WQ0024704_Application_20041217

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ) zt) Q000
1. Owner.- 7 t
1a.:TQW OF GCQZe F,E FAr4_S
Full Legal Name (company, municipality, HOA, utility, etc.)
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1 c. The legal entity who will 2wv E s system is:
❑ Individual ❑ Federal M Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1d. 14.0 1 emcite(AL FAIR.I,- COUIZ-17 1e. So Tuigww PIN II: S
Street Address City
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State Zip Code
1h. 9I19- 07--1163 1i. qio- (092- 1085 1j. -tee i Ne ,_fj' >�
Telephone Facsimile E-mail
2. Project (Facility) Information:
2a. 6M ITNFI6W'6 34W*44-J N' BAA -B'62 2b. MOOfE
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. K\Cbl e
Name and Affiliation of Someone Who Can Answer Questions About this Application
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3b. (9 — %-7�j - 3c. �k�INE��jp vitiP . mow..
Phone Number E-mail
Clifford E. Bullard, Sr. Trust
Checking Account
BB&T
Lumberton, NC
66-112/531
0e 4 Ki..�.T.�!�r �p
000086
***FOUR HUNDRED AND XX / 100 DOLLARS*****
DATE AMOUNT
Pay To NC DENR 11/19/2004 *******400.00*
The Order
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11800008611'

❑ Office
❑ Church
❑ Nursing Home
❑ Other (specify):
7. Volume of wastewater to be permitted in this project: 4BW gallons per day
8. If the permitted flow is zero, indicate why:
❑ 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
% Inoustrial
% Other (specify):

r . FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE I
OF W A rFR State of North Carolina
_
�Ot QG D �`... nR `�` .FDepartment of Environment and Natural Resources
DEC jj Division of Water Quality
o FAST -TRACK APPLICATION
WOor GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
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.
91. 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 1302).
® If. 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
N1 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
Nk the sewer extension is permitted by a private applicant and will be serving residential or commercial lots (e.g.,
houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. 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 COLOR 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 of the sewer line and pump stations, 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 shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location in Section C of the permit application.
❑ VII. Stream 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
nffinP

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
❑ 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
Tne application must be cer[iriea by Doin the appiicant ano a ivortn uaroiina Kegisrerea r-roressionai 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
Avery, Buncombe, Burke, Caldwell,
2090 US Highway 70
Cherokee, Clay, Graham, Haywood,
Swannanoa, North Carolina 28778
Henderson, Jackson, Macon,
[phone]
Madison, McDowell, Mitchell, Polk,
8)-2-7043_Fax—
Rutherford, Swain, Transylvania,
ance
Fay eville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301
Anson Bladen, Cumberland, Harnett,
[phone]
Hoke, ontgomery, Moore, Robeson,
[phone] Fax
Ric ond, Sampson, Scotland
Moore ille Regional Office
g19 N Main Street
Mooresville, North Caroli
Alexander, Cabarrus, Catawba,
Cleveland, Gaston, Iredell, Lincoln,
[phone] Fax
Mecklenburg, Rowan, Stanly, Union
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe,
Raleigh, North Carolina 27699-1628
Franklin, Granville, Halifax, Johnston,
[phone]
Lee, Nash, Northampton, Orange,
[phone] Fax
Person, Vance, Wake, Warren,
Wilson
Washington Regional Office
Beaufort, Bertie, Camden, Chowan,
943 Washington Square Mall
Craven, Currituck, Dare, Gates,
Washington, North Carolina 27889
Greene, Hertford, Hyde, Jones,
[phone]
Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington,
Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus,
Wilmington, North Carolina 28405
Duplin, New Hanover, Onslow,
[phone]
Pender
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
[phone]
Rockingham, Randolph, Stokes,
[phone] Fax
Surry, Watauga, Wilkes, Yadkin
Formore information, visit our web site at: http://h2o.enr.state.nc.us/ndpu/

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Application Number:
(to be completed by DWQ)
1.
Owner
1 a.
SoyJN OF S0V7'NjU=t4 IIn1ES
Full Legal Name (company, municipality, HOA, utility, etc.)
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1 c.
The legal entity who will owrOHs system is:
❑ Individual ❑ Federal ff Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
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Zip Code
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Telephone Facsimile
E-mail
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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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Contact Person:
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Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
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Phone Number
E-mail
1.
Project is ew ❑ Modification (of an existing permit)
If Modification, Permit No.:
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For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
phase, changing line size/length, etc.). Only include the modified information in this permit application - do not
duplicate project information in B(7) and B(10-11) that has already been included in the original permit
2. Owner is [ ublic (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ 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.
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. c Co.1Al4%#. pou.ustew 06,,me Fom,, :r, 4b. AI G 00 37 rj0
Name of WWTF 0 1 on to WWTF Permit No.
lryf_S 5b. '5c.
Owner of Downstream Sewer Receiving Sewer Size Permit Number of Downstream Sewer (if known)
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision ❑ Car Wash
❑ Apartments/Condominiums ❑ Institution 100 % Domestic/Commercial
❑ Mobile Home Park ❑ Hospital
❑ !�ahool ❑ Church % Industrial
estaurant ❑ Nursing Home /o o
❑ Office [I Other(specify):Other (specify):
7. Volume of wastewater to be permitted in this project: 4800 gallons per day
8. If the permitted flow is zero, indicate why:
❑ 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

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
e
Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(I) 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). DtnlitA AREA = 900 5F
40AAL, /s0,&T-` Dal 900 /15 = &0 x 40 = Z, 40o DPP
4aoo GPb
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) Gravity or Force Main
(use the pull down menu)
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ENTER TOTAL LINE LENGTH IN MILES
Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Q11.
Location ID Power Reliability Option
IX
(self chosen - as shown on Design Flow Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
0
plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
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12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
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Majps (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H _0200 as applicable?
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 APPLICATION
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No Eq N/A
Sedimentation and Erosion Control Plan? 93"�es ❑ No ❑ N/A
Stormwater? ❑ Yes [:]No WA

