WQ0040802_Permit (Issuance)_20190416

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ROY COOPER
Governor
MICHAEL S.REGAN
Secretary
LINDA CULPEPPER
Director NORTH CAROLINA
Environmental Quality
April 17, 2019
Hardin Watkins, City Manager
City of Burlington
425 South Lexington Avenue
Burlington, NC 27215
Subject: Permit No. WQ0040802
City of Burlington
Twin lakes Community Skilled Healthcare Building(Public Sewer)
Wastewater Collection System Extension Permit
Alamance County
Dear Mr. Watkins:
In accordance with your application received April 15, 2019, we are forwarding herewith Permit No.
WQ0040802 dated April 16, 2019,to the City of Burlington (Permittee)for the construction and operation
upon certification 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from the date of issuance until rescinded and shall be subject to the conditions and limitations as specified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 the following conditions contained within this permit:
Condition 1.1: This permit shall not be automatically transferable; a request must be made and
approved.
Condition IA: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 02T.0403 or any individual system-wide collection system
permit issued to the Permittee.
Condition 1.7: Upon completion of construction and prior to operation of these permitted facilities,the
completed Engineering Certification form with checklist attached to this permit shall be
submitted with the required supporting documents to the address provided on the form.
Permit modifications are required for any changes resulting in non-compliance with
this permit, regulations, or the Minimum Design Criteria. [15A NCAC 02T.0116]
It shall be responsibility of the Permittee 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.
N�T��R�ND-EQ>
fYpa,hnmlM EnWrenme�l pu.
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road,Suite 300 1 Winston-Salem,NC 27105
336-776-9800

City of Burlington
Permit No.WQ0040802
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 150B 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 Jenny Graznak at (336) 776-
9800 or via e-mail at [e-mail].
Sincerely,
EDocuS�igfned<by:
LJti l c. ,,Jcr
945B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
by Lon T. Snider,Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: Brent Gatlin, P.E.—Stimmel Associates, P.A. ([e-mail])
Winston-Salem Regional Office Files
Water Resources Central Files
PERCS (electronic copy)
Page 2 of 8

�OuoNVL�
NORTH CAROLINA
Environmental Quality
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
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
City of Burlington
Alamance County
for the construction and operation of approximately 86 linear feet of 8-inch gravity sewer to serve a 104-
bed nursing home facility with laundry facilities and an exercise/rehabilitation center with hydrotherapy
as part of the Twin Lakes Community Skilled Healthcare Building(Public Sewer) project, and the discharge
of "0" gallons per day of collected wastewater into the City of Burlington's existing sewerage system,
pursuant to the application received April 15, 2019 and in conformity with 15A NCAC 02T; 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
Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
The permitted flow is zero because flow for this project has been allocated in Permit Number WQ0040800.
The permitted flow in Permit Number WQ0040800 is 12,733 gallons per day.
Doc uS�igfned<by:
mdcr
-4'B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0040802
Permit Issued: April 17, 2019
Page 3 of 8

SUPPLEMENT TO PERMIT COVER SHEET
City of Burlington is hereby authorized to:
Construct,and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the City of Burlington's South
Wastewater Treatment Facility in accordance with Permit Number NC0023876.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable;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.
Construction and operation is contingent upon compliance with the Standard Conditions identified below.
I. STANDARD CONDITIONS
1. 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. [15A NCAC 02T.0116; G.S 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 02T; 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 materials unless specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T.0110]
4. 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 02T .0403. If an individual
permit is not required,the following performance criteria shall be met:
a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
Page 4 of 8

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-months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. 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.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease-related sanitary sewer overflows.
i. Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept for Subparagraphs(a)through (i)of this Rule for a minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staff member at the Winston-Salem
Regional Office,telephone number [phone], as soon as possible, but in no case more than 24
hours, 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 SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume,that reaches surface water
Voice mail messages or faxed information is permissible, but this 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 and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part 11 of Form CS-SSO(or the most current Division approved
form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)]
Page 5 of 8

