WQ0041559_Application (FTSE)_20200309

LW IN 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: ISS (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Davie County Water System (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ® State/County ❑ Municipal ❑ Other
3. Signature authority's name: Johnny Lambert per 15A NCAC 02T .0106(b)
Title: Utilities Director Ln%j
NC Department of
4. Applicant's mailing address: 298 East Depot St Environmental Quality
Received
city: Mocksville State: NC zip: 27028-MAR 0 9 2020
i
5. Applicant's contact information: },ay
Phone number: [phone] Email Address: ilambert(7a,daviecountvnc.gov_ Winston-Salem
' Regional Office
H. PROJECT INFORMATION:
1. Project name: Farmington Rd/US 158 Sewer
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: Davie
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.952242' Longitude:-80.538073'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: John Grey License Number: 015407
Firm: Grey Engineering,Inc.
Mailing address: P.O. Box 9
City: Mocksville State: NC Zip: 27028-
Phone number: (336 978-3222 Email Address: igrey(a)greyengineering.com
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
1. Facility Name: Dutchmans Creek Permit Number: NCO021491
Owner Name: Town Of Mocksville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than W WTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: 15 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):

1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No NN/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEVI been attached?
❑ 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 N 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
N 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 ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0l 14(fl? []Yes N 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 "h
No. of Units
Flow
Non Residential
880 gal/ac
34
30,000 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
30,000 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.
8. Wastewater generated by project: 30 000 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):

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 3027 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: 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)(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.

1. Does the project comply with all separations found in 15A NCAC 02T .0305(fl & (a) ® Yes ❑ No
rh.r shell he nrnvided for newer systems:
/ 1Jt1 LVl.tlli VL1.VJVJ a�V
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
An . riming pools
10 feet
Final earth grade (vertical)
36 inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305 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
➢ Seethe 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 .02007 ® 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 PermittingBranch
ranch
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
incnertinnc dnri,mented nee 19A NV AC a2T.ada3191l51 nr the nermitee'c individual Vvetem-Wider t'nnortinn nermitt

1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Puma 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. T
2. Professional Engineer's Certification:
that this application for
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 143-215.6B, 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, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
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.
Signature: Date: 12

r. NC Department or
Environmental Quality
Received State of North Carolina
MAR 0 9 2020 Department of Environmental Quality
DWR
s .'>
Division of Water Resources
i Winston-Salem
Division of water Reset V800% Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Town of Mocksville
Project Name for which flow is being requested: Farmington Road & US 158 Sewer
More than one B%SE may be required fora single project if the owner of the TH17'P is tot responsible for all pianp
stations along the ranee offhe proposed wastewater flow:
1. Complete this section only if you are the owner of the wastewater treatment plant.
a.
WWTP Facility Name: Dutchman's Creek WWTP
b.
WWTP Facility Permit #: NCO021491
A11 flows are in MGD
c.
WWTP facility's permitted flow
0.98
d.
Estimated obligated flow not yet tributary to the WWTP
0
e.
WWTP facility's actual avg. flow
0.470
f.
Total flow for this specific request
0.030
g.
Total actual and obligated flows to the facility
0.500
It.
Percent of permitted flow used
51 %
1I. 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)
Design
Pump
Average Daily
Station
Firm Flow**
(Name or
Capacity, * (Finn / pi),
Nmnber)
MOD MOD
(B)
(C)
(D)=(B+C)
(l)=(A-D)
Obligated,
Approx.
Not Yet
Total Current
Current Avg.
Tribunary
Flow Plus
Daily Flow,
Daily Flow,
Obligated
Available
MOD
MGD
Flow
Capacity***
*'rhe Firm Capacity of any pump station is defined as the maxinntm pumped flow that
can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking
factor (pf) not less than 2.5.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the W WTF where the Available Capacity is < 0.
Downstream Facility Name (Sewet): Dutchman's Creek WWTP
Downstream Permit Number: NCO021491
Page 1 of 6
F'1'SE 04-16

IlI. Certification Statement:
I Matt Settlemyer certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the flow from this project is not anticipated to
cause any capacity related sanitary sewer overflows or overburden any downstream pump station
on route to the receiving treatment plant under normal circumstances, given the implementation of
the planned improvements identified in the planning assessment where applicable. This analysis
has been performed in accordance with local established policies and procedures using the best
available data. This certification applies to those items listed above in Sections I and 11 plus all
attached planning assessment addendums for which I am the responsible party. Signature of this
form indicates acceptance of this wastewater flow.
Signing 0f(
Signature
3. S .U?,6
Dole
Page 2 of G
FTSG 04-16

