WQ0039621_Sewer Extension_20171109

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Division of Water Resources
State of North Carolina
Department of Environmental Quality
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: City of Lumberton (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Bruce W. Davis per 15A NCAC 02T .01060)
Title: Mayor
4. Applicant's mailing address: PO Drawer 1388
City: Lumberton State: NC Zip: 28359-1388
5. Applicant's contact information:
Phone number: [phone] Email Address: whorneaci.lumberton.nc.us
I1. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other RECEIVED
DECK/DWR
NOV 0 9 2017
!= 304
WQROS
AYETTEVILLE REGIONAL OFFICE
1. Project name: Sanitary Sewer Collection System Rehabiltiation - 2016 Priority Repairs Contract 2 - Ramada Inn Pump
Station Force Main Replacement
2. Application/Project status: ® Proposed (New Permit) [I Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
t N N
ry CITY OF LUMBERTON
4 GENERAL ACCOUNT
'! PO BOX 1388
LUMBERTON, NC 28359
PAY FOUR HUNDRED EIGHTY AND XX / 100
TO THE NCDEQ
ORDER OF LAND QUALITY SECTION
1612 MAIL SERVICE CENTER
RALEIGH, NC 27699-1612
Owner Name(s): City of Lumberton
First South Bank
LUMBERTON, NC 2&W
66-7162/2531
DATE CONTROL NO.
11/03/2017
M
23805
23805
N
AMOUNT o
N
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A
*********480.00
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CITY MANAGER
01 DIRECTOR
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AUTHOR D IGNATURE
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FORM: FTA 04-16 Page] of 5

DEQIDWR
NOV 0 9 2017 State of North Carolina
Department of Environmental Quality
DWR WQROS Division of Water Resources
FAYETTEVILMR+Mt- *2!r 60:�V'FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineerine practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC I .0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPs) or simplex grinder pumps;
Y STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an 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. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ if necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
❑ The Project Name in Item H. l shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 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).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Pagel of 3

'✓ I
E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE 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 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.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x l 1-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(l), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is
compatible with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or
proposed contractor, stating that "the portable power generation unit or portable, independently -powered pumping
units, associated appurtenances and personnel are available for distribution and operation of this pump 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
timefromes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide 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 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.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/ProWrtv Owners' Associations
❑ Per 15A NCAC 02T .0115(c) submit the properly executed Operational Ageement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEVZ.
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Realonal 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 Realonal Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Hamett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Realonal 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
Raleiah Realonal 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
Washinaton Realonal 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
Wllminaton Realonal Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-ftlem Realonal Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

i / s
State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: W Q003q,k 1N (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Lumberton (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: Bruce W. Davis per 15A NCAC 02T .0106(b)
Title: Mayor
4. Applicant's mailing address: PO Drawer 1388
City: Lumberton State: NC Zip: 28359-1388
5. Applicant's contact information:
Phone number: [phone] Email Address: whorneng.ci.lumberton.nc.us
II. PROJECT INFORMATION:
1. Project name: Sanitary Sewer Collection System Rehabiltiation - 2016 Priority Repairs, Contract 2 - Ramada Inn Pump
Station Force Main Replacement
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Robeson
4. Approximate Coordinates (Decimal Degrees): Latitude: 34.6452' Longitude:-79.0122'
5. Parcel ID (if applicable): 939266763600
(or Parcel 1D to closest downstream sewer)
Ill. CONSULTANT INFORMATION:
1. Professional Engineer: Chad D. Easter License Number: 033743
Firm: The Wooten Company
Mailing address: 1830 Marion Street, Suite A
City: Columbia State: SC Zip: 29201
Phone number: [phone] Email Address: ceaster _,thewootencompany.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: City of Lumberton WWTF Permit Number: NCO024571
Owner Name: City of Lumberton
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQunknown Downstream (Receiving) Sewer Size: 12 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00024
Owner Name(s): City of Lumberton
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'sOperational Agreement (FORM: DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/ProKgy Owners' Association has an Operational A ment(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
❑ offices /factories ❑Swimming Pool/Filter Backwash
Businesses /of
❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
-Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ® No
➢ If yes, provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f)
Daily Design Flow',b
No. of Units
Flow
N/A
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T 0114(b) W. a 1)annd (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. 42A-4).
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: 0 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
N/A
➢ Section 11 & 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 (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
Pump station number or name: Ramada Inn LS
2. Approximate Coordinates (Decimal Degrees): Latitude: 34.64760 Longitude:-79.01090
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 1.000 gallons per minute at 100 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
10
2,443
PVC
10
226
DIP
6. Power reliability in accordance with 15A NCAC 02T .030501)(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(hX 1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1XC):
➢ 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(1)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(t) & (g) ® Yes ❑ No
➢ 15A NCAC 02T.0305(fl contains minimum separations that shall he nrovided for sewer systemv
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 11 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 elevatioo and wetlands (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building 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(p,) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpUe
➢ If noncompliance with 02T.0305( 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 213.0202
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

