WQ0041637_Application (FTSE)_20200422

Green Mountain Engineering, PLLC Civil Engineering Consultants
Woodland Heights of Burlington Phase 3
Sanitary Sewer Permitting - Cover Letter
Attached please find the following information in duplicate (one original and one
copy):
1. Application fee of $480.00, payable to NCDEQ (one check)
2. FTA 04-16 Fast Track Sewer Extension Application
a. Woodland Heights of Burlington Phase 3, LLC articles of
incorporation
b. Woodland Heights of Burlington Phase 3, LLC latest annual report
3. Flow tracking form FTSE 04-16 completed by City of Burlington
4. 8.5"x11" copy of the applicable USGS Topographic Map of the area with the
site designated thereon.
5. Vicinity Map
6. One copy of items 2 through 5.
Project and System Description:
Woodland Heights of Burlington Phase 3 is a proposed apartment development
which will add 240 residential units and one clubhouse to the existing Woodland Heights
of Burlington apartment development. The proposed sewer mains will be privately
maintained and the system was designed in accordance with NCDEQ's Gravity Sewer
Minimum Design Criteria, and in compliance with City of Burlington Standards and
Specifications.
The gravity sewer needed to serve the site will tie into the existing private 8"
gravity sewer located in the adjacent Woodland Heights of Burlington Phase 2 (permit
no. WQCS032222). From this tie-in point, wastewater will flow through the private
sewer main to the City of Burlington's public sewer system, thence it will flow to the
South Burlington WWTP, permit number NC0023876.
The gravity sewer to be installed will include approximately 1439 linear feet of 8"
sewer mains, 6 manholes, 10 six-inch services, and 2 four -inch services. The projected
average daily waste -water flow is based upon the number of proposed bedrooms. There
are 120 proposed 3-bedroom units (ADF of 360 gpd/unit) and 120 proposed 2-bedroom
units (ADF of 240 gpd/unit), for a total projected average daily flow (ADF) of 72,000
gpd.
Requested Permitting Action:
With submittal of the attached application and materials, we are requesting
permission to extend gravity sewer to serve the above described project.
Please contact me if you require additional information. You can reach me via email
vine(aggreenmountainengineers.com or by telephone [phone] at your convenience.
Respectfully submitted,
Vincent C. Townsend, PE, PLS
Green Mountain Engineering, PLLC
7A Wendy Court - Greensboro, NC 27409 - [phone]
Page 1 of 1

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 INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T, 15A NCAC 02T .0300, Division policies and rood enizineerine practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC 1 C .0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
K Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
K Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
49 Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
® If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page I of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
R Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE 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 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 a project -specific FTSE.
F. Site Maps (All Application Packages):
M Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include a street level map showing general project area.
G. Existing Permit (All Modification Packages): ► /Pr
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station): # %A
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities): P/A
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold): u lA
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEW
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, 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,
Water Quality Section
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,
Water Quality Section
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,
Water Quality Section
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,
Water Quality Section
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 Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
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
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

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10065 A 12635 (2/16) 100651 Rev 2114

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: Woodland Heights of Burlington Phase 3, 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: Thomas S. Holserbv per 15A NCAC 02T .0106(b)
Title: Managing Member
4. Applicant's mailing address: 810 F Lawndale Drive
City: Reidsville State: NC Zip: 27320-6628
5. Applicant's contact information:
Phone number: [phone] Email Address: planninp-&P—ibsonville.net
II. PROJECT INFORMATION:
1. Project name: Woodland Heights of Burlington, Phase 3
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: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.061936' Longitude:-79.556055'
5. Parcel ID (if applicable): 883460140-000
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Vincent C. Townsend License Number: 23951
Firm: Green Mountain Engineering,PLLC
Mailing address: 7A Wendy Ct.
City: Greensboro State: NC Zip: 27409-
Phone number: 336) 294-9394 Email Address: vince &greenmountainengineers.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: South Burlington WWTP Permit Number: 0023876
Owner Name: City of Burlington
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: 100 % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
4 Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(t)? ❑ 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 a,b
No. of Units
Flow
Dwelling Unit - 3 bedroom
360 gal/day
120
43,200 GPD
Dwelling Unit - 2 bedroom
240 gal/day
120
28,800 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
72,000 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.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 72.000 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 1439 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(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f) & (s)
➢ 15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
® 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(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(f) or (gl. see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes [-]No
➢ 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 all setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes [:]No
➢ Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
➢ 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.0 I 05(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
➢ 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?
® 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:
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
innh,rle n 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 CPr+ifio4tion per 15A Nr A r AIT n i nf�rhL
I TW ,f5 J . _�-c�L 17 t tZQY GLt �� attest that this application for
(Signature Authority's name & title fl'om 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:
Date: � -a o
FORM: FTA 04-16
Page 5 of 5

