WQ0036022_Sewer Extension_20120621

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: OENR-FRCS
(to be completed by DWQ)
1.
6wner/Permittee:
1 a.
City of Lumberton j�Jj� 1 Z012
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Full Legal Name (company, municipality,, HOA�, utility,, etc`.) IWO
1b.
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Signing Official Name and Title (tease 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):
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1d.
P. 13g1e. LIAW% a%A_o14
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Mailing Address City
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State Zip Code
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QTelephone
Facsimile E-mail
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2.
Project (Facility) Information: US 301 (Fayetteville Road ) over 1-95 (Exit 22)
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2a.
1-4413 Fayetteville Road Project. 2b. Robeson
Brief Project Name (permit will refer to this name) County Where Project is Located
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3.
Contact Person:
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3a.
Corey Bousquet, PE
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
(919)-707-6697 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 C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3.
C/� of Lk ►beAAy%
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Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
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4a.
City of Lumberton WWTP 4b..vc Oo z y s 7 /
Name of WWTF WWTF Permit No.
BB&T
CITY OF LUMBERTON
BRANCH BANKING AND TRUST COMPANY
1-800-BANK BBTBBandTcom 93297
GENERAL ACCOUNT
66-112/531
P.O. BOX 1388
Void if not cashed
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LUMBERTON, N.C. 28359
in 120 days of
issue date.
1787
DATE CHECK NO. CHECK AMOUNT
F
PAY
THIS INSTRUMENTitAS.BEEN PREAUDITED IN THE MANNER REQUIRED
TO THE
BY THE LOCAL GOVERNMENT BUDGET AND FISCAL CONTROL ACT.
ORDER
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OF
'.• ^ FINANCE DIRECTOR
a e..
-
CITY MANAGER
FTA 12/07

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OF W ATFR .r. FRO State of North Carolina
\O�� 4G JUN 2 1202 Department of Environment and Natural Resources
� Division of Water Quality
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FAST -TRACK APPLICATION
(FTA 12/07 very)
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included/addressed the following list of required application package items by
checking the space provided next to each applicable item. Failure to submit all required items will lead to your application
being returned as incomplete. Forms are available from the web site or by calling the Regional Office serving your county:
http://h2o. enr. state. nc. us/peres/Collection % 20Systems/CollectionSystemApplications. html
® A. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. The application should include a project narrative describing the final build -out 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.). Only
include the modified information in this permit application - do not duplicate project information that has already
been included in the original permit.
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 1303).
Separate aDDlications should be made for non-contiouous sewer systems
® B. Application Fee - Submit a check in the amount of $480 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ C. 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(2)a of this application.
❑ D. Operational Agreements — Submit one original and two copies of a properly executed operational agreement, as
per 15A NCAC 02T .0115, if the application is submitted 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 home or property owner's association, use Form HOA 02/03. If the applicant is a developer,
use Form DEV 02/03. EVEN IF THE PROJECT MAY BE TURNED OVER TO A MUNICIPALITY UPON
COMPLETION, FORM DEV 02/03 IS REQUIRED.
❑ E. Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance — FORM FTSE 10/07 (Flow
Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant
(and owners of downstream sewers, pump stations and/or treatment facilities submitting FORM FTSE-10/07)
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 10/07
from the owner of the downstream sewer and owner of the WWTF, if different. The flow acceptance indicated in
FORM FTSE-10/07 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-10/07 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 project -specific FTSE 10/07.
® F Map — Submit an 8.5-inch by 11-inch COLOR copy of a USGS Topographic Map of sufficient scale to identify the
entire project area and the closest surface waters. Each map or maps must show the location of the sewer line
and pump stations and be of reproducible quality. Include a street level map showing the downstream connection
point, and the permit number for the downstream sewer, if known.
FTA 12/07

❑ G. Stream Classifications — Watershed Classification Attachment (Form WSCAS-12/07) If any portion of the
sewer system project is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment
may need to be completed. A variance must be requested for encroachment within required setbacks or buffers
pursuant to 2T .0305 (f) and be indicated in Item B-13 with supporting documentation/justification provided.
❑ H Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application cannot be used. Send the project application on the most current version of Form
PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications
cannot be accepted until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS)
has been issued. A copy is to be submitted with that permit application.
❑ I. 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 this project, please indicate in B(12) and give the permit
number of the second treatment facility.
J. 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(lb). 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 Fast -Track
Permitting of Pump Stations and Force Mains (most recent version), as applicable to the project.
THE COMPLETED FTA 12/07 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
DOCUMENTS AND $480 FEE, 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,
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,
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,
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,
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,
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
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell, Davidson,
Winston-Salem, North Carolina 27107
Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone]
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at.
httpJ/h2o. enr.state.nc. us/peres/Collection%20Systems/CollectionSystemsHome. html
or contact the Regional Office serving your county.
FTA 12/07

