NC0020567_AtC Request_20180827

EXECUTIVE DIRECTOR
Nicole Johnston �11�n Va//�,y
TREASURER '
Wayne Moore
SECRETARY 1A f
Woody FaulkNk
_
ADMINISTRATIVE ASSISTANT
Susan White
August 24, 2018
Bing Bai, Ph.D., EI
Environmental Engineer
NPDES Complex Permitting
NC DEQ / Division of Water Resources ± Water Quality Permitting
RE: 2017 WWTP Improvements Project
ATC Request NPDES NCO020567
Clean Water State Revolving Fund Project No. CS -370541-03
Dear Dr. Bai:
CHAIRMAN
J. L. Lowe, Jr.
VICE-CHAIRMAN
Wayne Moore
BOARD OF DIRECTORS
Anita Darnell
Woody Faulk
Victor Varela
The Yadkin Valley Sewer Authority is requesting authorization to construct various improvements at our
wastewater treatment plant. Therefore, please find enclosed for your review=
• Farm ATC -12-14
• Construction Drawings
• Construction Specifications
• Engineering Calculations
• Part I of the current NPDES permit
The project involves replacement or rehabilitation of various components of the existing facility, including
rehabilitation (including epoxy injection and various coatings) of a 40' din. x 22' digester and a 40' dta. x 20'
holding tank, reconstruction of three 40' x 100' sand and gravel sludge drying beds, replacement of two waste
activated sludge (WAS) pumps, construction of concrete vacuum truck unloading station, various chain link fence
repairs, drive areas rehabilitation (including approximately 450 tons of asphalt paving), insertion of 10" and a 14"
plug valve into active force mains, demolition of small abandoned structures, and miscellaneous site improvements.
The estimated construction timeline is:
• Start construction: February 4, 2019
• Finish construction February 4, 2020
If you need additional information concerning this request, please contact our consulting engineer for the project,
Benj ie Thomas of West Consultants, at (828) 5324728 or bthomas(@west-consultants.com.
Sincerely,
Nicole Johnston, Executive Director
Enclosures
500 NC Hwy 268 W -- Elkin, NC 38621
Phone: [phone] — www, -g.cru -- Fax- 336-835-9840

NcrthDivision of Water Resources State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
SECTION 1: INSTRUCTIONS AND INFORMATION
A. The Division of Water Resources will accept this application package for review only if all of the items are provided and the
application is complete. Failure to submit all of the required items will result in the application package being returned as incomplete
per 15A NCAC 02T.0105(b).
B. Plans and specifications must be prepared in accordance with 15 NCAC 02H. 0100. 15A NCAC 02T, North Carolina General Statute
133-3. North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES
Wastewater Treatment Facilities.
C. The plans and specifications submitted must represent a completed final design that is ready to advertise for bid.
D. Any content changes made to this Form ATC -12-14 shall result in the application package being returned.
E. The Applicant shall submit ONE ORIGINAL and ONE DIGITAL COPY (CD) of the application, all supporting documentation and
attachments. All information must be submitted bound or in a 3 -ring binder, with a Section tab for each Section, except the
Engineering Plans.
F. Check the boxes below to indicate that the information is provided and the requirements are met.
G. If attachments are necessary for clarity or due to space limitations, such attachments are considered part of the application
package and must be numbered to correspond to the item referenced.
H. For any project that requires review under the State Environmental Policy Act (SEPA), an Authorization to Construct cannot be
issued prior to the completion of a State Clearinghouse advertisement period for a FONSI, EIS, etc. unless the project qualifies for
a Determination of Minor Construction Activity.
I. For more information, visit the Division of Water Resources web site at: http://portal.ncdenr.ors/web/wgZswp/ps/npdes.
J. In addition to this Authorization to Construct, the Applicant should be aware that other permits may be required from other5ections
of the Division of Water Resources (for example: reclaimed water facilities permits; Class A or B biosolids residuals permit).
SECTION 2: APPLICANT INFORMATION AND PROJECT DESCRIPTION
A. APPLICANT
B. P
Applicant's name
Yadkin Valley Sewer Authority
Signature authority's name per 15A NCAC 02T.0106(b)
Nicole Johnston
Signature authority's title
Executive Director
Complete mailing address
500 Hwy 268 West; Elkin, NC 28621
Telephone number
[phone]
Email address
[e-mail]
ROFESSIONAL ENGINEER
Professional Engineer's name
Benjamin B. Thomas
Professional Engineer's title
Principal
North Carolina Professional Engineer's License No.
20767
Firm name
West Consultants, PLLC
Firm License number
P-0210
Complete mailing address
405 S. Sterling Street; Morganton, NC 28655
Telephone number
[phone]
Email address
[e-mail]
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 1

