WQ0037161_Sewer Extension_20140627

DENR-FRO State of North Carolina
Department of Environment and Natural Resources
flxAlu MAY j 7 20% Division of Water Resources
' Division of Water Resources �/ DWQ FAST -TRACK APPLICATION (FTA 08-13)
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
General — When submitting this 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.
For more information, visit the Surface Water Section's Collection Systems website or;
contact the Regional Office serving your county
Unless otherwise noted, the Applicant shall submit one original and one copy of the application and supporting
documentation to the appropriate Regional Office (see page 3).
A. Letter:
21"n'clude
a brief project narrative describing the final design (i.e system and/or pump station to ultimately
serve 500 homes, but flow for only 100 homes being requested now). For modifications, clearly explain
the reason for the modification (i.e. adding another phase, changing line size, length, etc).
B. Ap ation Form (FTA 08-13):
Submit the completed and appropriately executed Fast -Track (FTA 08-13) Application. Any
unauthorized content changes to this form shall result in the application being returned. If necessary
for clarity or due to space restrictions, attachment to the application may be made, as long as the
attachments are numbered to correspond to the section and item to which they refer. You do not need
JJo submit detailed plans and specifications unless you respond NO to item B(13).
The Professional Engineer's Certification of the application shall be signed, sealed and dated by a
orth Carolina licensed Professional Engineer.
tZ The Applicant's Certification 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).
C. Ap cation Fee:
Submit a check in the amount of $480 to: North Carolina Department of Environment and Natural
Resources (NCDENR).
Checks shall be dated within 90 days of application submittal.
D. Certificate of Public Convenience and Necessity (For Privately -Owned Public Utilities Only):
❑ Per 15A NCAC 02T .0115(a)(1), provide two copies of 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 two copies of 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.
❑ The project name in the CPCN or letter must match that provided in Item A(2)a of this application.
E. Operational Agreements (For Home/Property Owners' Associations and Developers of lots to be sold):
Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (HOA 08-13).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
y Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (DEV 08-13).
Even if the project may be turned over to a municipality upon completion, Form DEV 08-13 is required.
INSTRUCTIONS FOR APPLICATION FTA 08-13 & SUPPORTING DOCUMENTATION Page I of 6

F;; D�stream Sewer, WWTF Capacity and Flow Tracking/Acceptance Form (FTSE 08-13)
,d Submit the completed and appropriately executed Flow Tracking/Acceptance for Sewer Extension
Permit (FTSE 08-13) Form for all applications.
The applicant (and owners of downstream sewers, pump stations and/or treatment facilities submitting
form FTSE 08-13 certifies that the addition of the volume of wastewater to be permitted in this project
has been evaluated along the route to the receiving treatment plant, and that 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.
➢ Where the applicant is not the owner of the downstream sewer, submit two copies of form FTSE 08-13
from the owner of the downstream sewer and owner of the WWTF, if different.
➢ The flow acceptance indicated in form FTSE 08-13 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 08-13 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 08-13.
G. Si Map (All Application Packages):
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. Each map must include at a minimum:
➢ The location of the sewer line and pump stations and be of reproducible quality.
➢ Downstream connection points and the permit number for the receiving sewer (if known)
➢ Pump Station Locations and the longitude and latitude for each pump station (if applicable)
p Include a street level map showing all relevant project areas.
H. Stream Classification (WSCAS 08-13)
Submit the completed and appropriately executed Watershed Classification Attachment form
(WSCAS 08-13) if any portion of the sewer system project is within 100 feet of any surface water or
wetlands.
➢ A variance must be requested for encroachment within required setbacks or buffers,,pursuant to 15A
NCAC 02T .0305(f)
Environmental Assessments (Projects subject to an Environmental Assessment (EA)):
➢ Projects involving an Environmental Assessment per 15A NCAC 01C .0408, must be submitted for a
full technical review and must be submitted to the PERCS Unit on application forms provided by the
Division.
J. Alternative Sewer Systems
➢ Projects involving low pressure sewer systems, vacuum sewer systems and other alternative sewer
systems must be submitted for a full technical review and must be submitted to the PERCS Unit on
application forms provided by the Division.
K. Flow Direction
➢ Many wastewater treatment systems are entering into agreements for regionalization efforts and
emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be
directed to more than one treatment facility. If this is the case with the project, please indicate in B(12)
and give the permit number of the second facility.
L. Certifications — Section C
➢ The application must be certified by both the applicant and the design engineer who is 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 Chapter 2T, The Gravity Sewer Minimum Design Criteria (most recent version) and the Minimum
Design Criteria for the Permitting of Pump Stations and Force Mains (most recent version), as
applicable to the project.
INSTRUCTIONS FOR APPLICATION FTA 08-13 & SUPPORTING DOCUMENTATION Page 2 of 6

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
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Winston-Salem, North Carolina 27107
Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone]
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
INSTRUCTIONS FOR APPLICATION FTA 08-13 & SUPPORTING DOCUMENTATION Page 3 of 6

'
1.
1a.
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD
Owner/Permittee:
Moore County Public Utilities
Application Number: /;� r�
(to be completed by DWR) lx © 0 J -71k
Full Legal Name (company, municipality, HOA, utility, etc.)
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1b.
Randy Gould, P.E.
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S%m*gOft tAt Name and Title (Please review 15A NCAC 2T
.0106 (b) for authorized signing officials)
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1c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ❑ Municipality ® State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
0
1 d.
PO Box 1927
1 e. Carthage
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Mailing Address
City
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1f.
NC
1g. 28327
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State
Zip Code
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1h.
910-947-6315 1i. 910-947-1992
1j. [e-mail]
QTelephone
Facsimile
E-mail
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2.
Project (Facility) Information:
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2a.
Union Place
2b. Moore
a
Brief Project Name (permit will refer to this name)
County Where Project is Located
a
a
3.
Contact Person:
Q3a. M. Shane Sanders, PE, PLS
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 910-246-0038 3c. [e-mail]
Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
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2. Owner is ® Public (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 D)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction E)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
-. ......... _. _
3. Moore Countv
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Moore County Wastewater Treatment Facility 4b. NC 0037508
Name of WWTF WWTF Permit No.
5a. Moore County 5b. 8" ® Gravity 5c. NC 0037508
Owner of Downstream Sewer :Receiving Sewer Size '❑ Force Main Permit # of Downstream Sewer (Instruction F)
6. The origin of this wastewater is (check all that apply):
® Residential Subdivision ❑ Retail (Stores, shopping centers) 100% Domestic/Commercial
❑ Apartments/Condominiums ❑ Institution %Industrial
❑ Mobile Home Park ❑ Hospital
❑ School ❑ Church (Attach Description)
❑ Restaurant ❑ Nursing Home
❑ Office ❑ Other (specify):
% Other
(Attach Description)
7. Volume of wastewater to be allocated or permitted for this particular project: 11,160 gallons per day
'Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where 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
(see 15A NCAC 02T .0303 to determine if a permit is required)
FTA 08-13 APPLICATION Page 5 of 6

9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item 13(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item 13(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
31 Lots X 360 GPD = 11,160 GPD
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
8„
Length (feet) New Gravity or Additional
Force Main
1,846.91 New Gravity
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11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
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Q Pump Station Location ID: (self chosen - as shown on plans/map for reference)
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... Longitude: Latitude:
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Design Flow
Operational Point
Power Reliability Option
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(MGD)
GPM @TDH
1 - permanent generator w/ATS; Force Main Size Force Main Length.
2 - portable generator w/MTS
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;Pump Station Location ID:
(self chosen - as shown on plans/map for reference)
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'Longitude:
Latitude:
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Design Flow
Operational Point
Power Reliability Option
(MGD)
GPM @TDH
1 -permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
[:]Yes ® No If Yes, permit number of 2nd treatment facility
(RO — if "yes' to B,12 please contact the Central Office PERCS Unit)
13. Does the sewer system comply with the Minimum Design Criteria for the Permitting of Pump Stations and Force Mains
(latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T 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
FTA 08-13 APPLICATION Page 6 of 6

