NC0085120_Application (ATC)_20191101

Vv"artrr Resources
ENVIRONMENTAL QUALITY
14)
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
SECTION 1: INSTRUCTIONS AND INFORMATION
A. The Division of Water Resources will accept this application package for review only if all of the items are provided and the
application is complete. Failure to submit all of the required items will result in the application package being returned as
incomplete per 15A NCAC 02T .0105(b).
B. Plans and specifications must be prepared in accordance with 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General
Statute 133-3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES
Wastewater Treatment Facilities.
C. The plans and specifications submitted must represent a completed final -design that is ready to advertise for bid.
D. Any content changes made to this Form ATC-12-14 shall result in the application package being returned.
E. The Applicant shall submit ONE ORIGINAL and ONE DIGITAL COPY (CD) of the application, all supporting documentation and
attachments. All information must be submitted bound or in -a 3-ring binder, with a Section tab for each Section, except the
Engineering Plans.
F. Check the boxes below to indicate that the information is provided and the requirements are met.
G. If attachments are necessary for clarity or due to space limitations, such attachments are considered part of the application
package and must be numbered to correspond to the item referenced.
H. For any project that requires review under the State Environmental Policy Act (SEPA), an Authorization to Construct cannot be
issued prior to the completion of a State Clearinghouse advertisement period for a FONSI, EIS; etc. unless the project qualifies
for a Determination of Minor Construction Activity.
I. For more information, visit the Division of Water Resources web site at: http://portal.ncdenr.org/web/wq/swp/ps/npdes.
J. In addition to this Authorization to Construct, the Applicant should be aware that other permits may be required from other
Sections of the Division of Water Resources (for example: reclaimed water facilities permits; class A or B biosolids residuals
permit).
SECTION 2: APPLICANT INFORMATION AND PROJECT DESCRIPTION
A. APPLICANT
Q
Applicant's name
Lowe's Inc.
Signature authority's name per 15A NCAC 02T .0106(b)
Rocky L. Everidge
Signature authority's title
ORC
Complete mailing address
711 Tomlin Mill Rd. Statesville NC 28625
Telephone number
704-876-8561
Email address
[e-mail]
PROFESSIONAL ENGINEER
Professional Engineer's name
Benjamin D. Clawson
Professional Engineer's title
Project Engineer
North Carolina Professional Engineer's License No.
033710
Firm name
Municipal Engineering Services Co. P.A.
Firm License number
C-0281
Complete mailing address
68 Shipwash Drive Garner, NC 27529
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 1

YVcxter°Res Vtccs
ENVIRONMENTAL 0LfAL;TY
14I
C.
D.
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
Telephone number
919-772-5393
Email address
[e-mail]
NPDES PERMIT
NPDES Permit number
NCO085120
Current Permitted flow (MGD) — include permit
0.016 MGD
flow phases if applicable
PROJECT DESCRIPTION
Provide a brief description of the project: The proposed project will consist of constructing a second Equalization Basin at the
facility along with related piping and appurtenances
SECTION 3: APPLICATION ITEMS REQUIRED FOR SUBMITTAL FOR ALL PROJECTS
A. Cover Letter
® The letter must include a request for the Authorization to Construct; the facility NPDES Number; a brief project description
that indicates whether the project is a new facility, facility modification, treatment process modification, or facility
expansion; the construction timeline; and a list of all items and attachments included in the application package.
❑ If any of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North Carolina
General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES Wastewater Treatment
Facilities are not met by the proposed design, the letter must include an itemized list of the requirements that are not met.
B. NPDES Permit
❑ Submit Part I of the Final NPDES permit for this facility that includes Part A (Effluent Limitations and Monitoring
Requirements) for the monthly average flow limit that corresponds to the work that is requested for this project.
C. Special Order by Consent
❑ If the facility is subject to any Special Orders by Consent (SOC), submit the applicable SOC.
® Not Applicable.
D. Finding of No Significant Impact or Record of Decision
❑ Submit a copy of the Finding of No Significant Impact or Record of Decision for this project.
❑ Provide a brief description of any of the mitigating factors or activities included in the approved Environmental Document
that impact any aspect of design of this project, if not specified in the Finding of No Significant Impact or Record of Decision
® Not Applicable.
E. Engineering Plans
® Per 15A NCAC 02T .0504(c)(1), submit one set of detailed plans that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 2

