WQ0041622_Application (FTSE)_20200415

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TRANSMITTAL
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Date: March 12, 2020
WQROS
MOORESVILLE REGIONAL 01PPIC E.
Reference: 00639.03 Atrium Providence FSED - Private Sewer Permit
Attention: Barry Love
Company: NCDEQ
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Transmitting: 1- Fast Track Application with a copy
1- Engineers narrative
1- USGS Map
1 -Aerial Map
1 - Flow Acceptance Letter
1 - Business license confirmation
Transmitted
Via: ..-k-dEx- VIa„Ci Tl el.4w-
Comments: Please call (803-513-4734) or email ([e-mail]) me with any questions
you may have.
By:
David S. Klausman
Bloc Design, PLLC
CC: W. Larry Lockhart, Jr. PE, CMCSI - BD
Bloc Design
2923 South Tryon St., Suite 320
Charlotte, NC 28203
704.940.2883 www.bloc-nc.com

March 12, 2020
North Carolina Department of Environmental Quality
Division of Water Resources
610 East Center Avenue
Suite 301
Mooresville, North Carolina 28115
Re: 00639.03 — Atrium Providence FSED (FTA Cover Letter)
To Whom It May Concern,
The referenced project located at 11516 Providence Road, Charlotte, NC is a proposed Free Standing Emergency
Department. The proposed building will connect to an existing private sewer. An existing private permit could not
be located for this site as it serves multiple buildings. This application is to permit the existing sewer line that was
permitted and installed sometime between 2002 and 2003. Approximately 746 If of 8" gravity sewer will be
permitted as part of this application. The anticipated flow to the existing sanitary sewer system will be 3,000 gallons
per day.
This package includes the completed FTA 04-16 form, USGS topographic map, aerial, and flow acceptance
letter.
Upon your review of the enclosed information, please feel free to contact me for further discussion.
Regards,
David S. Klausman, PE
Bloc Design, PLLC
NC Firm: P-1007, C-390
803-513-4734
dsk
cc: Mr. W. Larry Lockhart, Jr., PE — BD
SEAL
35711
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The Beck Group Bloc Design
00639.03 - Providence Road FSED 2923 South Tryon St, Suite 320
Charlotte, North Carolina Charlotte, NC 28203
704.940.2883 www.bloc-nc.com

State of North Carolina
Department of Environmental Quality
_DWR Division of Water Resources
IV 1W
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
C'PVE&NCI)ENR/DWR
Application Number: (to be completed by DWR)
MAR 12 "020
All items must be completed or the application will be returned
WQROS
L APPLICANT INFORMATION: MOORESVILLE REGIONAL OFFICE
1. Applicant's name: Beck Architecture (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Shaun Atkinson per 15A NCAC 02T .0106(b)
Title: Project Manager
4. Applicant's mailing address: 4777 Sharon Road, Suite 500
City: Charlotte State: NC Zip: 28210-
5. Applicant's contact information:
Phone number: [phone] Email Address: ShaunAtkinsongbeckgroup com
II. PROJECT INFORMATION:
1. Project name: Atrium Providence FSED
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Mecklenburg
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.0523' Longitude:-80.7707'
5. Parcel ID (if applicable): 22917108
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: David S. Klausman License Number: 35711
Firm: Bloc Design, PLLC
Mailing address: 2923 S. Tryon St, Suite 320
City: Charlotte State: NC Zip: 28203-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: McAlpine Creek Permit Number: NCO024970
Owner Name: Charlotte Water
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 ®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/Property 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: % Domestic/Commercial 100 % Commercial
% 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',b
No. of Units
Flow
Free Standing Emergency Department
300 gal/bed
10
3000 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
3000 GPD
a See 15A NCAC 02T .0114(b , (dL ), (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: 3000 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:
❑ 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
8 746 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: Longitude: - °
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)
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(0):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g) ® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
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.0305W contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(_ or (g), 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 proj ect 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(cl(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:
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?
To the best of my knowledge the existing ® Yes ❑ No
private sewer meet these requirements.
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:
13 5 414U(m AY4 attest 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 vtk4,on.
North Carolina Professional Engineer's seal, signature, and date:
a SEAL
• 35711 —
�if S. KLPv \
q7o
Applicant's Certification per 15A NCAC 02T .0106(b):
I, �j h 3 wk '�"��� gd-^ attest that this application for
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 1.43-215.6A 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: 3" (L " 0 ZC>
FORM: FTA 04-16 Page 5 of 5

