WQ0035166_Application_20200108

401 Harrison Oaks Blvd.
Suite 220
Cary, NC 27513
Phone: [phone]
Fax: [phone]
LETTER OF TRANSMITTAL
To: Mooresville Regional Office WQS Date
610 E. Center Avenue
Mooresville, NC 28115
Re: 1-3819B Iredell County. 8" & 24" Gravity
Sewer Relocations. NCDOT Design Build
Project: 1-40/1-77 Interchange Improvement,
Statesville, NC.
I am sending you the following item(s):
PP. :[ "
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In/QR
hl! RESVILLE REN3!AL OFFICE
Rr_CE1VCD/NCb['NR/[3WR
JAN 07 2,020
VVOROS
MC(_,'?PSVILLE REGIONAL OFFICE
November 21, 2017
Emailed
Job No.: A2015503.00
NCDOT — 1-3802B Rowan
County
COPIES
DATE
NO.
DESCRIPTION
1
11-21-2019
1
Sewer Permit Application
1
11-21-2019
3
Vicinity Maps
1
11-21-2019
1
$480.00 Check
These are transmitted as checked below:
❑ As requested
® For approval
❑ For review and comment
Remarks:
❑ For your use
❑ For Signatures
Copy to: File Signed:
Jason Wilson
C ey D. Bousq,6et, PE
Project Manager

DocuSign Envelope ID: 6A960DDF-F2E4-4F18-8A08-DF4218EDEA3E State of North Carolina
Department of Environmental Quality
Division of Water Resources
P"m " VPPWs 15A NCAC 02T.0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
'Division of Water Resources FTA 04-16 & SUPPORTING -DOCUMENTATION
"7
77T-4, JAN 0 7 2020
Application Number: (to be completed by DWR)
All items mlist, be coon pmeted or,the application will be, returned WQROS
NA00prSVILLE REGIONAL- OFFICE
I. APPLICANT INFORMATION:
1. Applicant's name: City of Statesville (company, municapility, HOA, utility, etc.)
2. Applicant type: El Individual El Corporation El General Partnership
F-1 Federal F1 State/County Z Municipal
3. Signature authority's name: Scott Harrell, PE per t5A NC'AAC, 02T.0106 b
Title: Executive Director Public Works/City Engince
4. Applicant's mailing address: P.O. BOX I I I I
City: Statesville State: NC Zip: 28687
5. Applicant's contact information:
Phone number; [phone] Email Address:
H. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
1. Project name: NCDOT Project 1-3819B Iredell County
2. Application/Project status: El Proposed (New Permit) Existing Permit/Project
If a modification, provide the existing permit number: WQ003 5166 and issued date: 5jan201 I
If new construction but part of a master plan, provide the existing permit number: WQOO_
3. County where project is located: Iredell
4. Approximate Coordinates (Decimal. Degrees): Latitude: .5,791168' Longitude: -80.862535'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Corey BouNuet License Number: 023041
Finn: Hir
Mailing address: 401 Harrison Oaks Blvd., Suite 220
City: CM State: NC Zip: 27513
Phone number: [phone] Email Address: ebotisquet,'&Iiitidceggine,c-tliltlg.�gotiI
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Forth Creek WWTP Permit Number: NCO031836
Owner Name: City of Statesville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: inch
System Wide Collection Svsteni Permit Number(s) Ofappfigab e: WQCS
Owner Name(s):._
FORM: FTA 04-16 Page I 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?
Q4 . 0 .
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: 60 % Domestic/Commercial 20 % Commercial
20 % 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.0114(f))
Daily Design Flow n,b
No. of Units
Flow
gall
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal!
GPD
Total
GPD
a See 15A NCAC 02T .0114(h). (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
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: _GPD (per 15A NCAC 02T .0114)
i 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 Servers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 471 DI, PC 350
24 2796 DI, PC 250-350
+» 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:
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 the pump(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
6. Power reliability in accordance with 15A NCAC.02T,.0305(h)(I ):
❑ 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
r Must be permanent to facility
Or if the pump station has an average daily now 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)(l)(C):
i 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: ETA 04- l6 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & ISA NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(o & (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 impaunded 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
AnX swimming pools
10 feet
Final earth grade (vertical)
36 inches
i 15A NCAC 02T.030560 contains alternatives where separations in 02T.03051 cannot be achieved.
> **Stream classifications can be identified using the Division's NC Surface Water Classifications web )Lase
> If noncompliance with 02T.0305,(f) Or ; see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes [:]No ❑ N/A
i- See the Division's draft separation requirements for situations where separation cannot be meet
i No variance is required if the alternative design criteria specified is utilized in design and construction
i, 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?
D Information can be obtained from the 401 & Buffer Permittini Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6} (additional permits/cer(ifications)? ® Yes ❑ No
Per 15A NCAC 02T.0I05(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: FCA 04-16 Page 4 of 5

DocuSign Envelope ID: 6A960DDF-F2E4-4F18-8A08-DF4218EDEA3E
X. CERTIF.ICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria fo ILe _Pqrmittigg pf Pump S ticnts
a.,�lki&rce Mainsiatcatversionj, and theravit e r Ivxinim tDesttCriteria` latestversi rti as applicable?
®Yes FNo
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. A ravel of the request is re aired rior to submigill of he _F st Track Application and su rortin : d2cumen1j,
2. Professional Engineer's Certification:
I Corey D. Bousquet - Hinde Engineering 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 firrther 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 arty application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed S 10.000. as well as civil penalties uv to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1/7/2020
I Scott Harrell, Executive Director Public Works /City Engineer 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 unmediate 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 143-215.6.A 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.
DocuSigned by:
Signature: agDate: 1/7/2020
0888ENAMA942F...
FORM: FTA 04-16 Page 5 of 5

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PROP. 24" GRAVITY SEWER
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EXIST. 15" GRAVITY
SEWER LINE
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CINITY MAP
1-3819B Iredell County - NCDOT Design Build
Project: Improverrienis to the intersection of
1-40 and 1-77 in Statesville NC.
Proposed 24" Gravity Sewer Line Relocation
Crossing 1-40 North of the 1-40/1-77
Intersection.
11

L/,
PROPOSED 24" DI GRAVITY
SEWER LINE
PROPOSED 8" DI GRAVITY
SEWER LINE
EXISTING 8" VCP
GRAVITY SEWER
LINE
7
EXISTING 24" VCP
GRAVITY SEWER LINE
�,+ -� 6►
fill
VICINITY MAP
1-3819B Iredell County - NCDOT Design Build
Project: Improvements to the Intersection of
1-40 and 1-77 in Statesville NC.
Proposed 8" and 24" Gravity Sewer Line
Relocations at Broad Street and 1-77
Interchange.
0
I
R

Central Files: APS _ SWP
1 /8/2020
Permit Number WQ0035166
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
ori.tuvia
Coastal SWRuIe
Permitted Flow
0
Facility
Permit Tracking Slip
Status
Project Type
Active
Major modification
Version
Permit Classification
1.10
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
1-3819A Minor Mooresville
Location Address County
Iredell
Facility Contact Affiliation
Owner
Owner Name Owner Type
City of Statesville Government - Municipal
Owner Affiliation
Ron Smith
PO Box 1111
Dates/Events Statesville NC 28687111
Scheduled
Orig Issue App Received Draft Initiated Issuance
Public Notice Issue Effective Expiration
1 /5/2011 1 /8/2020
1 /8/2020 1 /8/2020
Regulated Activities
Requested /Received Events
Retail
Additional information requested
Subdivision
Additional information received
Wastewater collection
Outfall
Waterbody Name Streamindex Number Current Class Subbasin