WQ0028907_Sewer Extension_20050602

„RACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI Application Number:
(to be completed by DWQJ
1. Owner
1 a. City of Lumberton
Full Legal Name (company, municipality, HOA, utility, etc.)
Z 1 b. Dixon Ivey Interim City Manager
0 Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
Q 1 c. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality [I State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
O1 d. 501 E. 5th Street le. Lumberton
0 Mailing Address City
LL
Z 1f. North Carolina 1g. 28358
Z State Zip Code
1h. [phone] 1i. [phone] 1j.
Telephone Facsimile
(J :2. Project (Facility) Information:
j 2a. Lumbee Regional Development Association - Cypress Garden 2b
0. Estate Subdivision
a Brief Proiect Name (permit will refer to this name)
Q 3 Contact Person
E-mail
Robeson
County Where Project is Located
Q 3a. Harvey H. Allen PE - Engineer
KI.— n,4 nffJintinn of CnmannP Who Can Answer Questions About this Application
ALLEN-ALLEN & ASSOCIATES OF N.C., P.A.
136-D BOW STREET
P.O. BOX 1866
FAYETTEVILLE, NC 28302
PAY TO THE
ORDER OF
MEMO 1 12,_jNA
RBC CENTURA BANK
FAYETTEVILLE, NC 28302
66-85-531 S/iLyo S
2314
DOLLARS
-- — f - ------ -- "—”

--
C U. I ne onyln UI ullb wtXalcwaly� w w11c..n au L,1aa arrJ'�•
W® Residential Subdivision ❑ Car Wash
0. ElApartments/Condominiums El Institution � % Domestic/Commercial
❑ Mobile Home Park ❑ Hospital
❑ School ❑ Church %Industrial
❑ Restaurant ❑ Nursing Home % Other (specify):
❑ Office ❑ Other (specify):
7. Volume of wastewater to be allocated for this particular project: 5,760 gallons per day
'Do not include previously permitted allocations
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

YST-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
�pF W ATFgP RE��t State of North Carolina
�O G Department of Environment and Natural Resources
r JUN - 2 Division of Water Quality
o �c FAST -TRACK APPLICATION
FAYEMLL REGIONAL OFFICE
Y 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 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.
® 1. 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)
® II. 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.
❑ III. 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.
® VI. Map - Submit an 8.5-inch by 11-inch COLOR copy of the portion of a 7.5-minute USGS Topographic Map along
with this form. The map should identify the entire project area location as well as the closest downslope surface
waters as clearly as possible. Each map portion must be labeled with the map name and number, the identified
location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project
involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties,
basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location in Section C of the permit application.
❑ VII. Stream Classifications - Section C
• If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)" available from http://h2o.enr.state.nc.us/ndpu or by contacting the appropriate regional
nffinp

-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) [I SA NCAC
% 01C .05001, 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(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.
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FFF_ SHOULD RE 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
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
Moor No
Cleveland, Gaston, Iredell, Lincoln,
663le,
Mecklenburg, Rowan, Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe,
Raleigh, North Carolina 27699-1628
Franklin, Granville, Halifax, Johnston,
Lee, Nash, Northampton, Orange,
(919) 571-47
Person, Vance, Wake, Warren,
[phone] Fax
Wilson
Washington Regional Office
Beaufort, Bertie, Camden, Chowan,
943 Washington Square Mall
Craven, Currituck, Dare, Gates,
Washington, North Carolina 27889
Greene, Hertford, Hyde, Jones,
[phone]
Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington,
Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus,
Wilmington, North Carolina 28405
Duplin, New Hanover, Onslow,
[phone]
Pender
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
[phone]
Rockingham, Randolph, Stokes,
[phone] Fax
Surry, Watauga, Wilkes, Yadkin
For more information, visit our web site at: http://h2o.enr.state.nc.us/ndpu/