State of North Carolina
N«rI, caz Division of Water Resources Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
C. NPDES PERMIT
NPDES Permit number NC 0020567
Current Permitted flow (MGD) — include permit
flow phases if applicable 1.80
D. PROJECT DESCRIPTION
Provide a brief description of the project; including rehabilitation (including epoxy infection and various coatings) of a 40' dia.
x 22' digester and a 40' dia. x 20' holding tank, reconstruction of three 40'x 100' sand and gravel sludge drving beds.
replacement of two waste activated sludge WAS pumps, construction of a concrete vacuum truck unloading station various
chain link fence repairs, drive areas rehabilitation (including approximately 450 tons of asphalt pavingL insertion of a 10" and
a 14" plug valve into active force mains demolition of small abandoned structures and miscellaneous site improvements.
SECTION 3: APPLICATION ITEMS REQUIRED FOR SUBMITTAL FOR ALL PROJECTS
A. Cover Letter
® The letter must include a request for the Authorization to Construct; the facility NPDES Number; a brief project description
that indicates whether the project is a new facility, facility modification, treatment process modification, or facility expansion;
the construction timeline; and a list of all Items and attachments included In the application package.
❑ If any of the requirements of 15 NCAC 02H. 0100 15A NCAC 02T, North Carolina General Statute_ 133-3. North Carolina
General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES Wastewater Treatment
Facilities are not met by the proposed design, the letter must include an itemized list of the requirements that are not met.
B. NPDES Permit
® Submit Part I of the Final NPDES permit for this facility that Includes Part A (Effluent Limitations and Monitoring Requirements)
for the monthly average flow limit that corresponds to the work that is requested for this project.
C. Special Order by Consent
❑ If the facility is subject to any Special Orders by Consent (SOC), submit the applicable SOC.
® Not Applicable.
D. Finding of No Significant Impact or Record of Decision
❑ Submit a copy of the Finding of No Significant Impactor Record of Decision for this project.
❑ Provide a brief description of any of the mitigating factors or activities included in the approved Environmental Document
that impact any aspect of design of this project, if not specified in the Finding of No Significant Impact or Record of Decision.
® Not Applicable.
E. Engineering Pians
® Per 15A NCAC 02T .0SO4(c)(1). submit one set of detailed plans that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
® Per 21 NCAC 56.1103(a)(6). the name, address and License number of the Licensee's firm shall be included on each sheet of
the engineering drawings.
® Plans must be labeled as follows. FINAL DRAWING — FOR REVIEW PURPOSES ONLY — NOT RELEASED FOR CONSTRUCTION.
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 2

