WQ0041523_Application (FTSE)_20200225

DocuSign Envelope ID: 038A8A2C-2512-4F00-89A9-C305FD0607E3
A-40 HINDE
ENGINEERING
401 Harrison Oaks Blvd
Suite 220
Cary, NC 27513
Phone: [phone]
Fax: [phone]
LETTER OF TRANSMITTAL
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To: Washington Regional Office WQS Date: February 20, 2020
943 Washington Square Mall
Washington, NC 27889
Re: U-2714 Wayne County - 12" Force Main
Sewer Relocation. NCDOT Project: N
Williams St. from N of US 70 to Tommy's St.
(Town of Fremont)
Job No.: A2015902.00
NCDOT — U-2714 Wayne
County
I am sending you the following item(s):
COPIES
DATE
NO.
DESCRIPTION
1
02-20-2020
1
Sewer Permit Application
1
02-20-2020
1
Vicinity Maps
1
02-20-2020
1
$480.00 Check
These are transmitted as checked below:
❑
As requested
®
For approval
❑
For review and comment
Remarks:
❑ For your use
❑ For Signatures
ocuSigned by:
Copy to: File Signed: Ei
V. �oaorf.rl.�; f' ..e.
Steve Harrell RF23Fy28878C49A..
Corey D. Bousquet, PE
Project Manager

U-2714
P-1 Wayne County
PROJECT SPECIAL PROVISION
(10-18-95) (Rev. 3-21-17)) Z-la
PERMITS
The Contractor's attention is directed to the following permits, which have been issued to the
Department of Transportation by the authority granting the permit.
Dredge and Fill and/or U. S. Army Corps of Engineers
Work in Navigable Waters 404
Water Quality (401) Division of Environmental Management, DEQ
State of North Carolina
Buffer Certification Division of Environmental Management, DEQ
State of North Carolina
The Contractor shall comply with all applicable permit conditions during construction of this
project. Those conditions marked by * are the responsibility of the Department and the
Contractor has no responsibility in accomplishing those conditions.
Agents of the permitting authority will periodically inspect the project for adherence to the
permits.
The Contractor's attention is also directed to Articles 107-10 and 107-13 of the 2018 Standard
Specifications and the following:
Should the Contractor propose to utilize construction methods (such as temporary structures or
fill in waters and/or wetlands for haul roads, work platforms, cofferdams, etc.) not specifically
identified in the permit (individual, general, or nationwide) authorizing the project it shall be the
Contractor's responsibility to coordinate with the Engineer to determine what, if any, additional
permit action is required. The Contractor shall also be responsible for initiating the request for
the authorization of such construction method by the permitting agency. The request shall be
submitted through the Engineer. The Contractor shall not utilize the construction method until it
is approved by the permitting agency. The request normally takes approximately 60 days to
process; however, no extensions of time or additional compensation will be granted for delays
resulting from the Contractor's request for approval of construction methods not specifically
identified in the permit.
Where construction moratoriums are contained in a permit condition which restricts the
Contractor's activities to certain times of the year, those moratoriums will apply only to the
portions of the work taking place in the restricted waters, wetlands or buffer zones,
provided that activities outside those areas is done in such a manner as to not affect the
restricted waters, wetlands or buffer zones.

