WQ0031260_Sewer Extension_20070122

;ITT -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)
1. Owner.
1a. Moore County Utilities
Full Legal Name (company, municipality, HOA, utility, etc.)
1 b. CA9_4 AL c Sill ht rV . �VI.AW t A ,^.�1`1 MomXle -
Signing Official Name and Title (Please review 15AINCAC 2FV0206(b) for authorized signing officials!)
1 c. The legal entity who will own this system is:
❑ Individual ❑ Federal 11 Municipality State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1 d. P.O. Box 726 le. Carthage
Mailing Address City
If. North Carolina IQ. 28327
State Zip Code
1 h. 910-947-6315 1 i. 910-947-1992 1 j.
Telephone Facsimile E-mail
2. Project (Facility) Information:
2a. Cotswold 2b. Moore
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. 6L FWAI MAADU- Sf . elCNs'uLt'/bu'
Name and Affiliation of Someo6e Who Can Answer Questions About this Application
3b. r gc O) G'I S • 0 3 73 3c. a bear Nll,,:n k . rn e
_ Phone Number E-mail
1. Projectis XCR New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
phase, changing line sizellength, 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 ® Public (s)dp to Item B(3)) ❑ Private (go to Item 2(a))
-- - - - ------ -- ---- - -. --.. - ----
2a. If private, applicant will be: 2b. If— sd--d, fa--cil-ities- owned---- - by-- a -- (-must choose-- - one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction 111)
Z ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (instruction IV)
0 ❑ Selling units (lots, townhomes, etc. - go to Item 8(2b))
H 3. Moore County - - - --
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project -
4a. Moore County Water Pollution Control Facility 4b. NC 0037508
PLANET DEVELOPMENT LLC
184 LINDEN PINES PLACE
ABERDEEN, NC 28315
66-456/531
20072
1/12/2007
PAY TO THE NC DENR $ **400.00
ORDER OF
Four Hundred and 00/100.....«.**.,��«*,..*„►,.*.*******.#...*..**,...,,...«*.**�*„*..*«�##.*«**.**.«**,.�..«*.,..*«�«***««..�.
NC DENR
1601 Mail Service Center
Raleigh, NC 27699-1601
MEMO:
permits
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11202007211s 1:

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FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
OF W ATF State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
p---�"`�� c Jlna
COPY 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/addressed the following list of required application package items by
checking the space provided next to each applicable item. Failure to submit all required items will lead to your application
being returned as incomplete. This form may be photocopied for use as an original.
[ 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 B(12).
R/1I. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ Ill. 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 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.
4VI. 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.
❑ Vll. 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 ittp://h2o.enr.state.nc.us/peres or by contacting the appropriate regional
office.
FTA 02/03 - Rev. 3 04/05

'r-
FAST-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
❑ Vill. Environmental Assessments — ff this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the PERCS
Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be accepted 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.
@SIX. 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(1b). 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.
❑ X. Downstream Sever Nk Wastewater Treatment Plant Capacity
The applicant has assured downstream pipe, pump station and treatment plant capacity. The addition of new
sources of wastewater from this project has been evaluated along the route to the receiving treatment plant. The
flow from this project will not cause capacity related sanitary sewer overflows or overburden any downstream
pump station en route to the receiving wastewater treatment plant if the applicant is not the owner of the
downstream sewer or receiving treatment plant, submittal of flow acceptance letter(s) in dictates that owner has
adequate capacity and will not violate G.S. 143-215.67(a).
THE COMPLETED FTA 02103 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
2090 US Highway 70
Avery, Buncombe, Burke, Caklwell,
Swannanoa, North Carolina 28778
Cherokee, Clay, Graham, Haywood,
[phone]
Henderson, Jackson, Macon, Madison,
[phone] Fax
McDowell, Mitchell, Polk, Rutherford,
Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett,
Fayetteville, North Carolina 28301
Hoke, Montgomery, Moore, Robeson,
[phone]
Richmond, Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue, Suite 301
Alexander, Cabarrus, Catawba,
Mooresville, North Carolina 28115
Cleveland, Gaston, Iredell, Lincoln,
[phone]
Mecklenburg, Rowan, Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecornbe, Franklin,
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Penton, Vance,
919 571-4718 Fax
Wake, Warren, Wilson
Washington Regional Office
943 Washington Square Mail
Beaufort, Berne, Camden, Chowan,
Washington, North Carolina 27889
Craven, Currituck, Dan:, Gates, Greene,
(252) 94"481
Hertford, Hyde Jones, Lenoir, Martin,
[phone] Fax
Pamlico, Pasquotank, Perquimans, Pitt,
Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin,
Wilmington, North Carolina 28405
New Hanover, Onslow, Pender
(910) 395-39W
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Allegheny, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
[phone]
Rockingham, Randolph, Stokes, Suny,
[phone] Fax
Watauga, Wilkes, Yadkin
For more intorrrrahon, visit our web site at hM)Y^2o.enrstate .nc.usperrs/
FTA 02/03 - Rev. 3 04105