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14)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
❑ Per 21 NCAC 56 .1103(a)(6), the name, address and License number of the Licensee's firm shall be included on each sheet of
the engineering drawings.
❑ Plans must be labeled as follows: FINAL DRAWING —FOR REVIEW PURPOSES ONLY —NOT RELEASED FOR CONSTRUCTION.
❑ 15A NCAC 02H .0124 requires multiple (dual at a minimum) components such as pumps, chemical feed systems, aeration
equipment and disinfection equipment. Is this requirement met -by the design? ®Yes or ❑ No. If no, provide an
explanation:
Plans shall include:
® Plans for all applicable disciplines needed -for bidding and construction of the proposed project (check as appropriate):
® Civil ❑Not Applicable
® Process Mechanical
® Structural
❑ Electrical
❑ Instrumentation/Controls
Architectural
❑ Building Mechanical
❑ Not Applicable
❑ Not Applicable
❑ Nat Applicable
® Not Applicable-
® Not Applicable
® Not Applicable
❑ Building Plumbing ®Not Applicable
® Plan and profile views and associated details of all modified treatment units including piping, valves, and equipment
(pumps, blowers, mixers, diffusers, etc.)
❑ Are any modifications proposed that impact the hydraulic profile of the treatment facility? ❑Yes or � No. If yes, provide
a hydraulic profile drawing on one sheet that includes all impacted upstream and downstream units. The profile -shall
include the top of wall elevations of each impacted treatment unit and the water surface elevations -within each impacted
treatment unit for two flow conditions: (1) the NPDES permitted flow with all trains in service and (2) the peak hourly flow
with one treatment train removed from service.
❑ Are any modifications proposed that impact the process flow diagram or process flow schematic of the treatment facility?
❑ Yes or ®No. If yes, provide the process flow diagram or process flow schematic showing all modified flow paths
including aeration, recycle/return, wasting, and chemical feed, with the location of all monitoring and control instruments
noted.
F. ® Engineering Specifications
® Per 15A NCAC 02T .0504(c)(2), submit one set of specifications that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
❑ Specifications must be labeled as follows: FINAL SPECIFICATIONS —FOR REVIEW PURPOSES ONLY —NOT RELEASED FOR
CONSTRUCTION.
Specifications shall include:
❑ Specifications for all applicable disciplines needed for bidding and construction of the proposed project (check as
appropriate):
® Civil ❑Not Applicable
® Process Mechanical ❑Not Applicable
® Structural ❑Not Applicable
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 3

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G tdVifii>NtF EI�3TkL, t?iiAliTY
14)
G
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
® Electrical
❑ Instrumentation/Controls
❑ Architectural
❑ Building Mechanical
❑ Building Plumbing
❑ Not Applicable
® Not Applicable
® Not Applicable
®-Not Applicable
® Not Applicable
❑ Detailed specifications for all treatment units and processes including piping, valves, equipment (pumps, blowers, mixers,
diffusers, etc.), and instrumentation.
❑ Means of ensuring quality and integrity of the finisl-red product including leakage testing requirements for structures and
pipelines, and performance testing requirements for equipment.
❑ Bid Form for publically bid projects.
Construction Sequence Plan
® Construction Sequence Plan such that construction activities -will not result in overflows or bypasses to waters of the State.
The Plan must not imply that the Contractor is responsible for operation of treatment facilities. List the location of the
Construction Sequence Plan as in the Engineering Plans or in the Engineering Specifications or in both: Seg-uence Plan is laid
out as part of the Engineering Plans.
Engineering Calculations
® Per 15A NCAC 02T .0504(c)(3), submit one set of engineering calculations that have been signed, sealed and dated by a
North Carolina Licensed Professional Engineer; the seal, signature and date shall be placed on the cover sheet of the
calculations.
For new or expanding facilities and for treatment process modifications that are included in Section 4.C, the calculations shall
include at a minimum:
❑ Demonstration of how peak hour design flow was determined with a justification of the selected peaking factor.
❑ Influent pollutant loading demonstrating how the design influent characteristics in Section 4.6.2 of this form were
determined.
❑ Pollutant loading for each treatment unit demonstrating how the design effluent concentrations in Section 4.B.2 of this
form were determined.
❑ Hydraulic loading for each treatment unit.
❑ Sizing criteria for each treatment unit and associated equipment (blowers, mixers, pumps, etc.)
® Total dynamic head (TDH) calculations and system curve analysis for each pump specified that is included in Section 4.C.6.
® Buoyancy calculations for all below grade structures.
❑ Supporting documentation that the specified auxiliary power source is capable of powering all essential treatment units.
Permits
❑ Provide the following information for each permit and/or certification required for this project:
Permit/
If Not Issued Provide
Not
Date
Date
Certification
Status and Expected
Permit/Certification
Applicable
Submitted
Approved
Number
Issuance Date
Dam Safety
X
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 4

