WQ0032333_Application_20071015

t=TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
1.
1a
0 11 b. Richard Douglas, City Manager
p: Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
1 c The legal entity who will own this system is
❑ Individual ❑ Federal ® Municipality ❑ State/County❑ Private Partnership ❑ Corporation ❑ Other
0 1d. 315 N. Main St
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)
Owner:
City of Raeford
Full Legal Name (company, municipality, HOA, utility, etc.)
LL Mailing Address
Z
1f. North Carolina
Z State
e. Raeford
City
g. 28376
0 Zip Code
1 h. [phone] 1 i. [phone] 1)
Q Telephone Facsimile E-mail
O 2. Project (Facility) Information.
W___ ___. _.. __.—__
J 2a. Palmer St. Ext. Sewer Work 2b. Hoke
a Brief Project Name (permit will refer to this name) s County Where Project is Located
IL_ _ . _._ -__ ___._ _.__ ___m___ ---�__-._ _ _ ..__.__
Q 3 Contact Person
Q 3a. Richard Douglas City Manager for the City of Raeford
Name and Affiliation of Someone Who Can Answer Questions About this Application
_ _ _ ... ........ .... _....... ................. _._ .......
3b. [phone] 3c.
0
H
Q
NC Department of Transportation
1514 Mail Service Center `
Raleigh, NC 27699-1514
�fhF or Fr.Ma
Phone Number
E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
phase, changing line size/length, etc.). Only include the modified information in this permit application - do not
duplicate project information in B(7) and B(10-11) that has already been included in the original permit.
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑Public Utility (Instruction III)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction IV)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
of Raeford
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
da rrifv of P—f-4 %Al- -- — %A/-- .-
T
66-.1 Cf59
531
Warrant 2202604
Date 09/19/2007
Void after One Year

Central Files: APS SWP
10/31 /07
Permit Number WQ0032333
Program Category
Non -discharge
Permit Type Fast Track
Gravity Sewer Extension, Pump Stations, & Pressure Sewer
Extensions
Primary Reviewer
trent.allen
Permitted Flow
0
Facility
Facility Name
Palmer St. Ext. Sewer Work
Location Address
Owner Name
City of Raeford
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Major/Minor Region
Major Fayetteville
County
Hoke
Facility Contact Affiliation
Owner Type
Government - Municipal
Owner Affiliation
Richard Douglas
315 N Main St
Raeford NC 28376
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
10/31 /07 10/11 /07 10/31 /07 10/31 /07
Regulated Activities Requested/Received Events
Wastewater collection Additional information requested
Additional information received
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

.vAs,r-fRACK APPLICATION for GRAVITY SEWERS, P
r'���A'1'tctrv�;tv�'PORCE MAINS PAGE 1
O� WATFR v
O�
CQ
State of North Carolina
Department of Envir. nment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included/addressed the following list of required application package items by
checking the space provided next to each applicable item. Failure to submit all required items will lead to your application
being returned as incomplete. This form may be photocopied for use as an original.
I. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. Any changes to this form will result in the application being returned. The Division of Water Quality
(Division) will only accept application packages that have been fully completed with all applicable items
addressed. You do not need to submit detailed plans and specifications unless you respond NO to Item B(12)
ll. Application Fee - Submit a check in the amount of $480 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ III. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2a) of this application.
❑ IV. Operational Agreements — Submit one original and two copies of a properly executed operational agreement if
the sewer extension is permitted by a private applicant and will be serving residential or commercial lots (e.g ,
houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If the applicant is a
homeowners' association, use Form HOA 02/03. If the applicant is a developer, use Form DEV 02/03. EVEN IF
THE PROJECT WILL BE TURNED OVER TO A MUNICIPALITY, FORM DEV 02/03 IS REQUIRED.
❑ V. Flow Acceptance Letters — If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and name and permit number of the receiving sewers/WWTF. The flow acceptance must not
expire prior to permit issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
29 VI. Map — Submit an 8.5-inch by 11-inch COLOR copy of the portion of a 7.5-minute USGS Topographic Map along
with this form. The map should identify the entire project area location as well as the closest downslope surface
waters as clearly as possible. Each map portion must be labeled with the map name and number, the identified
location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project
involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties,
basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location in Section C of the permit application.
❑ VII. Stream Classifications — Section C
If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track:
Sewer Systems)" available from http://h2o.enr.state.nc.us/peres or by contacting the appropriate regional
office.
FTA 02/03 - Rev. 3 04/05

