WQ0045955_Application (FTSE)_20241029

TIDEWATER ASSOCIATES , INC .
ENGINEERS • SURVEYORS PLANNERS l
EST.1961 JACKSONVILLE , NORTH CAROLINA
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SEAL
CITY OF JACKSONVILLE 14575
HOLIDAY CITY PUMP STATION IMPROVEMEy
r U .FjyG I NE�P.'•�-
SEWER NARRA i iVE
October 2024
The Existing Holiday City Pump Station is an existing Suction Lift Pump Station
constructed in the 1960's. The pumps were originally designed for 175 GPM and pumps through
a 6" Sewage Force Main to an existing 8"Gravity Main, which flows to a 12"then 18" Gravity
Mains,to the existing Brynn Marr Sewage Pump Station.
It is proposed to replace the existing Suction Lift Pump Station with a Submersible Pump
Station. Per information provided by the City of Jacksonville,the Average Daily Flow going to
the pump station is approximately 50,000 GPD to 88,000 GPD. There is no new Flow proposed
to go to the pump station at this time. Due to existing high Inflow/Infiltration, it is proposed to
size the pumps for 250 GPM. The new 6" Force Main will tie to the existing 6"Force Main,
which pumps to the existing 8" gravity.
In addition, all of the existing control panels are being replaced and the existing generator
is being replaced.
RECElVE01NCMtAPj
pC 2 2024
Water oualty Reyiono
operations section
WilrrTington Regional otfice.
C 1.2024.Forms.HolidayCityPumpStationlmprovements.Narrative....10.16.2024
306 New Bridge Street I P.O. Box 976 1 Jacksonville,NC 28541-09761(910)455-2414
Firm License Number F-0108 1 www.tidewaterenc.com

ASSOCIATES ,TIDEWATER
ENGINEERS • SURVEYORS - PLANNERS RECEIVED/NCDENR/DWR
EST.1961
JACKSONVILLE, NORTH - •
OCT 2 4 2024
Water Qualty Regional
Operations section
Wilmglgtpn Regional Office
LETTER OF TRANSMITTAL
VIA EMAIL AND MAIL
TO: Mr. Tyler Benson DATE: October 22, 2024
NCDENR- DWR REF: City of Jacksonville
127 Cardinal Dr. Ext. Holiday City SPS Improvements
Wilmington,NC 28405-3845 Onslow County
Fast Track Sewer Application
WE ARE SENDING YOU:
One (1) Original and One (1) Copy of the Fast Track Application, One (1) Copy of Sewer Narrative;
One (1) Check in the Amount of$600.00 for the Application Fee; One (1) Portion of the USGS Map; and
One (1) Copy of the Cover Sheet(Sheet 1 of 6).
DELIVERY VIA:
❑x Regular Mail ❑ Hand ❑ Federal Express
❑ UPS Overnight ❑ UPS Ground ❑ Other
THESE ARE TRANSMITTED AS CHECKED BELOW:
x❑ For Approval ❑ As Requested ❑ For Review and Comment
❑ For Your Use ❑ For Bids Due
❑ Other
COMMENTS:
Timot y . S ewart, P.E.
ec: Christy Baysden (w/enclosures)
Wally Hansen(w/enclosures)
T.J. Johnson(w/enclosures)
Mike Moore (w/enclosures)
TMS/jrh CF (P), LAM,
(if enclosures are not as noted, kind/I, notify its at once)
C 1.2024.FORMS.HolidayCity.FastTrackSewerAppl.10.22.2024