P-2
U.S. ARMY CORPS OF ENGINEERS
WILMINGTON .DISTRICT
Action Id. SAW-2018-02162 County: Wayne County U.S.G.S. Quad: Northeast Goldsboro
GENERAL PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION
Permittee: Chad Coeeins
NCDOT/ Division 4 Environmental Officer
Address: PO Box 3165
Wilson NC, 27895
Telephone Number: C 252.717.8699
Size (acres) N/A Nearest Town Goldsboro
Nearest Waterway Little River River Basin Neuse
USGS HUC 03020202 Coordinates Latitude: 35.41195, Longitude:-77.98273
Location description: US 117A, between US 70 and SR 1571 (Tommys Road), in Goldsboro, NC
Description of projects area and activity: TIP U-2714; Road widening impacting 98 linear feet of tributary
Applicable Law: ® Section 404 (Clean Water Act, 33 USG 1344); ❑ Section 10 (Rivers and Harbors Act, 33 USC 403)
Authorization: Nationwide Permit Number: NWP 14 Linear Transportation Proieets
SEE ATTACHED NWP GE/'VERAL, REGIONAL AND/OR SPECIAL CONDITIONS
Your work is authorized by the above referenced permit provided it is accomplished in strict accordance with the attached
conditions and your submitted application and attached information dated November 16, 2018. Any violation of the attached
conditions or deviation from your submitted plans may subject the permittee to a stop work order, a restoration order, a Class
I administrative penalty, and/or appropriate legal action.
SPECIAL CONDITION
1. This USACE permit does not authorize you to take a threatened or endangered species, in particular,
the Northern Long-eared Bat (NLEB) (Myotis septentrionalis). In order to legally take a listed species,
you must have separate authorization under the Endangered Species Act (ESA) (e.g., a Biological
Opinion (BO) under the ESA, Section 7, with 'incidental take' provisions with which you must comply).
The U.S. Fish and Wildlife Service's (USFWS's) Programmatic .BO titled 'Northern Long-eared Bat
(NLEB) Programmatic Biological Opinion for North Carolina Department of Transportation (NCDOT)
Activities in Eastern North Carolina (Divisions 1-8),' dated March 25, 2015, and adopted on May 4,
2015, contains mandatory terms and conditions to implement the reasonable and prudent measures that
are associated with 'incidental take' that are specified in the BO. Your authorization under this USACE
permit is conditioned upon your compliance with all the mandatory terms and conditions (incorporated
by reference into this permit) associated with incidental take of the BO. Failure to comply with the terms
and conditions associated with incidental take of the BO, where a take of the listed species occurs,
would constitute an unauthorized take, and would also constitute non-compliance with your USACE
permit. The USFWS is the appropriate authority to determine compliance with the terms and conditions
of its BO and with the ESA.
This verification will remain valid until the expiration date identified below unless the nationwide and/or regional general permit
authorization is modified; suspended or revoked. If, prior to the expiration date identified below, the nationwide and/or regional general
permit authorization is reissued and/or modified, this verification will remain valid until the expiration date identified below, provided
it complies with all requirements of the modified nationwide permit. If the nationwide and/or regional general permit authorization
expires or is suspended, revoked, or is modified, such that the activity would no longer comply with the terms and conditions of the
nationwide permit, activities which have commenced (i.e., are under construction) or are under contract to commence in reliance upon
the nationwide and/or regional general permit, will remain authorized provided the activity is completed within twelve months of the
date of the nationwide and/or regional general permit's expiration, modification or revocation, unless discretionary authority has been
exercised on a case -by -case basis to modify, suspend or revoke the authorization.

P-3
This Department of the Army verification does not relieve the permittee of the responsibility to obtain any other required Federal, State
or local approvals/permits.
If there are any questions regarding this verification, any of the conditions of the Permit, or the Corps of Engineers regulatory program,
please contact Eric Alsmeyer at (919) 5544884 X 23 or Eric,C.Alsmever(a,uSaee.armv.mil.
Digitally signed by
MATTHEWS.MONTE.K.1284867633
DN: c=US, o=U.S. Government, ou=DoD,
au=PKI, ou=USA,
cn=MATTHEWS.MONTE.K.1284867633
Corps Regulatory Official: Date: 2018,11.2007:14:34-05'00'
Date: November 20, 2018, Expiration Date of Verification: March 18, 2022
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete our Customer Satisfaction Survey, located online at
http:Hcop2smapu.usace.arm�T.mil/cm apex%f?p=1s6:4:0.

