WQ0024673_Application_20041203

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI j Application Number: /
(to t. completed by DWQ) 9W000Q l0 7
1.
Owner.
1a.
CITY OF LUMBERTON
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
1b.
H. DIXON IVEY, INTERIM CITY MANAGER
Q
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
"
1 c.
The legal entity who will own this system is:
j
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1d.
501 E. 5th STREET 1e. LUMBERTON
O
Street Address City
1L
--
— ---- ----- -- ---- ---- -
if.
NORTH CAROLINA 1g. 28358
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State Zip Code
0
1 h.
910-671-3800 1 i. 910-671-3814 1 j.
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Telephone Facsimile E-mail
(,
2.
Project (Facility) Information:
J
a
2a.
SANITARY SEWER EXTENSION TO SERVE McLEOD ROAD 2b. ROBESON
4.
Brief Project Name (permit will refer to this name) County Where Project is Located
3.
Contact Person:
a
3a.
LARRY ANDERSON. ANDERSON ENGINEERING & ASSOCIATES. P.A.
Name and Affiliation of Someone Who Can Answer Questions About this Application
31b. 910-671-9530 3c. andersonacarolina._net
_
Phone Number
8959
ANDERSON ENGINEERING & ASSOCIATES PROGRESSIVE STATE BANE:
PH. 910-671-9530 LUMBERTON, NC 28359-1330
66-7370/2531 1 8959
305 N. CHIPPEWA ST.
P.O. BOX 1736
LUMBERTON, NC 28359
PAY **Four Hundred And 00/100 Dollars***********`'**************************
11/3DATE A 0/04 $ 40MQl�NT
TO THE 0 l�
ORDER OF
NC-DENR - Land Quality
225 Green Street, Suite 714 / Systel Building
Fayetteville, NC 28301-5043
o00895g1" 1:2531^r37001:
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❑ Other (specify):
AUTHORIZEb SIGNATURE
6 L..,B 50 1ggB0
7. Volume of wastewater to be permitted in this project: 4200 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
% Other (specify):
FTA 02/03 - Rev. 2 04/04

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE I
OF W ATFR � ' ; . " State of North Carolina
`DEC 3
O 1004 Department of Environment and Natural Resources
,o � -
7?!- Division of Water Quality
o rr FAST -TRACK APPLICATION
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(pressure s",ers systems are not to be included as part of this application package)
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 13(12).
oil. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ 111. 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 -speck 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
office.
FTA 02/03 - Rev. 2 04/04

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
❑ Vlll. 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
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(1 b). 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,
[phone] Fax
Rutherford, Swain, Transylvania,
Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301
Anson, Bladen, Cumberland, Harnett,
[phone]
Hoke, Montgomery, Moore, Robeson,
[phone] Fax
Richmond, Sampson, Scotland
Mooresville Regional Office
919 N Main Street
Moor No
Mooresville, North Carolina 28115
Alexander, Cabarrus, Catawba,
663le,
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
[phone]
Duplin, New Hanover, Onslow,
[phone] Fax
Pender
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
Sury, Watauga, Wilkes, Yadkin
For more information, visit our web site at: http://h2o.enr. state.nc.us/ndpu/
FTA 02/03 - Rev. 2 04/04

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! :, Application (to be completed by D r:
mpr: e Number:
(�) Ll � �
1.
—
Owner.
la.
CITY OF LUMBERTON
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
lb.
H. DIXON IVEY, INTERIM CITY MANAGER
0
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
Q
1c.
The legal entity who will own this system is:
❑ Individual El Federal ®Munici alit Private
p y ty ate Partnership ❑ Corporation ❑ Other (specify):
.State/Coun
Id.
501 E. 5th STREET le. LUMBERTON
0
Street Address City
U.
- --- --
Z
1f.
NORTH CAROLINA j1g. 28358
Z
State Zip Code
0
lh.
910-671-3800 +1 19i 0-671-3814 i1j.
F—
Telephone Facsimile E-mail
V
2.
Project (Facility) Information:
J
a
2a.
SANITARY SEWER EXTENSION TO SERVE McLEOD ROAD 2b. ROBESON
p
Brief Project Name (permit will refer to this name) County Where Project is Located
J.
Contact Person:
Q
3a.
LARRY ANDERSON, ANDERSON ENGINEERING & ASSOCIATES, P.A.
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
910-671-9530 3c. [e-mail]
Phone Number E-mail
1.
Project is ® 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 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 ® 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 III)
Z
I
El Leasing units (lots, townhomes, etc. -skip to Item 8(3))1 ❑ Homeowner Assoc./Developer (Instruction IV)
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,, i
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
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13.
CITY OF LUMBERTON
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
Q'4a.
CITY OF LUMBERTON 4b. 0024571
U.
Name of WWTF WWTF Permit No.
Z
5a,
b.
Owner of Downstream Sewer
IReceiving Sewer Size Permit Number of Downstream Sewer (if known)
6.
The origin of this wastewater is (check all that apply):
® Residential Subdivision ❑ Car Wash
UJ
a
❑ Apartments/Condominiums ❑ Institution i 100 % Domestic/Commercial
❑ Mobile Home Park ❑ Hospital
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❑ School % Industrial
Church
❑ Restaurant ❑Nursing Home % Other (specify):
❑ Office ❑ Other (specify):
7.
Volume of wastewater to be permitted in this project: 4200 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
FTA 02/03 - Rev. 2 04/04