y'i%ai�rR.esv�rr.�s
ENVIRONMENTAL QUALITY
14I
J
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
Soil Erosion and Sediment Control
X
USCOE / Section 404 Permit
X
Water Quality Certification (401)
X
USCOE / Section 10
X
Stormwater Management Plan
X
CAMA
X
NCDOT Encroachment Agreement
X
Railroad Encroachment Agreement
X
Other:
Residuals Management Plan
❑ For all new facilities, expanding facilities, or modifications that result in a change to sludge production and/or sludge
processes, provide a Residuals Management Plan meeting the requirements of 15A NCAC 02T .0504(j) and .0508; the Plan
must include:
❑ A detailed explanation as to how the generated residuals (including trash, sediment and grit) will be collected, handled,
processed, stored, treated, and disposed.
❑ An evaluation of the treatment facility's residuals storage requirements based upon the maximum anticipated residuals
production rate and ability to remove residuals.
❑ A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department approved
residuals disposal/utilization program that has adequate permitted capacity to accept the residuals or has submitted a
residuals/utilization program application.
❑ If oil, grease, grit or screenings removal and collection is a designated unit process, a detailed explanation as to how
the oil/grease will be collected, handled, processed, stored and disposed.
® Not Applicable.
SECTION 4: PROJECT INFORMATION
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 5

Y` iVIr° Rc�s
ENVIRONMENTAL QUAL'TY
14)
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
A. WASTEWATER TREATMENT PLANT FLOW INFORMATION —COMPLETE FOR NEW OR EXPANDING FACILITIES
1. Provide the following flow information:
Plant Flows
Existing Plant Design
0.016 MGD
Current NPDES Permit Limit
0.016 MGD
Current Annual Average
(past 12 months)
0.0054 MGD
For Past 12 Months:-
Start Date: 1/2019
End Date:7/2019
For Past 24 Months:
Start Date: month/yr
End Date: month/yr
Maximum Month
0.00836 MGD
0.0083E MGD
Maximum Day
0.0708 MGD
0.0708 MGD
Peak Hour
Information not available
MGD
Information not available MGD
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 6

State of North Carolina
Department of Environmental Quality
Division of Water Resources
PHA R.esvurccls
ENVIRONMENTAL OUALTY APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC42-
14)
B. WASTEWATER TREATMENT FACILITY DESIGN INFORMATION —COMPLETE FOR NEW OR EXPANDING FACILITIES AND
FOR TREATMENT PROCESS MODIFICATIONS
1. Have all of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North Carolina
General Statute 143-215.11 and Division of Water Resources Minimurrr Design Criteria for NPDES Wastewater Treatment
Facilities been met by the proposed design and specifications? ® Yes or ❑ No. If no, -provide justification as to why the
requirements are not met, consistent with 15A NCAC 02T .0105(n):
2. Provide the design influent and effluent characteristics that -are -used as the basis for the project design, and -the NPDES
permit limits for the following parameters:
Estimated, based
on industry Project Basis of Design
standards and
sampling at other
similar facilities
Design Influent Design Influent
ffluent
Influent Concentration Load Design Concentration - (Must be (Must be Concentration
Current Annual supported by supported by and/or Load
Average (past 12 Engineering Engineering
NPDES Permit Limits
months) if Calculations Calculations
Parameter Available [Section 3.Hj) [Section 3.H]) (Per Historic records) (monthly average)
Ammonia Nitrogen 3.61 mg/L Summer 6.3 mg/L Summer
(NH3-N) 15 mg/L mg/L lb/day
9.85 mg/L Winter 19 mg/L Winter
Biochemical 10.09 mg/L Summer 30 mg/L Summer
Oxygen Demand 250 mg/L mg/L Ib/day
(BODS) 11.29 mg/L Winter 30-mg/L Winter
Total Suspended I 150 mg/L I mg/L Ib/day I 45.41 mg/L 30 mg/L
Solids (TSS)
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 7

