WQ0041773_Application (FTSE)_20200629

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
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: Rockingham County (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: Ronald E. Tate per 15A NCAC 02T .0106(b)
Title: Director of Engineering and Public Utilities
4. Applicant's mailing address: 371 NC Hwy 65, Suite 200
City: Reidsville State: NC Zip: 27320-
5. Applicant's contact information:
Phone number: [phone] Email Address: rtate(a),co.rockingham.nc.us
II. PROJECT INFORMATION:
1. Project name: Wentworth Rehab, LLC
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000 and issued date:
If new construction but part of a master plan, provide the existing permit number: W000
3. County where project is located: Rockingham Counri
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.38586' Longitude:-79.74538'
5. Parcel ID (if applicable): 179477
(or Parcel ID to closest downstream sewer)
I1IW410`6YlilIIIEWN81aact] 90F:N1I610
1. Professional Engineer: B. Bruce Noce License Number: 23544
Firm: Stoltzfus Engineering, Inc.
Mailing address: 747 Park Lawn Court
City: Kemersville State: NC Zip: 27284-_
Phone number: 3( 36) 904-0207 Email Address: bnooe(a),seiengmeering com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Mebane Bridge W WTP Permit Number: NC 0025071
Owner Name: City of Eden
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than W WTF):
1. Permit Number(s): WQCS00364 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00364
Owner Name(s): Rockingham Counri
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: % Domestic/Commercial 100 % Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? [-]Yes ®No
➢ If yes, provide a covv of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(fl)
Daily Design Flow'"
No. of Units
Flow
Businesses, Offices
25 gal/Employee/Shift
10
250 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
250 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. 42A4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: _ 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

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 200 D.I.P.
➢ 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 (Puma 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(fl & (F)
® Yes ❑ No
D 15A NCAC 02T.0305(t) contains minimum senarations that shall be nrovided for sewer systems:
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-1 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
Anv buildiniz 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 webnage
➢ If noncompliance with 02T.0305(f) or (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No ❑ N/A
➢ 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 setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or [-]Yes ® No
individual permits or 401 Water Quality Certifications?
➢ 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.0105(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 ❑ N/A
➢ 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:
I. Does the submitted system comply with 15A NCAC 02T the Minimum Design Criteria for the Permitting of Pub 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:
name from Application
that this application for
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 143-215.60, 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.,,,,, I! I!'
North Carolina Professional Engineer's seal, signature, and date: 1 ; . —�y
c�Q,OF�SS/pN9'i.9
SEAL =
23544
.
3. Applicant's Certification per ISA NCAC 02T .0106(b):
C 7—ATE- Director of Engineering & Public Utilities
name
Item 1.3.)
that this application for
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. 1 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 143-215.60, 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: t tt&&C E Date:
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
Department of Environmental Quality
Division of Rater Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Rockingham County
Project Name for which flow is being requested: Wentworth Rehab, LLC
.More than one FTSE maybe required for a single project if the owner of the WNTP Is not responsible for allpump
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. WVJTP Facility Name: Mebane Bridge W WTP
b. W WTP Facility Permit #: NC 0025071
AU,/lows are in MGD
c. W WTP facility's permitted flow
13,5
d. Estimated obligated flow not yet tributary to the W WTP
3,436
e. WWTP facility's actual avg. flow
3. 571
f. Total flow for this specific request
0.00025
g. Total actual and obligated flows to the facility
7, 00 9
It. Percent of permitted flow used
5/. 92
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 W WTP:
(A)
(B) (C)
(D)=(B+C)
(E)=(A-D)
Design
Obligated,
Pump
Pump
Average
Approx. Not Yet
Total Current
Station
Station
Finn Daily Flow**
Current Tributary
Flow Plus
(Name or
Permit
Capacity, * (Firm / pf),
Avg. Daily Daily Flow,
Obligated
Available
Number)
No.
MGD MGD
Flow, MGD MGD
Flow
Capacity***
Al 4 Tu If I-ry PX- L-DEN
y8�
* 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 firm 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 W WTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I 23e✓ O 'De // certify to the best cif 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.
Signing Official Signature
RM
DrRFeraR OF dF rcDE+%1
Title of Signing Official
Page 2 of 6
FTSE 10-18