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(1) 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 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).
14 HOMES x 2.5 AVG. BEDROOMS PER HOME @ 120 GAL. PER DAY = 4,200 GAL. PER DAY
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet)
12"e 1251
Gravity or Force Main
ise the pull down menu)
Gravity
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ENTER TOTAL LINE LENGTH IN MILES 24 MILES
Q11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
.� Location ID Power Reliability Option
Flowpe
T—
(
F ""chosen -as shown on Design Operational Point (1-dual line feed; 2- permanent generator w/ATS; 3-
lane for cross-referenceP
ortablegenerator w/telemetry; 4-wet well storage
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... . ............ ... .
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a12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
m 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:
,SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICA
13. Have the following permitsicertifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan? ❑ Yes ❑ No ® N/A
Stormwater?
FTA 02/03 - Rev. 2 04/04

i
FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
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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
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
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 f !
(self chosen - as shown on Name of Waterbody Stream Waterbody
map for cross-reference) I Waterbodyi cou!q River Basin Index +Classification
Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
I. Applicant's Certification:
1, H. DIXON IVEY, attest that this application for SEWER EXTENSION TO SERVE McLEOD ROAD has been reviewed
by me and is accurate and complete to the best of my knowledge. 1 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 143-215.68, 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 "I penalties up to $25,000 per violation.
_ 1- _ O CJC'
,1a.
Signing Official Signature Date
2. Professional Engineer's Certification:
0 1 attest that this application for THE CITY OF LUMBERTON 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
H my knowledge. 1 further attest that to the best of my knowledge the proposed design has been prepared in accordance
Q ! with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February 12, 1996,
V and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000
LL 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
W General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
Q 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.
•a111IITlll1���/J_ --
2a. LARRY ANDERSON `��
Professional Engineer Name - _ VS/
•.•'�9�•
---- -
b. Anderson Engineering 8 Associates, P.A. +-
Engineering Firm 9<
--- -- _--------- - -- ------.__. --- - . Q SEAL : II
2c. 305 N. CHIPPEWA STREET 13325
Address
2d. LUMBERTON 2e. NC 2f. 28358 ��"9 '•.FiyG(NEF,.•' O
city State zip '�� 9,9 ••••....•••' ��,;
910-671-9530 �h. 910-618-0838 2i. [e-mail]
Telephone Facsimile ! E-mail Seal, Signre & Date
FTA 02/03 - Rev. 2 04/04

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Anderson Engineering & Assoc., P.A.
P.O. Box 1736
305 North Chippewa
Lumberton, N. C. 28359
November 30, 2004
NCDENR
Division of Water Quality
225 Green Street - Suite 714
Fayetteville, NC 28301
Re: Sanitary Sewer Extension to serve McLeod Road
Dear Sir or Madam,
Larry Anderson, P.E.
President
DEC 3 Lvd� "" 4
Please find enclosed the following on the above referenced project for your review and approval:
- 1 Original & 1 Copy of the Fast -Track Application for Sewers
- A Check for $400.00 for Application Fee
- 1 8 '/2" x 11" Color USGS Topographic Map
Should you have any questions, please do not hesitate to contact me.
Sincerely,
ANDERSON ENGINEERING & ASSOCIATES, P.A.
Lk�ek�Pn�
Renee Warren 1/
CAD Designer
RW/pr
Enclosures
National Society of
Professional Engineers®
NSPEUV#nS#d Nembor
Phone: [phone] - Fax: [phone] - Email: [e-mail]