WQ0024393_Sewer Extension_20040927

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI Application Number:
-- (to be completed by DWQ)
1. Owner: — - ---
1 a. City of Hamlet
Full Legal Name (company, municipality, HOA, utility, etch} Z 12001
1 b. Marchell Adams David, City Manager
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:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership [J Corporation ❑ Other (specify):
1 d. P. O. Box 1229
Street Address
le. Hamlet
1f. N. C. 1g
State
1 h. 910-582-2651 1 i. ar o .58 a a� ►5 1j.
Telephone Facsimile
2. Project (Facility) Information:
City
28345
Zip Code
�V c�Cllh�l i rr coin,
E-mail
2a. Lackey Subdivision 2b. Richmond
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. Don D. Jacobs, P. E. P. L. S. Design Engineer
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 910-521-2460 (office) or 910-827-9330 (cell) 3c.
Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly exalainina the reasnn fnir the
BLAND & JORDAN, INC.
151 SNEADS MILL RD.
ROCKINGHAM, NC 28379
PAY
TO THE C N
ORDER bF ------ --
2633
66-112/531
DATE � 61102
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_DOLLARS Bm
BBU
BRANCH BANKING AND TRUST COMPANY
ROCKINGHAM, NORTH CAROLINA / � /AV
FOR— U KO
11800263311' 1:053101120:52165172631"
_ .�___... _..._. __. .......... ..uuw LJ IIISUIULion 0
❑ Mobile Home Park 100 /o Domestic/Commercial
❑ Hospital
❑ School ❑ Church % Industrial
❑ Restaurant ❑ Nursing Home /o o
❑ Office ❑ Other (specify): Other (specify}:
7. Volume of wastewater to be permitted in this project: 21.960 gallons per day
8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted is subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI Application Number:
(to be coin ed by DWQ
1. Owner.'
1 a. City of Hamlet
Full Legal Name (company, municipality, HOA, utility. etc.) 2004
1 b. Marchell Adams David, City Manager I-- ' "_
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:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership Lj Corporation ❑ Other (specify):
1 d. P. O. Box 1229
Street Address
1f. N. C.
State
1h. 910-582-2651
le. Hamlet
City
1 g. 28345
ry �Q Zip Code r
1i. aio•58a �8�5 1j• �� (1L1G���i�CC(I'��1�1 r'r (Om
Telephone Facsimile E-mail
2. Project (Facility) Information.
2a. Lackey Subdivision 2b
Brief Project Name (permit will refer to this name)
3. Contact Person:
Richmond
County Where Project is Located
3a. Don D. Jacobs, P. E. P. L. S. Design Engineer
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 910-521-2460 (office) or 910-827-9330 (cell)
Phone Number
1. Project is ® New ❑ Modification (of an existing permit)
3c.
E-mail
If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining the reason for the modification (Leadding 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)
Z El Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction 111)
O ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction IV)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
City of Hamlet
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
O 4a. City of Hamlet 4b. 460647562
LL Name of WWTF WWTF Permit No.
Z 5a. City of _Hamiet____
;5b. 8 inch --
Owner of Downstream Sewer i
Receiving Sewer Size
Permit Number of Downstream Sewer (if known)
6. The origin of this wastewater is (check all that apply):
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Residential Subdivision
El Car Wash
a
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ Institution
❑Hospital
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/o 100 Domestic/Commercial
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❑ School
❑ Church
% Industrial
❑ Restaurant
❑ Nursing Home
❑ Office
❑ O
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7. Volume of wastewater to be permitted in this project: 21 � p j .960 gallons per day
8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted is subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
j ❑ Rehabilitation or replacement of existing sewer with no new flow expected

FAST -TRACK APPLICATION for GRAVITY SEWERS. PUMP STATIONS, AND FORCE MAINS PAGE 4
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9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(I) for Item B(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 approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality, Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(I)(3).
61 Lots @ 360 gpd = 21,960 gpd
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)
8 3808
�rvuv�fy
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Z ENTER TOTAL LINE LENGTH IN MILES 0.72
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H 11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
a
Location ID Power Reliability Option
(self chosen - as shown on Design Flow Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
0 plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
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md 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?
® Yes ❑ No If no, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested -
SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
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? 0 Yes ❑ No ❑ N/A

FAST-TkACK 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
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
Z regional office (see instructions for addresses) OR indicate the following:
0 ® A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
waterbody; AND,
V$ A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
option for any pump station near a Class C down slope waterbody.
Location ID on Map
(self chosen - as shown on Name of Waterbody Stream Waterbody
Jmap for cross-reference) Waterbody County River Basin Index Classification
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Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
Applicant's Certification:
1, SIGNING OFFICIAL NAME, attest that this application for PROJECT NAME
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, of
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.
Signing Official Signature ate
U) 2. Professional Engineer's Certification:
O I attest that this application for ,f � t K y' SNQj;"I s ' �+ �2 u�c*as been reviewed by me and is accurate, complete
and consistent with the information in the engineering plans, calculations, and all other supporting documentation to the
F" best of my knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in
Q accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February
V 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
P, package may have been developed by other professionals, inclusion of these materials under my signature and seal
W signifies that I have reviewed this material and have judged it to be consistent with the proposed design. Note: In
LL! accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
(� representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed $10, 000 as well as civil penalties up to $25, 000 per violation.
2a. Don D. Jacobs
Professional Engineer Name
2b. Jacobs Engineering
Engineering Firm
2c.
2d
P. O. Box 1147
Address
Pembroke
City
2e. NC 2f. 28372
State Zip
2g. 910-521-2460 2h. same 2i.
Telephone Facsimile
E-rnail

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Control by USGS, NOS/NOAA, and USCE
Topography by photogrammetric methods from aerial photographs
taken 1948. Culture and drainage revised from aerial
photographs taken 1955-1956. Field checked 1957
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