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23&SUPPORTING DOCUMENTATION
Application Number: w a 00 C�4�1� (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Jacksonville(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: Ronald F.Massey per 15A NCAC 02T.0106(b)
Title:Deputy City Manager
4. Applicant's mailing address: P.O. Box 128
City: Jacksonville State:NC Zip:28541-
5. Applicant's contact information:
Phone number: [phone] Email Address: massevCa,iacksonvillenc.gov
11. PROJECT INFORMATION:
1. Project name: Holiday City Sewage Pump Station Improvements
2. Application/Project status: ❑Proposed(New Permit) ®Existing Permit/Project ❑ARPA funded
If a modification,provide the existing permit number: WQ00 and issued date: ,
For modifications,also attach a detailed narrative description as described in Item G of the checklist.
If new construction,but part of a master plan,provide the existing permit number: WQ00
3. County where project is located:Onslow
4. Approximate Coordinates(Decimal Degrees): Latitude: 34.744'Longitude: -77.355'
S. Parcel ID(if applicable): 352-5.2 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer:Timothy M. Stewart License Number: L-14575
Firm:Tidewater Associates,Inc.
Mailing address: 306 New Bridge Street
City:Jacksonville State:NC Zip: 28540-
Phone number: [phone] Email Address:office ,tidewateretie.com
IV. WASTEWATER TREATMENT FACILITY(NVNNITF)INFORMATION:
1. Facility Name:City of Jacksonville Land Treatment System Permit Number: 0009267
Owner Name:City of Jacksonville
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQunluiown
2. Downstream(Receiving) Sewer Information: 8 inch x Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s)(if applicable): WQCS30
Owner Name(s): COJ
FORM: FTA 10-23 Pagel of 5

State of North Carolina
Department of Environmental Quality
DWR -do" Division of Water Resources
FAST TRACK SENVER SYSTEM EXTENSION APPLICATION
Division of Water Resources 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 02T and the Division's
Minimum Design Criteria(GravityS &Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T. 15A NCAC 02T .0300. Division policies, and 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 0_"Fspf3&NCDENR/DWR
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; OCT 2 4 2024
➢ 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 pumpffaterQualty Regionai
➢ Simplex STEP or simplex raider pumps connecting to pressurized systems e. force mains • Operations section
p p g p p g p Y ( g• )� Wilmington Regional Office
➢ Vacuum sewer systems.
General—When submitting an application,please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted,the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy(second copy may be digital)of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be"wet ink"or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description(Required for All Application Packages):
® List all items included in the application package,as well as a brief description of the requested permitting action.
➢ Be specific as to the system type,number of homes served,flow allocation required,etc.
➢ Include the permit number/status of any other required sewer permits(downstream/upstream)
➢ If necessary for clarity,include attachments to the application form.
➢ If the project is funded by American Rescue Plan Act (ARPA) funds,please include the ARPA project number in the cover
letter and in parentheses under Project Name(Section 11.1.of the application).
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 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 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 En ig neer.
INSTRUCTIONS FOR FORM: FTA 10-23&SUPPORTING DOCUMENTATION Pagel of 3

® 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).
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 .
➢ Intergovernnmental agreements or other contracts will not be accepted in lieu of a project-specific FTSE.
F. Site Maps(All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components(gravity sewer,pump stations,&force main)
➢ Downstream connection points and permit number(if known)for the receiving sewer
❑ Include an aerial location map showing general project area(such as street names or latitude/longitude)so that Division staff
can easily locate it in the field.
G. Existing Permit(Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to
be added,and/or items to be modified (the application form itself should include only include items to be added/modified).
The narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan(Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T.0305(h)(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 persomnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes,shall
be provided in the case of a multiple station power outage.(Required at time of certification)
I. Certificate of Public Convenience and Necessity(All Application Packages for Privately-Owned Public Utilities):
❑ Per 15A NCAC 02T .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(b),submit the properly executed Operational Agreement(FORM:DEW
For more information, visit the Division's collection systems lvebsite
INSTRUCTIONS FOR FORM:FTA 10-23&SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFOMIATION AND
MATERIALS, SHOULD BE SENT'1'0 'I'IIE 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 Currituck, 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, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office 450 W. Hanes Mill Road Alamance,Alleghany,Ashe, Caswell, Davidson,
Water Quality Section Suite 300 Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105 Stokes, Surry,Watauga,Wilkes,Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately-Owned Public Utility,has a Certificate of Public Convenience and Necessity been attached?
❑Yes ❑No ❑N/A
2. If the Applicant is a Developer of lots to be sold,has a Developer's Operational Agreement(FORM:DEV)been attached?
❑Yes ❑No ❑N/A
3. If the Applicant is a Home/Property Owners'Association,has an HOA/POA Operational Agreement(FORM:HOA)and
supplementary documentation as required by 15A NCAC 02T.0115(c)been attached?
❑Yes ❑No ❑N/A
4. Origin of wastewater: (check all that apply):
❑Residential(Individually Owned) ❑Retail(stores,centers,malls) ❑Car Wash
❑Residential(Leased) ❑Retail with food preparation/service ❑Hotel and/or Motels
❑ School/preschool/day care ❑Medical/dental/veterinary facilities ❑ Swimming Pool/Clubhouse
❑Food and drink facilities ❑Church ❑ Swimming Pool/Filter Backwash
❑Businesses/offices/factories ❑Nursing Home ❑ Other(Explain in Attachment)
5. Nature of wastewater: %Domestic %Commercial %Industrial(See 15A NCAC 02T .0103(20))
If Industrial,is there a Pretreatment Program in effect? ❑ Yes❑No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ 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 0 GPD
a See 15A NCAC 02T .0114(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 east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S.42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.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 now 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):
FORM: FTA 10-23 Page 2 of 5