6. 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. [15A NCAC 02T.0108(b)]
7. Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form with checklist 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. 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.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings(plan & profile views of sewer lines&force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media (CD or DVD disk) and are defined as the design drawings that are
marked up or annotated with after construction information and show required buffers,
separation distances, material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing,velocity,
pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge
protection, detention time in the wet well, and force main, ability to flush low points in force
mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or
pump is dedicated to multiple stations, an evaluation of all the pump stations' storage capacities
and the rotation schedule of the portable power source or pump, include travel timeframes, shall
be provided.
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including but not limited to pipe length changes of 10% or
greater, increased flow, pump station design capacity design increases of 5% or greater, and
increases in the number/type of connections), regulations, or the Minimum Design Criteria.
Requested modifications or variances to the Minimum Design Criteria will be reviewed on a case-by-
case basis and each on its own merit. Please note that variances to the Minimum Design Criteria
should be requested and approved during the permitting process prior to construction. After-
construction requests are discouraged by the Division and may not be approved, thus requiring
replacement or repair prior to certification &activation. [15A NCAC 02T.0116]
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
Page 6 of 8

on a case-by-case basis. Resolution of such request shall be evident prior to completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the individual permit and construction record drawings shall be maintained on file by the
Permittee for the life of the wastewater collection facilities. [15A NCAC 02T.0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T; 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, construction of additional or replacement wastewater collection facilities, and/or referral of
the North Carolina-licensed Professional Engineer to the licensing board. [15A NCAC 02T.0108(b-c)]
11. 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.
[15A NCAC 02T .0110; 15A NCAC 02T.0108(b)]
12. 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 the Division any other Federal,State,or Local
government agencies which have jurisdiction or obtaining other permits which maybe required by the
Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 8

CERTIFICATION CHECKLIST
To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116.
Certifying Engineer:
Certification Review Date:
Project Name:
WQ00 Project County:
1) Has permittee information changed since the permit was issued (or last modified): change of mailing address,
change of ownership, transfer from developer to HOA/POA, etc. ❑ Yes ❑ No
• If yes, please provide either a change of ownership form or new contact information. Note that transfer of
permits from the developer to the HOA/POA must occur with the first certification.
2) Have the as-built drawings have been signed,sealed,and dated by an N.C. PE? ❑ Yes ❑ No
3) Final Engineering certification? ❑ Yes ❑ No
• If Partial Engineering certification, provide detailed narrative including what is being certified in the current
phase,what was previously certified (if applicable),and what is left to be certified.
4) Adequate information related to sewer lines: ❑ Yes ❑ No ❑ N/A
• Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed.
• Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines.
• Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all
intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches).
5) Adequate information related to pump stations: ❑ Yes ❑ No ❑ N/A
• Ensure power reliability option was selected per 15A NCAC 02T.0305(h).
6) Was project construction completed in accordance with all of the following: ❑ Yes ❑ No ❑ N/A
• 15A NCAC 02T, Minimum Design Criteria (MDC)for the permitting of Gravity Sewers (latest version), and MDC
for the Permitting of Pump Stations and Force Mains (latest version)?
If not, a variance approval is required in accordance with 15A NCAC 02T.0105(b), prior to certification and operation.
• Contact the Central Office to discuss the variance to determine a course of action.
• Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other
pertinent information to the Central Office (one hard copy, one digital copy).
• The central office will review the variance request, and if approvable, specific language regarding the variance
will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the
reissued permit with variance language or the variance letter must be maintained with the original documents.
7) Does the project contains high priority lines(15A NCAC 02T .0402(2))? ❑ Yes ❑ No
• If yes,ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC
02T.0403 (a)(5). If the permit does not include this language,the Fast Track reviewer will reissue the permit with
the appropriate language.
8) Are Permit modifications are required for any changes resulting in non-compliance with this permit(including but not
limited to pipe length changes of 10%or greater,change in flow,pump station design capacity design change of 5%or
greater,and/or change in the number/type of connections)? ❑ Yes ❑ No
• If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified
permit with revised certification must be issued prior to certification and operation.
NC DWR—Water Quality Regional Operations Section 450 West Hanes Mill Road,Suite 300,Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE: City of Burlington
PERMIT#: WQ0040802
PROJECT: Twin Lakes Community Skilled Healthcare Building (Public Sewer)
ISSUE DATE: April 17, 2019
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMITTEE'S CERTIFICATION
I,the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name,Title Signature Date
ENGINEERS CERTIFICATION
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
project name and location as referenced above for the above Permittee hereby state that,to the best of
my abilities, due care and diligence was used in the observation of the following construction:
of approximately 86 linear feet of 8-inch gravity sewer to serve a 104-bed nursing home facility with
laundry facilities and an exercise/rehabilitation center with hydrotherapy as part of the Twin Lakes
Community Skilled Healthcare Building(Public Sewer) project, and the discharge of"0" gallons per day of
collected wastewater into the City of Burlington's existing sewerage system, pursuant to the application
received April 15,2019;such that the construction was observed to be built within substantial compliance
of this permit; 15A NCAC 02T;the Division of Water Resources' (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 w/signature &date:
❑ Final ❑ Partial (include description)
Certification Comments/Qualifiers (attach if necessary):
...............................................:
NC DWR—Water Quality Regional Operations Section 450 West Hanes Mill Road,Suite 300,Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