1V 410 R.CSQUI CC-5
ENVIRONMENTAL QUALITY
14I
C.
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
3. Based on I Basis of Design" parameters listed above, will the proposed design allow the treatment facility to
meet the NPDES Permit Limits listed above? ® Yes or ❑ No. If no, describe how and why the Permit Limits will not be
met:
4. Per 15A NCAC 02T .0505(1), by-pass and overflow lines are prohibited. Is this condition met by the design? ®Yes or ❑ No
If no, describe the treatment units bypassed, why this is necessary, and where the bypass discharges:
5. Per 15A NCAC 02T .0505(k), multiple pumps shall be,provided wherever pumps are -used. Is this condition -.met by the
design? ® Yes or ❑ No. If no, provide an explanation:
6. Per 15A NCAC 02T .0505(I), power reliability shall be provided consisting of automatically activated standby power supply
onsite capable of powering all essential treatment units under design conditions, or dual power supply shall be provided
per 15A NCAC 02H. 0124(2)(a). Is this condition met by the design? ® Yes or ❑ No. If no, provide (as an attachment
to this Application) written approval from the Director that the facility:
➢ Has a private water supply that automatically shuts off during power failures and does not contain elevated -water
storage tanks, and
➢ Has sufficient storage capacity that no potential for overflow exists, and
➢ Can tolerate septic wastewater due to prolonged detention.
7. Per 15A NCAC 02T .0505(o), a minimum of 30 days of residual storage shall be provided. Is this condition met by the -
design? ® Yes or ❑ No. If no, explain the alternative design criteria proposed for this project in accordance 15A NCAC
02T .105(n):
8. Per 15A NCAC 02T .0505(g), the public shall be prohibited from access to the wastewater treatment facilities. Explain how
the design complies with this requirement: Existing and proposed fence around the perimeter of the facility along with a
locked gate
9. Is the treatment facility located within the 100-year flood plain? ❑ Yes or ® No. if yes, describe how the facility is
protected from the 100-year flood:
WASTEWATER TREATMENT UNIT AND MECHANICAL EQUIPMENT INFORMATION —COMPUTE-FOR-NEW OR
EXPANDING FACILITIES AND FOR MODIFIED TREATMENT UNITS
1. PRELIMINARY AND PRIMARY TREATMENT (i.e., physical removal operations and flow equalization):
Calculations
No. of
Plan Sheet
Speccation
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
Manual Bar Screen
N/A
MGD at peak hourly flow
Mechanical Bar
N/A
MGD at peak hourly flow
Screen
Grit Removal
N/A
MGD at peak hourly flow
Flow Equalization
1
Steel Pre4ab
6,000 gallons
G1
Yes
structure
ft diameter; ft side
Primary Clarifier
N/A
Circular
water depth
Primary Clarifier
N/A
Rectangular
square feet; ft side
water depth
Other
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 8

ENVIRONMENTAL QUALITY
14I
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 9

