WQ0036139_Application_20121011

DENR—FRO
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: `°'—' ' ' .cul[ i
(to be completed by DWO)
1.
Owner/Permittee:
1a.
Hoke County
Full Legal Name (company, municipality, HOA, utility, etc.)
O1b.
Tim Johnson, County Manager
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
H
Q
1c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ❑ Municipality ® State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
0
1 d.
P.O. Box 210 1 e. Raeford
j LL
Mailing Address City
?
If
NC 1 g. 28376
Z
State Zip Code
1 h.
910-875-8751 1 i. 910-875-9222 1 j. i
QTelephone
Facsimile E-mail
} U
2.
Proiect (Facility) Information:
J
2a.
First Health Hospital Off -Site Sewer Improvements 2b. Hoke
i CL
Brief Project Name (permit will refer to this name) County Where Project is Located
kQ
3.
Contact Person:
3a.
Adam Kiker
Q
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 910-692-5616 3c. [e-mail]
j Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
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 n Puhlic Utility (Inctrnntinn rrl
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P-L McNAIR MILL, LLC
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PAY TO THE il/
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FIRST CITIZENS BANK
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DOLLARS e
MEMO #�
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AUTHORIZED SIGNATURE
Z Pump Station, Outfall or Interceptor Line where 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 (see 15A NCAC 02T .0303 to determine if a
permit is required)
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FTA 12/ 07

OF WATER DENR—FRO State of North Carolina
Q Department of Environment and Natural Resources
cry r 5EP r Division of Water Quality
>
o Y DWO FAST -TRACK APPLICATION
(FTA 12/07 very)
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer 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. Forms are available from the web site or by calling the Regional Office serving your county:
http.//h2o. enr. state. nc. us/peres/Collection % 20Systems/CollectionSystemApplications. html
® A. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. The application should include a project narrative describing the final build -out design (i.e. system and/or
pump station to ultimately serve 500 homes, but flow for only 100 homes being requested now). For modifications,
clearly explain 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 that has already
been included in the original permit.
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(13).
Separate applications should be made for non-contiguous sewer systems
® B. 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.
❑ C. 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(2)a of this application.
❑ D. Operational Agreements — Submit one original and two copies of a properly executed operational agreement, as
per 15A NCAC 02T .0115, if the application is submitted 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 home or property owner's association, use Form HOA 02/03. If the applicant is a developer,
use Form DEV 02/03. EVEN IF THE PROJECT MAY BE TURNED OVER TO A MUNICIPALITY UPON
COMPLETION, FORM DEV 02/03 IS REQUIRED.
® E. Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance — FORM FTSE 10/07 (Flow
Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant
(and owners of downstream sewers, pump stations and/or treatment facilities submitting FORM FTSE-10/07)
certifies that the addition of the volume of wastewater to be permitted in this project has been evaluated along the
route to the receiving treatment plant, and that 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. Where the applicant is not the owner of the downstream sewer, submit two copies of FORM FTSE 10/07
from the owner of the downstream sewer and owner of the WWTF, if different. The flow acceptance indicated in
FORM FTSE-10/07 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-10/07 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 project -specific FTSE 10/07.
® F Map — Submit an 8.5-inch by 11-inch COLOR copy of a USGS Topographic Map of sufficient scale to identify the
entire project area and the closest surface waters. Each map or maps must show the location of the sewer line
and pump stations and be of reproducible quality. Include a street level map showing the downstream connection
point, and the permit number for the downstream sewer, if known.
FTA 12/07

JE,G. Stream Classifications — Watershed Classification Attachment (Form WSCAS-12/07) If any portion of the
sewer system project is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment
may need to be completed. A variance must be requested for encroachment within required setbacks or buffers
pursuant to 2T .0305 (f) and be indicated in Item B-13 with supporting documentation/justification provided.
❑ H Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application cannot be used. Send the project application on the most current version of Form
PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications
cannot 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.
❑ I. Flow Direction — Many wastewater treatment systems are entering into agreements for regionalization efforts
and emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be directed
to more than one treatment facility. If this is the case with this project, please indicate in B(12) and give the permit
number of the second treatment facility.
® J. Certifications — Section C
The application must be certified by both the applicant and the design engineer who is a North Carolina
Registered Professional Engineer (PE). The applicant signature must match the signing official listed in Item
A(1 b). The PE should NOT certify the application if he/she is unfamiliar with 15A NCAC Chapter 2T, 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.
THE COMPLETED FTA 12/07 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
DOCUMENTS AND $480 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, Cherokee,
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,
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,
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,
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 Mail
Beaufort, Bertie, Camden, Chowan, Craven,
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
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell, Davidson,
Winston-Salem, North Carolina 27107
Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone]
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at:
h ttp://h2o.enr.sta te.nc. us/peres/Collection % 20Systems/CollectionSys temsHome. html
or contact the Regional Office serving your county.
FTA12/07