1,1. Have the following permits/certifications been submitted for approval for the system or project to be served?
Wetland/Stream Crossings - General Permit or 401 Certification? ® Yes ❑ No ❑ N/A
Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A
Trout Buffer Waiver? ❑ Yes ❑ No ® N/A
Stormwater? ® Yes ❑ No ❑ N/A
15. Does this project include any high priority lines (15A NCAC 02T .0402 (2)) involve aerial lines, siphons, or interference
manholes)? These lines will be considered high priority and must be checked once every six months
Check if Yes: ❑ and provide details:
1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1a.
1, __Randy Gould, P.E. , attest that this application for Union Place Subdivision 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
certificatio any application shall be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000
as well aeckl pe►3altkT IP tP42 )000 peryjolation.
Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
TO OTHER UTILITIES, DESIGN CALCULATIONS, ETC. REFER TO 15A NCAC 02T .0305
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Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
V 1, M. Shane Sanders, PE, PLS attest that this application for Union Place has been reviewed by me and is
LL accurate, complete and consistent with the information in the engineering plans, calculations, and all other supporting j
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
W adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force
V Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance. Although other
V 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 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.
2a. M. Shane Sanders, PE, PLS
Professional Engineer Name �� R �,Z_
2b. SNS Engineering, Inc. F q('•.:
Engineering Firm 2.4?0
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2c. 275 S. Bennett St, Ste A = S6 49
Mailing Address• �G • �� ' Q
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2d. Southern Pines 2e. NC 2f. 28387 ?�'••.�NGIN�' ��:
City
2g. 910-246-0038 2h. N/A
Telephone Facsimile
State Zip `'�.,19&AN�E sp
2i. [e-mail]
E-mail NC PE Seal, Signature & Date
FTA 08-13 APPLICATION Page 7 of 6

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Southern Pines, NC 28387 1; 2000 0 2000 Feet
E N G I N E E R I N r P: [phone]
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Southem Pines, NC 28387 2000 0 2000 Feet
E N G I N E E R I N G P: [phone]
www.snseriginears.com
Delivering efficient solutions.--

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 08-13)
Project Applicant Name: Moore County
Project Name for which flow is being requested: Union Subdivision
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: Moore County Water Pollution Control Plant
b. WWTP Facility Permit #: NC 0037508
All flows are in MGD
c. WWTP facility's permitted flow 10
d. Estimated obligated flow not yet tributary to the WWTP 2.292
e. WWTP facility's actual avg. flow 4.978
f. Total flow for this specific request 0.0112
g. Total actual and obligated flows to the facility 7.2812
h. Percent of permitted flow used 72.8
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 Average Daily
Approx.
Not Yet
Total Current
Station Firm Flow**
Current Avg.
Tributary
Flow Plus
(Name or Capacity,* (Firm / pfl,
Daily Flow,
Daily Flow,
Obligated
Available
Number) MGD MGD
MGD
MGD
Flow
Capacity***
v-2 0.181 0.072
0.0106
0
0.0106
0.0614
v-1 0.238 0.095
0.1203
0
0.1203
-0.0253
LR-1 0.461 0.184
0.0955
0
0.0955
0.0885
LR-2 0.504 0.202
0.0335
0.0840
0.1175
0.202
Q nAA S 1)
n 771 f)
n nRan
n Rssn
1 1 d5
* The Firm Capacity 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 firm capacity of the pump station divided by a peaking
factor (pf) not less than 2.5.
*** 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.
Page 1 of 6
FTSE 08-13

III. Certification Statement:
Randy Gould, PE, Moore County certify to the best of my knowledge that the addition of
Public Works Director
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 indicates acceptance of this wastewater flow.
7/2 ///10
Date
Page 2 of 6
FTSE 08-13

FTSE PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available
Capacity is < 0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
0 % and 0 MGD of the Available Capacity (E) in Pump Station
V-1 ; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
0 MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
Pump Station V-1 Elimination is in design or under construction with
planned completion in 2015 ; and/or
d. The following applies:
Pump Station V-1 is planning to be eliminated and forming a gravity system directing the
flow to Pump Station LR-1. This project is expected to be completed by the end of 20175.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification
to allow this flow to be permitted, without a significant likelihood of over -allocating capacity in
the system infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S.
143-215.67(a) which prohibits the introduction of any waste in excess of the capacity of the
waste disposal system.
Date
Page 3 of 6
FTSE 08-13

