WQ0041461_Application (FTSE)_20200204

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: ypw h I hl (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Dobson (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County E Municipal
3. Signature authority's name: Michael Frazier per 15A NCAC 02T .0106(b)
Title: Public Works Director
4. Applicant's mailing address: P.O. Box 351
City: Dobson State: NC Zip: 27017-
5. Applicant's contact information:
Phone number: 336 356-8962 Email Address: [e-mail]
II. PROJECT INFORMATION:
1.
2.
3.
4.
5.
Project name: Public Water & Sewer Relocation (Wayne Farms
❑ Privately -Owned Public Utility
❑ Other
Application/Project status: ❑ Proposed (New Permit) E Existing Permit/Project
If a modification, provide the existing permit number: W000215 and issued date: 06/08/05
If new construction but part of a master plan, provide the existing permit number: W000
County where project is located: Sm
Approximate Coordinates (Decimal Degrees): Latitude: 36.391 ° Longitude:-80.7100
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Parcel ID (if applicable): 499611652360 NC Department of
(or Parcel ID to closest downstream sewer) Environmental Quality
III. CONSULTANT INFORMATION:
1. Professional Engineer: Steve M. Causev License Number: 19701
Finn: Allied Design, Inc.
Mailing address: 4720 Kesler Mill Road
City: Winston-Salem State: NC Zip: 27103-
Phone number: 3( 36) 765-2377 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
1. Facility Name: Town of Dobson W WTP Permit Number: NC 0021326
Owner Name: Town of Dobson
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than W WTF):
1. Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: _ inch
System Wide Collection System Permit Number(s)(pplicable): WQCS
Owner Name(s):
Received
FEB 0 4 2020
Winston-Salem
Regional Office
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?
❑ 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. Has a 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(ft)
Daily Design Flow e,"
No. of Units
Flow
N/A (Relocation)
N/A gal/
N/A
N/A GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
N/A 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.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: N/A 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): Relocation
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
8 682 SDR 26 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:
2. Approximate Coordinates (Decimal Degrees): Latitude: 0Longitude:
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)(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
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(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 I5A 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.04021 "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, m
the Minimum Design Criteria for the Permitting of Pup 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:
1, S%E-W- IM . C/4VS,6`Y 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, signature, and date:
3. Applicant's Certifica 'on per 15A
I, /W
02T .0106(b):
lovt6hel Works 0.r2Ci-oc
(Signature Authority's name & title from Application Item I.3.)
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: 01 /Z9/ZO
FORM: FTA 04-16 Page 5 of 5

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January 30, 2020
Allied Design, Inc.
CIVIL ENGINEERING ❖ LAND SURVEYING
Firm License No.: C-1891
1VC bePt of'�?nvironrnepta1 Quatir
North Carolina Department of Environment and Natural Resources
Water Quality Section
Raleigh Regional Office
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
SUBJECT: PUBLIC SEWER RELOCATION PERMIT
WAYNE FARMS
ADI PROJECT: 19-027
kaleigij Reg;o�ai Office
We are pleased to submit the enclosed information for permitting of the sewer line relocation on
the subject project.
This project consists of relocation of 6821f or 8" SDR 26 PVC sanitary sewer line. The sewer
line is being relocated to avoid a future building addition for Wayne Farms.
Please find enclosed:
1. This cover letter with the project description in the paragraph above;
2. A check in the amount of $480.00 for the distribution system fee;
3. A completed "Fast Track Sewer System Extension Application";
4. Two color copies of the USGS topographic,,map of this area;
5. Two copies of the street level map showing the general project area.
Should you have any questions, please contact me at [phone].
Sincerely,
Steve M. Causey, P.E.
NC Department of
Environmental quality
Received
FEB 0 y 2020
Ki ` Winston-Salem
t Regional Office
4720 KESTER MILL ROAD WINSTON-SALEM, NORTH CAROLINA 27103
Phone: [phone] A Fax: [phone]

Henderson, Justin L
From: Steve Causey <scausey@allied -engsurv.com>
Sent: Tuesday, February 4, 2020 1:21 PM
To: Henderson, Justin L
Cc: 'Wayne Barber'
Subject: (External] RE: Public Water & Sewer Relocation (Wayne Farms)
Justin, it was great speaking with you this afternoon and thank you for the clarification.
Based on our discussion and my understanding now of the regulations, please process our submittal
as a "new permit" rather than a "modification".
Thanks again and please let me know if you need anything else.
Steve Causey, P.E.
Allied Design, Inc.
Firm License No. C-1891
4720 Kester Mill Road
Winston-Salem, North Carolina 27103
Office: [phone]
Direct: [phone]
Fax: [phone]
From: Henderson, Justin L<[e-mail]>
Sent: Tuesday, February 04, 2020 1:01 PM
To: [e-mail]
Subject: Public Water & Sewer Relocation (Wayne Farms)
Steve,
I am reviewing the Fast Track application for the subject project and have the following additional information to
request:
1) You indicated that a permit modification is being requested to address this relocate and provided a permit
number of WQ00215, this permit number does not exist in our database. Please review the permit you wish to
modify and provide the correct number.
2) Are you sure you need to request a modification as opposed to a new permit to address this relocation?
Please contact me with any questions you have regarding this inquiry. The application will be placed on hold until the
above requested information is received by this office. Thanks.
Justin Henderson