I IIulauay, UafIUaly L:JI cuur -,..Do rrvl blenn c5ramey J iu-mso-wt4
p.02
FASUTRACIi APPUCA71ON For GRAVITY SEWERS, PUMP SI'ATFONS, AND FORCE MAINS PAGE 3
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Application Number.
(to be eompkftd by UWVQ)
US=: Y1:`,=_ i,�P ; F! TO f..'OvE FROPA REELED TC
1. Owner. _
1a. Moore County Utilities
Fun.l.WW Name (conWany, m nldpalily, HOA, u6rdy, etc.)
1b. _ M�u�s a'ontl✓s , -I •dr
S�9 OQieW Nan and Title (Please review 1 CAC 21# MW(b) for authorized aW*g ofligalsq
'lc. The legal erft who will own this system is:
C7 IMMOU91.0 Federal IF Munidpalky 14 SW!4e County ❑ Private Partnership [] Corporation [I Other (specify):
1d. P.O. Box 72a 1e.
Mailing Address
1E North Carolina 1g.
State
1h. 91t1A47.8315 1 i • 010-947-1002
TphOne Facsiriiile
Z Pr+oyed (Fe0ity) lniownadon.
2a. cobawow -4 t%"%W.�t; Zp.
Brief Project Name (permit 1"11 niter to this name)
3. Contact Person. -
CRY
Zip Code
E-mail
Moore
County When; project is Located
3a.-
Name and AfRriedon of Someo a Who Can Answer Questions About This Application
3b. phone • 03 7� _ ' 3c� Pe4e
Phone Number . _
- E mail
_Project is X� New ❑ Modittcation (of an existing permit) If Modification. Permit No.:
For mods , stJach a separate SnAet clearly explaining to nWon for the modification p e. adding another
phase, changing lure slxellength, etc.)• Only include the modiNed information in ffiis permit application - do not
duplicate project infiormadon in B(7) and opa-11) that has already been included in the original permit ,
wne
2. Or is ®Public (S!� ro /tern p(SI) ❑ Pmrate
(4o
2a_ if privateto 11em
. applk�rrt will be: 2b_ If facilities owned by a (must choose one
❑ ReimWng Own w%hbp C.o- store, church. airrgte v(6«. eEr:) or p Publle UMW (Instruction ill)
[ILeasing units (lots. townhomes, etc. - slop to Rem 8(3)) ❑ Homeowner AsuziDeveloper (Inds etlme iv)
_ ❑ Seling units pots, townhornes, eta - go to Item B(2b))
_ Owner of Wastewater Treatment Faaity (INVVM Tre811ri9 Wadewm ar From This Project
'h`• MOOte rtY Weher Palo m Control Fadrdv 4b. NC 0037508
Name of vttwr>- • •' W WTF Permit No.
5a_ Moore cou p-
* Uti�t%s 6b. ReOA*V Sewer SizeRe—iniii—
ForcWn
Owner of Downstream Sewer r --- Perrrdt Number of Downstream Sewer (if known)
B. The origin of this w;u*w *sr is (check ell
Residenfiel Subdivision ❑ Car Wash --
APNtments/Condominiums 0 InsMon
[I 3dbool Homo Park % DomestidCommereial
13 El OaksChurch
Other
[] Nursing Home % Industrial
❑ Nursin
❑ Other (spedfy): % Other (spedfy):
Vdume of gall- - --
�ewater 1 be aY99&d for this particular projeck 9 ons per day
To not include previously permitted allocamons
8- if the permitted flow is zero, indicate why- I
❑ Interceptor Line - Flow will be permitted in subsequent penij that connect to this line
❑ Flow, has already been akxatBd In Permit No.
❑ RehabrTiFadon or replacement of existing sewer with no new flow eVected
T!'P• An M4 w • n..w-