FORM WSCAS 08-13
WATERSHED CLASSIFICATION ATTACHMENT
FOR SEWER SYSTEMS
Applicant Name
Project Name
. _ . -, tY l 0116 . 4 _
U'No t"Pt
Professional Engineer Name
Engineering Firm Name
Location
River
Waterbody Stream
Waterbody
ID
Name of Waterbody'
County
Basin
Index No.
Classification
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' If unnamed, indicate "unnamed tributary to V, where X is the named waterbody to which the unnamed tributary joins.
I certify that as a Registered Professional Engineer in the State of
North Carolina that 1 have diligently followed the Division's instructions
for classifying waterbodies and that the above classifications are
inclusive of the stated project, complete and correct to the best of my
knowledge and belief.
PE Seal, Signature and Date
*** END OF FORM WSCAS 08-13 ***
FORM: WSCAS 08-13 Page 1 of 1

S 275 S. Bennett St, Ste .A
Southern Pines, NC 28387
Phone: [phone]
E N G I N E E R I N G www. snsengineers. com
Delivering efficient solutions... License # C-3791
Project Narrative
The site is undeveloped woodland property that consists of 2 phases with a total of 31 lots.
Phase one has 18 lots, with a requested flow of 6,480 GPD. Phase two has 13 lots, and a requested flow
of 4,680 GPD. The total requested flow for the project is 11,160 GPD. Once Phase 1 construction is
completed, Phase 2 will start construction. All Sewer lines will be owned by Moore County and all waste
water will flow to Moore County wastewater Treatment Facility; 11W1 TF # NC 0037508.

275 S. Bennett St, Ste .A
Southern Pines, NC 28387
E N G I N E E R I N G Phone: [phone]
www. sn sengineers. com
Delivering efficient solutions... License # C-3791
LETTER OF TRANSMITTAL
To: NCDENR WQS Date: 5-16-14
225 Green Street Suite 714 SNS Project # 1310701
Fayetteville, NC 28301 Project Name: Union Place
Delivered Via: UPS
Phone: [phone] Tracking #:
THIS TRANSMISSION INCLUDES:
❑ Plans
® Specifications
® Calculations
❑ Comments
Other:
THESE ARE TRANSMITTED AS:
® For Approval ❑ Re -Submittal
❑ For Your Use For Your Record
❑ Requested El For Your Information
® For Review
Qty.
Date:
Description
REV. #
1
5-16-14
Cover Letter
1
5-16-14
Application Form
1
5-16-14
Application FEE
1
5-16-14
Flow Tracking/Acceptance
1
5-16-14
USGS Site Map
1- 5-16-14- Stream Classification (WSCAS 08-13)
M. Shane Sanders, PE, PLS Owner
SEWER SNS Transmittal to DWR Sewer 5-!; . ;o,-

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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD Application Number: (to be completed by DWR) DEA'Q �� ` -C R
1. Owner/Permittee.� 7���
la. Moore Count Public Utilities
run Leyai rvame kcompany, rnurnuNaniy, nvr+, uuniy, C(c.) ,A`/�+;
^
'1 O
1b.
Randy Gould, P.E.
SN'arv*g0ifttai frame acid Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials)
1 c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ❑ Municipality ® State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1d.
PO Box 1927 1e. Carthage
Mailing Address City
1f.
NC 1g. 28327
State Zip Code
1 h.
910-947-6315 1 i. 910-947-1992 1 j. [e-mail] I
Telephone Facsimile E-mail !
2.
Project (Facility) Information: '
2a.
Union Place 2b. Moore
Brief Project Name (permit will refer to this name) County Where Project is Located
3.
Contact Person:
!3a.
M. Shane Sanders, PE, PLS
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b..910-246-0038
3c. [e-mail]
Phone Number E-mail
1.
Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
2.
Owner is .® Public (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 D) f`f
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑Homeowner Assoc./Developer (Instruction E) I
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
—
3.
Moore County
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
1102
WOLF RAM, INC.
3100 VASS CARTHAGE ROAD
CARTHAGE, NC 28327 DATE _! U Z ?, 66-358-531
PAY
TO THE l C J 1�
ORDER OF y 00 p. V Q
.(-O �.� �,,./� ✓ �.�{ Kam/ / 0 o OLLARS
FidelityBank
.V BY YOU
,,
FOR L4_t1(0_ (act M'
71
U Pump a ion, u a r '(" t 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
(see 15A NCAC 02T .0303 to determine if a permit is required)
FTA 08-13 APPLICATION Page 5 of