WQ0024432_20041012_FTSEPERM

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Mr. Todd Clark, Town Manager
Town of Maiden
113 West Main Street
Maiden, North Carolina 28650
Dear Mr. Clark:
Michael F. Ewstey. Governor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Airm W,Klimek. F.E. Director
Division of Water Quality
October 12, 2004
Subject: Permit No. WQ0024432
Town of Maiden
Zeb Haynes Road Sewer Service Extension
Wastewater Collection System Extension
Catawba County, North Carolina
In accordance with your application received on September 30, 2004, we are forwarding
herewith Permit No. WQ0024432, dated October 12, 2004, to the Town of Maiden for the construction
and operation 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the date of issuance until rescinded, and shall be subject to the conditions and limitations as specified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 Permit Condition 3 which requires that the wastewater
collection facilities be properly operated and maintained in accordance with 15A NCAC 2H .0227 or any
individual system -wide collection system permit issued to the Permittee.
Permitting of this project does not constitute an acceptance of any part of the project that does
not meet 1) 15A NCAC 2H .0200; 2) the Division of Water Quality's (Division) Gravity Sewer Minimum
Design Criteria adopted February 12, 1996, as applicable; 3) 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. 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.
NorthCarolina
Naturallif
Mooresville Regional Office 610 East Center Ave., Suite 301 Mooresville, NC 28115 Phone: [phone] Fax: [phone]
Internet h2o.encstate.nc.us Customer Service: 1-877-623-6748
An Equal Opportunity/Af6rmalive Action Employer— 50% Recycled/10% Post Consumer Paper

Mr. Todd Clark
Page 2
October 12, 2004
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 Town of Maiden for the construction and operation of approximately 750 linear feet of 8 -
inch gravity sewer to serve a 200 member masonic lodge as part of the Zeb Haynes Road Sewer
Service Extension project, and the discharge of 4,000 gallons per day of collected domestic wastewater
into the Town of Maiden's existing sewerage system, pursuant to the application received September
30, 2004, and in conformity with 15A NCAC 2H .0200; 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 Environment and Natural
Resources and considered a part of this permit.
The sewage and wastewater collected by this system shall be treated in the Town of Maiden
WWTP (NPDES No. NC0039594) prior to being discharged into the receiving stream.
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 1508 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 Sonja Basinger at
[phone].
Sincerely, / .
for Alan W. Klimek, P. E.
cc: Catawba County Health Department
Mooresville Regional Office, Water Quality Section (WWTF Permit No. NCO039594)
Douglas Chapman, McGill Associates, PA
Water Quality Central Files
Marie Doklovic, PERCS

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
This permit shall be effective from the date of issuance until rescinded and shall be subject to the
following specified conditions and limitations:
This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 2H .0200; the Division of Water Quality's
(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 unless specifically
mentioned herein.
2. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data.
3. 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 2H .0227. If an individual
permit is not required, the following performance criteria shall be met as provided in 15A NCAC 2H
.0227:
a. The sewer system shall be effectively maintained and operated at all times to prevent
discharge to land or surface waters, and any contravention of the groundwater standards in
15A NCAC 2L.0200 or the surface water standards in 15A NCAC 2B .0200.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan shall be 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-month period of time.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Inspection and maintenance records shall be maintained for a period of at least three years.
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.

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.
5. 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.
6. Per 15A NCAC 2H .0220, upon completion of construction and prior to operation of these
permitted facilities, the completed Engineering Certification form 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.
A copy of the construction record drawings shall be maintained on file by the Permittee for the life
of the wastewater collection facilities.
8. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2H .0200; 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 by the Division, in accordance with North Carolina General Statutes §143-
215.6A through §143-215.6C.
9. 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.
10. 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 other government agencies
(local, state and federal) which have jurisdiction, including but not limited to applicable river buffer
rules in 15A NCAC 2B .0200, erosion and sedimentation control requirements in 15A NCAC Ch. 4
and under the Division's General Permit NCG010000, and any requirements pertaining to wetlands
under 15A NCAC 2B .0200 and 15A NCAC 2H .0500.
11. Noncompliance Notification:
The Permittee shall verbally report to a Division of Water Quality employee at the Mooresville
Regional Office, telephone number [phone], as soon as possible, but in no case more than
24 hours or on the next working day, 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 failure of a pumping station or sewer line resulting in a by-pass directly to receiving waters
without treatment of all or any portion of the influent to such station or facility.