mxth car*a Division of Water Resources State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
® 15A NCAC 02H .0124 requires multiple (dual at a minimum) components such as pumps, chemical feed systems, aeration
equipment and disinfection equipment. Is this requirement met by the design? ® Yes or ❑ No. If no, provide an
explanation:
Plans shall include:
® Plans for all applicable disciplines needed for bidding and construction of the proposed project (check as appropriate):
® Civil ❑ Not Applicable
® Process Mechanical ❑ Not Applicable
® Structural ❑ Not Applicable
❑ Electrical ® Not Applicable
❑ Instrumentation/Controls ® Not Applicable
❑ Architectural ® Not Applicable
❑ Building Mechanical ® Not Applicable
❑ Building Plumbing ® Not Applicable
® Plan and profile views and associated details of all modified treatment units including piping, valves, and equipment (pumps,
blowers, mixers, diffusers, etc.)
® Are any modifications proposed that Impact the hydraulic profile of the treatment facility? ❑ Yes or ® No. If yes, provide
a hydraulic profile drawing on one sheet that includes all impacted upstream and downstream units. The profile shall include
the top of wall elevations of each impacted treatment unit and the water surface elevations within each impacted treatment
unit for two flow conditions: (1) the NPDES permitted flow with all trains in service and (2) the peak hourly flow with one
treatment train removed from service.
® Are any modifications proposed that Impact the process flow diagram or process flow schematic of the treatment facility?
❑ Yes or ® No. If yes, provide the process flow diagram or process flow schematic showing all modified flow paths including
aeration, recycle/return, wasting, and chemical feed, with the location of all monitoring and control instruments noted.
F. ® Engineering Specifications
® Per 15A NCAC 02T .0504 c 2 submit one set of specifications that have been signed, sealed and dated by a North Carolina
Licensed Professional En ineer.
® Specifications must be labeled as follows: FINAL SPECIFICATIONS — FOR REVIEW PURPOSES ONLY — NOT RELEASED FOR
CONSTRUCTION.
Specifications shall include:
® Specifications for all applicable disciplines needed for bidding and construction of the proposed project (check as
appropriate):
® Civil ❑ Not Applicable
ID Process Mechanical ❑ Not Applicable
® Structural ❑ Not Applicable
❑ Electrical ® Not Applicable
❑ Instrumentation/Controls ® Not Applicable
❑ Architectural ® Not Applicable
❑ Building Mechanical ® Not Applicable
❑ Building Plumbing ® Not Applicable
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 3

Division of Water Resources State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-14)
® Detailed specifications for all treatment units and processes including piping, valves, equipment (pumps, blowers, mixers,
diffusers, etc.), and instrumentation.
® Means of ensuring quality and integrity of the finished product including leakage testing requirements for structures and
pipelines, and performance testing requirements for equipment.
® Bid Form for publically bid projects.
G. Construction Sequence Plan
I$I Construction Sequence Plan such that construction activities will not result in overflows or bypasses to waters of the State.
The Plan must not imply that the Contractor is responsible for operation of treatment facilities. List the location of the
Construction Sequence Plan as In the Engineering Plans or in the Engineering Specifications or in both: in Plans (Sheet 3)
H. Engineering Calculations
® Per 15A NCAC 02T.0504(c)(3), submit one set of engineering calculations that have been signed, sealed and dated by a North
Carolina Licensed Professional Engineer: the seal, signature and date shall be placed on the cover sheet of the calculations.
For new or expanding facilities and for treatment process modifications that are included in Section 4.C, the calculations shall
include at a minimum:
❑ Demonstration of how peak hour design flow was determined with a justification of the selected peaking factor.
❑ Influent pollutant loading demonstrating how the design influent characteristics in Section 4.6.2 of this form were
determined.
❑ Pollutant loading for each treatment unit demonstrating how the design effluent concentrations in Section 4.13.2 of this form
were determined.
❑ Hydraulic loading for each treatment unit.
® Sizing criteria for each treatment unit and associated equipment (blowers, mixers, pumps, etc.)
® Total dynamic head (TDH) calculations and system curve analysis for each pump specified that is included in Section 4.C.6.
❑ Buoyancy calculations for all below grade structures.
❑ Supporting documentation that the specified auxiliary power source is capable of powering all essential treatment units.
1. Permits
® Provide the following information for each permit and/or certification required for this project:
Permit/Certification
Not
Applicabie
Date
Submitted
Date
Approved
Permit/
Certification
Number
If Not Issued Provide
Status and Expected
Issuance Date
Dam Safety
X
Soil Erosion and Sediment Control
X
USCOE /Section 404 Permit
X
Water Quality Certification (4011
X
USCOE /Section 10
X
Stormwater Management Plan
X
CAMA
X
NCDOT Encroachment Agreement
X
Railroad Encroachment Agreement
X
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 4