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PACE 3
.. .................... ......................................... ............................................. ....................... ...............
... n .....Number:* ,''..." ...... ........... . ............
USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI
(to be rnpleted by DWG)
. .. ....... ...... . ........
........ . . . .......
1. Owner.,
1a. City of Lumberton
Full Legal Name (company, municipality, HbA, utility, etc.)
Z I b, Dixon Ivey, Interim City Manager
Signing official Name and Title (Please review 15.A NCAC 2H 0206(b) for authorized signing officials!)
.................................. I ............................ ........................ . ....................... I—- ............................................. I—— ..................... ...... . ........
0. .......
1c. The legal entity who will own this system is;
? g al 0 Federal Private Partnership 0 Corporation 0 Other Op�qqif
...... . ....... ...........
..... . ............ ...... ...... I .................. .. . ....... ..............
:ld.� 501 E. 5th Street ile. Lumberton
Mailing -Address city
. ......... . ....... ...........
1f. North Carolina i 1 g. 28358
Z state Zip Code
0 ;i In JS 10) 671-3806 [phone] i1j.
Telephone Facsimile E-mail
iV 2, Project (Facility) Information,
on -Cypress Garden
.2a. Lumbee Regional Development Associati
I 2b. Robeson
Estate Subdivision
County Where P�oject is Located
CL Brief prqi,�O,Namp (permi.w 11 ro me . .. .... .. . ...... ... ......
_1­0 1Prtpth1snA . .....
....... .... . . ..... ..... ............. .
.3 Contact Person
Harvey'H. Allen, PE - En6ih4er
Name and Affiliation of Someone Who Can Answer Question About this Application
......... ..... ............ ......... ........
............ I.:. .. . ......... .
........... 1.1- .............. ... . . ...... I ................ ......... ..... ...... I .........
3b, 910437-9600
Sc. [e-mail]
:()
PhoneNumber E-mail .................................. I ....................................... .............................................
.............. ............... ............... .. ............. ................. ..................
........ ..... .......... I .....................
o.,
1. Project is JR Now [J Modification (of an existing permit) .
I .
.... if Modification,..
... * ............ 1-1 .............. ......................
..................................................Permit N.....
............................................ I ............................................... ....
........... . .........
Fqr modifications, attach a separate sheet clearly explaining i he reason for the modification (i.e. adding another
phase, changing line size/length, etc.). Only include the modified Information In thi
s permit application - do not
ddiplicats project Information In 5(7) and 5(10-11) that has already been included in the original permit.
...................... ............... ............ ............ ..
............. ............. I ............ I ........................... I., ................ I ....................................................................... ...................
[I Private (go to Item 2(a))
2, Owner, is OD Public (skip to Item SP) ............. ... ............. 11.1 ..................................
.......... i ............ ....................... ......................................................................... I ................................................. ......
(must choose one
)
a. 1 1 private, applicant w", 2b, if sold, facilities owned by a m
II be.
❑ Retaining Ownership (i.e. store, church, single office, etc.) Public Utility (Instruction 111)
Z E3 Leasing units (lots, townho mes, etc, - skip to Item B(3)) ❑ Homeowner Assoc./Developer (instruction IV)
52 ❑
[J Selling units (lots, townhomes, etc, - go to Item 8(2b))
.......... : ............................................. .............. ..............................................................
................................................................................................................. 11 ..........
...
1. City of Lumberton
Project
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Pr
.... I .............. 11 ............... .............. ............... ........... .......
............................. I ..................................................... 1. ................ 11 ............. T ................................
4b. NC 0024571
City of Lumberton WWTF
4a. WWTF Permit No.
0
: Name of WWTF ........... ............ ................ "... ........ I ................................. ............................. ..........
..... ....... ....... .... ................ .........
"'Ci't" Y*L ....... ­­­ .................. Gravity c. Not Known
y o Lumberton 5b, 1 T
Receiving Sewer Size Force Main:! Permit Number of Downstream Sewer (if known)
Downstream Sewer 1; 1 ...........
... .......... ................ ............. ............. ................ I .................
Owner of ............ ............... ............. I ..............
...... ............ I ........... I ..................
S. The origin of this wastewater is (check all that apply)* .......... .. .. ......... . ............ . .. .......................... ............. ..... ... .. ... .... ..... .. .................
. . ................................. ... .. .......................................
.......... ....................
Residential Subdivision ❑ Car Wash
[3 Institution 1,00 Domestic/Commercial
LLI [3 Apartments/Condominiums
I[L
E3 Mobile Home Park El Hospital % Industrial
Church
School
❑ Restaurant El Nursing HomeI : % Other (specify);
El Office [J Other (specify)` Z
.......................................... ... .......... . ..........
........... :117..................................
............ ­11 ............ I .................................... .................... ................... ...........
7., Volume of wastewater to be _allocated for this particular proje�, 5,760 gallons: per day
*Do not include previously permitted allocations .... ...........
............. - .......................... ..................................... ........................... .......... ..................
........................................................... 11 ..........................
zero,' indicate why:
B.' If the permitted flow is
E3 Interceptor Line - Flow will be permitted in subsequent permits that connect to this line
E] Flow has already been allocated in Permit No.
[I Rehabilitation or replacement of existing sewer with no nei v flow expected
........................... ............ I .............. ................... ...... ............. ............ ............ ............ ......
..................... ................................. ..................... .....................................-A 10% 47
ZO 39vd DOSSV W'N3-nV 'N3-nV 900Z/90/90

