WQ0041844_Application (FTSE)_20200717

110 JithersRavenel
RioOur People. YOUr Success.
424 Gatlimore Dairy Road, Suite C
Greensboro, NC 27409
t: 336.605.3009 1 f: 919.467.6008
TO: wr nFn Vnnc+nn-Colcm aPotnnni nrfira V in+a n„ncry Ccrllnn
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Letter of Transmittal
•
7/15/2020 • a
06180244.00
•
Lon Snider, 336-776-9700
mum
City of Reidsville, Rural Ready Site
New Sewer Permitting Package
Environmental^ i alli,l
t<ecelve
�'t;n inn
WEARESENDINGYOU ❑X Attached ❑ Under Separate Cover via
THE FOLLOWING ITEMS ❑ Shop Drawings ❑ Prints ❑ Plans
❑ Copy of Letter ❑ Change Order ❑ Diskette
2 7/15/2020 Fast Track Permit (Form 04-16)
Winston-Salem
eglOna ClifiC:;
❑ Samples ❑Specifications
❑X Other Permit Application
2
7/15/2020
Flow Tracking/Acceptance form (FTSE-04-16)
2
7/15/2020
Site Map
1
7/02/2020
Copy of Application Fee Check (Original Was Mailed)
THESE ARE TRANSMITTED as checked below
❑O For approval
❑ Approved assubmitted ❑Resubmit copies for approval
❑For your use
❑ Approved asnoted ❑Submit copies for distribution
❑ As requested,
❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑ Other
❑ FOR BIDS DUE
❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS: The attached application is for 1,250 LF of 8 PVC Gravity Sewer, 2,980 LF of 6" PVC Force Main, and
new pump station.
New flow is estimated to be 126,400 GPD.
COPYTO: City of Reidsville SIGNED: John F. Akers, PE
If enclosures are not as noted, kindly notify us at once

State of North Carolina
Department of Environmental Quality
MVR
Division of Water Resources
15A NCAC 02T .0300 — 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 entlineerine 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 1C .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 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 (Ali 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 I.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 III 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

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable): .r
® 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 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):
❑ 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)
L 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: FICA).
❑ 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: 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, Cabarrus, 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, 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
Wilmington 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

State of North Carolina
DWR
Department i Environmental s'imrc y
Division of Water Resources
11
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by oWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
Applicant's name: CIty of Reidsville (company, municipality, FICA, utility, etc.)
2. Applicant type: ❑ Individual
❑ Corporation ❑ General Partnership
❑ Federal
❑ State/County ® Municipal
3. Signature authority's name: Preston Mitchell per 15A NCAC 02T .0106(b)
Title: Town Manaeer
4. Applicant's mailing address: 230 W. Morehead Street
City: Reidsville State: NC
Zip: 27320-
5. Applicant's contact information:
Phone number: [phone]
Email Address: pmitchelleci.reidsville.nc.us
❑ Privately -Owned Public Utility
❑ Other
II. PROJECT INFORMATION:
1. Project name: Reidsville Rural Ready Sitet
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: W00024881
3. County where project is located: Rockingham
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.20' 04° Longitude:-79.38.17'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
I . Professional Engineer: John F. Akers License Number: 024645
Firm: WithersRavenel
Mailing address: 424 Gallimore Dairy Road, Suite C
City: Greensboro State: NC Zip: 27409-
Phone number: 336 605-3009 Email Address: iakers(&,,withersravenel.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: City of Reidsville Permit Number: NCO024881
Owner Name: CIty of Reidsville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00
Owner Name(s):
FORM: FTA 04-16 Pagel of 5

