WQ0041159_Application_20190926

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: � 00 1 S (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Kings Mountain (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: G. Scott Neisler per 15A NCAC 02T .0106(b)
Title: Mao
4. Applicant's mailing address: P.O. Box 429
City: Kings Mountain State: NC Zip: 28086-
5. Applicant's contact information:
Phone number: [phone] Email Address: scottneislerAcityofkm.com
II. PROJECT INFORMATION:
RECEIVED/NCDENR/DWR
SEP 2 5,7019
WQROS
MOORESVILLE REGIONAL OFFICE
❑ Privately -Owned Public Utility
❑ Other
1. Project name: Beason Creek Lift Station Upgrade
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: 35.2425' Longitude:-81.3750"
5. Parcel ID (if applicable): 63050
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Joel E. Wood License Number: 7571
Firm: Joel E. Wood & Associates
Mailing address: P.O. Box 296
City: Clover State: SC Zip: 29710-
Phone number: [phone] Email Address: ioelwood(a,comnorium.net
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Pilot Creek Wastewater Facility Permit Number: NC 0020737
Owner Name: City of Kings Mountain
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ NC 0020737 Downstream (Receiving) Sewer Size: 12 inch
System Wide Collection System Permit Numbers (if applicable): WQCS00036
Owner Name(s): City of Kings Mountain
FORM: FTA 04-16 Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes [:]No ®N/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: 78 % Domestic/Commercial 12 % Commercial
22 % 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(fl? ❑ Yes ® No
➢ If Yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
Residential Lots (3 bedroom)
360 gal/day
280
100,800 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
100,800 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and Le, (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.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 100,800 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

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
N/A
➢ 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: Beason Creek Lift Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.22964' Longitude:-81.39047'
3. Design flow of the pump station: 0.898 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 1,475 gallons per minute at 115 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
N/A
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) ® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
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
hiRh 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 s stems 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(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ 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 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
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 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 supportine documents.
2. Professional Engineer's Certification:
1, .10 L_ C . WCK:D -PE- attest that this application for
(Professional Engineer's name frod Application Item II1.1.)
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 143-215.613, 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 $25,006 per violation.
North Carolina Professional Engineer's seal, sign\\la����te:
CAR04/
-SS/
_` : a SEAL vim•.
Q : P-0169
FN
�i iy'•. GIN
�P
A511G�
Applicant's Certification per 15A NCAC 02T .0106(b): 111
1, <:�-; . .S C� 4!T 1 S 'LiE-jZ attest that this application for
(Signature Authority's name & title from Application Item I.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 143-215.6B, 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:G% Date:
FORM: FTA 04-16 Page 5 of 5

VI.
.4 Origin of Wastewater.
Approximately 78% of the wastewater handled by the Beason Creek Lift
station is a combination of Residential / Commercial. Of the 78% Residential
/ Commercial approximately 12% is Commercial with approximately 66 %
Residential. Approximately 22 % is Industrial with the largest percentage
generated by NTE Energy cooling water.
Residential 66%
Commercial 12%
Industrial 22%
Total 100%