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)
1.�Owner/Permittee:
la.
Hoke Count
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
1b.
Tim Johnson, County Manager
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
Q
1 c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ❑ Municipality Z State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
O
1d.
P.O. Box 210 1e. Raeford
LL
Mailing Address City
Z
1 f.
NC 1 g. 28376
Z
State Zip Code
1 h.
910-875-8751 1 i. 910-875-9222 1 j.
QTelephone
Facsimile E-mail
V
2.
Proiect (Facility) Information:
J
2a.
First Health Hospital Off -Site Sewer Improvements 2b. Hoke
d
Brief Project Name (permit will refer to this name) County Where Project is Located
Q
3.
Contact Person:
Q
3a.
Adam Kiker
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
910-692-5616 3c. [e-mail]
Phone Number E-mail
1.
Project is Z New ❑ Modification (of an existing permit) If Modification, Permit No.:
2.
Owner is Z 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 (Le. store, church, single office, etc.) or ❑ Public Utility (Instruction C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3.
City of Fayetteville PWC
Z
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
0
4a.
Rockfish Creek WRF 4b. NCO050105
Name of WWTF WWTF Permit No.
5a.
Hoke County Public Works 15b. 12" ,Z Gravity 15c. WQ 0035688
Owner of Downstream Sewer Receiving Sewer Size i❑ Force Main Permit # of Downstream Sewer (Instruction E)
0
LL
6.
The origin of this wastewater is (check all that apply):
® Residential Subdivision Z Retail (Stores, shopping centers) — %Domestic/Commercial
❑ Apartments/Condominiums ❑ Institution % Industrial (attach
❑Mobile Home Park ®Hospital description.)
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❑ School ❑ Church
❑ Restaurant El Nursing Home (RO: contact your Regional Office
f3.
Z Office ❑ Other (specify): Pretreatment staff)
m
% Other (specify):
7.
Volume of wastewater to be allocated or permitted for this particular project: 0 gallons per day
*Do not include future flows or previously permitted allocations
8.
If the permitted flow is zero, indicate why:
Z Pump Station, Outfall or Interceptor Line where 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 (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA 12/07

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9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item B(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item B(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
12"
Length (feet) New Gravity or Additional
Force Main
1595 Gravity
11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID (self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator wIMTS
Pump Station Location ID (self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
Pump Station Location ID (self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
[:]Yes ® No If Yes, permit number of 2nd treatment facility
(RO — if "yes" to 6,12 please contact the Central Office PERCS Unit)
13. 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 Chapter 2T as
applicable?
® Yes ❑ No If No, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
FTA 12/07

14. Have the following permits/certifications been submitted for approval for the system or project to be served?
A
u
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan? ❑ Yes ® No ❑ N/A
Stormwater?
❑ Yes ❑ No ® N/A
15. Does this project include any high priority lines, [see 15A NCAC 02T .0402 (2)] involve aerial lines, siphons, or interference
manholes)? No.
Check if Yes ❑ and provide details
1. Owner/ Perm ittee's Certification: (Signature of Signing Official and Project Name)
1, Tim Johnson , attest that this application for First health Hospital Off -Site Sewer improvements 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't p tc425, 000 per violation.
! Signi icia0if I Si akute - -- — Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
Professional Engineers Certification: (Signature of Design Engineer and Project Name)
1, Adam P. Kiker attest that this application for First health Hospital Off -Site Sewer improvements has been
reviewed by me and is accurate, complete and consistent with the infomtafion in the engineering plans, calculations, and
all other supporting documentation to the best of my knowledge. 1 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 other professionals may have developed certain portions of this submittal package, inclusion of these materials
under my signature and seal signifies that 1 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. Adam P. Kiker
Professional Engineer Name
2b. Hobbs, Upchurch and Associates, P.A.
Engineering Firm
2c. 300 SW Broad Street
Mailing Address
2d. Southern Pines
2e. NC 2f. 28387
City
State Zip
2g. 910-692-5616 2h. 910-692-7342
2i. [e-mail]
Telephone Facsimile
E-mail
FTA 12/07

