WQ0039831_Application (FTSE)_20180820

Landworks Design Group, P.A.
7621 Little Avenue,Suite Ill Tel:[phone]
Charlotte, NC 28226 Fax:[phone]
Memorandum
RECEIVEDINCDENRIDWR
Date: August 15, 2018 AUG 17 2918
WQROS
To: NCDEQ MOORESVILLE REGIONAL OFFICE
Mooresville Regional Office
610 E. Center Ave.
Mooresville, NC 28115
From: Landworks Design Group, PA
Steven S. Wilson, PE
Project: Southminister
Job#: 16007
Re: Southminister Private Sanitary Sewer
On behalf of Southminister Inc. we are submitting a Fast-Track Application (FTA 04-16) modifying the
existing permit no WQ0039831 to add an additional 444 LF+/- of gravity sewer for the construction of
"Southminister" private sanitary sewer and related appurtenances. This additional length of sewer line
extension was not accounted for in the original permit, but please note that NO additional sewer flow
capacity is needed beyond the 18,000 gpd originally permitted.
• Project Narrative
• (2) Copies of completed application FTA 04-16
• Corporation Documents for Southminister Inc.
• Flow Acceptance letter
• Area Map
• Street Level Map
• Existing Permit No. WQ0039831 (for reference)
• $480.00 fee
Appropriate forms have been signed by the proper representatives.
We look forward to your favorable review and approval of the proposed construction. Should you have
any questions or if we could aid in your review, please feel free to contact me at 704.841.1604.
Regards,
Landworks Design Group,
ttC L��
Steven S. Wilson, PE
P.12016 Jobsk16007-Southminster 2016 ExpansionlPermit Submittals&ApprovalslSKILLED NURSING FACILITYIUtility Submittalslprivate
SewerWodified Permit 8-9-1811 16007 DENR Private Sewer Submittal Memo-Cover letter.docx

Landworks Design Group, P.A.
7621 Little Avenue,Suite 111 Tel:[phone]
Charlotte, NC 28226 Fax:[phone]
Project Narrative
Date: August 15, 2018
To: NCDEQ
From: Landworks Design Group, PA
Steven S. Wilson, PE
Project: Southminister
Job#: 16007
Re: Southminister Sanitary Sewer Narrative
The proposed Southminister Skilled Nursing Facility and Terraces 1-4 will be a planned 150 bed
nursing facility.
This project will consist of 444 If+/- of 8" private gravity sewer extension and related
appurtenances in addition to the 443 If+/- which was previously included with existing Permit
No. WQ0039831. This sewer (total of 8871f+/-) will connect to an existing 8" public gravity
sanitary sewer on Laxton Drive.
The previously permitted sewage flow from this project (18,000 gpd) is sufficient to serve this
proposed extension.
Regards
Landworks Design Group, P.A.
Steven S. Wilson, PE
P:12016 Jobs116007-Southminster 2016 ExpansionTermit Submittals&ApprovalslSKILLED NURSING FACILITYIUtility SubmittaislPrivate
SewerlModified Permit 8-9-1812 16007 DWQ-Fast Track Narrative.docx

State of North Carolina
Department of Environmental Quality ORr`' Division of Water Resources
�""- 15A NCAC 02T.0300—FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dlvlslon of Water Resources FTA 04-16& SUPPORTING DOCUMENTATION
2 � ' RECEIVED R
Application Number: (to be com leted by DwR) AUG 7 2018
All items must be completed or the application will be returned
WOROS
I. APPLICANT INFORMATION: MOORESVILLE REGIONAL OFFICE
1. Applicant's name: Southminster,Inc.(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:David Lae per 15A NCAC 02T.0106(b)
Title:President
4.Applicant's mailing address: 8919 Park Road
City:Charlotte State:NC Zip: 28210-
5. Applicant's contact information:
Phone number:[phone] Email Address:dlacyAsouthminstecorg
II. PROJECT INFORMATION:
1. Project name:Southminster
2. Application/Project status: ❑Proposed(New Permit) ®Existing Permit/Project
If a modification,provide the existing permit number: W00039831 and issued date: 3-13-1=18
If new construction but part of a master plan,provide the existing permit number: W000
3. County where project is located: Mecklenbure
4. Approximate Coordinates(Decimal Degrees):Latitude: 35.1105' Longitude:-80.8542°
5. Parcel ID(if applicable): 20951134
(or Parcel ID to closest downstream sewer) -
I11. CONSULTANT INFORMATION:
1. Professional Engineer: Steven S Wilson License Number: 15497
Firm:Landworks Design Group
Mailing address: 7621 Little Avenue
City:Charlotte State:NC Zip:28226-
Phone number:[phone] Email Address:swilsonAlandworksoa.com
IV. WASTEWATER TREATMENT FACILITY(W WTF)INFORMATION:
1. Facility Name:McAlpine Creek W WTP Permit Number:NCO024970
Owner Name:Charlotte Water
V. RECEIVING DOWNSTREAM SEWER INFORMATION(if different than WWTF):
1. PermitNumber(s):WQ_ Downstream(Receiving)Sewer Size: _inch
System Wide Collection System Permit Number(s)(if applicable):WQCS_
Owner Name(s):
FORM:FTA 04-16 Page I of 5