Central Files: APS _ SWP
4/18/2019
Permit Number WQ0040802 Permit Tracking Slip
Program Category Status Project Type
Non-discharge Active New Project
Permit Type Version Permit Classification
Gravity Sewer Extension,Pump Stations,&Pressure Sewer Extensions 1.00 Individual
Primary Reviewer Permit Contact Affiliation
jennifer.graznak
Coastal SWRule
Permitted Flow
0
Facility
Facility Name Major/Minor Region
Twin Lakes Community Skilled Healthcare Building(Public Sewer) Minor Winston-Salem
Location Address County
Wade Coble Dr Alamance
Facility Contact Affiliation
Glen Raven NC 27215
Owner
Owner Name Owner Type
City of Burlington Government-Municipal
Owner Affiliation
Frank H.Watkins
City Manager
PO Box 1358
Dates/Events Burlington NC 27216135
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
4/16/2019 4/15/2019 4/16/2019 4/16/2019
Regulated Activities Requested/Received Events
Nursing Home Additional information requested
Wastewater collection Additional information received
Outfall
Waterbody Name Streamindex Number Current Class Subbasin

1 .TRADE STREET SUITE 200 j
t.7 stimmel ww60wNs mmelpac m�336J23.1067
i� �aparim,ent cf '
Emviro,nmental Quality
April 12, 2019 Received
NCDEQ—Winston-Salem Regional Office
Division of Water Resources UVinstorl-�alem
450 W. Hanes Mill Road, Suite 300 Regional Gf"•l=e
Winston-Salem, NC 27105
Attn: Mr. Justin Henderson
Re: Fast-Track Sewer System Extension Application for
Twin Lakes Community Skilled Healthcare Building (Public Sewer)and
Twin Lakes Community Skilled Healthcare Building (Private Sewer)
Burlington, NC
i
Dear Mr. Henderson:
Attached you will find two(2) Fast-Track Sewer System Extension Applications and supporting information for
a public and private sewer that will serve the proposed Twin Lakes Community Skilled Healthcare Building
project within the existing retirement community. The new building to be served by these sewers will include a
104-bed nursing home facility with laundry facilities and an exercise/rehabilitation center with hydrotherapy.
The design is for an 86 LF of 8-inch public gravity sewer crossing S. Church St with connection to the existing
8-inch public gravity sewer on the south side of the street.The design also includes 540 LF of 6-inch and 59
LF of 8-inch private gravity sewer that will discharge sanitary flow from the building sanitary service lines to the
proposed public gravity sewer line. Sewer flows from the proposed private sewer are domestic and
commercial and are estimated at 12,733 gallons per day based on the enclosed calculations in Section VI of
the FTA for the private sewer.
i
The following information is included for your review and approval:
Public•Sewer<Documents
#Copies' Description
2 Fast-Track Application Form FTA 04-16 for Public Sewer
1 Review fee check in the amount of$480 for Public Sewer
2 Site Map on 8.5"x 11" USGS Quad Map
2 Site Map on 8.5"x 11"Aerial
Private Sewer aocu"mentS:
#Copies Description
2 Fast-Track Application Form FTA 04-16 for Private Sewer
1 Review fee check in the amount of$480 for Private Sewer
2 Flow Tracking/Acceptance Form FTSE 10-18 (signed by City of Burlington)
2 Site Map on 8.5"x 11" USGS Quad Map
2 Site Map on 8.5"x 11"Aerial
2 NCDSOS Corporation Division documentation for Presbyterian Homes, Inc.
LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LANDPLANNING
I