Voice mail messages or faxed information is permissible, but 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 Part I of Form CS-SSO (or the most current Division approved form), within five days
following first knowledge of the occurrence. This report shall outline the actions taken or
proposed to ensure that the problem does not recur. Part II of Form CS-SSO (or the most
current Division approved form) can also be completed to show that the SSO was beyond
control.
Permit issued this the 12th day of October, 2004.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Alan W. Klimek .E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0024432

Fast Track Engineering Certification
Permit No. W00024432
October 12, 2004
Complete and submit this form to the permit issuing regional office with the following:
• One copy of the project record drawings (plan & profile views of sewer lines) of the wastewater collection
system extension
• Supporting design calculations (selected pumps, system curve, operating point, available storage if portable
generator(s) or storage greater than longest past three year outage reliability option selected) for any pump
stations permitted as part of this project
to the project should be clearly identified on the record drawings or in written summary form. Permit
This project shall not be considered complete nor allowed to operate until this Engineer's Certification and all
required supporting documentation have been received by the Division. Therefore, it is highly recommended
that this certification be sent in a manner that provides proof of receipt by the Division.
ENGINEER'S CERTIFICATION
❑ Partial ❑ Final
I, , as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observe (❑ periodically, ❑ weekly, ❑ full time) the construction of the Zeb Haynes Road
Sewer Service Extension, Catawba County project for the Permittee hereby state that, to the best of my abilities,
due care and diligence was used in the observation of the construction such that the construction was observed
to be built within substantial compliance of this permit; 15A NCAC 2H .0200; the Division of Water Quality's
(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 Engineer's
seal, signature, and date:
SEND THIS FORM & SUPPORTING DOCUMENTATION
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS
MOORESVILLE REGIONAL OFFICE
610 EAST CENTER AVENUE, SUITE 301
MOORESVILLE NC 28115
ATTN: DEE BROWDER
The Permittee is responsible for tracking all partial certifications up until a final certification is received. 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.

FAST-TRACK APPLICATION for GRAVITt yyWtJj1 P 9TATWNS, AND FORCE MAINS PAGE 1
f4C}C?Rt ?'
OF W ATFq r State of North Carolina
Q Department of Environment and Natural Resources
Division of Water Quality
o Z-1 SEP 3 0 2004 FAST-TRACK APPLICATION
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you hav�y gd�the folloWing Ij,stjof jepuired application package items by checking the
space provided next to each item. Faii ure to sul5mit all regi7ited Ii�� will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
® I. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. Any changes to this form will result in the application being returned. The Division of Water Quality
(Division) will only accept application packages that have been fully completed with all applicable items
addressed. You do not need to submit detailed plans and specifications unless you respond NO to Item 1302)
® II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ III. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2a) of this application.
❑ IV. Operational Agreements — Submit one original and two copies of a properly executed operational agreement if
the sewer extension is permitted by a private applicant and will be serving residential or commercial lots (e.g.,
houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If the applicant is a
homeowners' association, use Form HOA 02/03. If the applicant is a developer, use Form DEV 02/03. EVEN IF
THE PROJECT WILL BE TURNED OVER TO A MUNICIPALITY, FORM DEV 02/03 IS REQUIRED.
❑ V. Flow Acceptance Letters — If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and name and permit number of the receiving sewers/WWTF. The flow acceptance must not
expire prior to permit issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
® VI. Map — Submit an 8.5 -inch by 11 -inch COLOR copy of the portion of a 7.5 -minute USGS Topographic Map along
with this form. The map should identify the entire project area location as well as the closest downslope surface
waters as clearly as possible. Each map portion must be labeled with the map name and number, the identified
location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project
involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties,
basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location in Section C of the permit application.
❑ VII. Stream Classifications — Section C
• If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(13)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)" available from http://h2o.enr.state.nc.us/ndpu or by contacting the appropriate regional
office.
FTA 02/03 - Rev. 2 04/04

