WQ0031435_Sewer Extension_20070312 (2)

USE•THE TAB KEY T
MOVE ft6k1k1'f:1:11J FIELD
Application Number:
--
(to be completed by DWQ)
I.
Owners
_ MAR 12 2007
-
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1 a.
Town of Pembroke
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Full Legal Name (comp
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EO-tA'LtTitauiQALUtt�G�
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1 b.
McDuffie Cummings, To
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
1 c.
The legal entity who will own this system is:
El Individual ❑Federal ®Municipality State/County Private Partnership ❑ Corporation Other (specify):
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0
1 d.
P.O. Box 866 1 e. Pembroke
ZMailing
Address City
1f.
North Carolina 1g. 28372-0866
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State Zip Code
1h.
910-521-9758 1i. 910-521-0472 1'. [e-mail]
) @pembrokenc.com
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Telephone Facsimile E-mail
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2.
Project (Facility) Information:
-J
2a.
FY2005 CDBG Project, Arrow Point Subdivision Phase 1 B 2b. Robeson
Oa.
Brief Project Name (permit will refer to this name) County Where Project is Located
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3.
Contact Person:
Q3a.
Luke T-L Kwong, P.E., The Wooten Company
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
919-828-0531 3c. [e-mail]
._ -
_ ..___----------
Phone Number
- E-mail
1.
Project is ® New [:]Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
FIRST CITIZENS BANK AND TRUST COMPANY
RALEIGH. NC 27602 03678 9 31711
120 N. Boylan Avenue 66-30/531
THE WOOTEN COMPANY Raleig 27603603
E N G I N E E R I N �; PLANNING, ARCHITECTURE 919-828-0531
Exactly Four hundred and no / 100 Dollars
Y
tTHE
:DER
NC DENR - DWQ
Raleigh NC
3/9/2007
DATE
$400.00
.AMOUNT
THE TEN OMPANY-ACCOUNTSPaYABLE
I 'I HI IN V'ED

7. Volume of wastewater to be allocated for this particular project: 0 gallons per day
"Do not include previously permitted allocations
I
8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted in subsequent permits that connect to this line
® Flow has already been allocated in Permit No. WQ0029864
❑ Rehabilitation or replacement of existing sewer with no new flow expected
FTA 02/03 - Rev. 3 04/05

r
FAST-TRA'CK-APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
of WAT�cR RECEIVED State of North Carolina
�O� QG 2 Department of Environment and Natural Resources
� Division of Water Quality
p DENR-FAYETiEVILLEREGIONALOFRCE
FAST -TRACK APPLICATION
for GRAM SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included/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. This form may be photocopied for use as an original.
® I. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. Any changes to this form will result in the application being returned. The Division of Water Quality
(Division) will only accept application packages that have been fully completed with all applicable items
addressed. You do not need to submit detailed plans and specifications unless you respond NO to Item 1302)
® II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ III. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2a) of this application.
❑ IV. Operational Agreements — Submit one original and two copies of a properly executed operational agreement if
the sewer extension is permitted by a private applicant and will be serving residential or commercial lots (e.g.,
houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If the applicant is a
homeowners' association, use Form HOA 02/03. If the applicant is a developer, use Form DEV 02/03. EVEN IF
THE PROJECT WILL BE TURNED OVER TO A MUNICIPALITY, FORM DEV 02/03 IS REQUIRED.
❑ V. Flow Acceptance Letters — If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and name and permit number of the receiving sewers/WWTF. The flow acceptance must not
expire prior to permit issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
® VI. Map — Submit an 8.5-inch by 11-inch COLOR copy of the portion of a 7.5-minute USGS Topographic Map along
with this form. The map should identify the entire project area location as well as the closest downslope surface
waters as clearly as possible. Each map portion must be labeled with the map name and number, the identified
location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project
involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties,
basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location in Section C of the permit application.
❑ VI1. Stream Classifications — Section C
• If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)" available from http://h2o.enr.state.nc.us/peres or by contacting the appropriate regional
office.
FTA 02/03 - Rev. 3 04105