VII. GRAVITY SEIVER 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: Existing Holiday City Pump Station
2. Approximate Coordinates(Decimal Degrees): Latitude: 34.744' Longitude: -77.3550
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.36 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): 250 gallons per minute(GPM)at 55 feet total dynamic head(TDH)
5. Summarize the force main to be permitted(for this Pump Station):
Size(inches) Length(feet) Material
6 14 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 2.01 C.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-
ur
❑ 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.
FORM: FTA 10-23 Page 3 of 5

➢ 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 pail of this permit application in the case of a multiple station power outage.
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FORM; PTA 10-23 Page 4 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)&(g)? ®Yes [:]No
15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter* Separation Required
Storm sewers and other utilities not listed below(vertical) 18 inches
ZWater 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-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,HQW,or SB from normal
high water(or tide elevation)and wetlands associated with these waters(see item IX.2) 50 feet
**Any other stream,lake,impoundment,or ground water lowering and surface drainage
ditches,as well as wetlands associated with these waters or classified as 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(g).see Section X.1 of this application
*15A NCAC 02T.0305(g)contains alternatives where separations in 02T.0305(1)cannot be achieved.Please check"yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
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/sealed by an NC licensed PE,verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes [:] No ❑N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑Yes Basin name: ®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 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6)(additional permits/certifications)? ❑ Yes ®No
Per 15A NCAC 02T.0 I 05(c)(6),directly related environmental permits or certification applications must be being prepared,
have been applied for,or have been obtained.Issuance of this permit is contingent on issuance of dependent permits(erosion
and sedimentation control plans,stormwater management plans,etc.).
?. Does this project include any sewer collection lines that are deemed"high-priority?" ❑ Yes ®No
Per 15A NCAC 02T.0402,"high-priority sewer"means any aerial sewer,sewer contacting surface waters,
siphon,or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes,include an attachment with details for each line,including type(aerial line,size,material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six-months and
inspections documented per 15A NCAC 02T.0403(a)(5)or the permittee's individual System-Wide Collection permit.
FORM: FTA 10-23 Page 5 of 5

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?
®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
concurrentIN, with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times.For projects requiring two or more variances or where the variance is determined by the Division to be
a significant portion of the project,the full technical review is required.
2. Professional Engineer's Certification:
I, 1 i�0� 'Yl• �� � ,attest that this application for.
(Professional Engin s name from Application Item Ill.1.) (Project N a from Application Item 11.1)
1 OA6 (N VE-MNTJ
has been reviewed by me and is accurate, complete and consistent with the information suppuea 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 143-215.613, 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:
SEAL9-
- 1`4575
QINIc�E.�.. 1P.. .. __... . ...
3. Applicant's Certification per 15A NCAC 02T.0106(b):
I,g12/11Q A15�`2 ,attest that this application for CAL4 urn h
(Signature Authority Name froTpplication Item I.3.) (Project ame fr Applica' n Item II.1) rolfotrentf
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included,this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non-discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this
application package are not completed and that if all required supporting information and attachments are not included, this
application package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 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: _ Date: (D `�ZL�
FORM:FTA 10-23 Page 66f of 5

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