NC Department of
c Environmental Quality Department of Environmental Quality
t Received Division of Water Resources
MAR 0 9 2020
Flow Tracking for Sewer Extension Applications
Winston-Salem (FTSE 10-18)
M
Entity Requesting Allocation: Davie County Water System
Project Name for which flow is being requested: Farmington Road & US 158 Sewer
More than one FTSE maybe required for a single project if the owner of the WWTP is not responsible for 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. WWTP Facility Name: Dutchmans Creek
b. WWTP Facility Permit #: NCO021491
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
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
All flows are in MGD
0.030
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)
Design
Average
Approx.
Pump
Daily
Current
Pump Station
Station
Firm
Flow**
Avg. Daily
(Name or
Permit
Capacity, *
(Firm / pf),
Flow,
Number)
No.
MGD
MGD
MGD
Dutchmans
0.288
0.115
0.041.
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Total
Not Yet
Current Flow
Tributary
Plus
Daily Flow,
Obligated
Available
MGD
Flow
Capacity***
0
0.041.
0.074
—;-The Firm Capacity (design flow) of any pump 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 firm 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): Dutchman Creek WWTP
Downstream Permit Number: NCO021491

III. Certification Statement:
I Johnny Lambert certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the flow from this project is not anticipated to cause any
capacity related sanitary sewer overflows or overburden any downstream pump station en route to the
receiving treatment plant under normal circumstances, given the implementation of the planned
improvements identified in the planning assessment where applicable. This analysis has been performed
in accordance with local established policies and procedures using the best available data. This
certification applies to those items listed above in Sections I and II plus all attached planning assessment
addenduins for which I am the responsible party. Signature of this form certifies that the receiving
collection system or treatment works has adequate capacity to transport and treat the proposed new
wastewater.
Signature
of Signing Ojjtcial
2 25`'-Zo2o
Date
Page 2 of 6
FTSE 10-18

GREY
ENGINEERING, INC.
2/25/20
:•, Environmental
NC Department of
quality
R
Received
Winston Salem Regional Office
MAR 0 9 2020
Water Quality Section
W
Winston-Salem
450 Hanes Mill Rd, Suite 300
'-
Regional Office
Winston-Salem, NC 27105
Re: Davie County Farmington Road & US 158 Sewer Fast Track Permit Application
The Davie County Water System proposes to construct 3,027 If of 8" sewer from its
Dutchmans Creek interceptor parallel to US 158 south of 1-40 and crossing Farmington
Road to serve prospective developments including a new County Departmental
administration building, fast food restaurants and office structures.
Approximately 30,000 gpd of additional flow will be generated by 34 acres of non-
residential development (at 880 gpd/ac) and pass through the County's Dutchman
Creek pump station to be delivered to the Town of Mocksville's Dutchman Creek
WWTP.
Enclosed please find one original and one copy of the following:
1. A $480.00 check to NCDEQ — Water Quality for permit fees.
2. Executed form FTA 04-16 and supporting documentation.
3. Executed form FTSE 10-18 for intermediate sewers in Davie County.
4. Executed form FTSE 10-18 for Intermediate sewers and treatment in Forsyth
County.
5. 8.5X11" USGS topo map of project area.
6. 8.5X11" aerial photomap of the project area.
Thank you,
Grey Engineering, Inc.
John Grey, PE
President
Cc: Johnny Lambert
P.O. Box 9 • Mocksville, NC 27028 • Phone: [phone] • Fax: [phone] • www.greyengineering.com

NAD83 COORDINATES 0 Boo 1,600
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_Farmington-158 aerial SS permit
GREY ENGINEERING, ING. DAVI E COUNTY UTILITIES
Civil Design and Surveying
P.O. Box 9 Mocksville, N.C. 27028
greyengineering.com [phone] FARMINGTON ROAD AT US158
DRAWN BY: G. BULLARD PROJ. NO.: 20231.GE SEWER EXTENSION ON AERIAL MAP 11
DESIGN BY: G. BULLARD DATE: 02/25/20

NAD83 COORDINATES USGS QUAD u oUu i,ouu
LAT= 35.9522423225 MOCKSMLLE 360BO—H5
LONG=—80.5380736599 SCALE: 1"=800' CONTOURS AT 10'
1 \ \ b r a\ ✓ f / i? `111 f 1 A th 1 /
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0 800 1.600
SCALE: 1"=800'
—Farmington-158 usgs SS permit
GREY Civil Design anddE urveyi glNc. DAVI E COUNTY UTILITIES
P.O. Box 9 Mocksville, N.C. 27028
greyengineering.com [phone] FARMINGTON ROAD AT US158
DRAWN BY: G. BULLARD PROJ. NO.: 202.131.GE SEWER EXTENSION ON USGS MAP 11
DESIGN BY: G. BULLARD DATE: 02/25/20