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
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a
9. 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(1)(1-2) must be supported with actual water or wastewater use data in accordance with 15A
NCAC 2H .0219(D(3).
10. Summary of Sewer Lines to be Pemlitted (attach additional sheets if necessary)
Size (inches) Length (feet) Gravity or Force Main
(use the pull down menu)
8 105 Gravity
8 150 Gravity
ENTER TOTAL LINE LENGTH IN MILES .048
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID Power Reliability Option
(self chosen -as shown on Design Flow Operational Pant (1- dual line feed; 2- permanent generator w/ATS; 3-
plans for cross-reference) (MGD) GPM @ TDH portable generator witelemetry; 4-wet well storage)
i
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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;
Mains (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. SUBMT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPUCATION
I
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No [9/N/A
Sedimentation and Erosion Control Plan? Q Yes ❑ No ❑ WA
Stormwater?
❑ Yes ❑ No N4A
14. Does this project involve aerial lines or siphons? Check if yes: ❑
These fines will be considered high priority and must be checked once every W mwft
15. Does this project have gravity sewer lines designed at minimum slopes? ❑
Be aware that the Division will not act W Malted lines more than 10% flatter than the minimum slope. Lines installed outside this tolerance WMW be
wed prior to subrn bng the final engineering certificaWn..
FTA 02/03 - Rev. 3 04/05

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
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
ZO regional office (see instructions for addresses) OR indicate the following:
A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
Q waterbody, 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
y (self chosen - as shown on Name of Waterbody Sbeam Waterbody
map for cross-reference) Waterbody County River Basin Index Classification
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Submit the 8.5" x 11" COLOR taopographic map as required in Instruction VI
regardless of whether a clarification is provided!
Applicant's Certification:
1, SIGNING OFFICIAL NAME, attest that this application for PROJECT NAME ITS w*G-0 - '� t W6001LVr
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required
Pads 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, c
certification in any application shag be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10,000
as weg as civil penalties up $25,000 per violation►.
la.
Signing Offic
2. Professional
Certification:
Date
I attest that this application for G0-MW0t1P -OP �bu6t{URs'r' has been reviewed by me and is accurate, complete
and consistent with the info►mation in the engineering plans, calculations, and aff other supporting documentation to the
best of my lviowledge. 1 further attest that to Hie 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 Pemritbng of Pump Stations and Force Mains adopted June
1, 2000 and the watershed dassirrcation 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/ have reviewed this material and have judged it to be consistent wiHr the proposed design. Note. In
accordance with NC General Statutes 143-215.6.4 and 143-215.68, any person who knowingly makes any false statement,
representation, or certification in any application shall be gully of a Class 2 misdemeanor which may include a fine not to
exceed $10,000 as well as chdi penalties up to $25,000 per violation.
2a. Joseph M. Robinson, Jr.
Professional Engineer Name
2b. Joseph M. Robinson, Jr. P.E. GgI►rri��
Engineering Finn ���� Q���• • • �•�. 0��4,
2c.162 Waccamaw Rd.
Mailing Address r' L r ;
2d. Carthage, 2e. N.C. 2f 28327 r -
Ctiy State Zip i�.Ot•S�y
ire
29. 1-910-692-1889 2h. 1-910-M-1689 2i. romileseearthlink.netROB1N``���
Telephone Facsimile E-mail Seal Sb
FTA 02103 - Rev. 3 04/05