BEASON CREEK LIFT STATION UPGRADE
PROJECT DESCRIPTION
The City of Kings Mountain, NC is proposing to upgrade their existing Beason
Creek Lift Station by adding a mechanical bar screen, replacing the existing pumps
with new pumps with additional capacity, replacing the existing control panels, new
electrical wiring utilizing the existing generator and existing 12" force main to the
discharge point. The upgrade of the existing lift station is to replace an existing lift
station that has exceeded its useful life an making a small addition to the capacity of the
station. For design purposes, a REU is considered to be a three -bedroom residential unit
with an average daily volume of flow of 120 gal./bedroom (360 Gal./day total). The
proposed design capacity for the station is as follows:
I. Existing Station Capacity 1222 REU's X 360 Gal/day per REU = 439,920 Gal/day Avg.
New Customers (Future) 280 REU's X 360 Gal/day per REU = 108,800 Gavday Avg.
Average Daily Flow Design = 548,720 Gal/day
Il. Peak Day Design = Avg Day Flow Design X Peak Factor
Peak Day Design = 548,720 Gal/day X 2.5 = 1,371,800 Gal/ Day = 952.6 Gal/Min
1,440 Min/day
H
Peak Pumping Rate NTE Lift Station = 385.0 Gal/Min
Peak Design Pumping Rate
= 1,337.6
For the design of the Pump Station see the Station Calculation that are attached and made
part of this submittal. The pump selected will pump 1,560 Gal/min at 115 feet Total
Head.
After the construction of the proposed lift station upgrade the City of Kings Mountain
will own, operate, and maintain the lit station. The wastewater will be treated at the Pilot
Creek Wastewater Facility (WWTF # NC 0020737) and there are no lift stations between
the discharge point and the Pilot Creek Wastewater Facility. „ 0 1 7
CARS
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RECEIVEDINC®ENR/DWR
BEASON CREEK LIFT STATION UPGRADE SE , � o� ` I N
PROJECT DESCRIPTION MOOREWQRGI
SVILLE REGIONAL OFFICE
The City of Kings Mountain, NC is proposing to upgrade their existing Beason
Creek Lift Station by adding a mechanical bar screen, replacing the existing pumps
with new pumps with additional capacity, replacing the existing control panels, new
electrical wiring utilizing the existing generator and existing 12" force main to the
discharge point. The upgrade of the existing lift station is to replace an existing lift
station that has exceeded its useful life an making a small addition to the capacity of the
station. For design purposes, a REU is considered to be a three -bedroom residential unit
with an average daily volume of flow of 120 gal./bedroom (360 Gal./day total). The
proposed design capacity for the station is as follows:
I. Existing Station Capacity 1222 REU's X 360 Gal/day per REU = 439,920 Gal/day Avg.
New Customers (Future) 280 REU's X 360 Gal/day per REU = 108,800 Gal/day Avg.
Average Daily Flow Design = 548,720 Gal/day
II. Peak Day Design = Avg Day Flow Design X Peak Factor
Peak Day Design = 548,720 Gal/day X 2.5 = 1,371,800 Gal/ Day = 952.6 Gal/N in
1,440 Min/day
H
Peak Pumping Rate NTE Lift Station = 385.0 Gal/Min
Peak Design Pumping Rate
= 1,337.6
For the design of the Pump Station see the Station Calculation that are attached and made
part of this submittal. The pump selected will pump 1,560 Gal/min at 115 feet Total
Head.
After the construction of the proposed lift station upgrade the City of Kings Mountain
will own, operate, and maintain the lit station. The wastewater will be treated at the Pilot
Creek Wastewater Facility (WWTF # NC 0020737) and there are no lift stations between
the discharge point and the Pilot Creek Wastewater Facil t ,1,f f f �ILI It
sipp`�'9 �� aS
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State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: City of Kings Mountain
Project Name for which flow is being requested: Beason Creek Lift Station Upgrade
More than one FTSE may be required for a singleproject if the owner of the WWTP is not responsible for allpump
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: Pilot Creek Wastewater Facility
b. WWTP Facility Permit #: NC 0020737
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
6.0 MGD
0.14
1.85
0.1008 MGD
2.0908
34.85
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)
Design
Pump
Pump
Average
Approx.
Station
Station
Firm Daily Flow**
Current
(Name or
Permit
Capacity, * (Firm / pf),
Avg. Daily
Number)
No.
MGD MGD
Flow, MGD
N/A
N/A
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Not Yet
Total Current
Tributary
Flow Plus
Daily Flow,
Obligated
Available
MGD
Flow
Capacity***
* 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): Pilot Creek WWTP
Downstream Permit Number: NCO020737
Page 1 of 6
I`TSE 10-18

III. Certification Statement:
I G. Scott Neisler, Mayor 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 of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official Signature
r
Title of
'7//,7
Date
Page 2 of 6
F-FSE 10-1 S

