WQ0041828_Application (FTSE)_20200714

Fast Track Application for:
✓Gl
2018 Wastewater System Improvemen
Town of Windsor, North Carolina
July 2020
TV
THE WOOTEN COMPANY
1.11h ti4rpp.r Orpeny P. Nr 27K4
Firm License: F-0115
TWC Project No. 2290-CK

TOWN OF WINDSOR/WINDSOR, N.C. CURRENT EXPENSE ACCOUNT
2106 NC DEQ
iVA:i.Yll
Invoice # Inv Date
SEWER REHAB PR06/24/2020
Check Date 6/24/2020
Description PO Number
PERMIT FEE SEWER REHAB PROJECT
Check Total
Amount
$480.00
p THIS DOCUMENT HAS A COLORED SECURITY BACKGROUND THIS PAPER HAS AN ARTIFICIAL WATERMARK ON REVERSE SIDE AND.IB ALTERATION PROTECTED.,
12861
SouthwitHank
TOWN OF [ • ' DATE
WINDSOR,
CURRENT EXPENSE • _ �.w...•, • F
20
This Disbursement has been approved as
Required by The Local Government & Fiscal Control Act
PAY Exactly **FOUR HUNDRED EIGHTY AND 00/100 dollars" .........
«..«„.
TO THE
ORDER
OF NC DEQ
1646 MAIL SERVICE CENTER
RALEIGH NC 27699-1646
AMOUNT
$480.00
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Appendix A
Cover Letter

FAST TRACK COVER LETTER
2018 WASTEWATER SYSTEM IMPROVEMENTS
Town of Windsor
July 2020
PREPARED BY:
T T
THE WOOTEN COMPANY
301 West 14th Street. Greenvue. NC 27834
Licenses No. F-0115

A. DESCRIPTION OF PROJECT
Location of Project
The Town of Windsor is located in the eastern part of North Carolina's coastal plain; located along
N.C. Highway 17 in Bertie County bordering Cashie River between the Town of Williamston and
the Town of Edenton. The Town of Windsor has a population of approximately 3,578 according to
the 2010 census data.
Type of Development
The proposed portion of the project is replacing an existing 12-inch gravity sewer main and
manholes, to create a new parallel, alignment along King Street, along with the abandonment of an
existing 8-inch gravity sewer main, the services connected to the 8-inch main will be jack & bored
across King street and reconnected to the new 12-inch main. The new 12-inch line will realign the
sewer so it is out of the ditch along the right-of-way and away from existing utilities along the
alignment. The new 12-inch gravity sewer will not cause an increase in flow as there will be no new
customers. The project includes the replacement of the Windsor Village pump station and its
components within the system, with no increase of flow or capacity. The proposed project also
includes the removal and replacement of the communitor with a new automatic bar screen at the
Wastewater Treatment Plant.
3.1
King
8-Inch Sewer Main
Abandonment
e 12-Inch Sewer Main
Horizontal Realignment
12-inch Sewer Main
Existing Alignment
This project is more specifically defined as follows:
New 12-inch Gravity Sewer
e Abandon 1,017 LF of Existing 8-inch Gravity Sewer;
e Abandon 2,130 LF of Existing 12-inch Gravity Sewer;
e 3,525 LF of Replacement12-inch PVC Gravity Sewer;
e 65 LF of new 12-inch DIP Gravity Sewer w/ 24-inch Steel Encasement;
e Abandon 10 Existing Manholes of Various Depths;
e Replacement of 11 Existing Manholes of Various Depths;
e 5 New Manholes of Various Depths;
e Replace 19 Sanitary Sewer Services.
Pump Station and Wastewater Treatment Plant
e Replacement of the 45 GPM Windsor Village Pump station;
Puy 12

• Removal of Comminutor,
• Replacement of bar screen with an automatic bar screen;
• Replacement of concrete of Clarifier.
Existing Drainage Patterns
Geological features are typical of the North Carolina coastal plain region with gradual elevation
changes. There are no sudden or significant elevation changes in the area. The specific topography
within the project area consists of gradual elevation changes leading to roadside ditches or natural
drainage features.
B. TIME SEQUENCE OF OPERATIONS
Construction is anticipated to begin in the spring of 2021. Permits are being secured now and once
the project is awarded, construction will be able to start. The contractor shall complete all
construction within the easements and rights -of -ways as shown on the plans. All utilities must be
checked and tested and any areas that can be seeded should be done as soon as possible.