State of North Carolina
Department of Environmental Quality
sion of Water Resources
�i%czfi�r R.e�aure�s
ENVIRONMENTAL OUALITY APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC42-
14)
2. SECONDARY TREATMENT (BIOLOGICAL REACTORS AND CLARIFIERS) (i.e., biological and chemical processes to remove
organics and nutrients)
Calculations
No. of
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
Aerobic Zones/
N/A
gallons
Tanks
Anoxic Zones/
gallons
Tanks
Anaerobic
gallons -
Zones/Tanks
Sequencing Batch
--
gallons
Reactor (SBR)
Membrane
--
gallons
Bioreactor (MBR)
ft diameter; ft side
Secondary Clarifier
Circular
water depth
Secondary Clarifier
Rectangular
square feet; ft side
water depth
Other
3. TERTIARY TREATMENT
Calculations
No. of
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
ft diameter; ft side
Tertiary Clarifier
N/A
Circular
water depth
Tertiary Clarifier
Rectangular
square feet; ft side
water depth
Tertiary Filter
square feet
Tertiary Membrane
feet
Filtration
square
Post -Treatment
-
gallons
Flow Equalization
Post -Aeration
gallons
Other
4. DISINFECTION
Calculations
No. of
Plan Sheet
Specification
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
(Yes or No)
gal/day per bank at peak
hourly flow; number of
Ultraviolet Light
N/A
(Parallel; in
banks; number of
series)
lamps/bank
(Gas;
gallons of contact
Chlorination
tablet; liquid)
tank/unit
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 10

Yvdiei vesources
ENVIRONMENTAL OVAL TY
14)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
Dechlorination
(Gas;
gallons of contact
tablet; liquid)
tank/unit
5. RESIDUALS TREATMENT
Calculations
Treatment Unit
No. of
Type
Size per Unit
Plan Sheet
Specification
Provided?
Units
Reference
Reference
(Yes or No)
Gravity Thickening
N/ A
square feet; ft side
Tank
water depth
Mechanical
Thickening/
dry lb/hour
Dewatering
Aerobic Digestion
gallons
Anaerobic
gallons
Digestion
Composting
dry lb/hour
Drying
dry lb/hour
Other
6. PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain oumos)
Location
No. of
Pumps
purpose
Type
Capacity of
each pump
Plan Sheet
Reference
Specification
Reference
GPM
TDH
Proposed EQ Basin
2
Convey flow from
EQ Basin into
treatment train
Submersible pumps
55
50'
G1
7. MIXERS
Location
No. of
Mixers
Purpose
Type
Power of
each Mixer
(HP)
pian Sheet
Reference
Specification
Reference
N/A
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 11

i CiR71 R.eSvurCVs
ENVIRONMENTAL OUALiTY
14)
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 12

EN IRONVIGNTAL QUALITY
14)
9.
BLOWERS
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM AC-"M
Location
No. of
Blowers
purpose
Type
Capacity of
each Blower
(Clo
plan Sheet
Reference
Specification
Reference
N/A
Location
No. of
Units
Purpose
Type
Plan Sheet
Reference
Specification
Reference
N/A
D. SETBACKS —COMPLETE FOR NEW WASTEWATER TREATMENT STRUCTURES
1. The minimum distance for each setback parameter to the wastewater treatment/storage units per 15A NCAC 02T .0506(b)
are as follows:
Is Minimum Distance
Minimum Distance
Requirement met by the
Setback Parameter
Required from Nearest
Design? If "No", identify
Treatment/Storage
Setback Waivers in Item D.2
Unit
Below
100 ft
® Yes
❑ No
Any habitable residence or place of assembly under separate
ownership or not to be maintained as part of the project site
Any private or public water supply source
100 ft
® Yes
❑ No
Surface waters (streams — intermittent and perennial, perennial
50 ft
® Yes
❑ No
waterbodies, and wetlands)
Any well with exception of monitoring wells
100 ft
Yes
❑ No
Any property line
50 ft
® Yes
❑ No
2. Have any setback waivers been obtained per 15A NCAC 02T .0506(d)? El Yes or ®No. If yes, have these waivers been
written, notarized and signed by all parties involved and recorded with the County Register of Deeds? El Yes or ❑ No. If
no, provide an explanation:
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 13