VL GENERAL REQUIREMENTS
I. If the Applicant is a Privately-Owned Public Utility,has a Certificate of Public Convenience and Necessity been attached?
❑Yes ❑No NN/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 NN/A
3. If the Applicant is a Home/Property Owners'Association.has an Operational Agreement(FORM:HOA)been attached?
❑Yes ❑No NN/A
4. Origin of wastewater:(check all that apply):
❑Residential Owned ❑Retail(stores,centers,malls) ❑Car Wash
❑Residential Leased ❑Retail with food preparation/service ❑Hotel and/or Motels
❑ School/preschool/day care N Medical/dental/veterinary facilities ❑Swimming Pool/Clubhouse
❑Food and drink facilities ❑Church ❑Swimming Pool/Filter Backwash -
❑Businesses/offices/factories N Nursing Home ❑Other(Explain in Attachment)
5. Nature of wastewater: 100%Domestic/Commercial %Commercial
_%Industrial(See 15A NCAC 02T.0103(20))
L--->Is there a Pretreatment Program in effect? ❑Yes ❑No
6. Hasa flow reduction been approved under 15A NCAC 02T.0114(f)? ❑Yes N No
➢ If Yes,provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type(see 221.01140 Daily Design Flow''b No.of Units Flow
Convalescent Facility 0 gal/unit/day 0 0 GPD,
gal/ GPD
gall 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.,minimum flow per
dwelling;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.0114]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)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero,indicate why:
❑Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
N Flow has already been allocated in Permit Number: W00039831
❑Rehabilitation or replacement of existing sewer with no new flow expected
❑Other(Explain):
FORM:FTA 04-16 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
8 444 DIP This length is in addition to the
previously permitted 4431f.
➢ 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 requirement is not allowed and a violation of the MDC
VIIL PUMP STATION DESIGN CRITERIA(If Applicable)—02T.0305&MDC(Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates(Decimal Degrees):Latitude: Longitude:- °
3. Design flow of the pump station: _millions gallons per day(firm capacity)
4. Operational point(s)of the pump(s): gallons per minute at_feet total dynamic head(TDH)
5. Summarize the force main to be permitted(for this Pump Station):
Size(inches) Length(feet) Material
6. Power reliability in accordance with 15A NCAC 02T.0305(h)(1):
❑ Standby power source or pump with 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
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation,quick-connection receptacle and telemetry- 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry- 15A NCAC 02T.0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant(draft agreement)
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
in the case of a multiple station power outage.
FORM:FTA 04-16 Page 3 of 5

IX. SETBACKS&SEPARATIONS-(02B.0200& 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(fl&(2) ®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 24 inches
Water mains vertical-water over sewer 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 100 feet
i
**Waters classified WS(except WS-1 or WS-V),B,SA,ORW,HQW,or SB from normal
high water or tide elevation and wetlands see item IX.2 50 feet
**Any other stream,lake,impoundment,or ground water lowering and surface drainage
ditches 10 feet
Any building foundation 5 feet
Any basement 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
➢ 15A NCAC 02T.0305(g)contains alternatives where separations in 02T.0305(0 cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(f)or W.see Section X of this application
2. Does the project comply with separation requirements for wetlands?(50 feet of separation) ❑Yes ®No ❑N/A
➢ Seethe Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? [-] Yes ®No [-]N/A
-
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ®Yes ❑No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 &Buffer Permitting Branch
5. 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 are 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.).
6. Does this project include any sewer collection lines that are deemed"high-priority?"
Per 15A NCAC 02T.0402, "high-priority sewer"means"any aerial sewer,sewer contacting surface waters,siphon,or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑Yes ®No ❑N/A
➢ 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 permitee's individual System-Wide Collection permit.
FORM:FTA 04-16 Page 4 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,complete and submit the Variance/Alternative Design Request application(VADC 10-14)and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and supporting documents.
2. Professional Engineer's Certification:
1, t lF-#L S , W 11!LO'% attest that this application for
(Professional Engineer's name from Application Item I1I.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, Gravity Sewer
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 143-215.6B, 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.
;......_.....,......- ,.�•NU11.1.10.. .I......................
North Carolina Professional Engineer's seal,signature,and date: ••��'1-1� CARol/%,
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3. Applicant's Certification per 15A NCAAC 02T.0106(b):
I, .ewu k ab! attest that this application for
(Signature Authority's name&title from Application Item 1.3.)
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 143-215.613 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$$�10,00000 as well as civil penalties up to$25,000 per violation.
Signature: Date: U
FORM:FTA 04-16 Page 5 of 5