Appendix B
Application Fee

Appendix C
Application Form

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Watei 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 Hood engineering 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 IC .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;
➢ 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
-ind 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 I.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 II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
l ® 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 Page i of 3

L.

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
E 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):
E Submit an 8.5-inch x 11-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):
E Per 15A NCAC 02T .0305(h)(1), 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
timeframes, 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/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of hicorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
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 Regional 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 Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarms, Catawba, Cleveland,
Water Quality Section
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,
Water Quality Section
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, Bartle, 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
Vilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

DWR
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 DW R)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Windsor (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Allen Castello per 15A NCAC 02T .0106(b)
Title: Town Manager
4. Applicant's mailing address: P.O. Box 508
City: Windsor State: NC Zip: 27983-_
5. Applicant's contact information:
Phone number: [phone] Email Address: windsor.adminOmchsi.com
❑ Privately -Owned Public Utility
❑ Other
II. PROJECT INFORMATION:
1. Project name: 2018 Wastewater System Improvements
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00_
3. County where project is located: Berrie
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.989552' Longitude:-76.935589'
5. Parcel ID (if applicable): _
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: William A. Larsen PE License Number: 041415
Firm: The Wooten Company
Mailing address: 301 West 14" Street
City: Greenville State: NC Zip: 27834-
Phone number: [phone] Email Address: wlarsenathewootencompany.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Windsor WWTP Permit Number: NCO026751
Owner Name: Town of Windsor
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
l.- System Wide Collection System Permit Number(s) (if applicable): WQCS_
Owner Name(s):
FORM: FTA 04-16 Page I of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
[—]Yes [—]No ®N/A
4. Origin of wastewater: (check all that apply):
® Residential Owned ® Retail (stores, centers, malls) ❑ Car Wash
® Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
® School / preschool / day care ® Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
® Food and drink facilities ® Church ❑ Swimming Pool/Filter Backwash
® Businesses / offices / factories ® Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 75 % Domestic/Commercial 25 % Commercial
Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ® No
6. Hasa flow reduction been approved under 15A NCAC 02T .01 14(f)? ❑ Yes ® No
➢ If yes, provide a copy 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
N/A gal/
N/A
N/A GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
N/A GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use
areas; and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: — GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number: —
® Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
12 2,130 PVC, DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Windsor Village Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.007071 ° Longitude:-76.955870'
3. Design flow of the pump station: 0.0072 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 45 gallons per minute at 66 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
N/A
N/A
N/A
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be
provided in the case of a multiple station power outage.
FORM: FTA 04-16
Page 3 of 5

IX. SETBACKS & SEPARATIONS - (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(fl & (g)
➢ 15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
® Yes [-]No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains horizontal
10 feet
Reclaimed water lines vertical - reclaimed over sewer
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
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(e) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpaee
➢ If noncompliance with 02T.0305(for (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes [-]No ❑ N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No ® N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ® No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes [-]No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per.] 5A NCAC 02T.04021 "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16
Page 4 of 5

X. CERTIFICATIONS:
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 p/No �Jp� TS.76YJ
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 William A. Larsen, PE attest that this application for
(Professional Engineer's name from Application Item III.1.)
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 143-215.6B, 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. 0,,oll _1,,,,,,
North Carolina Professional Engineer's seal, signature, and date:
041415 =
NGINS !v?
/ghfA.�PPy`,
3. Applicant's Certification per 15A NCAC 02T .0106(b):
Allen Castelloe, Town Manager attest that this application for
(Signature Authority's name & title from Application Item I.3.)
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. I 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 143-215.6B, 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: 0`-�'�'�...� Date:
FORM: FTA 04-16 Page 5 of 5

Appendix D
Flow Tracking/Acceptance Form
(Not Applicable)
The project is replacement/realignment only, resulting in
no new flow.

Appendix E
Site Map

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Appendix F
Power Reliability Plan

Power Reliability
(Windsor Village Pump Station)
Reliability for Pump Station:
The Windsor Village Pump Station will have an available standby generator
located at the pump station site for operation.
Further discussion and details are provided in the contract documents and
the project plan sheets.

Appendix G
Certificate of Public Convenience and Necessity
(Not Applicable)

Appendix H
Operational Agreements
(Not Applicable)