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in
d. The following applies:
; and/or
There are no lift stations between this project and the Pilot Creek WWTP. The upgrade
to Beason Creek lift station will add an additional capacity of 100,800 gallons per day to
the existing permitted capacity of the Beason Creek Lift Station.
See Pump Station Calculations included in the Preliminary Engineering Report.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
IAWA
Page 3 of 6
VFS1~ 10-18

North Carolina Secretary of State Search Results
Page 1 of 1
• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online
Add Entity to My Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print
an Amended a Annual Report form
Business Corporation
Legal Name
Coulston Enterprises, Inc.
Information
Sosld: 0767529
Status: Current -Active
Annual Report Status: Current
Citizenship: Foreign
Date Formed: 2/17/2005
Fiscal Month: December
State of Incorporation:
SC
Registered Agent: Coulston, Alfred E
Addresses
Reg Office
7050 Buckland Rd
Charlotte, NC 28278
Officers
President
Earl Coulston
8332 Regent Parkway
Fort Mill SC 29715
Stock
Reg Mailing
7050 Buckland Rd
Charlotte, NC 28278
Mailing
8332 Regent Pkwy
Fort Mill, SC 29715
Principal Office
8332 Regent Pkwy
Fort Mill, SC 29715
https://www.sosnc.gov/onlinc__services/search/13usiness Registration Results 8/29/2019

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State of North Carolina
DWR
Department of Environmental Quality
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: i � ' � J (to be completed by DWR) 1 ECl;IVE0/NCDENR/D1Nf1
All items must be completed or the application will be returned `' P 1
I. APPLICANT INFORMATION:
1. Applicant's name: City of Kings Mountain (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: G. Scott Neisler per 15A NCAC 02T .0106(b)
Title: Mayor
4. Applicant's mailing address: P.O. Box 429
City: Kings Mountain State: NC Zip: 28086-
5. Applicant's contact information:
Phone number: [phone] Email Address: scottneisler(a-)cityofkm.com
H. PROJECT INFORMATION:
t"OORESVILLE RL-"� ONAL OFFICE"
❑ Privately -Owned Public Utility
❑ Other
1. Project name: Beason Creek Lift Station Upgrade
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: 35.2425' Longitude:-81.3750'
5. Parcel ID (if applicable): 63050
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Joel E. Wood License Number: 7571
Firm: Joel E. Wood & Associates
Mailing address: P.O. Box 296
City: Clover State: SC Zip: 29710-
Phone number: 803 684-3390 Email Address: ioelwoodAcomporium.net
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Pilot Creek Wastewater Facility Permit Number: NC 0020737
Owner Name: City of Kings Mountain
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ NC 0020737 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): City of Kings Mountain
FORM: FTA 04-16 Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes [:]No ®N/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/Proyerty 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))
�' Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ Yes ®No
➢ If yes, provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,n
No. of Units
Flow
Residential Lots (New)
360 gal/day
280
100,800 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
100,800 GPD
a See 15A NCAC 02T .0114(b) (d),(e)(l) 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.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 100,800 Plus flow previousl allocated 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) [Length (feet) Material
N/A
➢ 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: Beason Creek Lift Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.22964' Longitude:-81.39047'
3. Design flow of the pump station: 0.8646 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 1,475 gallons per minute at 115 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
12"
3,600
PVC
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(0):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g) ® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum senarations that shall he nmvided fnr sewer ,,vQtPme-
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(g) contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webnaee
➢ If noncompliance with 02T.0305Lfl 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 213.0202
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 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:
�L F. • W.0 attest that this application for
(Professional Engineer's name from Application Item III.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 143-215.613, 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 violation.
North Carolina Professional Engineer's seal, signatu rf}>%e%
A CAR����
SiC> /
:-a
. SEMI.
r : P-016C
3. Applicants Certification per 15A NCAC 02T .0106(b):
5coT7 tQ E is L.e Z attest that this application for
(Signature Authority's name & title from Application Item I.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 143-215.6B, 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: 7
FORM: FTA 04-16 Page 5 of 5