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X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump 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:
I, C/MD D . F As -re attest that this application for
(Professional Engineer's name from Application Item III. I.)
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 143-215.613, 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. ��ttEt I ItNi•
North Carolina Professional Engineer's seal, signature, and date:
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3. Applicant's_gSilifigation per 15A NCAC 02T .0106(b):
1, attest that this application for
gnature Authority's name & title from Application Item 1.54
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 143-215.613, 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: Date:
FORM: FTA 04-16 Page 5 of 5

17,
THE
WOOTEN
COMPANY
1830 Marion Street, Suite A
Columbia, SC 29201-2528
:I119MON-MV:I3
1 (tUtN tV
DEQIDWR
NOV 0 9 2017
November 3, 2017
VVQROS
AYE?TEVILLP aFGlOh1AL OFFICE
NCDEQ
Water Quality Section
225 Green Street, Suite 714
Fayetteville NC 28301-5094
Re: Fast Track Application
City of Lumberton
Sanitary Sewer Collection System Rehabilitation — 2016 Priority Repairs
Contract 2 — Ramada Inn Pump Station Force Main Replacement
TWC No. 2799-BP
Dear Regional Office Staff:
On behalf of the City of Lumberton, The Wooten Company is submitting a Fast Track Application
for the project referenced above. The follow items are enclosed:
1. One original and one copy of the Application Form.
2. Application fee.
3. A USGS topographic map covering the project area.
4. A street level map covering the project area.
5. Project Narrative located in the following paragraphs of this letter:
The City of Lumberton's Ramada Inn Pump Station currently conveys wastewater across
Highway 211 to the gravity sewer system near the intersection of Rowland Avenue and 33`d
Street via an 8-inch diameter asbestos cement force main. Due to past failures of the force
main, the City proposes to replace the existing force main with a new 10-inch diameter main
constructed of PVC and ductile iron materials.
The new force main will be installed within the same corridor that currently houses the
existing force main and the discharge location for the force main will remain unchanged.
Upon completion of the new 10-inch main, the existing main will be abandoned in place.
The Ramada Inn Pump Station serves a basin of the City's collection system which is exists in
nearly a fully developed condition. As a result, the pumping rate of the station is considered
sufficient to serve the drainage basin into the future. Upsizing the force main from 8-inch to
10-inch diameter will allow the system to operate with lower pressure in the piping system
while maintaining a minimum scouring velocity of 2.0 feet per second. By reducing the
diameter of the impellers of the existing pumps, the City will be able to keep the stations
pumping rate near its current rate of 1,000 gpm without requiring additional horsepower.
Although equipment upgrades are being planned for the Ramada Inn Pumping station, no
immediate upgrades are proposed at this time. Standby power as well as telemetry equipment
currently in service will remain.