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
Vill. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the PERCS
Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be accepted until a Finding of No
Significant Impact (FONSI) or Environmental Impact Statement (EIS) has been issued. A copy is to be submitted
with that permit application.
❑ IX. Certifications— Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE). The applicant signature must match the signing official listed in Item A(1b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, the Gravity Sewer Minimum Design Criteria (most
recent version) and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
(most recent version), as applicable to the project. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral.
❑ X. Downstream Sewer & Wastewater Treatment Plant Capacity
The applicant has assured downstream pipe, pump station and treatment plant capacity. The addition of new
sources of wastewater from this project has been evaluated along the route to the receiving treatment plant. The
flow from this project will not cause capacity related sanitary sewer overflows or overburden any downstream
pump station en route to the receiving wastewater treatment plant. If the applicant is not the owner of the
downstream sewer or receiving treatment plant, submittal of flow acceptance letter(s) indicates that owner has
adequate capacity and will not violate G.S. 143-215.67(a).
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell,
Swannanoa, North Carolina 28778
Cherokee, Clay, Graham, Haywood,
[phone]
Henderson, Jackson, Macon, Madison,
[phone] Fax
McDowell, Mitchell, Polk, Rutherford,
Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett,
Fayetteville, North Carolina 28301
Hoke, Montgomery, Moore, Robeson,
[phone]
Richmond, Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue, Suite 301
Alexander, Cabarrus, Catawba,
Mooresville, North Carolina 28115
Cleveland, Gaston, Iredell, Lincoln,
[phone]
Mecklenburg, Rowan, Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance,
919 571-4718 Fax
Wake, Warren, Wilson
Washington Regional Office
943 Washington Square Mail
Beaufort, Bertie, Camden, Chowan,
Washington, North Carolina 27889
Craven, Currituck, Dare, Gates, Greene,
[phone]
Hertford, Hyde, Jones, Lenoir, Martin,
[phone] Fax
Pamlico, Pasquotank, Perquimans, Pitt,
Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin,
Wilmington, North Carolina 28405
New Hanover, Onslow, Fender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
[phone]
Rockingham, Randolph, Stokes, Surry,
[phone] Fax
Watauga, Wilkes, Yadkin
For more information, visit our web site at: http://h2o.enrstate.nc.us/peres/
FTA 02/03 - Rev. 3 04/05

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: W00032333
(to be completed by DWQ)
1. Owner:
1 a. City of Raeford
Full Legal Name (company, municipality, HOA, utility, etc.)
0 1 b. Richard Douglas City Manager
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
......... ............. _........... _.._.... _..........._.._._...._—__.__.......__..-_-.__-........._.__._..---._.__.._.._....___..-...__._._._..__..._..._...._.---.._.__..__....---......_._.... _ __._____...._.._...__._._.___... .......... _.............. _....._..__..
1 c. The legal entity who will own this system is:
0, ❑ Individual ❑ Federal ® Municipality❑ State/County O Private Partnership_❑ Corporation ❑ Other (spec).
® 1d. 315 N. Main St. le. Raeford
LL Mailing Address City
=
1f.
North Carolina
11g. 28376
Z
State
I Zip Code
_
1 h.
[phone] 1 i. [phone]
=1 j.
~
Q...
Telephone Facsimile
._.......... .__..._.._._.__._.._.._.....__...---__—.---_._.._...---.._.----._.__
E-mail
—_..---..._._....._.__..__..__...__..___.._._._...................... ..... ._.._....._.._-_---__.._..__...__..____._._..--
U
2.
Project (Facility) Information:
J
2a.
Palmer St. Ext. Sewer Work
2b. Hoke
�-
Brief Project Name (permit will refer to this name)
County Where Project is Located
Q
3
Contact Person:
Q 3a. Richard Douglas City Manager for the City of Raeford
Name and Affiliation of Someone Who Can Answer Questions About this Application
_....---.._... -
.,._
_..........................__....._...._..._._..__......_......_....-..._............._....._....._...._..... ..__.........__..._........_..._._..................__.-----
......_....._.............._._..................__....._........._...__..._...._...._....
3b. [phone] `3c.
Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
phase, changing line size/length, etc.). Only include the modified information in this permit application - do not
duplicate project information in B(7) and B(10-11) that has already been included in the original permit.
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑Public Utility (Instruction III)
Z ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction IV)
Q ❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
H 3. City of Raeford
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. City of Raeford Waste Water Treatment Plant 4b. NC0026514
o Name of WWTF WWTF Permit No.
LL 5a. City of Raeford Pb. 8" ® Gravity c. WQCS00074
Z Owner of Downstream Sewer 'Receiving Sewer Size ❑Force Main Permit Number of Downstream Sewer (if known)
F— 6. The origin of this wastewater is (check all that apply):
❑ Car Wash
❑Residential Subdivision ❑ Institution
11J ❑ Apartments/Condominiums ❑Hospital 100 % Domestic/Commercial
a ❑ Mobile Home Park
❑ School ❑Church % Industrial
❑ Restaurant El Nursing Home a
® Office ® Other (specify): Gas Stations,
/o Other (specify):
Chiropractors Office
7. Volume of wastewater to be allocated for this particular project: gallons per day i
'Do not include previously permitted allocations j
8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
® Rehabilitation or replacement of existing sewer with no new flow expected
FTA 02/03 - Rev. 3 04/05