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dlvlston of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
(to be completed by D WR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
l . Applicant's name: Cltv of Reidsville (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Preston Mitchell per 15A NCAC 02T 0106(b I
Title: Town Manager
4. Applicant's mailing address: 230 W. Morehead Street
City: Reidsville State: NC Zip: 27320-
5. Applicant's contact information:
Phone number: 336) 349-100 Email Address: pmitchellCaci.reidsville.nc.us
❑ Privately -Owned Public Utility
❑ Other
IL PROJECT INFORMATION:
1. Project name: Reidsville Rural Ready Sitet
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: W00024891
3. County where project is located: Rockingham
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.20' 04° Longitude:-79.38.17'
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
11I. CONSULTANT INFORMATION:
I. Professional Engineer: Sohn F. Akers License Number: 024645
Firm: WithersRavenel
Mailing address: 424 Gallimore Dairy Road, Suite C
City: Greensboro State: NC Zip: 27409-_
Phone number: [phone] Email Address: fakers i withersravenel.com
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
I. Facility Name: City of Reidsville Permit Number: NCO024881
Owner Name: Clty of Reidsville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
L Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicablel: WQCS00
Owner Name(s):
i nmi—Cll lei lL(i(
Environmental Quality
Received
Winston-Salem
Regional Orfice
FORM: FTA 04-16 Paget 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?
IMEMO //
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: 0 % Domestic/Commercial 50 % Commercial
50 % Industrial (See 15A NCAC 02T .0103(20))
L—>Is there a Pretreatment Program in effect? ® Yes ❑ No
6. Hasa flow reduction been approved under I5A NCAC 02T .01 t40l? ❑ Yes ®No
➢ If ves, provide a co ov of flow reduction aporoval letter
7. Summarize wastewater generated by project:
Establishment Type (see 021.0114(f))
Daily Design Flow a'"
No. of Units
Flow
Commercial Development
35,400 gal/daqy
1
39400 GPD
Industrial Development
61,500 gal/
1
61,500 GPD
Hotel
120 gal/day
100
12,000 GPD
Hotel with in room cooking
175 gal/day
100
17,500 GPD
gal/
GPD
gal/
GPD
Total
126,400 GPD
a See 15A NCAC 02T .0114�1i). (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: 126,400 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

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 1,250 PVC
➢ 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: Diesel Drive
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.20.05' Longitude:-79.38.18°
3. Design flow of the pump station: 0.126 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 225 gallons per minute at 122 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6
2,980
PVC
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(f) & W
➢ 15A NCAC 02T.0305(f) 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, W S-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 sloe 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(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webnage
➢ If noncompliance with 02T.0305(f) or (0, 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 .02009 ® 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

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 Min imum Design Criteria (latest vers,L�i 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:
that this application for
Engineer's name from Application Item 111,1.)
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 143-215.613, 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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
to. (A-k atieII (4'(i'tivaaypf'
Authority's name & title from Application Item I.3.)
_ attest that this application for
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: V�` / Date:
FORM: FTA 04-16 Page 5 of 5

o
SU! MMIT AVE e s ~ ~
890� WALKER Si
00
D u pl0. Greennew Cem 1 RT ~
0
OD�AON cT�
Ery MaN° ��'p WPLN�4�'B 1 rr G
�a 23
a t Tao
,Rei lawn Cem13 "
d 3h
JW
pP�P
0 TURNER DR p
RE SDI+ VILLE
aT p
DRUM'R022
Q cPm
m
f
-
c MRM [N (80�
pRh3 d P�O'1� S�'Pya a
w t°R V B pf,P
Project Area
S PPRM OR
d-
- GROO
OMS RO
SRIARWOOO ST- OP �` ,p � °ROgO ADD.
0B .P 4 sr �° 21
A(c" 4" OLIVE', -. Bp0
hOL°9
v4'c �y -� OR fiPo
/-0WND9CEOR
a
i V;
a �
aR.�h 20
4p �^
,I
WPSNBUBN -\ !� 19
�U -.
R
—WHEELER RO W -
v
Bus 9
29
<a ¢
WATER WORMS PD
18
9 p
°
17
9
�o NchUgch,Ra "Y'
Op