State of North Carolina
a�orth [aroma Division of Water Resources Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
i Other:
J. Residuals Management Plan
❑ For all new facilities, expanding facilities, or modifications that result in a change to sludge production and/or sludge
processes, provide a Residuals Management Plan meeting the requirements of 15A NCAC 02T.0504(i) and .0508: the Plan
must include:
❑ A detailed explanation as to how the generated residuals (including trash, sediment and grit) will be collected, handled,
processed, stored, treated, and disposed.
❑ An evaluation of the treatment facility's residuals storage requirements based upon the maximum anticipated residuals
production rate and ability to remove residuals.
❑ A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department approved
residuals disposal/utilization program that has adequate permitted capacity to accept the residuals or has submitted a
residuals/utilization program application.
❑ If oil, grease, grit or screenings removal and collection is a designated unit process, a detailed explanation as to how the
oil/grease will be collected, handled, processed, stored and disposed.
® Not Applicable.
SECTION 4: PROJECT INFORMATION
A. WASTEWATER TREATMENT PLANT FLOW INFORMATION —COMPLETE FOR NEW OR EXPANDING FACILITIES
1. Provide the following flow information: N/A
Existing Plant Design
Current NPDES Permit Limit
Current Annual Average
(past 12 months)
Maximum Month
Maximum Day
Peak Hour
Plant Flows
MGD
MGD
For Past 12 Months:
Start Date: month/yr
End Date: month/yr
MGD
MGD
MGD
81C
For Past 24 Months:
Start Date: month/yr
End Date: month/yr
MGD
MGD
MGD
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 5

North cw*w Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
B. WASTEWATER TREATMENT FACILITY DESIGN INFORMATION —COMPLETE FOR NEW OR EXPANDING FACILITIES AND
FOR TREATMENT PROCESS MODIFICATIONS
1. Have all of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T. North Carolina General Statute 133-3. North Carolina
General Statute 143-215.1, and Division of Water_ Resources Minimum Design Criteria for NPDES Wastewater Treatment
Facilities been met by the proposed design and specifications? ® Yes or ❑ No. If no, provide justification as to why the
requirements are not met, consistent with 15A NCAC 02T.0105(n): _
2. Provide the design influent and effluent characteristics that are used as the basis for the project design, and the NPDES
permit limits for the following parameters:
3. Based on the "Project Basis of Design" parameters listed above, will the proposed design allow the treatment facility to
meet the NPDES Permit Limits listed above? ❑ Yes or ❑ No. If no, describe how and why the Permit Limits will not be
met:
4. Per 15A NCAC 02T .0505(i), by-pass and overflow lines are prohibited. Is this condition met by the design? ® Yes or ❑ No
If no, describe the treatment units bypassed, why this is necessary, and where the bypass discharges:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 6
Project Basis of Design
Design Influent
Design Influent
Influent
Concentration
Load
Concentration -
(Must be
(Must be
Current Annual
supported by
supported by
Design Effluent
Average (past
Engineering
Engineering
Concentration and/or
NPDES Permit Limits
12 months) if
Calculations
Calculations
Parameter
Available
[Section 3.H])
[Section 3.H])
Load
(monthly average)
Ammonia Nitrogen
mg/L Summer
N/A mg/L Summer
(NH3-N)
mg/L
mg/L
Ib/day
mg/L Winter
N/A mg/L Winter
Biochemical
mg/L Summer
30 mg/L Summer
Oxygen Demand
mg/L
mg/L
Ib/day
(BODS)
mg/L Winter
30 mg/L Winter
Fecal Coliform
per 100 mL
200 per 100 mL
Nitrate + Nitrite
Nitrogen (NO3-N +
mg/L
N/A mg/L
NO2-N)
Total Kjeldahl
mg/L
Nitrogen
mg/L
N/A mg/L
Total Nitrogen
Ib/year
N/A Ib/year
mg/L
N/A mg/L
Total Phosphorus
mg/L
mg/L
Ib/day
Ib/year
N/A Ib/year
Total Suspended
Solids (TSS)
mg/L
mg/L
Ib/day
mg/L
30 mg/L
3. Based on the "Project Basis of Design" parameters listed above, will the proposed design allow the treatment facility to
meet the NPDES Permit Limits listed above? ❑ Yes or ❑ No. If no, describe how and why the Permit Limits will not be
met:
4. Per 15A NCAC 02T .0505(i), by-pass and overflow lines are prohibited. Is this condition met by the design? ® Yes or ❑ No
If no, describe the treatment units bypassed, why this is necessary, and where the bypass discharges:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 6

