WQ0022714_Application_20030605

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI
Application Number:
(to be completed by DWQ)
1.
Owner:
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1a.
(mit-1 OF
Full Legal Name (company, municipality, HON utility, etc.)
1b.
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Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authoriAed slgniryq— fMcials}j j
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1c.
The legal entity who will own this system is: - -
❑ Individual ❑ Federal IS Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify): C
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Street Address
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Project (Facility) Information
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Brief Project Name (permit will refer to this name)
County Where Project is Located
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3.
Contact Person:
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3a.
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Name and Affiliation of Someone Who Can Answer Questions
About this Application
3b.
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3c. -U i S,z( L
Phone Number
E-mail
1.
Project is ® New ❑ Modification (of an existing permit)
If Modification, Permit No.:
2.
Owner is R Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a.
if private, applicant will be:
I 2b. If sold, facilities owned by a (must choose one)
❑ Retaining Ownership (i.e. store, church, single office, etc.)
❑ 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))
3.
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Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
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4a.
4b.
TOWN OF BISCOE
CENTRAL DEPOSITORY
PAY ****400 DOLLARS AND NQ CENTS****
NCDENR DIVISION OF WATER OUALI
PAY FAYETTEVILLE REGIONAL OFFICE
TO THE 2'25 GREEN STREET, SUITE 714
OR OFFAYETTEVILLE, NC 28301
THE FIDELITY BANK U-7 66- 58
BISCOE, N.C. 27209 531
No.021730
MAY 30, 2003 21730 $ 400. 00
THIS DISBURSEMENT HAS BEEN APPROVED AS REQUIRED BY
THE LOCAL GOVERNMENT BUDGET AND FISCAL CONTROL ACT.
L"AUTHORIZED SIGNATUFIE

OF 144A T� State of North Carolina
ot'✓ Department of Environment 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 the following list of required application package items by checking the
space provided next to each item. Failure to submit all required items will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
[7j 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 13(12)
Q II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ 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 will be serving residential or commercial lots (e.g., houses, condominiums, townhomes,
outparcels, etc.) that will be owned by a homeowners' association or developer (Item B(2b)). 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.
[� VI. Map — Submit an 8.5-inch by 11-inch 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,
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
for each different waterbody (where the sewer line is within 100 feet of such waterbody - see Instruction VII).
[ VII. Watershed 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/ndpu or by contacting the appropriate regional
office.
INSTRUCTIONS FOR FORM FTA 02/03

❑ Vill. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) ]15A NCAC
01C .0500], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
processed 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(lb). 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.
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
59 WooPlace
Avery, Buncombe, Burke, Caldwell,
As
Asheville, North Carolina 28801
Cherokee, Clay, Graham, Haywood,
(828) 251-6
Henderson, Jackson, Macon, Madison,
[phone] 52 Fax
McDowell, Mitchell, Polk, Rutherford, Swain,
Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, -Cumberland, Harnett, Hoke,
Fayetteville, North Carolina 28301
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
[phone]
[phone] Fax
Mooresville Regional Office
919 N Main Street
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,
Northampton, Orange, Person, Vance, Wake,
[phone]
Warren, Wilson
[phone] Fax
Washington Regional Office
Beaufort, Bertie, Camden, Chowan, Craven,
943 Washington Square Mall
Currituck, Dare, Gates, Greene, Hertford,
Washington, North Carolina 27889
Hyde, Jones, Lenoir, Martin, Pamlico,
[phone]
[phone] Fax
Pasquotank, Perquimans, Pitt, Tyrrell,
Washington, Wayne
Wilmington Regional Office
Brunswick, Carteret, Columbus, Duplin, New
127 Cardinal Drive Extension
Hanover, Onslow, Pender
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Winston-Salem Regional
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Office
Winston-Salem, North Carolina
Davidson, David, Forsyth, Guilford,
27107
Rockingham, Randolph, Stokes, Surry,
[phone]
Watauga, Wilkes, Yadkin
[phone] Fax
For more information, visit our web site at: http://h2o.enr.state.nc.uslndpul
INSTRUCTIONS FOR FORM FTA 02/03