State of North Carolina
Department of Environmental Quality
P I I Division of Water Resources
W- w 15A NCAC 02T.0300—FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16&SUPPORTING DOCUMENTATION
Application Number: ( �qD8021 (to be completed byoWR)
All items must be completed or the application will be returned
L APPLICANT INFORMATION:
1. Applicant's name: City of Burlington,NC(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: Hardin Watkins per 15A NCAC 02T.0106(b)
Title:City Manager
LIIVSR)I-I Ttental Quality
4. Applicant's mailing address:425 S.Lexington Avenue Received
City:Burlington State:NC Zip: 27215-_ f , ..) i J
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail] ✓::/It?strn-`>alem
'•a'IEYi l
11. PROJECT INFORMATION:
I. Project name:Twin Lakes Community Skilled Healthcare Building(Public Sewer)
2. Application/Project status: ® Proposed(New Permit) ❑ Existing Permit/Project
If a modification,provide the existing permit number:W000_ and issued date: _
If new construction but part of a master plan,provide the existing permit munber: W000_
3. County where project is located: Alamance
4. Approximate Coordinates(Decimal Degrees): Latitude: 36.08106' Longitude: -79.522870
5. Parcel ID(if applicable): 106886, 106888, 106940, 106943
(or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer:K.Brent Gatlin License Number:041137
Firm: Stimmel Associates, P.A.
Mailing address: 601 N.Trade St.
City: Winston-Salem State: NC Zip: 27101
Phone number: [phone] Email Address:[e-mail]
IV. WASTEWATER TREATMENT FACILITY(WWTF) INFORMATION:
1. Facility Name:South Burlington W WTP Permit Number:NCO023876
Owner Name:City of Burlington,North Carolina
V. RECEIVING DOWNSTREAM SEWER INFORMATION(if different than WWTF):
1. Permit Number(s): WQ Downstream(Receiving)Sewer Size: 8 inch
System Wide Collection System Permit Number(s)(if applicable): WQCS00008
Owner Name(s):City of Burlington
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 RN/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 Operational Agreement(FORM:HOA)been attached?
❑ Yes ❑No ®N/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 ® 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: 100 %e Domestic/Commercial %Commercial
%Industrial(See 15A NCAC 02T.0103(20))
"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 cony of flow reduction annroval letter
7. Summarize wastewater generated by project:
Establishment Type(see 02T.01140 Daily Design Flow''h No.of Units Flow
gal/ GPD
gal/ GPD
gal/ GPD
gal/ GPD
gal/ GPD
gall 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 I5A NCAC 02T.01141 shall
be detemtined using available flow data,water using fixtures,occupancy or operation patterns,and other measured data.
8. Wastewater generated by project:0 GPD(per ISA 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
❑Flow has already been allocated in Permit Number:_
❑Rehabilitation or replacement of existing sewer with no new flow expected
❑Other(Explain):
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA(If Applicable)-02T.0305&MOC(Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size(inches) Length(feet) Material
8 86 DI
➢ Section 11& Ill of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section Ill 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
Vill. PUMP STATION DESIGN CRITERIA(If Applicable)—02T.0305&MDC(Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Putnp 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 thepump(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
G. ewer reliability in accordance with 15A NCAC 02T A305 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 timefratnes,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(t)):
1. Does the project comply with all separations found in 15A NCAC 02T 0305( &(a) ®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 1 or
Class 11 impounded reservoirs used as a source of drinking water 100 feet
**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
Anyswimming pools 10 feet
Final earth grade vertical 36 inches
➢ 15A NCAC 02T.0305(e)contains alternatives where separations in 02T.0305 cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpaee
➢ If noncompliance with 02T.0305(f)or(g),see Section X of this application
2. Does the project comply with separation requirements for wetlands?(50 feet of separation) ❑ Yes ❑ No ®N/A
➢ See the 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 0213.0200? ❑ Yes ❑No Z N/A
➢ This would include Trout Buffered Streams per 15A NCAC2B.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.0105(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 pernritee's individual System-Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

j
i
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Putn Stp ations
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
-_ —or re t . a va of-the repuestis re uri-e-d urtui`-tti s�ibmrRa(of fhe s rack An tc3 ton an sun rort me
documents.
2. Professional Engineer's Certification: �j
1 9� gA40-A FrI2114 &rn 4-I i.q f . •- attest that this application for
(Professional Engineer's name from Application Item 111.1.)
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.
1 ?
North Carolina Professional Engineer's seal,signature,and date: �``�\R�A CA
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=x 41137
?Gl NG� Pti\�
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_.........................................................
3. Applicant's Certification per 15A NCAC 02T.0106(b):
1, Hardin Watkins City Manager attest that this application for
(Signature Authority's name&title from Application Itent 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. 1 understand that any discharge of wastewater front this non-
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injmmctive 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: c
i4
FORM: FTA 04-16 Page 5 of 5