it AST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE
'9
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
Length (feet)
8"
137.7
10" i
784.3
2" i
-... .................. ... ..... _.......... ... _ ........._... _.....
138.5 t
_._._._ .._.__..._...--.._._......_.._..
(I
W
---............. ........ .... -..._.._....... _...... .... ............ �__...._......__..__....__........ ................................ --- ... ..............._.......--.._...._..__..._..
-.._... ........ _..-_..-............_.._........... _..-_
OENTER
TOTAL LINE LENGTH IN MILES
0.202
U
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
..._.._.___..............
Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(I) for Item 13(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that in 15A NCAC 2H .0219(I)(1-2) must be supported with actual water or wastewater use data in accordance with 15A
NCAC 2H .0219(I)(3).
Gravity or Force Main
(use the pull down menu)
Gravity Sewer
Gravity sewer
Force Main
O Location ID ! Power Reliability Option
(self chosen - as shown on ` Design Flow' Operational Point (1- dual line feed; 2- permanent generator MATS; 3-
plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry: 4-wet well storaqe)
.12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
UJ CK Yes ❑ No If no, please reference the pertinent minimum design criteria or regulation and indicate why a
a variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
m
lowing permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification?
Sedimentation and Erosion Control Plan?
Stormwater?
[� Yes ❑ No ❑ N/A
($� Yes ❑ No ❑ N/A
Yes ❑ No ❑ N/A
4. Uoes this project Involve aerial lines or siphons? Check if yes: U
less_Iines.w ll.be considered hi.Qh. orionty.an.d rnust..be.checked_once everv..slx months. _................... . .................... _ .. _ ...._.__._ _.__ _ .
5. Does this project have gravity sewer lines designed at minimum slopes? ❑
Be aware that the Division will not accept installed lines more than 10% Flatter than the minimum slope. Lines installed outside this tolerance should be
corrected prior to submitting the final engineering certification..
FTA 02/03 - Rev. 3 04/05

', 411T=TRACT{ APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
Q
W
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Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02103
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
regional office (see instructions for addresses) OR indicate the following:
..._..... .............
NJ A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
waterbody; AND,
Q A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
option for any pump station near a Class C down slope waterbody.
Location ID on Map i
(self chosen - as shown on ? Name Of
map for cross-reference) Waterbod
Waterbody Stream Waterbody
River Basin Index Classification
Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
1. Applicant's Certification
1a.
1, SIGNING OFFICIAL NAME, attest that this application for PROJECT NAME
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. Note: In accordance with North Carolina
General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
certification in any application 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.
Signing Official Signat4re
Professional Engineer's Certification:
/O -Z -07
Date
I attest that this application for has been reviewed by me and is accurate, complete
and consistent with the information in the engineering plans, 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 adopted February
12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June
1, 2000 and the watershed classification in accordance with Division guidance. Although certain portions of this submittal
package may have been developed by other professionals, inclusion of these materials under my signature and seal
signifies that / have reviewed this material and have judged it to be consistent with the proposed design. Note: In
accordance with NC General Statutes 143-215.6A and 143-215. 6B, any person who knowingly makes any false statement,
representation, or certification in any application 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.
2a. Carl Barcla
Professional Engineer Name
2b. North Carolina Department of Transportation
Engineering Firm__.__
2c. 1591 Mail Service Center
Mailing Address
_..__.__._.___._...__..._..._......__._...._ ..... __.... __.___...._____..._..._._...___...._._..._...._.._._._......
.._._....___..__.....__......_............
2d. Raleigh 2e. NC 2f. 27699-1591
City ...__.._ State Zip
2g. (919)-250-4128 2h. (919)-250-4119 2i. Cbarclay@dot. state. nc.us
Telephone i Facsimile E-mail
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FTA 02/03 - Rev. 3 04/05

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