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Rockingham County
Project Name for which flow is being requested: Wentworth Rehab, LLC
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: Mebane
b. WWTP Facility Permit #: NPD
WWTP
Permit NCO025071
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
0.00025
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, *
(Firm / pf),
Avg. Daily
Daily Flow,
Obligated
Available
Number) No.
MGD
MGD
Flow, MGD
MGD
Flow
Capacity***
sC.tiooL CENATM
C AFit-to FRY
0.288
0.115
0.0050
0.0500
0.0550
0.060
$EAR
0.720
0.288
0.0061
0.0700
0.0761
0.2119
ISHINfa
CREEK
0.756
0.302
0.0062
0.0750
0.0812
0.2208
* 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 firm capacity of the pump station divided by a peaking factor
(pt) 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): Mebane Bridge WWTP
Downstream Permit Number: NPDES Permit NCO025071
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Ronald E Tate 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.
?JOf cial Signature Date
Director of Engineering & Public Utilities
Title orSigning Official
Page 2 of 6
FTSE 10-18

WENTWORTH REHAB, LLC
400' 200' 0' 400' 8001
—� SCALE V = 400'
Aden R. Stoltzfus, PE C-3812
[e-mail]
336-904-0207
747 Park Lawn Court
Sto tz us MEngineInc. Kernersville, NC 27284
Civil Engineering Consultants
USGS QUAD MAP
SOUTHEAST EDEN QUADRANGLE 2019
CITY: REIDSVILLE
COUNTY:ROCKINGHAM
TOWNSHIP: WENTWORTH
DATE: 6/12/2020

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WENTWORTH REHAB, LLC 400' z°°' 400 B001
SCALE V = 400'
Stoltz us
Civil Engineering Consultants
Aden R. Stoltzfus, PE C-3812
[e-mail]
336-904-0207
747 Park Lawn Court
Kernersville, NC 27284
STREET LEVEL MAP
NC ONEMAP ORTHOIMAGERY 2018
CITY: REIDSVILLE
COUNTY: ROCKINGHAM
TOWNSHIP: WENTWORTH
DATE: 6/12/2020

Stoltzfus Engineering, Inc.
June 22, 2020
North Carolina Department of Environmental Quality
Division of Water Resources
450 West Hanes Mill Road, Suite 300
Winston-Salem, N.C. 27105
Re: Fast -Track Application (FTA 04-16)
For Rockingham County
Reidsville, NC 27320
Sanitary Sewer Extension
Project Name: Wentworth Rehab, LLC
TUN 2 9 2020
Winston-Salem
Regional Office
On behalf Rockingham County, we are submitting herewith for your review and approval the
following documents relative to the above referenced project:
- (1) Original Fast -Tract Application
- (1) Copy of Fast -Tract Application
- (1) Cover Letter
- (1) Check for $480 (Application Fee)
- (1) FTSE Form (City of Eden)
- (1) FTSE Form (Rockingham County)
- (1) USGS Topographic Map
- (1) Street Level Map
The project will consist of core drill and install a rubber boot in an existing manhole within the
right of way of NC Highway 65 and extending a new 8" D.I.P. gravity sanitary sewer line in a
southwesterly direction for 20011 to a proposed manhole. Specifications for this project will be
per Rockingham County, NC standards and specifications. We respectfully request your review
and approval of these items. If you have any questions or need any additional information, please
give me a call.
Thank you for your assistance with this matter.
Sincerely,
SEI Engineering, Inc
Bruce Nooe, P.E., P.L.S.
bruce ,seienisineering.com
Enclosures
747 Park Lawn Court ♦ Kernersville, NC 27284 ♦ [phone]