WQ0041623_Application (FTSE)_20200415 (3)

State of North Carolina
Department of Environmental Quality
DWR 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: Northlake West Real Estate Investors, LLC (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: Trent Gustafson per 15A NCAC 02T .0106(b)
Title: Manaizer
4. Applicant's mailing address: 5960 Fairview Road
City: Charlotte State: NC Zip: 28210-
5. Applicant's contact information:
Phone number: [phone] Email Address: tgustafson(c_gpartnerscre.com
II. PROJECT INFORMATION:
1. Project name: Northlake West Mixed Use
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 County
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.3466' Longitude:-80.8582'
5. Parcel ID (if applicable): 02522114
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Daniel Renckens License Number: 048031
Firm: Bohler
Mailing address: 1927 S Tryon St, Suite 310
City: Charlotte State: NC Zip: 28203-
Phone number: [phone] Email Address: drenckens@_bohlereng.co
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 Pagel of 5