Action ID Number: SAW-2018-02162 County: Wayne County
Permittee: Chad Coodus
NCDOT/ Division 4 Environmental Officer
Project Name: NCDOT U-271.4 US117A widen Wavne Div4
Date Verification Issued: November 20, 2018
Project Manager: Eric Alsmever
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification and return it to the following address:
US ARMY CORPS OF ENGINEERS
WIL INGTON DISTRICT
Attn: Eric Alsmever
Raleigh Regulatory Field Office
3331 Heritage Trade Drive, Suite 105
Wake Forest, NC 27587
Please note that your permitted activity is subject to a compliance inspection by a U. S. Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending, modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.

i2k
NATIONWIDE PERMIT 14
DEPARTMENT OF THE ARMY
CORPS OF ENGINEERS
FINAL NOTICE OF ISSUANCE AND MODIFICATION OF NATIONWIDE PERMITS
FEDERAL REGISTER
AUTHORIZED MARCH 19, 2017
Linear Transportation Proiects. Activities required for crossings of waters of the United
States associated with the construction, expansion, modification, or improvement of linear
transportation projects (e.g., roads, highways, railways, trails, airport runways, and taxiways)
in waters of the United States. For linear transportation projects in non -tidal waters, the
discharge cannot cause the loss of greater than 1/2-acre of waters of the United States. For
linear transportation projects in tidal waters, the discharge cannot cause the loss of greater
than 1/3-acre of waters of the United States. Any stream channel modification, including bank
stabilization, is limited to the minimum necessary to construct or protect the linear
transportation project; such modifications must be in the immediate vicinity of the project.
This NWP also authorizes temporary structures, fills, and work, including the use of
temporary mats, necessary to construct the linear transportation project. Appropriate measures
must be taken to maintain normal downstream flows and minimize flooding to the maximum
extent practicable, when temporary structures, work, and discharges, including cofferdams,
are necessary for construction activities, access fills, or dewatering of construction sites.
Temporary fills must consist of materials, and be placed in a manner, that will not be eroded
by expected high flows. Temporary fills must be removed in their entirety and the affected
areas returned to pre -construction elevations. The areas affected by temporary fills must be
revegetated, as appropriate.
This NWP cannot be used to authorize non -linear features commonly associated with
transportation projects, such as vehicle maintenance or storage buildings, parking lots, train
stations, or aircraft hangars.
Notification: The permittee must submit a pre -construction notification to the district engineer
prior to commencing the activity if. (1) the loss of waters of the United States exceeds 1/10-
acre; or (2) there is a discharge in a special aquatic site, including wetlands. (See general
condition 32.) (Authorities: Sections 10 and 404)
Note 1: For linear transportation projects crossing a single waterbody more than one time at
separate and distant locations, or multiple waterbodies at separate and distant locations, each
crossing is considered a single and complete project for purposes of NWP authorization.
Linear transportation projects must comply with 33 CFR 330.6(d).
Note 2: Some discharges for the construction of farm roads or forest roads, or temporary
roads for moving mining equipment, may qualify for an exemption under section 404(f) of the
Clean Water Act (see 33 CFR 323.4).
Note 3: For NWP 14 activities that require pre -construction notification, the PCN must
include any other NWP(s), regional general permit(s), or individual permit(s) used or intended

Permit Number WQ0041523
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
sarah.toppen
Coastal SWRule
Permitted Flow
Factitty
Facility Name
NCDOT Project U-2714 Wayne County- Fremont
Location Address
Owner
Central Files: APS _ SWP
3/5/2020
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit Classification
A
Individual
Permit Contact Affiliation
MajodMinor Region
Minor Washington
County
Wayne
Facility Contact Affiliation
Owner Name Owner Type
Town of Fremont Government - Municipal
Owner Affiliation
W Darron Flowers
PO Box 4
Dates/Events Fremont
Orig Issue App Received
2/25/2020
Scheduled
Draft Initiated Issuance
NC 27830000
Public Notice Issue Effective Expiration
Requested /Received Events
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10815 Sikes Place, Suite 210t Charlotte NC
Charlotte, NC 28277 66 21/530
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PAY TO THE NCDEQ- Division of Wafer Resources QQ
ORDER OF `�' **480.00
Four Hundred Eighty and
DOLLARS (`
NCDEQ- Division of Water Resources
Washington Regional Office
Water Quality Section
943 Washington Square Mall
er F
Washington, NC 27889
MEMO
Sewer Permit Fee-U-2714, Town of Fremont