RECEiVEMCDENR/DWR State of North Carolina
RECEIVED/WCDE / Wa Department of Environmental Quality
APRo8 z'
z
� 0920,0 Division of Water Resources
WQROS Flow Tracking for Sewer Extension Applications
MOORESVILLWQSWNAL OFFICE
MOORESVILLE REGIONAL OFFICE (FTSE 10-18)
Entity Requesting Allocation: Bloc Design
Project Name for which flow is being requested: Atrium Providence FSED
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: McAlpine Creek, Irwin Creek, Sugar Creek
b. WWTP Facility Permit #: NCo024970, NC0024945, NCO024937
All flows are in MGD
c. WWTP facility's permitted flow 99.0
d. Estimated obligated flow not yet tributary to the WWTP 11.95
e. WWTP facility's actual avg. flow 72.6
f. Total flow for this specific request 0.003
g. Total actual and obligated flows to the facility 84.5
h. Percent of permitted flow used 85.4
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)
Design
Obligated,
Pump Pump
Average
Approx.
Not Yet
Total Current
Station Station
Firm Daily Flow**
Current
Tributary
Flow Plus
(Name or Permit
Capacity, * (Firm / pi),
Avg. Daily
Daily Flow,
Obligated
Available
Number) No.
MGD MGD
Flow, MGD
MGD
Flow
Capacity***
Six Mile Creek
18 7.2
5.05
.251
5.3
1.896
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped now
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(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 < 0.
Downstream Facility Name (Sewer): Unknown
Downstream Permit Number: Unknown
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Keri Cantrell
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 en 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 Signature
Chief Engineer
Title of Signing Official
� ��► �.► Rom► \..
3/30/2020
Date
Page 2 of 6
FTSE 10-18

CHARLOTTE
W4)TER
July 8, 2019
Mr. David Klausman
Bloc Design
2923 South Tryon Street
Suite 320
Charlotte, NC 28202
SUBJECT: CAPACITY ASSURANCE REVIEW
ATRIUM PROVIDENCE FSED
11516 PROVIDENCE ROAD, CHARLOTTE, NC
CLTWATER TRACKING# 20193398
After analysis of the sanitary sewer associated with the proposed design of project 20193398,
ATRIUM PROVIDENCE FSED, it was determined that there is sufficient capacity to accommodate
the proposed sewer flow of 3,000 gallons per day (10 beds x 300 gpd/bed) at the connection
point(s) indicated on the submitted utility plan for transmission to the McAlpine Creek Wastewater
Treatment Plant; NPDES permit number NC0024970, for treatment. This acceptance of flow is
based upon the existing capacity of the designated publicly owned treatments works.
CLTWater agrees to furnish water to the subject project. The water quality to the subject project is
regulated by the State Drinking Water Act Amendments of 1986, and The Water Supply
Management Plan, PWS ID # 0160010, on file with the Public Water Supply Section of NCDEQ.
However, CLTWater cannot guarantee a constant pressure or quality of flow.
Due to the involvement of other agencies and continuing growth of the water and sewer system, the
ability to provide service for future projects cannot be guaranteed nor reserved. Connection to the
CLTWater and sewer system is accepted on a first come, first served basis.
The applicant should understand that this letter is not authorization to construct private water or
sewer systems, as the appropriate local or State permits are required prior to construction. If the
appropriate authorization to construct permits are not obtained and construction has not started
within two (2) years of issuance of this Capacity Assurance Review, and payment for any service
connection() has not been received within two (2) years of issuance of this Capacity Assurance
Review letter, this approval shall be rescinded and a new Capacity Assurance Review must be
made. If you have any questions, you may contact me at [phone].
Sincerely,
4!vW,e rvwo- Arzo-La-
Guillermo Anzola
Engineering Assistant
Charlotte Water 5100 Brookshire Blvd, Charlotte, NC 28216 charlottewater.org
�A Operated by the City of Charlotte

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3/12/2020
North Carolina Secretary of State Search Results
• Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings
Professional Limited Liability Company
Legal Name
Beck Architecture, PLLC
Home State Name
Beck Architecture, LLC
Information
Sosld: 1028837
Status: Current -Active
Date Formed: 2/20/2008
Citizenship: Foreign
State of Incorporation: DE
Annual Report Due Date:
Currentgnnual Report Status:
Registered Agent: CT Corporation System
Addresses
Reg Office Reg Mailing
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Raleigh, NC 27615 Raleigh, NC 27615
Mailing
1807 Ross Avenue, Suite 500
Dallas, TX 75201
Principal Office
c/o the Corporation Trust Company Corporation Trust Center 1209 Orange Street
Wilmington, DE 19801
Professions
Architectural services
https://www.sosnc.gov/online_services/search/Business_Registration_ResuIts 1/1