WQ0041588_Application (FTSE)_20200326

Green Mountain Engineering, PLLC Civil Engineering Consultants
To, NCDEQ — Water Quality Section
Address: 450 W. Hanes Mill Rd — Suite 300., Winston-Salem, NC 27105
From: Jordan D. Young E.I., Green Mountain Engineering, PLLC
Date: 2019-October 28th
Re: Meadow Valley -Phase 5
Messages
Attached please find application packages for the private sewer extension off Basswood
Ave. that includes a pump station to serve the residential housing proposed by Meadow
Valley Phase 5. Included are one (1) original and one (1) copy of the Application
Package, and one (1) check for $480.00.
Please let us know if you have any questions or require additional information. I can be
reached via email iordanggreenmountainengineers.com or by cell phone [phone])
at your convenience.
1 1., G73Nartmcrit u7
Environmental Quality
Received
Best Regards, VU 3 G 20119
Winston-Salem
Jordan D. Young, E.I. R^cionai Office
Green Mountain Engineering, PLLC
7A Wendy Court - Greensboro, NC 27409 - [phone]

Green Mountain Engineering, PLLC Civil Engineering Consultants
Project Narrative 1 'z"artmcnt of
For Environmental Quality
Meadow Valley Subdivision — Phase 5 Received
Located in High Point, NC V T 3 0 2019
October 28", 2019
Winston-Salem
To Whom It May Concern: Rogional Office
This application is being submitted to obtain permitting for 973 if of private 4-inch
schedule 40 pvc force main and a pump station located at the Northwest corner of
Meadow Valley Phase 5. Also, 359 If of 8-inch PVC located from SSMH-80 to SSMH-
110 and 23 if of 12" PVC private gravity sewer located from SSMH-110 to SSMH-120.
The aforementioned extension is located in the City of High Point, to provide service to
38 new lots in Meadow Valley Phase 5.
The design and plan review was done in accordance with NCDEQ's Gravity
Sewer Minimum Design Criteria, NCDENR's Minimum Design Criteria.for the
Permitting of Pump Stations and Force Mains, and the City of High Point standards and
specifications. Work on the sewer installation is planned to begin in summer of 2020.
Please contact me if you require additional information. You can reach me via email
Jordan(a)ereenmountaineneineers.com or by telephone [phone] at your convenience.
Respectfully submitted,
Jordan D. Young E.I.
Green Mountain Engineering, PLLC
7A Wendy Court - Greensboro, NC 27409 - [phone]
Page 1 of 1

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 INSTRUCTIONS FOR FORM: ETA 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.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC 1 C .0100;
➢ 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;
➢ 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 I.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 I.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 II.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 Professional 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 Pagel of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
❑ 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 11-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
❑ 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)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ 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 .0115(a)(1) 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.
Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational 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

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, Berle, 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
Wilminaton Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Fender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Allegheny, 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

DWR
Dlvlsion of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Clayton Properties Group, Inc (dba Shugart Homes) (company, municipality, FICA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Greg Garrett per 15A NCAC 02T .0106(b)
Title: Vice President of Land
{'.:., U'partment (il'
4. Applicant's mailing address: 221 Jonetown Rd Environmental Quality
Received
City: Winston Salem State: NC Zip: 27104-
5. Applicant's contact information: CCU 3 0 2019
Phone number: [phone] Email Address: [e-mail] Winston-Salem
II. PROJECT INFORMATION: Regional Office
1. Project name: Meadow Valley- Phase 5
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: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.037347' Longitude:-80.02933'
5. Parcel ID (if applicable): 6893448523 & 6893542546
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Vincent C. Townsend, P.E., PLLS License Number: 23951
Firm: Green Mountain Engineering, PLLC
Mailing address: 7A Wendy Ct.
City: Greensboro State: NC Zip: 27409-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside WWTP Permit Number: NCO024210
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (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 MN/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/Pro e�rty 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 0 % Commercial
0 % 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 .0114(f)? ❑ Yes ®No
➢ If yes, provide a eopv of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(fl)
Daily Design Flow','
No. of Units
Flow
Dwelling unit- 3 bedrooms
270 gal/day
38
10,260 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
10,260 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: 10260 GPD (per 15A NCAC 02T .0114)
➢ Do not include fature flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8"
359
pvc
12"
23
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
VHL 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: 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.039716' Longitude:-80.030286'
3. Design flow of the pump station: 10260 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 92 gallons per minute at 100 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
4"
973
pvc
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(fl & (g) ® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewers stems:
Setback Parameter*
Separation Re uired
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 D(.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
36inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webuage
➢ If noncompliance with 02T.0305(fl 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(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 Pump 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:
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 Certification per 15A NCAC 02T .0106(b):
that this application for
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 $25,000 per violation.
Signature: / Date: i �$
FORM: FTA 04-16 Page 5 of 5