AST -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(l) for Item 13(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(I)(3).
16 residences " 3 bdnn/residence " 120 gal/bdrm = 5,760 gpd
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) Gravity or Force Main
(use the pull down menu)
8 J(oS &gA\'l TY
10 Z40 6?Aq IT--r
W
M
_Z
H
Z
0 ENTER TOTAL LINE LENGTH IN MILES D- 2.3
V
Z 11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
0 Location ID Power Reliability Option
H (self chosen - as shown on Design Flow Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
it N/A
0
LL.
Z
H
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?
a® Yes El 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
id PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A
Stormwater? ® Yes [:]No ❑ N/A
14. Does this project involve aerial lines or siphons? ❑
These lines will be considered high priority and must be checked once every six months

AST -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
Z regional office (see instructions for addresses) OR indicate the following:
0 ® A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down
Q 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.
N Location ID on Map
Q(self chosen - as shown on Name of Waterbody Stream Waterbody
map for cross-reference) Waterbody County River Basin Index Classification
V N/A
Q
W
U)
A
Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is providedl
Applicant's Certification:
1, Dixon Ivey, attest that this application for Lumbee Regional Development Association - Cypress Garden Estate
Subdivision has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that it
all required parts of this application are not completed and that if all required supporting documentation and
attachments are not included, this application package is subject to being returned as incomplete. Note: In
accordance with North Carolina General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any
false statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed $10,O�as well as civil penalties up to $25,000 per violation.
1 a.
8ffgnir5g O ignatu Date
2. Professiona Engineers Certification:
O I attest that this application for Lumbee Regional Development Association - Cypress Garden Estate Subdivision
has been reviewed by me and is accurate, complete and consistent with the information in the engineering plans,
UH calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best of my
knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
_ Minimum Design Criteria for Gravity Sewers adopted February 12, 1996, and the Minimum Design Crite�or the Fast -
Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 and the watershed classification in
F- accordance with Division guidance. Although certain portions of this submittal package may have been developed by
X other professionals, inclusion of these materials under my signature and seal signifies that I have reviewed this material
W 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
Q application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10, 000 as well as civil
2a. Harvey H. Allen
Professional Engineer Name
2b. Allen -Allen & Associates of NC, PA
Engineering Firm
2c. 136D Bow Streel
Mailing Address
2d. Fayetteville 2e. North Carolina 2f. 28301
City State Zip
2g. [phone] 2h. [phone] 2i. hallen136dearthlink.net
Telephone Facsimile E-mail
Seal, Signature & Date

TopoZone - The Web's Topographic Map
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Pembroke quadrangle PSI=-B . 206
Projection is UTM Zone 17 NAD83 Datum >>=1..!.-4:
http://www.topozone.com/print.asp?z=17&n=3 836719.00001924&e=667931.000010079&... 5/27/2005

ALLEN-ALLEN & ASSOCIATES of N.C., P.A.
Engineers, Land Planners & Surveyors
136D Bow Street
Fayetteville, N.C. 28301
Mr. Mike Lawyer
NCDENR - DWQ
225 Green Street
Suite 714, Systel Bldg
Fayetteville, NC 28301
Date: May 27, 2005
[phone] (Phone)
[phone] (Fax)
RE: Lumbee Regional Development Association - Cypress Garden Estate
Subdivision - Fast Track Application for Gravity Sanitary Sewer
Dear Mike:
Please process the enclosed applicable documentation.
1. Two (2) copy of the subject Sanitary Sewer Application;
2. one (1) copy of the subject USGS Topo Map;
Cordially:
iL��
Harvey Allen
enclosures

ALLEN-ALLEN & ASSOCIATES of N.C., P.A.
Engineers, Land Planners & Surveyors
136D Pow Suwt [phone](Phone)
FayoUvillo, N.C. 28301 (910) 4R6.99R2 (Fax)
Mr. Mike Lawyer
NCDENR - DWQ
225 Green Street
Suite 714, Systel Bldg
Fayetteville, NC 28301
Date: May 27, 2005
RE- Lumbee Regional Development Association - Cypress Garden Estate
Subdivision - Fast Track Application for Gravity Sanitary Sewer
Dear Mike:
Please find the following enclosed for your use in permitting.
1. Revised Page 3. Showing the Project is NEW and not a Modification
Cordially:
Harvey Allen
enclosure by FAX
Z ` -1 AUES
TO 39dd OOSSd ?'N3-11d `N3-11a EZ66LEb0T6 SP:ET SOOZ/90/90