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�x
"'i% i
COTSWOLD (PHASE 2D-G)
PINEHURST, NC
SITE MAP
FROM MOORE
COUNTY
GIS MAP
GBD/B
Scale: 1 "= ZOO ,
ENMRONMENTAL PLANNING & DESIGN
Date: 1-10-07
PO. Box 1"3
® Southern Pines, Nor0i QaroOia 28388
Phone f [phone]
North Fax / (910) 693-OW

Thursday, January 25, 2007 4:36 PM
Glenn Bradley 910-695-0373
P.01
CUD/H
R;M()N-MLNTAL PIANNINQ
AND Dr. -SR iN
Message:
FAX TRANSMI'I'J'AL
late: 25j°m. 2ob7_ No. Of Pages Including Cover Sheet;
To:
Company/Org-mization-
To Fax Number; 10) b-707
Fmm:
Project Name &Number: GCnLk4 cc pwef+VMT
Paper Copy By: Mail: 0 Hand: 1 1 Other:
lt�!�LAJG CCKJ 1�,4-TCQAJ mitts
NAME
fA8r--, r og,
SE(,-aj!vj T
FLouj cqLckjt-Aitor,'35 SLR(o6p-TW(7
4
S vvd r- AA IkK- cj'iE�cycr=�p
--Tip -1 cA
NOTK IF YOU NEED A Rr-,SDJD OF ANY PAGE(S),' PLKASE CALL WITHIN 15 MINUTES. IF YOU DO NOT CALT., WE
AUL ASSIMF 'yOu HAVE Rr(-.-,1'1VED THE

•FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE T HE TAB KEY TO MOVE FROM FIELD TO FIELD! A4)plication Number. {� f�oo� � � C 0
(to be compWted by DMIQ) ■i V
1. Owner i
la. Moore County Utilities
f
Full Legal Name (company, municipality, HO,A, utility, etc.)
Z
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1b. C> t%J ALCSklJ!(M. �ifi'!'��lIM' �]17111`i Mo(A0. Y'
Signing Official Name and Title (Please review 15A NCAC 24.0206(b) for authorized signing officials!)
1 c. The legal entity who will own this system is:
a,
• I
❑_ Individual [I Federal � Municipality R StatelCounty [I Private Partnership [I Corporation [I Other (specify):
O
Id. P.O. Box 726 le. Carthage
U.
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Mailing Address City
It North Carolina 1g. 28327
0
State Zip Code
H
1 h. 910-947-6315 11. 910-947-1992 1 j.
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Telephone Facsimile E-mail
2. Project (Facility) Information:
aa
2Cotswold •C 2b. Moore
a
Brief Project Name (permit will refer to this name) County Where Project is Located i
Q
3. Contact Person:
Q
3a. GLENN DKADLEY
Name and Affiliation of Someohe Who Can Answer Questions About this Application
3b. (Ifto) 6gs. 037?, 3c• ab�rd 4 !ea,rN-rl.�nk . r!�r
Phone Number -mail j
f
(
I. Project is XCR New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
phase, changing line sbanength, etc.). Only include the modified information in this permit application - do not I
duplicate project information in B(7) and B(10-11) that has already been included in the original permit. f
2. Owner is ® Pubic (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 Unity (Instruction 111)
Z
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner AssocJDeveloper (Instruction IV)
0
❑Selling units (lots, townhomes, etc. - go to Item B(2b))
F-
3. Moore County
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Moore County Water Pollution Control Facility 4b. NC 0037508
Name of WWTF WWTF Permit No.
Z
5a. Moore county Utilities 15b. _e3�p Gravity 5c. i
_
Owner of Downstream Sewer IReceiving Sewer Size Force Main I Permit Number of Downstream Sewer (if known)
E—
6. The origin of this wastewater is (check all that apply): 1
09 Residential Subdivision ❑ Car Wash
IJ.1
❑ Apartments/Condominiums ❑ Institution {Oa % Domestic/Commercial
Home Park El Hospital
ILElMobile
❑ School ❑ Church % industrial
m
❑ Restaurant ❑ Nursing Home % Other (spay).
❑ Office ❑ Other (specify):
7. Volume of wastewater to be allocated for this particular project: 9W gallons per day
"Do not include previously permitted allocations i
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8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted in 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
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FTA 02/03 - Rev. 3 04105