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
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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:
Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
w rbodv: AND.
A Stream 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 on Map
(self chosen - as shown on Name of Waterbody Stream Waterbody
map for cross-reference) Waterbody County River Basin Index Classification
Submit the 8.5" x I I" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
1. Applicant's Certification:
1, SIGNING OFFICIAL NAME, attest that this application for PROJECT NAME
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. 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 misdemeanor which may include a fine not to exceed $10, 000
as well as civil penalties u to 2 000 per violation.
Signing Official Signature
2. Professional Engineer's Certification:
Date
I attest that this application for 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
1Z 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 fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation. ,`���i��iir►►rrrrrr
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2a. LEE �. A)NE5 4/ •��
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Professional Engineer Name .Q J,
2b. SoL4y14WlPJD SuRV6VIW6 +- In1G
Engineering Firm 22; 93 4
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2c. 201 GL.gtj 90Ab
Address
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2d. C�A►2N6,2 2e. N 2f. 2'7529 '.'�f, ►�� � ���'�
City State Zip /C -V v vv 10l /,
2g. 9 9-773 o1832n. 19-77 =0141b 2i. RYIN9�� ��WnfG. own ZZ ��
Telephone Facsimile E-mail Seal, Signature & Date

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0 0.09 0.18 0.27 0.36 0.45 mi
Map center is UTM 17 644773E 3892064N (WG584/NAD83)
Southern Pines quadrangle
Projection is UTM Zone 17 NAD83 Datum
http://www.topozone.com/print.asp?z=17&n=3892064.00006361 &e=644773.000003793... 11/15/2004

iN
SOUTHWIND
lo-- I SURVEYING AND ENGINEERING, INC.
SURVEYING / ENGINEERING / LAND PLANNING
201 GLEN ROAD
GARNER N C. 27529
91
919-773-0183
919-773-0148(FAX)
Leigh Potts
[e-mail]

TO
SOUTHWIND
SURVEYING AND ENGINEERING
201 Glen Road
Garner, North Carolina 27529
Phone: [phone]
Fax: [phone]
�II
-7/4-
/—,�`�c���/iL.Lr�
LETT M OF UMMSEOCTUL
DATE
JOB NO.
ATTENTIONRE
/ ('j
WE ARE SENDING YOU Attached ❑ Under separate cover via
❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples
❑ Copy of letter ❑ Change order ❑
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
I
�qST- � � v iT`' s � � fL �- �� � o ►�
THESE ARE TRAN TTED as checked below:
or approval ❑ Approved as submitted
❑ For your use ❑ Approved as noted
❑ ;Srre ted ElReturned for corrections
eview and comment ❑
❑ FOR BIDS DUE 19
El Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS
'PL ei4SE (:::-A-LL w tTj-t Xh"9 62LtE577 oN s flF /F Va,-t
COPY
t� 6-9-P A P\, Q DD i770441_ ) tjrc)a—P-14-'n-o,4
DEL 17 2004
SIGNED:
N enclosures are not as noted, kindly not us at

County of Noore
Tu6Cic Works Department
P. O. Box 1927
Carthage, North Carolina 28327
AQN�
`[1ticities Solid 'Waste
�rj- iitiv
910-947-6315 (Telephone) r■ 910-947-3037 ('leuepnane)
910-947-1992 (Facsimi[e) N9 ? ;_'� fl r� 910-947-1992 (Facsimi[e)
rf �FNOflTH �P�o�
November 22, 2004
Mr. Leigh Potts
Southwind Surveying & Engineering
201 Glen Road
Garner, NC 27529
Dear Mr. Potts:
RE: Flow Acceptance Letter for Sanitary Sewer Improvements to Serve Smithfield's
Chicken N' Bar B Q for Sticky Fingers Enterprises, LLC.
The Moore County Water Pollution Control Facility, permit # NC 0037508, presently has
sufficient capacity available to conditionally accept up to 4,800 gallons per day from the
above referenced project.
This project will be required to comply with all specifications, and requirements of the
Town of Southern Pines, NC.. In addition all required fees must be paid to the Town of
Southern Pines.
Upon completion of the referenced project, the applicant's engineer is to provide our
office with the following items:
1. Certification of Completion.
2. Complete set of As -Built drawings.
If you have any questions or comments please call me at [phone].

Sincerely,
IvIUUttr, l UUIN I Y YUBIAC Wuk&b-
Ernie Black
Engineering Project Technician
Cc: Mr. Phillip Boles, Director
Delmo Frye, Superintendent
Mr. Bobby Teague, Town of Southern Pines

SOUTHWIND
SURVEYING AND ENGINEERING
201 Glen Road
Garner, North Carolina 27529
Phone: [phone]
Fax: [phone]
TO M)W-6 LAwy,64__
NGD6/1(2!_
LETTER of "TRUMEDUMEL
DATE �f�
2 t:/
JOB NO.
ATTENTION
RE:
H-.a.� Y"-
NCiS AJC_
XL
DWQ
WE ARE SENDING YOU Attached ❑ Under separate cover via
❑ Shop drawings ❑ Prints ❑ Plans
❑ Copy of letter ❑ Change order ❑
❑ Samples
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
THESE ARE TRANSWTTED as checked below:
For approval ❑ Approved as submitted
❑ For your use ❑ Approved as noted
❑ As requested ❑ Returned for corrections
❑ For review and comment ❑
❑ FOR BIDS DUE 19
DCMA,DI(C
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
COPY TO _
SIGNED:
If enclosures are not as noted, kindly notify us at