WQ0045398_Encore_at_Bentley_Manor_Public_FTSSE_Permit_Application_2nd_Submission_20240521_20240521

t ""� S. -• '- `— i eeaT✓e t .1z.1za,24 State of North Carolina
n1 R epartmeD Environmental Quality
�-_/"�f/_ -- Division of Water Resources
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: 0466 W34 S (to be completed by MR)
All items must be completed or the anplication will be returned
L APPLICANT INFORMATION:
1. Applicant's name: City of Randleman (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: Shain Sexton per 15A NCAC 02T .0106(b)
Title: Interim City Manager
4. Applicant's mailing address: 204 S. Main Street
City: Randleman State: NC _ Zip: 27317-,
5. Applicant's contact information:
Phone number: 020 495-7500 Email Address: ssextonlAcitvofinndleman.com
II. PROJECT INFORMATION:
1. Project name: Encore at Bentley Manor P"if, c.
2. Application/Project status: ® Proposed (New Permit) ❑ Existing PermitMwjcct
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 cbec&list.
If new construction, but part of a master plan, provide the existing permit number. W000_
3. County where project is located: Randolph
4. Approximate Coordinates (Decimal Degrees): Latitude: 35,820457° Longitude:-79.827613°
5. Parcel ID (if applicable): — (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Vince C. Townsend. PE, PLS License Number: 23951
Firm: Green Mountain Engineering. PLLC
Mailing address: IA Wendy Court
City: Greensboro State: NC Zip: 27409-_
Phone number 336 294-9394 Email Address: vine(alffeepmountainengineers.com
IV. WASTEWATER TREATMENT FACILITY (W WTF) II
1. Facility Name: City of Randleman Wastewater Treatment Plant Permit Number: NCO025445
Owner Name: City of Randleman
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(sj:WQN/A
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Numbcr(s) (if applicable): WQCS 00099
OwnerName(s): City of Randleman
FORM: FTA 10-23 Page I of 5

.. .:A

VL 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 NIA
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 NIA
3. If the Applicant is a llomelFroperty 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 N/A
4. Origin ofwastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
N Residential (Leased) ❑ Retail with food preparation/service El Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities N Swimming Pool/Clubhouse
❑Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature ofwastewater : 100 %Domestic ^°/u Commercial _ % Industrial (See 15A NCAC 02T .0103(201)
If Industrial is there a Pretreatment Program i¢ effect? ❑Yes❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ Yes N No
➢ NY provide a coav of flow redaction approval letter with this apalication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daffy Design Flow' °
No. of Units
Flow
gal/
GPD
gaff
GPD
gal/
GPD
gay
GPD
gay
GPD
gay
GPD
Total
0 GPD
a See 15A NCAC'02T 0114(b) (d). (e)(11 and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located now 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. 42
b Per 15A NCAC 02T .0114(c), design flaw rates for establishments not identified [in table, 15A NCAC 02T.01141 shall be
determined using available flaw 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
N permitted flow Is zero, please indicate why:
❑ Fump 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
N Other (Explain): The flow for this application is being nemdted under the Encore at Bentley Manor apartment permit
FORM: FTA 10-23 Page 2 of 5

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8" 2,002 PVC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
D Section III contains information related to minimum slopes for gravity sower(s)
➢ Overardng lines to meet minimum slope requirements is not allowed and a vlolation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pum) Stations/Force Mainsl:
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. Told 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 in 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 2.01C.l.b. ❑ Grinder Pwnp ❑ Mechanical Ear 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)(B);
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:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source orpump 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 of5

DL SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
I. Does the project comply with all sepamtions/altematives found in 15A NCAC 02T .0305(fl & (a)? ® Yes ❑ No
15A NCAC 02T.0305 contains minimum separations that shall be provided for s ersystems.
Setback Parameter*
Separation Required
Storm sewers and other utilities not fisted below (vertical)
18 inches
rWater mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
ZWater 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-iwaters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
"Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX2)
50 feet
"Any other stream, lake, impoundment, or groundwater dowering 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
➢ Ifnoncompliance with 02T.0305(t) or (s). see Section X.1 of this application
*15A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(t) 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 weboage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/scaled by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? - ® Yes [:]No ❑VIA
D Please provide supplementary information identifying the areas of non-confermence.
➢ See the Division's draft smaratiom 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: Cape Fear ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 NationwMe/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coveragetauthorization is required.
6. Does project comply with 15A NCAC 02T.0105(cl(6) (additional pemrits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have beea 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 Interferencetconfllct boxes require a variance approval
➢ If yes, include an attachment with details for each line, including We (aerial line, size, material, and location).
High priority Hues 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.
FORM: FTA 10.23 Page 4 of

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
�. ■
If no, for projects requiring a single variance, complete and submit die Variance/Altemadve Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Avoroval of the renuest will be issued
2. Professional Engineer's Certification:
I. Vince C. Townsend, PE, PLS , attest that this application for Encore at Bentley Manor
(Prorestiorml Engineer's name from Application Item Ill. 1.) (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 i have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.68, 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 S10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of die application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, Shain Sexton , attest that this application for Encore at Bentley Manor
(Signature Auttwrity Name from Application Item 1.3.) (Project Name from Application Item 11.1)
attest that this application has been revletved 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 die 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: 4/22_ L Date: �p/(J•
FORM: FTA 10-23 Page 5 of 5