i)iirk Ioil c1i lti%atCI. Rv,ource
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Application Number: 2019-140
Entity Requesting Allocation: Clayton Properties (Private)
Project Name for which flow is being requested: Meadow Valley Subdivision - Phase 5
More than one FTSE may be requiredfor a single projeet if file owner of the WWTP is not responsible jar all pump
stations along the route of the proposed wasimpaterjlow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a.
WWTPFacility name: Eastside WWTP
b.
WWTP Facility Permit #: NC-0024210
All flows are in MGD
c.
WWTP facility permitted flow:
26.0000
d.
Estimated obligated flow not yet tributary to the WWTP:
0.7521
e.
WWTP facility's actual average flow:
15.5833
f.
Total flow for this specific request:
0.0100
g.
Total actual and obligated flows to the facility:
16.3454
It.
Percent of permitted flow used:
62.87%
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)
Pump
Pump
Firm
Design
Approx.
Obligated,
Total Current
Available
Station
Station
Capacity'
Average
Curren
Not Yet
Flow Plus
Capacity`
(Name or
Permit
Daily Flow°
Avg. Daily
Tributary
Obligated
Number)
Number
(Firm/pt),
Flow,
Daily Flow,
Flow
MGD
MGD
MGD
MGD
MGD
MGD
Wat.,we
W00024300
2.2V6
0.8870
0.5501
0.3864
0.9365
-0.0495
luvwddl
W00008572
22.2093
8.8837
8.3996
0.7346
9.1341
-0.2504
--
MIA
NN/A
#N/A
MIA
W/A
MIA
WIA
NN/A
NN/A
NN/A
NN/A
M/A
WIA
NN/A
NN/A
NN/A
#N/A
#WA
WA
NN/A
WA
fti/A
NN/A
The Firm Capacity (design flow) of any pump station is defined as the maximum pumped Bow that
can be achieved with the largest pump taken out of service.
"* Design Average Flow is the firm capacity of the pump station divided by the peaking factor (pQ not
less than 2.5, per Section 2A2(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 5 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
Pagel of FTSE 10-18

III. Certification Statement
I, Terry Houk 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 II plus all attached planning assessment addendums 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.
Signing Official
A -)&IC she✓icc'S AAEE Zo- Z
Title of Signing Official
10/9/2019
Date
Page 2 of 6 FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
The City of High Point met with NCDEQ on February 9, 2017 to discuss the flow
allocation to Riverdale Pump Station while the station was being studied for an additional
increased capacity of 2.0 MGD. As a result of the meeting, the City and DEQ agreed that
the current average daily flow for the Riverdale Pump Station was 8.4 MGD. The City of
High Point has contracted with 3 engineering firms to expand the capacity of the Riverdale
Pump Station to 30 MGD. The pump station upgrades are anticipated to be completed
November 2019
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official
Date
Page 3 of 6
FTSE 10-18

Instructions for Flow Tracking/Acceptance form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
C. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not yet tributary to the WWTP, MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through
interlocal agreements or other contracts not yet contributing flow to the collection system are also
included. For POTWs that implement a pretreatment program, include flows allocated to industrial
users who may not be using all of their flow allocation. Please contact your Pretreatment Coordinator
for information on industrial flow tributary to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years
and reconciled their flow records, to the best of their ability, so it is known how much flow has been
obligated and is not yet been made tributary to the WWTP, in accordance with local policies and
procedures employed by the reporting entity.
e. WWTP facility's actual avg. flow, MGD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + f]
h. Percent of permitted flow used: Equals [(g / c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there
is 0.5 MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7
MGD. There is a proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f. = 0.015 MGD
g. = 3.215 MGD
h. = 53.6 %
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d.
= 0.515 MGD
e.
= 2.73 MGD
f.
= 0.102 MGD
g.
= 3.349 MGD
h.
= 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 04-16