nn`7LIMITED LIABILITY COMPANY ANNUAL REPORT
10/2017 M
NAME OF LIMITED LIABILITY COMPANY: Woodland Heights of Burlington Phase 3, LLC
SECRETARY OF STATE ID NUMBER: 1555592 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: qnj o
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Sheridan, Desmond G.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
3. REGISTERED OFFICE STREET ADDRESS & COUNTY
804 Green Valley Road, Suite 200
Greensboro, NC 27408-7044 Guilford Countv
E - Filed Annual Report
1555592
CA201907702547
3/18/2019 11:26
Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
4. REGISTERED OFFICE MAILING ADDRESS
804 Green Valley Road, Suite 200
Greensboro, NC 27408-7044
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Residential Real Estate owner
2. PRINCIPAL OFFICE PHONE NUMBER: [phone]
4. PRINCIPAL OFFICE STREET ADDRESS & COUNTY
810 F Lawndale Drive
Reidsville, NC 27320-6628
3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
5. PRINCIPAL OFFICE MAILING ADDRESS
810 F Lawndale Drive
Reidsville, NC 27320-6628
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Thomas S Holderby
TITLE: Manager
ADDRESS:
1101 Ivey Rd.
Graham, NC 27253
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT Section D must be completed in its entirety by a person/business entity.
Thomas S Holderby 3/18/2019
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
DATE
Thomas S Holderby Manager
Print or Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

Articles of Organization
Of
SOSID: 1555592
Date Filed: 11/17/2016 12:04:00 PM
Elaine F. Marshall
North Carolina Secretary of State
C2016 315 00182
Woodland Heights of Burlington Phase 3, LLC
Pursuant to Article 2 of Chapter 57D of the North Carolina General Statutes, the
undersigned natural person of the age of eighteen (18) years or more does hereby make and
acknowledge these Articles of Organization for the purpose of establishing a limited liability
company (the "Company") under and by virtue of the laws of the State of North Carolina, and to
that end does hereby set forth the following:
ARTICLE I
The name of the Company is Woodland Heights of Burlington Phase 3, LLC.
ARTICLE II
No date for the dissolution of the Company is herein specified.
ARTICLE III
The Company shall have the purpose of engaging in any lawful business and shall have all
of the powers set forth in Section 5713-2-03 of the North Carolina General Statutes.
ARTICLE IV
The address of the initial registered office of the Company is 804 Green Valley Road, Suite
200, Greensboro, Guilford County, North Carolina 27408, and the name of the initial registered
agent of the Company at such address is Desmond G. Sheridan.
ARTICLE V
Pursuant to Section 57D-3-20(d) of the North Carolina General Statutes, the Company's
operating agreement will provide that members are not necessarily managers and will designate
other persons who are managers.
ARTICLE VI
The name and address of the organizer of the Company are:
Name
Desmond G. Sheridan
Address
Isaacson Isaacson Sheridan Fountain
& Leftwich, LLP
804 Green Valley Road
Suite 200
Greensboro, NC 27408

Articles of Organization
Woodland Heights of Burlington Phase 3, LLC
Page 2
ARTICLE VII
The street and mailing address of the principal office of the Company is:
810 F Lawndale Drive
Reidsville NC 27320
The principal office of the Company is in Rockingham County, North Carolina.
ARTICLE VIII
Pursuant to Section 57D-2-20(c) of the North Carolina General Statutes, the organizer shall
designate those persons, firms or corporations who shall be the initial members of the Company.
ARTICLE IX
To the fullest extent permitted by the North Carolina Limited Liability Company Act, as it
exists or may hereafter be amended, no member of the Company, nor any person who is serving
or has served as a manager of the Company, shall be personally liable to the Company or any of
its members for monetary damages or breach of duty as a member of manager. In addition, to the
fullest extent permitted by the North Carolina Limited Liability Company Act, as it exists or may
hereafter be amended, the Company shall indemnify all persons who are members or managers of
the Company against any of the matters described in N.C.G.S. § 57D-3-31. No amendment or
repeal of this article, nor the adoption of any provision of these articles of organization inconsistent
with this article, shall eliminate or reduce the protection granted herein with respect to any matter
which occurred prior to such amendment, repeal or adoption. The members shall have the express
authority, pursuant to an operating agreement, to extend and clarify the limitation of liability and
indemnity provided hereunder.
ARTICLE X
of StateThese articles shall be effective upon filing in the Office of the North Carolina Secretary
IN WITNESS WHEREOF, the undersigned has hereunto set his hand, this the 1 Oth day of
November, 2016.
A,- 'f-Stephen C. Pritchard, Organizer
2

State of North Carolina
Department of Environmental Quality
WDivision of Water Resources
-�- - -
13mdon of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Woodland Heights of Burlington Phase 3 LLC
Project Name for which flow is being requested: Woodland Heights Phase 3
More than one FTSE may be required for a single project if the owner of the WWTP is not respo asible 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: South Burlington WWTP
b. WWTP Facility Permit #: 0023876
All flows are in MGD
c. WWTP facility's permitted flow 12.000000
d. Estimated obligated flow not yet tributary to the WWTP 1.662283
e. WWTP facility's actual avg. flow 8 752000
f. Total flow for this specific request 0.072000
g. Total actual and obligated flows to the facility 10.486283
h. Percent of permitted flow used 87.4%
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, * (Finn / pf),
Avg. Daily
Daily Flow,
Obligated Available
Number)
No.
MOD MOD
Flow, MOD
MOD
Flow Capacity***
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the flrm 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): Woodland Heights Phase 2
Downstream Permit Number: WQ0032222
Page l of 6
FTSE 10-18

III. Certification Statement:
I W. Todd Lambert 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.
w vv
Signing Official Signature Date
City Engineer
Title of Signing Official
Page 2 of 6
FTSE 10-18

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