State of North Carolina
DWI, Department of Environmental Quality
-4k Division of Water Resources
Division of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-23 )
Entity Requesting Allocation: Encore at Bentley Manor LLC
Project Name for which flow is being requested: Encore at Bentley Manor
More than one FTSE maybe required for a ,single project if the owner of the "'WTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
L Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: City of Randleman Wastewater Treatment Plant
b. WWTP Facility Permit #: NCO025445
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
It. Percent of permitted flow used
All flows are in MGD
1.745
.454
0.044
.511
29.28%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Design
Obligated,
Pump
Pump
Average
Approx.
Not Yet
Total Current
Station
Station
Firm
Daily Flow"
Current
Tributary
Flow Plus
(Name or
Permit
Capacity, •
(Firm / pf),
Avg. Daily
Daily Flow,
Obligated
Available
Number)
No.
MGD
MGD
Flow, MGD
MGD
Flow
Capacity""*
Main Ps
WQCS00099
2 MGD
0.8
.500
.057
.557
.243
* The Firm Capacity (design Bow) of any pump station is defined as the maximum pumped flow that can be
achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) not
less than 25, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located between the
project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): City of Randleman
Downstream Permit Number: WQCS00099
FTSE 10-23

111. Certification Statement:
I Michael Glass certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and 11 plus all attached planning assessment addendums for which 1
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
-4 1 y 2/
Signing Official Signature late
Wastewater Director
Title of Signing Olftcial
FTSE 10-23

10/11/23, 8:33AM
North Carolina Secretary of State Search Results
• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings • Print a Pre -
Populated Annual Report form • Print an Amended a Annual Report form
Limited Liability Company
Legal Name
ENCORE AT BENTLEY MANOR, LLC
Information
Sosld:2628243
Status: Current -Active O
Date Formed: 5/9/2023
Citizenship: Domestic
Annual Report Due Date: April 15th
CurrentAnnual Report Status:
Registered Agent: CR Services, LLC
Addresses
Reg Office Reg Mailing
235 N. Edgeworth Street 235 N. Edgeworth Street
Greensboro, NC 27401-2217 Greensboro, NC 27401-2217
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D320.
https9/www.sosnagov/online seMwslsearch/Business Regisbadon_ResuBs 1/1

10/11 /23, 8:48 AM
tv_browse.pl (7409.8874)
ELL-zs$
j
I
x•
r
t
SITE
..
1
1. I _,...
` •_• ..
_
t
1 e
t
https://ngmdb.usgs.gov/ht-binitv_bmwse.pl?id=7b1 ab41 b29f1 b9a4c525a53d4cfofac3 1 /1

1
,.
'.
Hwy 5,&FBurgers
ShIkakes8fries 4
N
I'll It ch 0
m°IE
1.1
NCu'r,he7§
is
felme�
9
r.F
9

\' Green Mountain Engineering, PLLC
Civil Engineering Consultants
Land Surveyors
Transmittal
To: NCDEQ — Public Water Supply Section
Address: DEQ — PWS Section, 1634 Mail Service Center, Raleigh, NC 27699
From: Vince C. Townsend, PE, PLS
Date: May 2, 2024
Re: Encore at Bentley Manor
Messages
Attached, please find the application package for the public sewer extension off Old High
Point Street and Commonwealth Road, to serve the residential housing proposed by
Encore at Bentley Manor Apartments. Included are one (1) copy of the public
application package.
Please let us know if you have any questions or require additional information. I can be
reached via email vincengreenmountainengineers.com or by phone [phone] at
your convenience.
Best Regards,
Vince C. Townsend, PE, PLS
1A Wendy Court - Greensboro, NC 27409 - [phone]
Page 1 of 1

C!�
Green Mountain Engineering, PLLC
Civil Engineering Consultants
Land Surveyors
Project Narrative For
Public Sanitary Sewer Collection System
Encore at Bentley Manor
Located in Randleman, NC
May 2, 2024
To Whom It May Concern:
This proposed public 8 inch sanitary sewer main will be located along Old High Point
St. (SR 1952) and Commonwealth Rd (SR 1990). This private sewer system includes
approximately 2,002 linear feet of new 8 inch PVC sewer main and 9 Sewer Manhole
that will tie into an existing 8 inch sewer main also located on Commonwealth Rd.
This application is a zero (0) flow application. The flow allocation to this proposed
public sewer system is being permitted simultaneously with the private sanitary sewer
permit application of Encore at Bentley Manor Apartments.
The design and plan review was done in accordance with NCDEQ's Gravity Sewer
Minimum Design Criteria and the City of Graham's standards and specifications.
Work on the sewer installation is planned to begin once the permit has been obtained.
Please contact me if you require additional information. You can reach me via email
vincea-greenmountainengineers.com or by telephone [phone] at your
convenience.
Respectfully submitted,
Vincent C. Townsend, P.E.
Green Mountain Engineering, PLLC
1A Wendy Court - Greensboro, NC 27409 - [phone]
Page 1 of 1

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR FORM: FTA 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 02
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force MT and the Division's
ains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02'l 15A NCAC 02T.0300 Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T 0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required Items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for Ali Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $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 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 1I.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 1 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 titan 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 I1-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)
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 Geld.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, Items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump Is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, Including travel timefromes, shall
be provided in the case of a multiple station power outage. (Required at time of certification)
L Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per I SA 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/Prooerty Owners' Associations
❑ Per I SA NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV)
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION - Page 2 of 3