Should you have an questions, please give me a call.
Respectfully,
THE WWOOTTEN COMPANY
1�� C---v zd-�
Chad D. Easter, PE
Project Manager
Enclosures
Cc: Wayne Horne, City of Lumberton
Steve Tsadwa, NCDEQ DWI

STATE OF NORTH CAROLINA
ROUTE SR 1792, Hwy 211 PROJECT Sanitary Sewer COUNTY OF Robeson
Rehabilitation, 2016
Priority Repairs
DEPARTMENT OF TRANSPORTATION RIGHT OF WAY ENCROACHMENT AGREEMENT
-AND- PRIMARY AND SECONDARY HIGHWAYS
City of Lumberton
THIS AGREEMENT, made and entered into this the day of 20 by and between the Department
of Transportation, party of the first part; and City of Lumberton
party of the second part,
WITNESSETH
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) SR 1792 and Hwy 211 , located on the north side of Lumberton
with the construction and/or erection of: Approximately 380 linear feet of 10-inch diameter sanitary sewer force main,
Including bore and jack of 20-inch steel encasement under SR 1792 and Hwy 211 to accommodate the proposed force main.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the party of
the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment within the limits of the
right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second part the right
and privilege to make this encroachment as shown on attached plan sheet(s), specifications and special provisions which are
made a part hereof upon the following conditions, to wit:
That the installation, operation, and maintenance of the above described facility will be accomplished in accordance with the party of
the first part's latest POLICIES AND PROCEDURES FOR ACCOMMODATING UTILITIES ON HIGHWAY RIGHTS -OF -WAY, and such
revisions and amendments thereto as may be in effect at the date of this agreement. Information as to these policies and procedures
may be obtained from the Division Engineer or State Utility Agent of the party of the first part.
That the said parry of the second part binds and obligates himself to install and maintain the encroaching facility in such safe and
proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper maintenance
thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways and structures
necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the party of the first part
shall require the removal of or changes in the location of the said facilities, that the said parry of the second part binds himself, his
successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said requirement, without any cost to the
party of the first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal lights,
flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic Control Devices
for Streets and Highways and Amendments or Supplements thereto. Information as to the above rules and regulations may be obtained
from the Division Engineer of the party of the first part.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages and
claims for damage that may arise by reason of the installation and maintenance of this encroachment.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of the
Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution during
construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and regulations
of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and with ordinances
and regulations of various counties, municipalities and other official agencies relating to pollution prevention and control. When any
installation or maintenance operation disturbs the ground surface and existing ground cover, the party of the second part agrees to
remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division Engineer of the party of the
first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary by the
Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the construction site, at all times during construction, a copy of this
agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all work unless
evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the second part
agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has been completed.
Unless specifically requested by the party of the first part, written notice of completion of work on highway projects under construction will
not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part, the party of the first part reserves
the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to the party of the
first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein is not
begun within one (1) year from the date of authorization by the party of the first part unless written waiver is secured by the party of the
second part from the party of the first part.
During the performance of this contract, the second party, for itself, its assignees and successors in interest (hereinafter referred to as
the "contractor"), agrees as follows:
a. Compliance with Regulations: The contractor shall comply with the Regulations relative to nondiscrimination in Federally -
assisted programs of the U. S. Department of Transportation, Title 49, Code of Federal Regulations, Part 21, as they may be
amended from time to time, (hereinafter referred to as the Regulations), which are herein incorporated by reference and
made a part of this contract.
FORM R/W 16.1 (Rev. July 1, 1977)