WILSON A. LACY, COMMISSIONER PUBLIC WORKS COMMISSION 955 OLD WILMINGTON RD
TERRI UNION, COMMISSIONER P.O. BOX 1089
LUIS J. OLIVERA, COMMISSIONER OF THE CITY OF FAYETTEVILLE FAYETTEVILLE, NORTH CAROLINA 28302-1089
MICHAEL G. LALLIER, COMMISSIONER TELEPHONE (AREA CODE 910) 483-1401
STEVEN K. BLANCHARD, CEO/GENERAL MANAGER ELECTRIC & WATER UTILITIES FAX (AREA CODE 910) 829-0207
Mr. Tim Johnson
County Manager
Hoke County
227 North Main Street
Raeford, NC 28376
September 5, 2012 DENR-FRC
SEP 10 201Z
Dwo
Subject: First Health Hospital Offsite Sewer Improvements — Hoke County
Dear Mr. Johnson:
Enclosed, please find a flow acceptance letter from PWC for the subject project. The
amount of flow that PWC is willing to accept for this project is 0 gallons per day as the
flow will be allocated in a forthcoming permit. PWC has reviewed and approved the
plans for the above referenced project.
Should you have any questions or require additional information regarding this project,
please contact Mr. Chris Rainey at [phone]. Your cooperation is appreciated.
Sincerely,
PUBLIC WORKS COMMISSION
oseph E. Glass, P.E.
Manager
Water Resources Engineering
cc: Dennis Baxley (Hoke County)
Adam Kiker, PE (HUA)
Mike Lawyer (DENR)
Bill Berry
Project file
BUILDING COMMUNITY CONNECTIONS SINCE 1905
AN EQUAL EMPLOYMENT OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

copyngnt (c) 1991, maptecn, Inc.

WILSON A. LACY, COMMISSIONER PUBLIC WORKS COMMISSION 955 OLD WILMINGTON RD
TERRI UNION, COMMISSIONER P.O. BOX 1089
LUIS J. OLIVERA, COMMISSIONER OF THE CITY OF FAYETTEVILLE FAYETTEVILLE, NORTH CAROLINA 28302-1089
MICHAEL G. LALLIER, COMMISSIONER TELEPHONE (AREA CODE 910) 483-1401
STEVEN K. BLANCHARD, CEO/GENERAL MANAGER ELECTRIC & WATER UTILITIES FAX (AREA CODE 910) 829-0207
September 5, 2012 SEP j 0
ZU12
Mr. Tim Johnson
County Manager
Hoke County
227 North Main Street
Raeford, NC 28376
Subject: First Health Hospital Offsite Sewer Improvements — Hoke County
Dear Mr. Johnson:
Enclosed, please find a flow acceptance letter from PWC for the subject project. The
amount of flow that PWC is willing to accept for this project is 0 gallons per day as the
flow will be allocated in a forthcoming permit. PWC has reviewed and approved the
plans for the above referenced project.
Should you have any questions or require additional information regarding this project,
please contact Mr. Chris Rainey at [phone]. Your cooperation is appreciated.
Sincerely,
PUBLIC WORKS COMMISSION
Joseph E. Glass, P.E.
Manager
Water Resources Engineering
cc: Dennis Baxley (Hoke County)
Adam Kiker, PE (HUA)
Mike Lawyer (DENR)
Bill Berry
Project file
BUILDING COMMUNITY CONNECTIONS SINCE 1905
AN EQUAL EMPLOYMENT OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

FORM WSCAS-12/07
WATERSHED CLASSIFICATION ATTACHMENT
FOR SEWER SYSTEMS
Applicant Name
Project Name
Hoke County
First Health Hospital Off -Site Sewer Improvements
Professional Engineer Name
Engineering Firm Name
Adam P. Kiker, P.E.
Hobbs, Upchurch and Associates, P.A.
Location
ID
Name of Waterbody'
County
River
Basin
Waterbody Stream
Index No.
Waterbody
Classification
1
Black Branch
Hoke
Cape Fear
18-31-19-4-1
C
' If unnamed, indicate "unnamed tributary to X", where X is the named waterbody to which the unnamed tributary joins.
I certify that as a Registered Professional Engineer in the State of
North Carolina that I have diligently followed the Division's instructions
for classifying waterbodies and that the above classifications are
inclusive of the stated project, complete and correct to the best of my
knowledge and belief.
PE Seal, Signature and Date
*** END OF FORM WSCAS-12/07 ***
FORM: WSCAS-12/07 Page 1 of 1

DENR-FRO
SEp 1 1 2012 14J Hobbs, Upchurch
nw,a & Associates, P.A.
Consulting Engineers
TRANSMITTAL P.O. Box 1737
290 S.W. Broad Street
Southern Pines, North Carolina 28387
[phone] FAX [phone]
TO: NC Dept. of Environment, Health and HUA PROJECT # HC 1214
Natural Resources
Water Quality Section
225 Green Street
Fayetteville, N.C. 28301
Attn: Trent Allen
FROM: Lee Humphrey HUA FILE NO. # HC 1214
Hobbs, Upchurch & Associates, P.A.
DATE: September 4, 2012
RE: First Health Hospital Off -Site Sewer Improvements
Permit Application
Hoke County, North Carolina
MESSAGE:
Please find enclosed two copies of the permit application, USGS map, Watershed
Classification and Flow Tracking letter for your review.
If you should have any questions, please contact this office.
c: lmy documentsVrent allen trans-doc