FAST-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE
❑ VIII. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C .05001, this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
Processed until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS) has been
issued. A copy is to be submitted with that permit application.
® IX. Certifications —Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE). The applicant signature must match the signing official listed in Item A(1 b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, the Gravity Sewer Minimum Design Criteria (most
recent version) and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
(most recent version), as applicable to the project. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral.
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
REGIONAL OFFICE ADDRESS
Asheville Regional Office COUNTIES SERVED
2090 US Highway 70 Avery, Buncombe, Burke, Caldwell,
Swannanoa, North Carolina 28778 Cherokee, Clay, Graham, Haywood, .
[phone] Henderson, Jackson, Macon,
[phone] Fax Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania,
=ayetteville Regional Office Yance
225 Green Street Suite 714
Fayetteville, North Carolina 28301 Anson, Bladen, Cumberland, Harnett;
[phone] Hoke, Montgomery, Moore, Robeson;
[phone] Fax Richmond, Sampson, Scotland
9ooresville Regional Office
919 N Main Street
Mooresville, North Carolina 28115 Alexander, Cabarrus, Catawba,
[phone] Cleveland, Gaston, Iredell, Lincoln,
[phone] Fax Mecklenburg, Rowan, Stanly, Union
sleigh Regional Office
1628 Mail Service Center Chatham, Durham, Edgecombe,
Raleigh, North Carolina 27699-1628 Franklin, Granville, Halifax, Johnston,
[phone] Lee, Nash, Northampton, Orange,
[phone] Fax Person, Vance, Wake, Warren,
ashington Regional Office Wilson
Beaufort, Bertie, Camden, Chowan,
943 Washington Square Mall
Washington, North Carolina 27889 Craven, Hertford,, Dare, Gates,
[phone] Greene, Hertford, Hyde, Jones,
[phone] Fax Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington,
Imington Regional Office Wa ne
127 Cardinal Drive Extension
Wilmington, North Carolina 28405 Brunswick, Carteret, Columbus,
[phone] Duplin, New Hanover, Onslow,
[phone] Fax Fender
585 Waughtown Street
Winston-Salem, North Carolina 27107
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell,
Davidson, Davie, Forsyth, Guilford,
Rockingham, Randolph, Stokes,
Surry, Watauga, Wilkes, Yadkin
For more information, visit our web site at http.//h2o.enrstate.nc.us/ndpu/

FAST-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
Z
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI Application Number:
Owner (to be completed by DW(
Full Legal Name (company, municipality, HOA, utility, etc.)
1b. Tadd Clark Tnv.,.. KA....-,--- --
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officialsl)
1c. The legal entity who will own this system is:
❑ Individual 11 Far1cr.1 RI
1 d. 113 West Main Street
Street Address 1e. Maiden
1f. NC City _
State 1g. 28650
— -- — -- --Zip Code
— --- — —
1 h. 828-428-5000 �1 i. 828-428-5017
Telephone
Facsimile E-mail
2. Project Facinformation:
2a. Zeb Haynes Road Sewer Service Extensic
Mier Project Name (permit will refer to this
3. Contact_P_er_son:_
3a. Doualas Chammnn RA„r_m n...
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
Phone Number
Z
E-mail
. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
Phase, changing line size/length, etc.). Only include the modified information In this permit application - do not
duplicate project information in B(7) and B(10-11) that has already been included In the original permit.
. Owner is IN Public (skip to Item B(3)) ❑ Private
(go to Item 2(a))
a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one)
PAGE3
Rev.
El Retaining Ownership (i.e. store, church, single office, etc.) or: EJ Public Utility (Instruction III)
ElLeasing units (lots, townhomes,
_0
etc. - skip to Item B(3))
[ISelling units (lots, townhomes, etc. - go to Item B(2b)) Homeowner Assoc./Developer (Instruction IV)
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3.
Town of Maiden
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
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LL
4a,
Maiden WWTP 4b. NCO039594
Name of WWTF
Z
5a.
Town of Maiden WWTF Permit No.
b. 8 -inch
6.
c. Information not available
Owner of Downstream Sewer Receiving Sewer Size Permit Number of Downstream Sewer (if known)
The
origin of this wastewater is (check all that apply).
W❑
Residential Subdivision ElCar Wash j
❑ Apartments/Condominiums
IL
m
❑ Institution
❑ Mobile Home Park ❑ Hospital 100 % Domestic/Commercial
❑ School
El Restaurant I ❑Church I _ % Industrial
❑ Nursing Home
❑ Office
® Other (specify): Masonic Lodge i — % Other (specify):
7.
Volume of wastewater to be Permitted in this project: 4000 gallons per day
8.
If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted Is subsequent permits that connect to this line
❑ Flow has already been allocated in Permit
No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected
Rev.