2/20/2020
Map produced by GISsurfer from mappingsupport.com
VICINITY MAP
U-2714 Wayne County - NCDOT Project:
Improvements to N Williams from N of US 70
to Tommy's Road
Proposed 12" PVC Force Main Relocations at
Industry Ct and N Williams St.
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DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63 State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineering practices.
CSC,'
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .030, design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would inc)ude pla design
calculations, and project specifications referenced in 15A NCAC 02'r .0305 and the applicable m121mup des*-,criteriahese
documents shall be available upon request by the Division. ' IS 2 S
IP
C''` Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCA3. \�
�s Po �i9
Projects not eligible for review via the fast track process (must be submitted for full technical review): o� o.'o
➢ Projects that require an environmental assessment in accordance with 15A NCAC IC .0100; �- °5 °�y
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T; c0
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General - When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary_of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item 11.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina_ licensed _Prgfessional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of

. DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63
E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
M Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-
215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 1 1-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
M Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(D, submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
)0- It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .01 15(a)( I) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Flome/Property Owners' Associations
❑ Per 15A NCAC 02T .QI I S(c), submit the properly executed Ocrational Agreement FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63 State of North Carolina
Department of Environmental Quality
DWR 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: to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Town of Fremont (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Barbara Aycock per 15A NCAC 02T.0106(bl
Title: Town Administrator
4. Applicant's mailing address: P.O. Box 4
City: Fremont State: NC Zip: 27830-
5. Applicant's contact information:
Phone number: [phone] Email Address: baycock6bfremontnc.yov
11. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
1. Project name: NCDOT Project U-2714 Wayne County —Fir e fYl0 &t
2. Application/Project status: ❑ Proposed (New Permit) p ® Existing Permit/Project
If a modification, provide the existing permit number; �Q 102 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Wayne
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.417448' Longitude:-77.982061'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Corey Bousquet License Number: 023041
Firm: Hinde Engineering
Mailing address: 401 l larrison Oaks Blvd., Suite 220
City: Cary State: NC Zip: 27513-
Phone number: [phone] Email Address: cbousquet0hindeenu�ineering.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Fremont WWTP Wastewater Irrigation System Permit Number: W00034102
Owner Name: Town of Fremont
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: 12 inch
System Wide Collection System Permit Numbcrts ifa (icable): WQCS00023
Owner Name(s): City of Goldsboro
FORM: FTA 04-16 Page I of 5

DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63
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: 80 % Domestic/Commercial 20 % Commercial
% Industrial (See 15A NCAC 02T .0103-(20))
o Is there a Pretreatment Program in effect? ® Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .01 14(t)? ❑ Yes ® No
➢ If Yes, provide a copy of now reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.01140
Daily Design Flow ° b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC _02'I_.01 14(WAO). (e)(1) and (e)(2for 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: 0 GPD (per 15A. NCAC 02"1'„0 1_I 4)
➢ 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

DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
l . Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
➢ 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) — Q2T .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
12
1366
PVC, DR 18
6. Power reliability in accordance with I5A NCAC 02T .0305 h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(l)(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)(l)(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

DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63
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(t) 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 lI 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 , contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpaQe
➢ 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 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(cx6) (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

DocuSign Envelope ID: FE9CFE61-4D49-4CC8-86C7-5825A005AA63
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum DesLn Criteria for the Permitting of PumStations
and Force Mains (latest versiony 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 C OXE 7- 13_attest that this application for
(Professional Engineer's name from Application Item Ill. 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:
2/6/2020
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, g Ac,C ve /f' �wN fiG+�/yi N4P.J f�C, /64 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.
DocuSigned by:
2/10/2020
Signature: G�''e"'��1� _ Date:
6F841B5AA72B4B2...
FORM: FTA 04-16 Page 5 of 5