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! r
....................-- __ _ __�—_ _—. `— Application
be completed by DWQ) Wo i
1.
�._
Owner:
la.
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Full Legal Name (company, municipality, HOA, utility, etc.) - —
.... .................. ._ . _ ,t _ ...
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1 b.
S AMES C . i3LA�F k. f
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Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for autho ' "` s ni I Cuui
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1c.
The
Individuallegal
ndrndualtlYsystem 0 Federal C9 Mun cipal ty art State/County Private Pnership Corporatiorh ❑Other (specify):
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Telephone Facsimile E-mail
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2.
Project (Facility) Information:
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2a.
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Brief Project Name (permit will refer to this name) County Where Project is Located
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3.
Contact Person
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3a,
low \SHF 2 A nES�Gn� >#.SS�cc�AtFS \ I� .
Name and Affiliation of Someone Who Can Answer Questions About this Application
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3b.
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Phone Number E-mail —
1.
Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
2.
Owner is R Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a.
i
If private, applicant will be: 2b. If sold, facilities owned by a (must choose one)
❑ Retaining Ownership (i.e. store, church, single office, etc.) ❑ 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))
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Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
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Name of WWTF i WWTF Permit No.
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Owner of Downstream Sewer
Receiving Sewer Size
Permit Number of Downstream Sewer
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6.
The origin of this wastewater is (check all that apply):
❑ Residential Subdivision ❑ Car Wash —
W❑
Apartments/Condominiums El Institution WC %Domestic/Commercial
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❑ Mobile Home Park El Hospital
❑ School ❑ Church % Industrial
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❑ Restaurant ❑ Nursing Home /° ° Other (specify):
El Office Other (specify):
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7.
Volume of wastewater to be permitted in this project: 3C 2`-1 gallons per day
8.
If the permitted flow is zero, indicate why: j
❑ Interceptor Line - Flow will be permitted is 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

'FAST —TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(l) for Item B(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 approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality, Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(I)(3).
U5, Zoo SvZo C"m/ i000 ss) _ '302`i G-I' n
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) Gravity or Force Main
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in
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OENTER TOTAL LINE LENGTH IN MILES O,27.
Q11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Power Reliability Option
Location ID Design Flow Operational Point (dual line feed, permanent generator w/ATS,
0 (as shown on planGPM 9t TDH portable generator w/autodialer, wet well storage)
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12. Does the sewer syst� - _ —_ _.._ ._ .. _.--D_.___ .___.. _ . _.___ _ .----___._ ._. _.-__-- -__...
em comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
IM Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
C,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
.13. Have the following permits/certifications been submitted for approval? T
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No I[ N/A
Sedimentation and Erosion Control Plan? 19 Yes ❑ No ❑ N/A
Stormwater? RYes ❑ No ❑ N/A
FTA 02/03

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
Q
3
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1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02/03
(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:
❑ A Watershed Classification is not needed because all parts of the project are at least 100 feet away from any down
slope waterbody; AND,
❑ A Watershed 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 Name of Waterbody Stream Waterbody
on Map Waterbody County River Basin Index Classification
i �sNrc� �� ve. Mc,H �cc�r��rzy y Ank� ►.� �3• Z5 ' ZZ.-� Cr
UN NAMEA �p1Aj. MuN 1GtfME2`( y Ankh N �'� . Z rj, 22 • '�
Submit the 8.5" x 11" topographic map as required in Instruction VI regardless of whether a classification is providedl
1. Applicant's Certification:
I attest that this application for has been reviewed by me and is accurate
and complete to the best of my knowledge. I understand that if all required pants 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 misdern r which may include o f a not to exceed $10,000 as well as civil penalties up to $25,000 per
1 a.
! s ' Engineer's Certification:
I attest that this application for Mom'C 144z^12't 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 I 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 tune not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
2a. IQ. Tocln F
Professional Engineer Name
2b. G N A
Engineering Firm
2c. _ IAZV F_ Ft;,v%Z7\K S i S�t�E tic, ! 025163
Address
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City State Zip ,,rJ �cir
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_ Telephone_ Facsimile _ E-mail _ v_ Seal, Signature & Date
FTA 02/03

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