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
❑ Vill. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the PERCS
Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not 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.
® IX. Certifications — Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE). The applicant signature must match the signing official listed in Item A(1b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, the Gravity Sewer Minimum Design Criteria (most
recent version) and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
(most recent version), as applicable to the project. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral.
❑ X. Downstream Sewer & Wastewater Treatment Plant Capacity
The applicant has assured downstream pipe, pump station and treatment plant capacity. The addition of new
sources of wastewater from this project has been evaluated along the route to the receiving treatment plant. 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. If the applicant is not the owner of the
downstream sewer or receiving treatment plant, submittal of flow acceptance letter(s) indicates that owner has
adequate capacity and will not violate G.S. 143-215.67(a).
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell,
Swannanoa, North Carolina 28778
Cherokee, Clay, Graham, Haywood,
[phone]
Henderson, Jackson, Macon, Madison,
[phone] Fax
McDowell, Mitchell, Polk, Rutherford,
'
Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett,
Fayetteville, North Carolina 28301
Hoke, Montgomery, Moore, Robeson,
[phone]
Richmond, Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue, Suite 301
Alexander, Cabarrus, Catawba,
Mooresville, North Carolina 28115
Cleveland, Gaston, Iredell, Lincoln,
[phone]
Mecklenburg, Rowan, 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,
919 571-4718 Fax
Wake, Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan,
Washington, North Carolina 27889
Craven, Currituck, Dare, Gates, Greene,
[phone]
Hertford, Hyde, Jones, Lenoir, Martin,
[phone] Fax
Pamlico, Pasquotank, Perquimans, Pitt,
Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin,
Wilmington, North Carolina 28405
New Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
[phone]
Rockingham, Randolph, Stokes, Surry,
[phone] Fax
Watauga, Wilkes, Yadkin
Formore information, visit our web site at: http://h2o.enrstate.nc.us/peres/
FTA 02/03 - Rev. 3 04/05

FAST-.F"C.K APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: wQp03143 5
(to be completed by DWQ)
1. Owner:
1 a. Town of Pembroke
Full Legal Name (company, municipality, HOA, utility, etc.)
1 b. McDuffie Cummings, Town Manager
Signing Official Name and Title (Please review 15A NCAC 2H .0206(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):
1 d. P.O. Box 866 le. Pembroke
Mailing Address
1f. North Carolina
City
1 g. 28372-0866
State Zip Code
1h. 910-521-9758 1i. 910-521-0472 1j. [e-mail]
Telephone Facsimile E-mail
2. Project (Facility) Information:
2a. FY2005 CDBG Project, Arrow Point Subdivision - Phase 1 B 2b. Robeson
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. Luke T-L Kwong, P.E., The Wooten Company
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-828-0531 3c. Ikwonaa-thewootencom
com
Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another
phase, changing line size/length, etc.). Only include the modified information in this permit application - do not
duplicate project information in B(7) and B(10-11) that has already been included in the original permit.
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold, facilities owned by a must choose one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3. Town of Pembroke
❑ Public Utility (Instruction III)
❑ Homeowner Assoc./Developer (Instruction IV)
Owner of Wastewater Treatment Facility (1NWTF) Treating Wastewater From This Project
4a. Pembroke Waste Treatment Facility 4b. NCO027103
Name of WWTF WWTF Permit No.
5a. Town of Pembroke 5b. 10-inch J® Gravity C.
Owner of Downstream Sewer Receiving Sewer Size I❑ Force Main
6. The origin of this wastewater. is (check all that apply):
® Residential Subdivision ❑ Car Wash
❑ Apartments/Condominiums ❑ Institution
❑ Mobile Home Park ❑ Hospital
❑ School ❑ Church
❑ Restaurant ❑ Nursing Home
❑ Office ® Other (specify):
864 Dated 02-24-2006
Permit Number of Downstream Sewer (if known)
7. Volume of wastewater to be allocated for this particular project: 0 gallons per day
*Do not include previously permitted allocations
100 % Domestic/Commercial
8. If the permitted flow is zero, indicate why:,
❑ Interceptor Line - Flow will be permitted in subsequent permits that connect to this line
® Flow has already been allocated in Permit No. WQ0029864
❑ Rehabilitation or replacement of existing sewer with no new flow expected
% Industrial
% Other (specify):
FTA 02/03 - Rev. 3 04105

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(I) for Item 13(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that in 15A NCAC 2H .0219(I)(1-2) must be supported with actual water or wastewater use data in accordance with 15A
NCAC 2H .0219(I)(3).
SEE ATTACHED SHEET Asp / — 3 �o7y k 3&04,111) rZ1/O7P
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) Gravity or Force Main
(use the pull down menu)
10 1475 Gravity
8 1025 ! Gravity
0
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Z ENTER TOTAL LINE LENGTH IN MILES 0.48
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V11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Z Location ID Power Reliability Option
0 (self chosen - as shown on Design Flow , Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
Qplans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
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12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
W ® Yes El No If no, please reference the pertinent minimum design criteria or regulation and indicate why a
a variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
m
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A
Stormwater? ❑ Yes ❑ No ® N/A
14. Does this project involve aerial lines or siphons? Check if yes: ❑
These lines will be considered high priority and must be checked once every six months
15. Does this project have gravity sewer lines designed at minimum slopes? Yes:
Be aware that the Division will not accept installed lines more than 10% flatter than the minimum slope. Lines installed outside this tolerance should be
corrected prior to submitting the final engineering certification..
FTA 02/03 - Rev. 3 04/05

