WQ0041356_Application (FTSE)_20191212

State of North Carolina
Department of Environmental Quality
Division of Water Resources
DWR , ,
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dh4slon of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:Q go C) _1 !67
//�� (to be completed by DWR)
All items must be completed or the aoolication will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Lexington (company, municipality, FICA, utility, etc.)
2. Applicant type: ® Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
i
3. Signature authority's name: Roger Jones per 15A NCAC 02T .0106(b)
Title: Owner
4. Applicant's mailing address: 28 West Center Street Eilviroijaiertal Qllafliq
City: Lexington State: NC Zip: 27292-Received_
5. Applicant's contact information: u { Z
Phone number: 336) 248-3930 Email Address: [e-mail] Ir";.ril^S Ctt-Salem
II. PROJECT INFORMATION: 10
1. Project name: Welcome Tire Sanitary Sewer Extension
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date: _
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Davidson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.91189' Longitude:-80.253025'
5. Parcel ID (if applicable): 6728-02-89-8171
(or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer: Timothy S. Kennerly License Number: 29317
Firm: Kennerly Engineering & Design. Inc
Mailing address: 12133 N. NC HWY 150, STE F
City: Winston-Saelm State: NC Zip: 27127
Phone number: 3( 36) 775-2118 Email Address: timothy.kennerly@kennerlveneineerin,-,.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Lexington Regional Wastewater Treatment Plant Permit Number: NCO055786
Owner Name: City of Lexington
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: _ inch
System Wide Collection System Permit Numberls) (if applicable): WQCS_
Owner Name(s):
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?
El Yes ❑No NN/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No NN/A
4. Origin of wastewater: (check all that apply)
❑ Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service El Hotel and/or Motels
❑ School / preschool / daycare ❑Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse _
❑.Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
N 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 N No
6. Hasa flow reduction been approved. under 15A NCAC .02T .0114(fl? ❑ Yes N No
➢ If yes provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
S.
Establishment Type (see 02T.0114 f 1
Daily Design Flow'"
No. of Units
Flow
Service. Station
25Qgal/Fixture
12
3,000"GPD
gall
GPD
gal/
GPD
' gall
GPD -
gal/
GPD
gall
GPD
Total
3,000 GPD
a See 15A NCAC 02T .0114(b), (d). (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
Wastewater generated by project: 3 000 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why: -
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:._
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain): _
FORM: FTA 04-16 Page 2of 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
8 383 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: N/A
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)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(13):
➢ 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) & N ® Yes ❑ No
➢ 15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer includin 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, W S-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 1X.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 trade vertical
36 inches
➢ 15A NCAC 02T.0305(e) 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.0305(f) or (a), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ❑ Yes ❑ No ®N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No ® N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ® No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(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 Punm 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 reauired Prior to submittal of the Fast Track Application and supporting documents
2. Professional Engineer's Certification:
I,—12Me]'I►fY 5 Krrti�/�¢c 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 Sower
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 143-215.6E, 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: �0g06ef9oaa9otpper
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
CO- -TOO S A $U C SLAICOS A js}l/1)AQAlest 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 143-215.613, 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 penaltie up to $25,000 per violation.
Signature: Date:
FORM: FTA 04-16 Page 5 of 5

f'-
7,evl�e� WS i� cececve�% a 1���
State of North Carolina
Department of Environmental Quality
Division of Water Resources
PIVIOlonKetwat"M g ,r1Ges Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: City'of Lexington ..
Project Name for which flow is being requested: Welcome Tire Sanitary Sewer
More than one FTSE maybe required for a single project if the owner of the R'WTP is not responsible far ali pump
stations along the route of the proposed wastewater flow
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. W WTPFacility Name:
b. WWTP Facility Permit
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the W W'
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
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)
(C)
(D)=(B+C) (E)=(A-D)
Design
Obligated,
Pump
Pump
Average
Approx.
Not Yet
Total Current
Station
Station
Firm Daily Flow**
Current
Tributary
Flow Plus
(Name or
Permit
Capacity, * (Firm / p fl,
Avg. Daily
Daily Flow,
Obligated Available
Number)
No.
MGD MGD
Flow, MGD
MGD
Flow Capacity***
RCR 0.29 0.12 0.08 0 0.08 0.04
Swearin& 5.91 2.36 1.5 0.13 1.63 0.73
Creek
* The Firm Capacity (design flow) of --any 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 flrm 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):
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

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193 Greenbriar Lane, Lexington, NC 27295
PH: 336.775.2118 Fax \3�3�6.764.0797
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