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Non-Profit Corporation
Legal Name
Southminster, Inc.
Prev Legal Name
South Mecklenburg Retirement Community, Inc.
Information
Sosld: 0114820
Status: Current-Active
Annual Report Status: Not Applicable
Citizenship: Domestic
Date Formed: 5/1/1984
Registered Agent: Robertson, Allen K.
Addresses
Reg Office Reg Mailing
101 North Tryon St Suite 1900 101 North Tryon St Suite 1900
Charlotte, NC 28246 Charlotte, NC 28246
https://w .sosnc.gov/online services/search/Business_Registration_Results 1/1

CHARLOTTE
W ' TER
April 12, 2017
Mr. Michael Askin
Landworks Design Group
7621 Little Av
Suite 111
Charlotte, NC 28226
SUBJECT: WATER AND SEWER FLOW ACCEPTANCE
SOUTHMINSTER
8919 PARK ROAD, CHARLOTTE NC
CLTWATER TRACKING#2017435
After an analysis of the sanitary sewer associated with the proposed design of project Southminster,
it was determined that there is sufficient capacity to accommodate the proposed sewer flow of
18,000 gallons per day(150 bed convalescent facility x 120 gpd/bed) at the connection point(s)
shown on the submitted utility plan for transmission to the McAlpine Creek Wastewater Treatment
Plant; NPDES permit number NC0024970, for treatment. This acceptance of flow is based upon the
existing capacity of the designated publicly owned treatments works. Please see attached NC DEQ
FTSE form.
Charlotte Water(CLTWater) agrees to furnish water to the subject project. The water quality to the
subject project is regulated by the State Drinking Water Act Amendments of 1986 and The Water
Supply Management Plan, PWS ID#0160010 on file with the Public Water Supply Section of
NCDEQ. However, CLTWater cannot guarantee a constant pressure or quality of flow.
The applicant should understand that due to the involvement of other agencies and continuing
growth of the water system, the ability to provide service for future projects cannot be guaranteed
nor reserved. Connection to the CLTWater system is accented on a first come, first served basis.
The applicant should understand that this letter is not authorization to construct private water
systems, as the appropriate local or State permits are required prior to construction. If the
appropriate authorization to construct Permits are not obtained construction has not started within
one(1)year of issuance of this flow acceptance, and payment for any service connections have not
been received within (1) year of issuance of this flow acceptance letter. this flow acceptance
approval shall be rescinded and a new flow acceptance request must be made. If you have any
questions, please do not hesitate to contact me at(704)432-5801.
Sincerely.
�Qh�xZ traJ
Barbara Gross
Engineering Assistant
Charlotte Water 5100 Brookshire Blvd,Charlotte, NC 28216 charlottewater.org
bOperated by the City of Charlotte

State of North Carolina
4 ' Department of Environmental Quality
tMj
r Division of Water Resources
Division of Water nesources Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Landworks Design Group, PA
Project Name for which flow is being requested: southminster
More than one FINE may be required for a single project if the owner of the WWTP is not responsible far all pump
stations along the route of the proposed wastewater flow. .
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: McAlpine Creek, Irwin Creek, Suqar Creek
b. WWTP Facility Permit M NC0024970, NC0024945, NCO024937
Al[flows are in MGD
c. WWTP facility's permitted flow 99.0
d. Estimated obligated flow not yet tributary to the WWTP 12.600
e. WWTP facility's actual avg. flow 65.760
f. Total flow for this specific request 0.018
g. Total actual and obligated flows to the facility 78.378
h. Percent of permitted flow used 79.2%
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 Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm/pl), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
*The Firm Capacity 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 2.5.
***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): Cameron wood Trunk (1986)
Downstream Permit Number: 12867
Page I of 6
FTSE 04-16

III. Certification Statement:
I Carl Wilson 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 II
plus all attached planning assessment addendums for which I am the responsible party.
Signature oft is form(indicates acceptance of this wastewater flow.
�I DY
Signing Offi 1 gignature Date
Page 2 of 6
FTSE 04-16

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Central Files: APS _ SWP _
8/20/2018
Permit Number WQ0039831
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
barry.love
Coastal SWRuIe
Permitted Flow
18,000
Facility
Permit Tracking Slip
Status
Project Type
Active
Major modification
Version
Permit Classification
1.10
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
Southminster Minor Mooresville
Location Address County
Mecklenburg
Facility Contact Affiliation
Owner
Owner Name Owner Type
Southminster Inc Non -Government
Owner Affiliation
David Lacy
CEO
8919 Park Rd
Dates/Events Charlotte NC 28210
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
3/1 /2018 8/17/2018 8/20/2018 8/20/2018
Regulated Activities Requested /Received Events
Nursing Home Additional information requested
Wastewater collection Additional information received
Outfall
Waterbody Name Streamindex Number Current Class Subbasin