State of North Carolina
Department of Environmental Quality
ht5
Division of Water Resources
Division of Water Resources Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: City of Reidsville
Project Name for which flow is being requested: Rural Ready Site Utilities
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible far all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: City of Reidsville Wastewater Treatment Plant
b. WWTP Facility Permit #: NC0024881
All flows are in MGD
c. WWTP facility's permitted flow 7.5
d. Estimated obligated flow not yet tributary to the WWTP 1,013
e. WWTP facility's actual avg. flow 2.500
f. Total flow for this specific request 0.034
g. Total actual and obligated flows to the facility 3.547
It. Percent of permitted flow used 47.29%
II. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow* * Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm / pf), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
* The Firm Capacity of any pump station is defined as the maximum pumped flow that
can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking
factor (pf) not less than 2.5.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
Page 1 of 6
FTSE 04-16

III. Certification Statement:
I 5 1 Gti: MO i-P , Q. e , certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the flow from this project is not anticipated to
cause any capacity related sanitary sewer overflows or overburden any downstream pump station
en route to the receiving treatment plant under normal circumstances, given the implementation
of the planned improvements identified in the planning assessment where applicable. This
analysis has been performed in accordance with local established policies and procedures using
the best available data. This certification applies to those items listed above in Sections I and II
phis all attached planning assessment addendums for which I am the responsible party.
Signature of this form indicates acceptance of this wastewater flow.
Signing Official Signature Date
C 4—i-t L- 16J f.-I E�E(L
SCAL
S.
Page 2 of 6
FTSE Q4-16

FTSE Data
W WTP Flows
(MGD)
2019
June
2.74
July
2.43
August
2.27
September
2.12
October
2.32
November
2.34
December
2.39
2020
January
2.64
February
3.00
March
2.51
April
2.23
May
2.95
12 Mo.Avg. =
2.50
Estimated obligated flow not yet tributary to =
the W WTP as of the end of December 2016
Date: 6/30/2020
By: SBM
Industries (from 5/20/20 spreadsheet)
MonthlvAve
(Julythru Dec 2019)
Flow (MGD)
Aibaad USA
0.0474
Beta Fueling Systems-01
0.0012
Beta Fueling Systems-02
0.0018
Commonwealth Brands
0.0320
DyStar
0.0316
Envisions Plastics
0.1328
Dorada Foods
0.2410
Henniges
0.0027
Tamco
0.0013
Unifi
0.5952
Total =
1.0870
Permitted flow =
2.100
from 11 industries
2.1 - 1.087 = 1.013

320M
CITY OF REIDSVILLE * 730 W. MOREHEAD ST * REIDSVILLE, NC 27320 * ACCTS PAYABLE 336-349-1056
VENDOR:1505 NCDEQ-DIVISION OF WATER RESOURCE 07/02/2020 Chk#:260097
DATE INVOICE# PO# DESCRIPTION AMOUNT
5/29/2020 06292020 REIDSVILLE RURAL READY/DIESEL DR SEWER APP FEE 480.00
CHECK TOTAL 480.00
DETACH AT PERFORATION BEFORE DEPOSITING CHECK
r;
N�glECM 13 VfW 4nriNlVf pC9LW1�AN�WICKOp9uNPM.Y6ANN16M SflNGEItPRINY WAiERNA9K ON TIWE rdrt4K.. N6LD AT ANGI.L^TO. k1EYt -
.
-- 4
CITY OF REIDSVILLE
Home Trust Bank NO 260097
'n °
°
230 W. MOREHEAD ST
66-7027/2531
r
REIDSVILLE, NC 27320
DATE AMOUNT
i
-,
07/02/2020 $480.00
This Disbursement has been approved as required by the Local
�
Government Budget and Fiscal Control Act.
`T
PAY: ---Four Hundred Eighty Dollars and Cents---
r'
Yf
TO THE NCDEQ-DIVISION OF WATER RESOUESOU RCE
_
—,
ORDER 1617 MAIL SERVICE CENTER
OF: RALEIGH, NC 276991617_�
A�
26009?1[' 1:2S31702791:
000097728011•
i.l
SEE REVERSE SIDE FOR OPEN11 G INS79UC.'TIONS
CITY OF REIDSVILLE
230 W. MOREHEAD ST
REIDSVILLE, NC 27320
NCDEQ-DIVISION OF WATER RESOURCE
1617 MAIL SERVICE CENTER
RALEIGH, NC 276991617