FAST-T"C-C APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02/03
Z (FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
0 necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
regional office (see instructions for addresses) OR indicate the following:
Q ❑ A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
V waterbody; AND,
LL
Fn ❑ A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
U) option for any pump station near a Class C down slope waterbody.
JLocation ID on Map
V (self chosen - as shown on Name of Waterbody Stream Waterbody
map for cross-reference) Waterbody County River Basin Index Classification
W
() Submit the 8.5" x I I" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
1. Applicant's Certification:
1, McDuffie Cummings. , attest that this application for Gravity Sewer, Lift Station and Force Main for the Town of
Pembroke FY2005 Community Development Project, Arrow Point Subdivision - Phase 1 B 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. 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 vioyion.
1 a.
Signing O i gn ure Date
_.__-_-_-___ _—___._-_ _ -----
2. Professi al ngineer's Certificaf n:
f)
Z 1, Luke T-L Kwong, attest that this application for Gravity Sewer, Lift Station and Force Main for the Town of Pembroke
0 FY2005 Community Development Project, Arrow Point Subdivision - Phase 1 B has been reviewed by me and is accurate,
complete and consistent with the information in the engineering plans, calculations, and all other supporting documentation
Q to the best of my knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in
0 accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February
12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June
LL 1, 2000 and the watershed classification in accordance with Division guidance. Although certain portions of this submittal
F— package may have been developed by other professionals, inclusion of these materials under my signature and seal
signifies that I have reviewed this material and have judged it to be consistent with the proposed design. Note: In
W accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
V representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to
6 exceed $10,000 as well as civil penalties up to $25,000 per violation.
2a. Luke T-L Kwong
Professional Engineer Name
2b. The Wooten Company
Engineering Firm
2c. 120 North Boylan Ave.
Mailing Address
2d. Raleigh 2e. NC 2f. 27603
City State Zip
2i.
Ikwong@thewootencompany.c
2g. 919-828-0531 2h. 919-834-3589 om
Telephone Facsimile E-mail
Seal, Signature & Date
FTA 02/03 - Rev. 3 04/05

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PAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02103
Z (FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
0 necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
regional office (see instructions for addresses) OR indicate the following:
Q ® A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
V waterbody; AND,
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�®A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
(1)option for any pump station near a Class C down slope waterbody.
J Location ID on Map
V (self chosen - as shown on Name of Waterbody Stream Waterbody
map for cross-reference) Waterbody County River Basin Index Classification
Q
LL!
H
(� Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
1. Applicant's Certification:
1, McDuffie Cummings, , attest that this application for Gravity Sewer, Lift Station and Force Main for the Town of
Pembroke FY2005 Community Development Project, Arrow Point Subdivision - Phase 18 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. Note: In accordance with North Carolina General Statutes 143-
215.6A and 143-215.68, any person who knowingly makes any false statement, representation, or certification in any
application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10, 000 as well as civil
penalties up to $25,000 per violation.
1 a.
Signing Official Signature Date
2. Professional Engineer's Certification:
Z1, Luke T-L Kwong, attest that this application for Gravity Sewer,.Lift Station and Force Main for the Town of Pembroke
Q FY2005 Community Development Project, Arrow Point Subdivision - Phase 18 has been reviewed by me and is accurate,
H complete and consistent with the information in the engineering plans, calculations, and all other supporting documentation
Q to the best of my knowledge. i further attest that to the best of my knowledge the proposed design has been prepared in
V accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February
12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June
1, 2000 and the watershed classification in accordance with Division guidance. Although certain portions of this submittal
F— package may have been developed by other professionals, inclusion of these materials under my signature and seal
signifies that I have reviewed this material and have judged it to be consistent with the proposed design. Note: In
W accordance with NC General Statutes 143-215.6A and 143-215.68, any person who knowingly makes any false statement,
V 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. Luke T-L Kwong
Professional Engineer Name
2b. The Wooten Company
Engineering Firm
2c. 120 North Boylan Ave.
Mailing Address
2d. Raleigh 2e. NC 2f. 27603
City State Zip
2i.
Ikwong@thewootencompa ny.c
2g. 919-828-0531 2h. 919-834-3589 om
Telephone Facsimile E-mail Seal, Signature & Date