m-thcw*z Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
5. Per 15A NCAC 02T .0505(k), multiple pumps shall be provided wherever pumps are used. Is this condition met by the
design? ® Yes or ❑ No. If no, provide an explanation:
6. Per 15A NCAC 02T .0505(1), power reliability shall be provided consisting of automatically activated standby power supply
onsite capable of powering all essential treatment units under design conditions, or dual power supply shall be provided
per 15A NCAC 02H. 0124(2)(a), Is this condition met by the design? ® Yes or ❑ No. If no, provide (as an attachment
to this Application) written approval from the Director that the facility:
Hasa private water supply that automatically shuts off during power failures and does not contain elevated water
storage tanks, and
Has sufficient storage capacity that no potential for overflow exists, and
D Can tolerate septic wastewater due to prolonged detention.
7. Per 15A NCA_ C 02T .0505(o), a minimum of 30 days of residual storage shall be provided. Is this condition met by the
design? ® Yes or ❑ No. If no, explain the alternative design criteria proposed for this project in accordance 15A NCAC
02T .105 n :
B. Per 15A NCAC 02T .0505(0), the public shall be prohibited from access to the wastewater treatment facilities. Explain how
the design compiles with this requirement: All areas enclosed by chain-link fencing.
9. Is the treatment facility located within the 100 -year flood plain? ® Yes or ❑ No. If yes, describe how the facility is
protected from the 100 -year flood: All structures located outside flood plain.
C. WASTEWATER TREATMENT UNIT AND MECHANICAL EQUIPMENT INFORMATION —COMPLETE FOR NEW OR
EXPANDING FACILITIES AND FOR MODIFIED TREATMENT UNITS
1. PRELIMINARY AND PRIMARY TREATMENT (i.e., physical removal operations and flow equalization):
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 7
No, of
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
Manual Bar Screen
MGD at peak hourly flow
Mechanical Bar
Screen
Grit Removal
MGD at peak hourly flow
Flow Equalization
--
gallons
Primary Clarifier
Circular
Primary Clarifier
Rectangular
square feet; ft side
water depth
Other
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 7