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design
average daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow
through the pump station (C) for each pump station that will be impacted by the proposed sewer extension
project. Calculate the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D).
Include the proposed flow for this project with other obligated flows that have been approved for the pump
station but are not yet tributary (C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as
per the Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not
less than 2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump
station if the system has future specific plans related to capacity that should be considered in the permitting
process.
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Design
Approx.
Not Yet
Total Current
Firm
Average
Current Avg.
Tributary
Flow Plus
Pump Station
Capacity
Daily Flow
Daily Flow,
Daily Flow,
Obligated
Available
(Name or Number)
MGD
(Firm / pf)
MGD
MGD
Flow
Capacity*
Kaw Creek PS
0.800
0.320
0.252
0.080
0.332
-0.012
Valley Road PS
1.895
0.758
0.472
0.135
0.607
0.151
Page 5 of 6
FTSE 04-16

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity
is < 0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether
there is significant likelihood that needed improvements or reductions in obligated flows will be in place
prior to activating the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to
manage the flow without capacity related sanitary overflows and must take all steps necessary to complete
the project or control the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned
project in the future not yet funded but in a formal plan adopted by the system. The system should carefully
weigh the certainty of successful timely project completion for any expansion, flow management diversion
or infiltration and inflow elimination projects that are the foundation of a planned solution to capacity
tracking and acceptance compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080
MGD of the committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01
MGD per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project
entitled Kaw Creek Pump Station upgrade with funding planned in July 2014 This project is planned to
add 0.100 MGD to the firm capacity of the pump station by October 2015 Inclusion of this proposed
capital project as a condition of this Flow Tracking/Acceptance for Sewer Extension Permit Application
elevates this project's priority for funding and construction to be implemented ahead of the activation of
obligated not yet tributary flows in amounts that exceed the firm pump station capacities identified in
Section 11 above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
Page 6 of 6
FTSE 04-16

STATE OF NORTH CAROLINA
COUNTY OF GUILFORD
Permit No.
DEVELOPER'S OPERATIONAL AGREEMENT
This AGREEMENT made pursuant to G.S. 143-215.1 (dl) and entered into this 28th day of
OCTOBER by and between the North Carolina Environmental Management
Commission, an agency of the State of North Carolina, hereinafter known as the COMMISSION; and
CLAYTON PROPERTIES GROUP (dba SHURGART HOMES, LLC) a corporation/general partnership registered/licensed to do
business in the State of North Carolina, hereinafter known as the DEVELOPER.
WITNESSETH:
1. The DEVELOPER is the owner of the certain lands lying in GUILFORD County, upon
which it is erecting and will erect dwelling units and other improvements, said development to be known
as MEADOW VALLEY PHASE 5 (hereinafter the Development).
2. The DEVELOPER desires, to construct a wastewater collection system with pumps, wastewater treatment
works, and/or disposal facilities (hereinafter Disposal System) to provide sanitary sewage disposal to serve
the Development on said lands.
3. The DEVELOPER has applied to the COMMISSION for the issuance of a permit pursuant to G.S. 143-
215.1 to construct, maintain, and operate the Disposal System.
4. The DEVELOPER has created or shall create unit ownership in said dwellings units, other improvements
and lands through filing of a Declaration of Unit Ownership (hereinafter Declaration), pursuant to Chapter
47C or 47F of the North Carolina General Statutes.
The DEVELOPER has caused to be formed or will cause to be formed at the time of filing of the
Declaration, MEADOW VALLEY HOA, INC (heremater
Association), a non-profit corporation organized and existing under and by the virtue of the laws of the State
of North Carolina, for the purpose, among others, of handling the property, affairs and business of the
Development; of operating, maintaining, re -constructing and repairing the common elements of the lands
and improvements subject to unit ownership, including the Disposal System; and of collecting dues and
assessments to provide funds for such operation, maintenance, re -construction andrepair.
6. The COMMISSION desires to assure that the Disposal System of the Development is properly constructed,
maintained and operated in accordance with law and permit provisions in order to protect the quality of the
waters of the State and the public interest therein.
NOW, THEREFORE, in consideration of the promises and the benefits to be derived by each of the parties
hereto, the COMMISSION and DEVELOPER do hereby mutually agree as follows:
1. The DEVELOPER shall construct the Disposal System in accordance with the permit and plans and
specifications hereafter issued and approved by the COMMISSION, and shall thereafter properly operate
and maintain such systems and facilities in accordance with applicable permit provisions and law.
2. The DEVELOPER shall not transfer ownership and/or control of the Disposal System to the Association
until construction has been completed in accordance with the permit and approved plans, and the staff of
the Division of Water Resources has inspected and approved of the facilities. hi order to change the name
of the permit holder, the DEVELOPER must request that the permit be reissued to the Association. The
request must include a copy of the Association Bylaws andDeclaration.
3. The DEVELOPER shall not transfer, convey, assign or otherwise relinquish or release its responsibility for
the operation and maintenance of its Disposal System until a permit has been reissued to the DEVELOPER's
successor.

4. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System and
appurtenances thereto are part of the common elements and shall thereafter be properly maintained and
operated in conformity with law and the provisions of the permit for construction, operation, repair, and
maintenance of the system and facilities. The Declaration and Bylaws shall identify the entire wastewater
treatment, collection and disposal system as a common element which will receive the highest priority for
expenditures by the Association except for Federal, State, and local taxes andinsurance.
5. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System will
be maintained out of the common expenses. In order to assure that there shall be funds readily available to
repair, maintain or construct the Disposal System, beyond the routine operation and maintenance expenses,
the Declaration and Association Bylaws shall provide that a fund be created out of the common expenses.
Such fund shall be separate from the routine maintenance funds allocated for the facility and shall be part
of the yearly budget.
6. In the event the common expense allocation and separate fund are not adequate for the construction, repair,
and maintenance of the Disposal System, the Declaration and Association Bylaws shall provide for special
assessments to cover such necessary costs. There shall be no limit on the amount of such assessments, and
the Declaration and Bylaws shall provide that such special assessments can be made as necessary at any
time.
7. If a wastewater collection system and wastewater treatment and/or disposal facility provided by any city,
town, village, county, water and sewer authorities, or other unit of government shall hereinafter become
available to serve the Development, the DEVELOPER shall take such action as is necessary to cause the
existing and future wastewater of the Development to be accepted and discharged into said governmental
system, and shall convey or transfer as much of the Disposal System and such necessary easements as the
governmental unit mayrequire as condition of accepting the Development's wastewater.
8. Recognizing that it would be contrary to the public interest and to the public health, safety and welfare for
the Association to enter into voluntary dissolution without having made adequate provision for the continued
proper maintenance, repair and operation of its Disposal System, the DEVELOPER shall provide in the
Association Bylaws that the Association shall not enter into voluntary dissolution without first having
transferred its said system and facilities to some person, corporation or other entity acceptable to and
approved by the COMMISSION by the issuance of apermit.
9. The agreements set forth in numbered paragraphs 1, 2, 3, 4, 5, 6, 7, and 8 above shall be conditions of any
permit issued by the COMMISSION to the DEVELOPER for the construction, maintenance, repair and
operation of the Disposal System.
10. A copy of this agreement shall be filed at the Register of Deeds in the County(ics) where the Declaration is
filed and in the offices of the Secretary of State of North Carolina with the Articles of Incorporation of the
Association.
IN WITNESS WHEREOF, this agreement was executed in duplicate originals by the duly authorized
representative of the parties hereto on the day and year written as indicated by each of the parties named below:
FOR THE ENVIRONMENTAL
MANAGEMENT COMMISSION
Linda Culpepper
Director, Division of Water Resources
(Date)
CLAYTON PROPERTIES GROUP (dba SHURGART HOMES LLC)
Name of DEVELOPER
By
(Signature)
Gte (�ttfc SST•
Print Ndme and Title
10 2'91
(Date)