WQ0041048_Application_20190815

Odom
Engineering rLrc
July 23, 2019
Mr. Wes Bell
Mooresville Regional Office
Water Quality Section
610 E. Center Avenue
Mooresville, NC 28115
Subject: Fast Track Sewer System Extension Application
Crossroads Rescue Mission Project
Dear Mr. Bell,
169 Oak Street • Forest City, NC 28043
office 828.247.4495 • fax [phone]
RE'CEIVEDINCDtNR/DWR
JUL 2 5 2Q19
WQROS
MOORESVILLE REGIONAL. OFFICE
We are submitting a Fast Track Sewer System Extension Application for Crossroads Rescue Mission
Project located at Seattle St., Cor. Dekalb St., Shelby, NC. This submittal includes the following items:
■ Signed Fast Track Sewer Application (FTA 04-16)
■ Check for application fee - $480.00
■ Signed Flow Tracking/Acceptance Form (FTSE 04-16)
■ USGS Topographic Map
Should you need more information or have any questions, please feel free to contact me at 828-
247-4495 or email me at [e-mail].
Sincerely,
Larissa Coles, P.E.

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: '' `�©Ti5 (to be completed by DWR) RECEIVE-D/NCDENR/DWr,
All items must be completed or the application will be returned JUL 2 5 2019
I. APPLICANT INFORMATION: WORO
MOORESVIL.LE REGIONAL OFFICE
1. Applicant's name: CROSSROADS RESCUE MISSION (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: ROCKY SHELTON per 15A NCAC 02T .0106(b)
Title: EXECUTIVE DIRECTOR
4. Applicant's mailing address: P.O. BOX 2090
City: SHELBY State: NC Zip: 28151-
5. Applicant's contact information:
Phone number: [phone] Email Address: rshelton a,crossroadsrescuemission.oru
II. PROJECT INFORMATION:
1. Project name: CROSSROADS RESCUE MISSION
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: CLEVELAND
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.259436' Longitude:-81.559154'
5. Parcel ID (if applicable): 63871
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: LARISSA COLES License Number: 029478
Firm: ODOM ENGINEERING, PLCC.
Mailing address: 169 OAK ST,
City: FOREST CITY State: NC Zip: 28043-
Phone number: 828 247-4495 Email Address: larissa@odomen ing eerieg com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: First Broad River Wastewater Treatment Plant Permit Number: NCO024538
Owner Name: City of Shelby
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): WQCSWQCS00037
Owner Name(s): City of Shelby
FORM: FTA 04-16 Page 1 of 5

R1FCFIVFCN CDENR/DWR
VI. GENERAL REQUIREMENTS
Air,
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity eon attached?
❑ Yes ❑No ®N/A WQRC)s
?-A0QRFSViLLE
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: D ti2 fijgt-
❑ 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 % Domestic/Commercial % Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
1Is there a Pretreatment Program in effect? ❑ Yes ® No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ® No
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0.114(f))
Daily Design Flow','
No. of Units
Flow
RETAIL
100 gal/1,000 SF
12
1,200 GPD
RESTAURANT
20 gal/SEAT
30
600 GPD
WAREHOUSE
100 gal/LOADING BAY
2
200 GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
2,000 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.011.41 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 2.000 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
❑ 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

V11. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8" 1,002 SDR-21 PVC
➢ 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
VIII. 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: PS-1
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.25950 Longitude:-81.5585'
3. Design flow of the pump station: .002 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 15.45 gallons per minute at 30 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
1-1/2 340
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(f) & (g,)
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
® Yes ❑ No
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 II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation) and wetlands (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(e) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(fl 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 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)(61(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 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:
I,
LARISSA COLES, PE
attest that this application for
(Professional Engineer's name from Application Item III.1.)
CROSSROADS RESCUE MISSION
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 farther 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 C' t cria for the Fast -Track
Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violatig�;,te;ii;;e�
North Carolina Professional Engineer's seal, signature, and date:
Applicant's Certification per 15A NCAC 02T .0106(b):
ROCKY SHELTON, EXECUTIVE DIRECTOR
(Signature Authority's name & title from Application Item I.3.)
�•- ��@ bra-y/'•�® ��,r
��• Svs
,uni��
that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a
condition of this permit be violated. I also understand that if all required parts of this application package are not completed
and that if all required supporting information and attachments are not included, this application package will be returned to
me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date:
FORM: FTA 04-16 Page 5 of 5

North Carolina Secretary of State Search Results
Page I of l
• Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings
Non -Profit Corporation
Legal Name
Crossroads Rescue Mission
Information
Sosld: 0563137
Status: Current -Active
Annual Report Status: Not Applicable
Citizenship: Domestic
Date Formed: 9/7/2000
Registered Agent: Not Listed
Addresses
Principal Office Reg Office Reg Mailing Mailing
206 Mt. Sinai Road 206 Mt. Sinai Road P 0 Box 2090 P 0 Box 2090
Shelby, NC 28152 Shelby, NC 28152 Shelby, NC 28151 Shelby, NC 28151
https://www.sosne.gov/online_services/searcli/13usiness Registration Results 7/26/2019

R'CE'VEDlNCDENR/nWR
MOORESVILLE REGIONAL OFFICE
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CEIVEDINCDENR/DWR
State of North Carolina
Department of Environmental Quality
WQROS Division of Water Resources
1MOORESVILLE REGIONAL OFFICE
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: CROSSROADS RESCUE MISSION
Project Name for which flow is being requested: CROSSROADS RESCUE MISSION
More than one FTSE 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: CITY OF SHELBY
b. WWTP Facility Permit #: NCO024538
All flows are in MGD
c. WWTP facility's permitted flow 6.0
d. Estimated obligated flow not yet tributary to the WWTP 0.431
e. WWTP facility's actual avg. flow 3.87
f. Total flow for this specific request 0.0021
g. Total actual and obligated flows to the facility 4.30
h. Percent of permitted flow used 72%
il. 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 Pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm / p fl, Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
N/A
N/A
N/A
N/A
* The Firm Capacity (design flow) 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, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** 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): SHELBY
Downstream Permit Number: W00007780
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I l�_ 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 If plus all attached planning assessment
addendums for which I am the responsible party. Signature of this form certifies that the receiving
collection system or treatment works has adequate capacity to transport and treat the proposed new
'wastewater. rl
Signing Official. a1ure
Title of Signing Official
Page 2 of 6
IFMA
FTSE 10-18