Nwthc=w Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
2. SECONDARY TREATMENT (BIOLOGICAL REACTORS AND CLARIFIERS) (i.e., biological and chemical processes to remove
organics and nutrients)
TERTIARY TREATMENT
No. of
Type
Size per Unit
Pian Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
gal/day per bank at
(Yes or No)
Aerobic Zones/
Circular
gallons
Tanks
series]
side water depth
Anoxic Zones/
Tertiary Clarifier
Rectangular
square feet; ft
Tanks
Chlorination
gallons
side water depth
Anaerobic
Tertiary Filter
gallons
square feet
Zones/Tanks
Tertiary Membrane
(Gas;
square feet
Sequencing Batch
Filtration
gallons
tank/unit
Reactor (SBR)
Post -Treatment
gallons
Membrane
Flow Equalization
gallons
Bioreactor (MBR)
Post -Aeration
gallons
Secondary Clarifier
Other
Secondary Clarifier
square feet; ft
side water depth
Other
TERTIARY TREATMENT
4. DISINFECTION
Treatment Unit
No. of
Type
Size per Unit
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
gal/day per bank at
(Yes or No)
Tertiary Clarifier
Circular
ft diameter; ft
series]
side water depth
Tertiary Clarifier
Rectangular
square feet; ft
Chlorination
(Gas;
side water depth
Tertiary Filter
tablet; liquid)
square feet
Tertiary Membrane
(Gas;
square feet
Filtration
tablet; liquid)
tank/unit
Post -Treatment
gallons
Flow Equalization
Post -Aeration
gallons
Other
4. DISINFECTION
Treatment Unit
No. of
Type
Size per Unit
Plan Sheet
Specification
Calculations
Provided?
Units
Reference
Reference
(Yes or No)
gal/day per bank at
Ultraviolet Light
(Parallel; in
peak hourly flow;
series]
number of banks;
number of lamps/bank
Chlorination
(Gas;
gallons of contact
tablet; liquid)
tank/unit
Dechlorination
(Gas;
gallons of contact
tablet; liquid)
tank/unit
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 8

State of North Carolina
Ncnhcarow DIVISlOf10f Water Resources Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-14)
5. RESIDUALS TREATMENT
6. PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain pumps)
Location
No. of
purpose
Type
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
53'
8
43 23 76.51
(Yes or No)
Gravity Thickening
Tank
Mechanical
Thickening/
dry Ib/hour
Dewatering
Aerobic Digestion
Anaerobic
gallons
Digestion
Composting
dry Ib/hour
Drying
dry lb/hour
Other
6. PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain pumps)
Location
No. of
Pumps
purpose
Type
Capacity of
each pump
plan Sheet
Reference
Specification
Reference
GPM
TDH
WAS Pump Room
2
Waste Activated
Sludge
Reciprocating Disc
65
53'
8
43 23 76.51
7. MIXERS
Location
No. of
Mixers
Purpose
Type
Power of
each Mixer
(HP)
plan Sheet
Reference
Specification
Reference
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 9

State of North Carolina
Division of Water Resources Department of Environment and Natural Resources
8. BLOWERS
Location
9. ODOR CONTROL
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
Capacity of
No. of purpose Type each Blower pian Sheet Specification
dowers j Reference Reference
Location
No. of
Units
Purpose
Type
Plan Sheet
Reference
Specification
Reference
Setback Parameter
Treatment/Storage
Design? If "No", identify
Unit
Setback Waivers in Item D.2
Below
Any habitable residence or place of assembly under separate
100 ft
® Yes
❑ No
ownership or not to be maintained as part of the project site
D. SETBACKS —COMPLETE FOR NEW WASTEWATER TREATMENT STRUCTURES
1. The minimum distance for each setback parameter to the wastewater treatment/storage units per 15A NCAC 02T .0506ibi
are as follows:
2. Have any setback waivers been obtained per 15A NCAC 02T .0506fdi? ❑ Yes or ® No. If yes, have these waivers been
written, notarized and signed by all parties involved and recorded with the County Register of Deeds? ❑ Yes or ❑ No. If
no, provide an explanation:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 10
Minimum Distance
Is Minimum Distance
Required from Nearest
Requirement met by the
Setback Parameter
Treatment/Storage
Design? If "No", identify
Unit
Setback Waivers in Item D.2
Below
Any habitable residence or place of assembly under separate
100 ft
® Yes
❑ No
ownership or not to be maintained as part of the project site
Any private or public water supply source
100 ft
® Yes
❑ No
Surface waters (streams — intermittent and perennial, perennial
50 ft
® Yes
❑ No
waterbodies, and wetlands)
100 ft
® Yes
❑ No
_
Any well with exception of monitoring wells
Any property line
soft
® Yes
❑ No
2. Have any setback waivers been obtained per 15A NCAC 02T .0506fdi? ❑ Yes or ® No. If yes, have these waivers been
written, notarized and signed by all parties involved and recorded with the County Register of Deeds? ❑ Yes or ❑ No. If
no, provide an explanation:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 10