yi%ater Resources
ENVIRONMENTAL QUALITY
14)
State of North Carolina
Department of Environmental Quality
sion of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC-12-
SECTION 5: APPLICATION CERTIFICATION BY PROFESSIONAL ENGINEER
Professional Engineer's Certification per 15A NCAC 02T .0105:
attest that this application package for an Authorization to Construct
(Typed Name of ProfessionvA
al Engineer)
y
for the v !"
(Facility and Project Name)
was prepared under my direct supervisory control and to the best of my knowledge is accurate, complete and consistent
with the information supplied in the engineering plans, specifications, calculations, and all other supporting
documentation for this project. I further attest that to the best of my knowledge the proposed design has been
prepared in accordance with all applicable regulations and statutes, 15 NCAC 02H. 01001 15A NCAC 02T, North Carolina
General Statute 133-3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design
Criteria for NPDES Wastewater Treatment Facilities, and this Authorization to Construct Permit Application, except as
provided for and explained in Section 4.13.1 of this Application. I understand that the Division of Water Resources,
issuance of the Authorization to Construct Permit may be based solely upon this Certification and that -the Division may
waive the technical review of the plans, specifications, calculations and other supporting documentation provided in this
application package. I further understand that the application package may be subject to a future audit by the Division.
Although certain portions of this submittal package may have been prepared, signed and sealed by other professionals
licensed in North Carolina, inclusion of these materials under my signature and seal signifies that I have reviewed the
materials and have determined that the materials are consistent with the project design.
I understand that in accordance with General Statutes 143-215.6A and 143-215.6B, 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.
North Carolina Professional Engineer's seal with written signature placed over or adjacent to the seal and dated:
S
0 ;
SEAL Tr a
.� 10
Application for Authorization to Construct Permit (FORM ATC-12-14) Page 14

ry "I >rResource$
[NV1RONMENTAL OUAL1TY
14).
ION &. APALICATIC
State of North l
Department of Environmental
Division Lof Water Ete
APRLCCATION Ott: IUTHC)IilZ1TIC?N TO C{7h15TRUC I'RNIIT 4i CRilll A1iC-:
Applicants Certification per 15A NCAC 02T .01U6fb};
(Typed
far the
Name of Signature Authority and Title}
4 i e. 41 0 S T r lr
(Facility -and project Name)
has been reviewed by me and inaccurate and complete
required parts of this application package are not comp!
attachments are not included, this application package'
accordance with 15A NCAC 02T .0120(b), the Applicant
has not abandoned -a wastewater facility without proper
appeals have been abandoned or exhausted, are comp)
overdue annual fees.
I_understand that the Division of Water Resources' iss
solely upon acceptance of the licensed Professional E
may waive the technical review of the plans, specifica
in this application package. I further understand that
I understand that in accordance with General Statutes 1
any false statement, representation, or certifiication in a
which may include a fine not to exceed $10,000, as well
Signature: T� .
THE COMPLETED l�PPLICATION ANn SU
NO-RTIi CARQLINA t)EPARTMENT
DIVISION OF VU
t that this application package for an Authorization to {
o the best of my knowledge. I also understand that if a
ted and that if all required supporting information and
ill be returned to me as incomplete. 1 further certify th
or any affiliate has not been convicted of environmental closure, does not have an outstanding civil penalty why
i nt with any active compliance schedule, and does not l ceofthe Authorization to Construct Permit may be ba
Y
; neeesCertification contained in Section 5, and that tht
rs, calculations and other supporting documentation p
application,package may be subject to a future audit.
�3-215:CA and 143-2� S.6R an erson who knowin 1 r
Y P !a Y
y application package shall be guilty of a Class 2 misde
s civil penalties up to $25,000 per violation.
Date:
0 0,, �-1'�
)RTING INFORMATIC)N SHALL BE SL#BMITTED T0;
ENVIRONMENT AND NATURAL RESOURCES
TER RESOURCES/NPITES
By Ci,S. Postal Service � B Courier 5 ecial Detiveryl
�G�,7 MAIL Sl*RI/ICE CENTER S12 N. SALISBl1RY STF{I_Et', 9TH FLOOR
RALEIGH, NORTH CAROLINA 2769. -161 RALEIGH, NORTH CAROLINA 27604
TELEPHON NUMBER. [phone]
Application for Authorization to Construct Permit (FORM A�`C�i2-14)
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