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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)
1. Owner/Permittee:
1 a. City of Lumberton
Full Legal Name (company, municipality, HOA, utility, etc.)
1b. QhL.PA Ar%iAk_raa0&_ Puhlie_ Wov-k< D�rcc.-.or
Signing Official Name and Title (P%ase review 15A NCAC 2T .0106 (b) for authorized signing officials!)
1c. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1d. P.0 f6ox 1351e. Luw. er±±_o►,!%
Mailing Address City
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State Zip Code
67/— 3SS11i. pYlYw� i.t�'onal9lQLX/. 1j rarm-cf_ o�tinQGr.1w�. ber•1.,�,._rtt.t r
Telephone Facsimile V— 37�, E-mail '�
2. Project (Facility) Information: US 301 (Fayetteville Road ) over 1-95 (Exit 22)
2a. 1-4413 Fayetteville Road Project. 2b.
Brief Project Name (permit will refer to this name)
3. Contact Person:
Robeson
County Where Project is Located
Q3a. Corey Bousquet, PE
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. (919)-707-6697 3c. [e-mail]
Phone Number E-mail
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if
1. Project is ❑ New 0 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 C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3. CC/'Jy of L14�10eA0y%
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. City of Lumberton WWfP 4b. /UG DD Z q S -7
Name of WWTF WWTF Permit No.
5a. City of Lumberton 5b. 12". 6" ® Gravity 5c.
Owner of Downstream Sewer 'Receiving Sewer Size ® Force Main
The origin of this wastewater is (check all that apply):
® Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
Permit # of Downstream Sewer (Instruction E)
❑ Retail (Stores, shopping centers)
❑ Institution
❑ Hospital
❑ Church
❑ Nursing Home
❑ Other (specify): Relocation of existing
sewer to a new location
Volume of wastewater to be allocated or permitted for this particular project:
*Do not include future flows or previously permitted allocations
If the permitted flow is zero, indicate why:
• Domestic/Commercial
• Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify)
0 gallons per day
❑ 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 12/07

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).
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) New Gravity or Additional
Force Main
6 145 Force Main
6 142 Force Main
6 12 Force Main
12 20 Gravity Sewer
.-.
C) 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
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Pump Station Location ID
(self chosen - as shown on plans/map for reference)
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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
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2 - portable generator w/MTS
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QPump
Station Location ID
(self chosen - as shown on plans/map for reference)
Design Flow
Operational Point
Power Reliability Option
(MGD)
GPM @TDH
t - permanent generator w/ATS; Force Main Size Force Main Length
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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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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
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 2"d treatment facility
(RO — if "yes" to 13,12 please contact the Central Office PERCS Unit)
13. 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 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 12/07

14. 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
Stormwater? ® Yes ❑ No ❑ N/A
15. Does this project include any high priority lines, [see 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
Owner/Permittee's Certification: (Signature of Signing Official and Project Name) 1, ROWU 1, ktUS(kXh 10 st that this application for 1- u 1 t.3 FH`liTevi+-L,�,f Roft l)iZuStZ7las 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
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.
1a. S- j 6--1
Signing Official Signature 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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Q2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
_V 1, . attest that this application for1_ iY/j FAu+e A&.W1/1 44c/ nL�jict-- has been
LL reviewed by me and i accurate, complete and consistent with the information in the engineering plans, calculations, and
j= all other supporting documentation to the best of my knowledge. I further attest that to the best of my knowledge the
lc proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria
LL1 for Gravity Sewers adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump
C) Stations and Force Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance.
Although other professionals may have developed certain portions of this submittal package, inclusion of these materials
V under my signature and seal signifies that 1 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. Corey Bousquet, PE
Professional Engineer Name
2b. NCDOT
Engineering Firm
2c. 1555 Mail Service Center
Mailing Address
2d. Raleigh 2e. NC 2f.27699-1591
City State Zip
2g. [phone] 2h. [phone] 2i. [e-mail]
Telephone Facsimile E-mail
NC PE Seal, Signature & Date
FTA 12/07

DENR-FRO
JUN 21 2012
S.��.
DWO
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
BEVERLY EAVES PERDUE
GOVERNOR
June 18, 2012
Department of Environment and Natural Resources
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301-5094
Subject: Permit application for sewer line on NCDOT Project
I-4413 Bridge No.36 ON US 301 (Fayetteville Road) over I-95
EUGENE A. CONTI, JR.
SECRETARY
Attached are one (1) copy and one (1) original permit application for installation of the
proposed waste water facilities on the above highway project.
These facilities are owned by City of Lumberton and are to be constructed as part of the highway
contract. We respectfully request your review and approval.
Enclosed is a check in the amount of $480 from the City of Lumberton for the permit
applications fee.
If we can be of any assistance, please do not hesitate to call me at [phone].
MAILING ADDRESS:
NC DEPARTMENT OF TRANSPORTATION
UTILITIES AND ENCROACHMENTS ENGINEERING UNIT
1555 MAIL SERVICE CENTER
RALEIGH NC 27699-1591
Sincerely,
Corey D. Bousquet, PE
Utility Squad Leader
Utilities Unit
TELEPHONE: [phone]
FAX: [phone]
WEBSITE: www.NC.DOT.ORG/DOH
LOCATION:
CENTURY CENTER COMPLEX
ENTRANCE B-2
1020 BIRCH RIDGE DRIVE
RALEIGH NC

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PLAN VIEW DIVISION OF HIGHWAYS
ROBESON COUNTY
PROJECT: I-4 413
BRIDGE 36 OVER I-95 ON US 301
2000' 0' 2000'
SHEET 1 OF 1
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