North caro6na Division of Water Reso� u State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
SECTION 5: APPLICATION CERTIFICATION BY PROFESSIONAL ENGINEER
Professional Engineer's Certification per 15A NCAC 02T.0105:
I, Beniamin B. Thomas, attest that this application package for an Authorization to Construct
(Typed Name of Professional Engineer)
for the 2017 WWTP Improvements Proiect (CWSRF Proiect No. CS -370541-03}.
(Facility and Project Name)
was prepared under my direct supervisory control and to the best of my knowledge is accurate, complete and consistent
with the information supplied in the engineering plans, specifications, calculations, and all other supporting
documentation for this project. I further attest that to the best of my knowledge the proposed design has been
prepared in accordance with all applicable regulations and statutes, 15 NCAC 02H. 0100. 15A NCAC 02T, North Carolina
General Statute 133:3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design
Criteria for NPDES Wastewater Treatment Facilities and this Authorization to Construct Permit Application, except as
provided for and explained in Section 4.B.1 of this Application. I understand that the Division of Water Resources'
issuance of the Authorization to Construct Permit may be based solely upon this Certification and that the Division may
waive the technical review of the plans, specifications, calculations and other supporting documentation provided in this
application package. I further understand that the application package may be subject to a future audit by the Division.
Although certain portions of this submittal package may have been prepared, signed and sealed by other professionals
licensed in North Carolina, inclusion of these materials under my signature and seal signifies that I have reviewed the
materials and have determined that the materials are consistent with the project design,
I understand that 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 $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal with written signature placed over or adjacent to the seal and dated:
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 11

Nwth State of North Carolina
to Division of VIIat@f R@S011l'CeS Department of Environment and Natural Resources
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC -12-14)
SECTION 6: APPLICATION CERTIFICATION BY APPLICANT
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Nicole Johnston. Executive Director, attest that this application package for an Authorization to Construct
(Typed Name of Signature Authority and Title)
for the 2017 WWTP !m rovem n Pro ec SRF Prolect No. CS -370541-031
(Facility and Project Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. 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. I further certify that in
accordance with ISA NCAC 02T.01201b), the Applicant or any affiliate has not been convicted of environmental crimes,
has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all
appeals have been abandoned or exhausted, are compliant with any active compliance schedule, and does not have any
overdue annual fees.
I understand that the Division of Water Resources' issuance of the Authorization to Construct Permit may be based
solely upon acceptance of the Licensed Professional Engineer's Certification contained in Section 5, and that the Division
may waive the technical review of the plans, specifications, calculations and other supporting documentation provided
in this application package. I further understand that the application package may be subject to a future audit.
I understand that in accordance with General Statutes 143-215.6A and 143-215.611 any person who knowingly makes
any false statement, representation, or certification in any application package Shall be guilty of a Class 2 misdemeanor,
which may include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation.
Signature: i� ---� _ Date:
THE COMPLETED APPLICATION AND SUPPORTING INFORMATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES/NPDES
By U.S. Postal Service iBy Courier/Special Delivery
1617 MAIL SERVICE CENTER 512 N. SALISBURY STREET, 9TH FLOOR
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604 ,
TELEPHONE NUMBER: [phone]
Application for Authorization to Construct Permit (FORM ATC -12-14) Page 12