" Pantograph
N' "Original Document"
Security Screen
t Multi -lone Background
on White. Stock
128LBB