WQ0023070_Sewer Extension_20030905

FAST -TRACK APPLICATION for GRAyITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
OF W ATFR State of North Carolina
O� �G Department of Environment and Natural Resources
0 D n�� 5� ' S 2003 Division of Water Quality
r
o r FAST -TRACK APPLICATION
M, " for GRAVITY 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 the following list of required application package items by checking the
space provided next to each item. Failure to submit all required items will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
[a 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 B(12).
ET'II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
[a'lIl. 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.
E941V. 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 02103 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.
Q 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.
EJ,V . 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 httpi/th2o.enr.state.nc.us/ndpu or by contacting the appropriate regional

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
j 94III. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C .0500], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
processed 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.
I� lX. 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(1 b). 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.
THE COMPLETED FTA 02103 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
Avery, Buncombe, Burke, Caldwell,
59 Woodfin Place
Cherokee, Clay, Graham, Haywood,
Asheville, North Carolina 28801
Henderson, Jackson, Macon,
[phone]
Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania,
Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Faye vine,
Fayetteville, North Carolina 28301
Anson, Bladen, Cumberland, Harnett,
4 1
Hoke, Montgomery, Moore, Robeson,
[phone] Fax
Richmond, Sampson, Scotland
Mooresville Regional Office
919 N Main Street
Moor N
Mooresville, North Carolina 28115
Alexander, Cabarrus, Catawba,
66ille,
Cleveland, Gaston, Iredell, Lincoln,
[phone] Fax
Mecklenburg, Rowan, Stanly, Union
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe,
Raleigh, North Carolina 27699-1628
Franklin, Granville, Halifax, Johnston,
(919) 5714700
Lee, Nash, Northampton, Orange,
(919) 5714718 Fax
Person, Vance, Wake, Warren,
Wilson
Washington Regional Office
Beaufort, Bertie, Camden, Chowan,
943 Washington Square Mall
Craven, Currituck, Dare, Gates,
Washington, North Carolina 27889
Greene, Hertford, Hyde, Jones,
[phone]
Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington,
Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
Brunswick, Carteret, Columbus,
[phone]
Duplin, New Hanover, Onslow,
[phone] Fax
Pender
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
(336) 7714600
Rockingham, Randolph, Stokes,
(336) 7714631 Fax
Surry, Watauga, Wilkes, Yadkin
For more info►mation, visit our web site at: h1tp://h2o. enr state. nc. us/ndpu/

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
2
USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI Application Number: n
- (to be completed by DWQ)
1. Owner.
1 a. City of Rockingham
Full Legal Name (company, municipality, HOA, utility, etc.)
1 b. City of Rockingham
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 ❑ Corporation ❑ Other (specify):
1d. 514 Rockingham Road 1e. Rockir
Street Address City
1f. North Carolina 1g, 28379
State
1 h. 910-997-5546 1 i.
Telephone Facsimile
2. Project (Facility) Information:
2a. Roberdel Hill Subdivision
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Monty Crump. Citv Manager
1j.
Zip Code
E-mail
2b. Richmond
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 910-997-5546 3c.
Phone Number E-mail
1. Project is Z 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 Z Public (ship 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 ❑ Public Utility (Instruction III)
Z ❑ Leasing units (lots, townhomes, etc. - skip to Item 8(3)) ❑ Homeowner Assoc./Developer (Instruction IV)
O ❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
Q 3. City of Rockingham
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
O 4a. Rockingham Wastewater Treatment Facility 4b. NCO020427
LL Name of WWTF WWTF Permit No.
Z 5a. of Roddn ham 6b. 8 inch 15c. WQCS00041
Owner of Downstream Sewer
Receiving Sewer Size
6. The origin of this wastewater is (check all that apply):
® Residential Subdivision
❑ Car Wash
a❑
Apartments/Condominiums
❑ Institution
❑ Mobile Home Park
❑ Hospital
❑ School
❑ Church
❑ Restaurant
❑ Nursing Home
❑ Office
❑ Other (specify):
Permit Number of Downstream Sewer rd known)
100 % Domestic/Commercial
% Industrial
% Other (specify):
7. Volume of wastewater to be permitted in this project: 7,800 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.
(1 RPhahititntion or rPnlar.PmPnt of PxiMinn SPwPr with no nPw flow PxnPr:tPr1

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(1)(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).
The development consists of twenty lots. Flow is estimated by assuming that three bedroom homes will be built on the
lots smaller than 25,000 square feet and four bedroom homes will be constructed on the remaining larger lots.
15 residences X 360 gallons per day per residence = 5,400 gallons per day
5 residences X 480 gallons per day per residence = 2,400 gallons per day
Total New Flow = 7,800 gallons per day.
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (Best) Gravity or Force Main
(use the pull down menu)
8 inch 583 Gravity
ENTER TOTAL LINE LENGTH IN MILES 0.11
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID Power Reliability Option
(self chosen - as shown on Design Flow Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
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?
❑ Yes ❑ No ® N/A

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
Z 1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02103
O (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
Q regional office (see instructions for addresses) OR indicate the following:
V❑ A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
LL waterbody; AND,
❑ A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
Q 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
UT to Hancock
W #1 Creek Richmond Yadkin-PeeDee 13-39-(10) C
__ __
H #2 UT to
Hancock Richmond Yadkin-PeeDee 13-39-(10) C
Creek
Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
6 regardless of whether a classification is provided!
1. Applicants Certification:
W
1 a.
I, Monty Crump, City Manager, attest that this application for Roberdel Hill Subdivision 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 of Class 2 misdemeanor which may include a fine not to exceed $10, 000 as well as civil penalties up to
$25,00viol do
91
ing Official Signature Date
Professional Engineers Certification:
I attest that this application for Roberdel Hill Subdivision has 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 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 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 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 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. G. Richard Saao II. PE
Professional Engineer Name
2b.
Engineering Firm
2c. 139 EV Hogan Road
Address
2d. Rockingham 2e. NC
City State
CANot
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_2f. 28379 �oe�scbr,
Zip 'A���rfie
2g. 910 419-9398 2h. 2i. [e-mail] �3'0 3
Telephone Facsimile E-mail Seal, Signature & Date

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