b. Nondiscrimination: The contractor, with regard to the work performed by it during the contract, shall not discriminate on the
grounds of race, color, or national origin in the selection and retention of subcontractors, including procurements of materials
and leases of equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by
Section 21.5 of the Regulations, including employment practices when the contract covers a program set forth in Appendix B
of the Regulations.
c. Solicitations for Subcontracts. including Procurements of Materials and Eauipment: In all solicitations either by competitive
bidding or negotiation made by the contractor for work to be performed under a subcontract, including procurements of
materials or leases of equipment, each potential subcontractor or supplier shall be notified by the contractor of the
contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race, color,
or national origin.
d. Information and Reports: The contractor shall provide all information and reports required by the Regulations, or directives
issued pursuant thereto, and shall permit access to its books, records, accounts, other sources of information, and its
facilities as may be determined by the Department of Transportation or the Federal Highway Administration to be pertinent to
ascertain compliance with such Regulations or directives. Where any information required of a contractor is in the exclusive
possession of another who fails or refuses to furnish this information, the contractor shall so certify to the Department of
Transportation, or the Federal Highway Administration as appropriate, and shall set forth what efforts it has made to obtain
the information.
e. Sanctions for Noncompliance: In the event of the contractor's noncompliance with the nondiscrimination provisions of this
contract, the Department of Transportation shall impose such contract sanctions as it or the Federal Highway Administration
may determine to be appropriate, including, but not limited to,
(1) withholding of payments to the contractor under the contract until the contractor complies, and/or
(2) cancellation, termination or suspension of the contract, in whole or in part.
Incorporation of Provisions: The contractor shall include the provisions of paragraphs "a" through "f" in every subcontract,
including procurements of materials and leases of equipment, unless exempt by the Regulations, or directives issued
pursuant thereto. The contractor shall take such action with respect to any subcontract or procurement as the Department
of Transportation or the Federal Highway Administration may direct as a means of enforcing such provisions including
sanctions for noncompliance: Provided, however, that, in the event a contractor becomes involved in, or is threatened with,
litigation with a subcontractor or supplier as a result of such direction, the contractor may request the Department of
Transportation to enter into such litigation to protect the interests of the State, and, in addition, the contractor may request
the United States to enter into such litigation to protect the interests of the United States.
R/W (161) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R/W (161) incorporating all revisions to date.
IN WITNESS WHEREOF, each of the parties to this agreement has caused the same to be executed the day and
year first above written.
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�Uiey . Mitchell- clntosh, Ci Clerk
INSTRUCTIONS
DEPARTMENT OF TRANSPORTATION
AN
DIVISION ENGINEER
t
ayne orne, City Manager
Second Party
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and be attested by the corporation
secretary or by the empowered city official, unless a waiver of corporate seal and attestation by the secretary or by the empowered City
official is on file in the Raleigh office of the Manager of Right of Way. In the space provided in this agreement for execution, the name of
the corporation or municipality shall be typed above the name, and title of all persons signing the agreement should be typed directly
below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The address should be included in this
agreement and the names of all persons signing the agreement should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the existing and/or proposed encroachment.
4. Length, size and type of encroachment.
5. Method of installation.
6. Dimensions showing the distance from the encroachment to edge of pavement, shoulders, etc.
7. Location by highway survey station number. If station number cannot be obtained, location should be shown by
distance from some identifiable point, such as a bridge, road, intersection, etc. (To assist in preparation of the
encroachment plan, the Department's roadway plans may be seen at the various Highway Division Offices, or at the
Raleigh office.)
8. Drainage structures or bridges if affected by encroachment (show vertical and horizontal dimensions from
encroachment to nearest part of structure).
9. Method of attachment to drainage structures or bridges.
10. Manhole design.
11. On underground utilities, the depth of bury under all traveled lanes, shoulders, ditches, sidewalks, etc.
12. Length, size and type of encasement where required.
13. On underground crossings, notation as to method of crossing - boring and jacking, open cut, etc.
14. Location of vents.
GENERAL REQUIREMENTS
1. Any attachment to a bridge or other drainage structure must be approved by the Head of Structure Design in Raleigh
prior to submission of encroachment agreement to the Division Engineer.
2. All crossings should be as near as possible normal to the centerline of the highway.
3. Minimum vertical clearances of overhead wires and cables above all roadways must conform to clearances set out in
the National Electric Safety Code.
4. Encasements shall extend from ditch line to ditch line in cut sections and 5' beyond toe of slopes in fill sections.
5. All vents should be extended to the right of way line or as otherwise required by the Department.
6. All pipe encasements as to material and strength shall meet the standards and specifications of the Department.
7. Any special provisions or specifications as to the performance of the work or the method of construction that may be
required by the Department must be shown on a separate sheet attached to encroachment agreement provided that
such information cannot be shown on plans or drawings.
8. The Department's Division Engineer should be given notice by the applicant prior to actual starting of installation
included in this agreement.