FAST-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(1) for Item B(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that in 15A NCAC 2H .0219(1)(1-2) must be approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality, Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(1)(3).
Masonic Lodge (Country Club -nonresident members) - 200 members at 20gpd/member 4wo
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (Inches) Length (feet) Gravity or Force Main
- ---- —�__ (use the pull down menu)
8 -inch
___-- 750 Gravity
--------- --
Z ` ---
O ENTER TOTAL LINE LENGTH IN MILES 0,14
-
Q11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID Power Reliability Option
(self chosen - as shown on Design Flow Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
plans for cross-reference (MGD) GPM @ TDH portable generator w/telemetry; 4 -wet well storage)
Z
i
11 12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
m Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
® Yes ❑ No If no, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested:
SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR
3. Have
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan?
Stormwater?
❑ Yes ❑ No ® N/A
❑ Yes ❑ No ® N/A

FAST-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGES
1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSI ACAC N0171F S FOR FORM FTA 02/03
(FAST-TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
O regional office (see instructions for addresses) OR indicate the following:
® A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
Q waterbody; AND,
_
A Stream Classifica y tion is not needed because the design does not depend on wet well storage as a power reliability
ei ❑
LL option for an Pump station near a Class C down slope waterbody.
yLocation ID on Map
Q ! (self chosen - as shown on Name of
J map for cross-reference) Waterbody I Count Waterbody Stream ! Waterbody
Index
U Y River Basin Classification
Q
W -
- t
U
— —. re regardless of whether a classification Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
1 • Applicant's CarFif r�ri g ication is Provided
1, Todd Clark, attest that this application for Zeb Haynes Road Sewer Service Extension 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. Note., In accordance with North Carolina General Statutes 143-215.6A and
143-215.68, any person w
shall be guilty of a Class 2hmisdemeknowinanl or hich mayy makes anyf inl clse ude aafinee not or esentationexceed $1, or0,000 as wetllin any i
as civil penalties up fo I
$25100 perwo tion
nnicialSgnatSicaon
ure 9-.?Q-oq
N ?. Professional Engineer's Certification:Date
Z a -
0 1 attest that this application
complete and consistent with theinformation oynes naServiceoad Sewer has ben reviewed by me and is accurate
in engineering Plants, calculat onseand all other supporting documentation
Q to the best of my knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in
U 12, 1996, and accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February
- Track
LL 1, 2000 and the hwatershed classification e Minimum In accordancfor the e with Division / guidanng of ce. Althump tough certain portionations and Force s of thisosubm�ttal
Package may have been developed by other professionals, inclusion of these materials under my signature and seal
signifies that l have reviewed this material and have judged it to be consistent with the proposed design. Note: In
W accordance with NC General Statutes 143-215.6A and 143-215.6B, an
y person who
U representation, or certification in any application shall be guilty of a Class 2 misdemeanorvwhich may includingmakes any false fine not tont,
Q exceed $10,000 as well as civil penalties up to $25,000 per violation.
2a. Dou las Cha man -
Professional Engineer Name
2b. McGill Associates, PA _ _ _ __ _ _" 4on Syxtv'• 'e 3J1 uea'�1',� �Oo
Engineering Firm m �yf��q�.
2c. 123619"
Street Lane NW - a 4 SEAL �� E
Address 20622 l a
2d. Hickory 'j, °eJrf(r+t�
2e. NC
City 2f. 28601 °�
State
2g. 828-328-2024 _2h. 828-328-3870
Telephone _Facsimile
Seal, ign e & Date
A 02/03 - Rev. 2

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Map center is UTM 17 479290E 3938055N (WGS84/NAD83)
Maiden quadrangle M=-6.886
Projection is UTM Zone 17 NAD83 Datum G= -O. 133
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