WQ0041604_Application (FTSE)_20200325

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 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: Town of Yadkinville (company, municipality, HOA, utility, etc.)
2.
Applicant type: ❑ Individual
❑ Corporation ❑ General Partnership
❑ Federal
❑ State/County M Municipal
3.
Signature authority's name: Perry
Williams per 15A NCAC 02T .0106(b)
Title: Town Manager
4.
Applicant's mailing address: 213 S. Van Buren Street
City: Yadkinville
State: NC Zip: 27055-_
5.
Applicant's contact information:
Phone number: [phone]
Email Address: uwilliamsAyadkinville.org
❑ Privately -Owned Public Utility
❑ Other
NC Department of
Environmental Quality
Received
MAR 2 5 2020
Winston-Salem
Regional Office
II. PROJECT INFORMATION:
1. Project name: Femwood Subdivision, Phase 2
2. Application/Project status: M 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: Yadkin
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.1308' Longitude:-80.6523°
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Steve M. Cause v License Number: 19701
Firm: Allied Design, Inc.
Mailing address: 4720 Kester Mill Road
City: Winston-Salem State: NC Zip: 27103-_
Phone number: (3� 765-2377 Email Address: scausey(a),allied-engsurv.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Town of Yadkinville W WTP Permit Number: NCO020338
Owner Name: Town of Yadkinville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Pennit Number(s): W00028848 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00130
Owner Name(s): Town of Yadkinville
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 ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Pronertv 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: 0 % Domestic/Commercial % 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 copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f)
Daily Design Flow ' ^
No. of Units
Flow
Residential, Single -Family Home
0 gal/day
12
0 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gall
GPD
galJ
GPD
Total
N/A 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: 0 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: WO0028848
❑ Rehabilitation or replacement of existing sewer with no new flow expected
® Other (Explain): Relocation
FORM: FTA 04-16 Page 2 of 5

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 369 SDR 26 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: 0Longitude: - °
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)
❑ 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(f) & 60
➢ 15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
® Yes ❑ No
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
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ 15A NCAC 02T.0305(Q) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications weboaee
➢ If noncompliance with 02T.0305(f) or (e). 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 Minimutn 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 nahie from Application Item
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):
I, %U,4 (tm� rrr) 5 16wv /ns ,U,4QQ attest that this application for
(Signature Authority's name & title from Application Item I.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if all required parts of this application package are not completed and that if
all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: P Date:o�i�
FORM: FTA 04-16 Page 5 of 5

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Allied Design,
CIVIL ENGINEERING 4-LAND!
Firm License No.: C-1891
March 19, 2020
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Winston-Salem Regional Office
450 West Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
SUBJECT: FAST TRACK SEWER SYSTEM EXTENSION
FERNWOOD SUBDIVISION, PHASE 2
SANITARY SEWER EXTENSION
ADI PROJECT: 20-017
To Whom It May Concern:
EOenartment of
nmental Quality
Received
MAR 25 2020
Winston-Salem
Regional Office „ y
We are pleased to submit the enclosed information for permitting of the sewer line extension on
the subject project.
This project includes a new sewer extension of approximately of 3721f of 8" SDR 35 PVC
sanitary sewer line. The sewer line is being extended to serve 12 single-family lots.
Please find enclosed:
1. This cover letter with the project description in the paragraph above;
2. A check in the amount of $480.00 for the distribution system fee;
3. The original and one copy of the completed "Fast Track Sewer System Extension
Application" (FTA 04-16);
4. A completed "Flow Tracking for Sewer Extension Applications" (FTSE 04-16);
5. One 8 % x 11 color copy of the USGS topographic map of this area;
6. One copy of the street level map showing the general project area.
Should you have any questions, please contact me at [phone].
Sincerely,
Steve M. Causey, P.E.
4720 KESTER MILL ROAD WINSTON-SALEM, NORTH CAROLINA 27103
Phone: [phone] •:• Fax: [phone]

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1. ROAD, STORM AND EROSION CONTROL DESIGN IS BY OTHERS.
2. VERIFY LOCATION AND DEPTH OF STORM PIPE AND BOXES.
3. OPEN CUT EXISTING PAVEMENT AS NEEDED FOR SEWER INSTALLATION.
4. PROVIDE MINIMUM OF 12" SEPARATION FOR WATER SERVICE UNDER NEW STORM.
5. PROVIDE MINIMUM OF 12" SEPARATION FOR 4" SEWER SERVICE UNDER NEW STORM.
6. SEE TOWN OF YADKINVILLE STANDARDS FOR WATER AND SANITARY SEWER
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WATER PROJECT NOTES:
1. WATER MAIN SHALL BE DUCTILE IRON OR 200 PSI
SDR-21 PVC PIPE WITH:
A. 36" MINIMUM GROUND COVER.
B. 42" LOWER THAN PAVEMENT EDGE.
SEWER PROJECT NOTES:
1. STANDARD GRAVITY SANITARY SEWER SHALL BE 8" SDR-35 PVC.
2. NEW SEWER MAIN BEGINS AT EXISTING MANHOLE #4 IN FRONT OF
LOT 11 AT CORNER OF FERNWOOD DRIVE AND HELIX COURT.
3. SEE ROAD DESIGN DRAWINGS BY OTHERS FOR ADDITIONAL DETAILS.
0 40 80 120 160
SCALE: 1 "=40' CONTOURS AT 2'
GREY ENGINEERING HAS PERFORMED WATER AND SEWER DESIGN.
ANY ADDITIONAL DESIGN IS BY OTHERS.
® ++'°"`p•Nr� FERNWOOD SUBDIVISION
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SEAL FERNWOOD DRIVE — PHASE 2
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P.O. Box 9 Mocksville, N.C. 27028 OF 2
greyengineering.com DRAWN BY: G. BULLARD PROJ. NO.: 185.005.GE
[phone] DESIGN BY: G. BULLARD DATE: 07/07/10
DATE: