WQ0028842_Sewer Extension_20050512

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ) /'4) QQal,
1. O_1111.1.1wner:
1a. City of Rockingham
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
1 b.
Monty Crump, City Manager
O
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
Q1
c.
The legal entity who will own this system Is.
_._ . _ _. ........
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private
Partnership ❑ Corporation ❑ Other
0
1d.
514 Rockingham Road 1e.
Rockingham
0
LL
Street Address
City
Z
1f.
North Carolina 1g.
28379
Z
State
Zip Code
_0-
~
1 h.
[phone] Ili. [phone] ;1 j.
—
[e-mail]
Telephone Facsimile
E-mail
2.
Project (Facility) Information:
cL2a.
a
Richmond Co. sewer line for Impact Plastics 2b.
Richmond County
a
Brief Project Name (permit will refer to this name)
County Where Project is Located
R11CHIPvIOND COUNTY
CENTURA BAN
ROC <INGHANI NC
DATE
PAY T ,
ORiDFIR O
t
t:: r
PROVISION FOR PAYMENT OF THIS WARRANT (CR
BEEN MADE BY AN APPROPRIATION DULY MADE 0-
NOTE DULY AUTHORIZED. AS REQUIRED BY THE _
GOVERNMENT. ACT."
iJ
H
W
i

CEi4TS'`
RICHP41OND COUNTY
INTER -FUND
X
5a. City of Rockingham
5b. 8"
5c.
Owner of Downstream Sewer
Receiving Sewer Size
Permit Number of Downstream Sewer (if known)
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision ❑ Car Wash
-!
❑ Apartments/Condominiums ❑ Institution 100 % Domestic/Commercial
❑ Mobile Home Park ❑ Hospital
j
❑ School ❑ Church % Industrial
❑ Restaurant ❑ Nursing Home %Other (specify):
® Office ❑ Other (specify):
I
7. Volume of wastewater to be permitted in this project: 625 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 1
State of North Carolina
Department of Environment and Natural Resources
, 0u5 Division of Water Quality
FAv-TrvU '.'. FAST -TRACK APPLICATION
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.
® 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).
® II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ 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.
N 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.
❑ VII. 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/ndpu or by contacting the appropriate regional
office.
FTA 02/03 - Rev. 1 06/03

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 .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.
❑ 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(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 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
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
Fayetteville,N
Faye
Fayetteville, North Carolina 28301
Anson, Bladen, Cumberland, Harnett,
48
Hoke, Montgomery, Moore, Robeson,
[phone] Fax
Richmond, Sampson, Scotland
Mooresville Regional Office
919 N Main Street
Moor N
Mooresville,
Mooresville, North Carolina 28115
Alexander, Cabarrus, Catawba,
66
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) 571-47
Lee, Nash, Northampton, Orange,
[phone] 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,
[phone]
Rockingham, Randolph, Stokes,
[phone] Fax
Surry, Watauga, Wilkes, Yadkin
For more information, visit our web site at: http://h2o.enr.state.nc.us/ndpu/
FTA 02/03 - Rev. 1 06/03

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
r—
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)/-,f
�tth
1.
Owner.
1 a.
City of Rockingham j
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
11 b.
Monty Crump, City Manager
0
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
Q1
c.
The legal entity who will own this system is:
❑ Individual ❑ Federal'Z Municipality ❑ State/County❑ Private Partnership ❑ Corporation ❑ Other (specify):
1d.
514 Rockingham Road le. Rockingham
0
U.
Street Address City
Z
1f.
North Carolina 1g. 28379
Z
State Zip Code
1h.
[phone] 1i. [phone] 1j. [e-mail]
V
Telephone Facsimile E-mail
2.
Project (Facility) Information:
'J
2a.
Richmond Co. sewer line for Impact Plastics 2b. Richmond Count
p_
Brief Project Name (permit will refer to this name) County Where Project is Located
Q
'3.
Contact Person:
Q
3a.
Bryan Bade , Staff Engineer
Name and Affiliation of Someone Who Can Answer Questions About this Application
'3b.
[phone] '3c. bbadey@mesco
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.
Owner is ® Public (skip to Item B(3)) El Private (go to Item 2(a))
2a.
If private, applicant will be: 2b. If sold, facilities owned by a (must choose on
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction 111)
Z
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction IV)
0
❑ 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
O4a.
Rockingham 4b. NC 0020427
IUL
Name of WWTF --- WWTF Permit No.
Z
5a.
Cityof Rockingham
5b.
--
Receiving Sewer Size
—----
Permit Number of Downstream Sewer (if known)
Owner of Downstream Sewer
6.
—�—— —
The origin of this wastewater is (check all that apply):
W❑
Residential Subdivision El Car Wash
IL
❑ Apartments/Condominiums ❑ Institution o
100 /o Domestic/Commercial
❑ Mobile Home Park ❑ Hospital
j
❑ School ❑ Church % Industrial
❑ Restaurant ❑ Nursing Home o
® Office El Other (specify): /o Other (specify):
7.
Volume of wastewater to be permitted in this project: 625 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
FTA mint - RPv 1 06/01

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(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).
i
25 employees x 25gpd = 625 gallons per day
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" Ductile Iron 135 Gravity
W
3
Z
Z
0
z' ENTER TOTAL LINE LENGTH IN MILES, 0.03
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-
0 plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
LL
Z N/A N/A N/A N/A
F-
W_ ,
C; ii Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
m 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:
I
I
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
PTA r»mz - Pf-v 1061M

FAST -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 02/03
(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:
® A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
Qwaterbody; AND,
(,� ® 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.
Location ID on Map
(self chosen - as shown on Name of Waterbody Stream Waterbody
Jmap for cross-reference) Waterbody County River Basin Index Classification
Q
W
U)
A
1dw
Submit the 8.5" x I I" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
Applicant's Certification:
1, Monty Crump, City Manager, attest that this application for a Sewer Service line to Impact Plastics
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 tutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
certifi io in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10,000
as 11 a civil en 'e to $25,000 per violation. A
Signing Official Signature 1-%
Professional Engineer's Certification:
Date
I attest that this application for a Sewer Service line to Impact Plastics 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 143-215.613, 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. Jimmy D. Woodie
Professional Engineer Name
2b. Municipal Engineering Services Co., P.A.
Engineering Firm
2c. P.O. Box 97
Address
2d. Garner
City
2e. NC 2f. 27529
State Zip
2g. [phone] 2h. [phone] 2i. [e-mail]
Telephone Facsimile E-mail
Seal, Signature & Date
FTA 02103 - Rev. 1 06/03

,
P
- _ <'— a ait
-
4� E�
Sl: Itt(11`
rf 1SFf "�
r
L t i F�r I�r
{
SITE s -
1 `n
r
,re
Al
[r �• r� �'! ti' __,. : r t - �,q : -' t �#� 1 1 � bfi I 1 _ l r �i
.c. rjs`�� '' �•
rl'
— —
.+ -... •v; ,� ... >: 1, "., i .. ''t. , � i _, If
s 1
HAMLET, NC,
DATED: 2002
71
j i

Transmittal Municipal Engineering
Se is Company, P.A.
m Garner, N.C. Boone, N.C.
LDENIR-Fq Date May 11, 2005
YETTEVLLE REGIONAL OFFlCE
Number of pages including cover sheet:
TO: NCDENR
Division OF Water Quality
225 Green Street, Suite 714
Fayetteville, NC 28301
Phone [phone]
Fax [phone]
FROM: Bryan Badey
Municipal Engineering
Services Company
P.O. 97
Garner,NC 27529
Phone [phone]
Fax [phone]
IRE: Richmond County Sewer line
IREMARKS: ® Urgent ❑ For your review ❑ Reply ASAP ❑ Please Comment
Dear Sir or Madam:
Please find attached our Fast Track sewer application for approximately 135 feet of 8" gravity sewer
under CSX railroad spur line in Richmond County. We have received an approved agreement from CSX,
which is included. We have enclosed one original and one copy of the application along with a check for
$400.00. If you have any questions regarding this application please call us.
Sincerely,
Bryan Badey
Municipal Engineering Services Company P.A.

05/17/05 1R:07 FAX Ulu Irz 11/6 mui�L�+_�+• _•+„'�'-""'
FAX
TO: Mr. Mike Lawyer
NCDENR
Division of Water Quality
Atin
Phone [phone]
Fax [phone]
RE: CSX Railroad Permit
]Kunieipal U uu W Engineering
Saevieae � Coop�vy,P.A.
�rcv, N C f Heaaq N.C.
Date May 17, 2005
Number of pages including cover sheet 6
_j
FROM: Bryan Badey
Municipal Engineering
Services Company
P.O. 97
Garner,NC 27529
Phone [phone]
Fax [phone].
IREMARKS: ® Urgent ❑ For your review 0 Reply ASAP ❑ Please Comment
Mr. Lawyer:
As per our conversation today, please find attached the permit from CSX railroad for the 8" sewer line
extension in Richmond County. If you have any questions do not hesitate to contact me.
Sincerely,
Bryan Badey
Municipal Engineering Services Company P.A.

05/17/05 19:08 FAX [phone] MUNICIPAL ENGINEERING W &
TRANSPORTATION
Ken Lisenby
specialist
Contact ,q dminishmdon
a z
fl pPR 2 6 2005 D
Mr. Rick Sago
County Engineer
County of Richmond
P. 0. Box 504
Rockingham, NC 28379
500 Water Sleet, SC 1190
Jacksomillo, FL 32202.4423
[phone]
FAX [phone]
E-Mail: Kcn Lisenby@ct-00m
April 20, 2005
Agreement No. CSX-048657
Customer Reference No.: PROJECT
#G04095
Re: Installation of pipeline(s) in Dobbins Heights, North Carolina.
Dear Mr. Sago:
Attached is your fully -executed original of Agreement No. CSX-048657, dated
April 4, 2005.
No work is to be performed on CSXT property without Roadmaster's authorization. It is
your responsibility to schedule any work on CSXT property with CSXT Roadmaster by sending
notification via fax, which includes the project description and date and time of work, to fax
number: [phone], at least thirty (30) days in advance of the date you desire to commence
the project. If after one week of faxing notification to CSXT Roadmaster you receive no
response, you may call the CSXT Roadmaster at telephone number: [phone](ideally
between the hours of 6:30 AM and 8:30 AK. If you still have trouble receiving a response from
the CSXT Roadmaster, please contact the CSXT Division Engineer's office at telephone number:
[phone] for assistance.
Once work has been scheduled with the Roadmaster, complete and send the attached
"FLAGGING REQUEST FORM" to:
Property Services - Flagging Project
CSX Transportation, Inc.
500 Rater Street, 1180
Jacksonville, FL 32202
Licensee is responsible for paying the actual cost of CSXT flagging and/or support
services including all applicable surcharges (collectively "Fees").

05/17/05 16:08 FAX [phone] MUNICIPAL ENGINEERING
�J v v Y
CSX-048657 - 2 - April 20, 2005
Any questions about the form should be directed to 904-359-1387 or 904-359-3404.
This agreement, and your right to an encroachment, will expire on. April 3, 2030. L Please
make a note of this date. If you require to utilize CSXT property beyond that date, it is your
responsibility to contact us, at least 30 days prior to expiration of the agreement.
Very truly yours,
Ken Lisenby
Attachment

05/17/05 16:08 FAX [phone] MUNICIPAL ENGINEERING
LWUU%
FORM CSXT 7455 -Rev. i :1-';,/03
Rim
APPLICATION FOR -PIPELINE
CROSSING OR PARALLELYNG PROPERTIES AND TRACK
Submit one original and one copy of both the application and drawing along with a S750.00
nonrefundable Application Fee to CSX Transportation, Property'Services J180, 500 Water
Street, Jacksonville, FL 32202,
Application and plans must be approved and written authority received from the Railroad before
construction is begun. Your proposal and construction must be in accordance with CSXT's -
Specifications and any current governing laws or regulations. Note: Specifications fiuttished in
the Application Package are to be used as a guideline only. CSXT reserves the right to approve
or decline any application-
i of
L
i
r.` CL_
s
..
If Q
C-2�
PLEASE SIGN BEFORE COMPLETING: AgreementNo.:
I affirm the information I am furnishing in this application will comply with the current CSX Standards, veMing
laws or re ns, and accuratel cu the proposed construc etion plans:
Si�ature: Application Date: 3 L�
ro'ect Owner Information: 3 Check here if agreement should be mailed to this address
1. Complete Legal Name of applicant as it would appear in a legal document (inaccurate information will delay
Your reauest):
County of Richmond, North Carolina
2. Company Contact Name: Rick Sago, PE
Title: County Engineer
3. Telephone: aij 99Z-8234 Fax: 1l9 997-8208 E-Mail: richord coeng@infoave net
4- Street Address: 125 S_ Hancock St.__ City: Rockingham State: NC Zip: 28379
5. Type of business: p 0 Box 504
❑ Corporation (State of incorporation )
❑ Partnership (Type and State of partnership )
❑ Individual ❑ Developer ❑ Municipality 19 Other County
Engineer/Consultant
Information: I
❑ Check here if agreement should be mailed to this address
6.
Company Name: Municipal
Engineering Services Co. , PA
7.
Company Contact Name:
Bryan B a d e v Title:
8.
Telephone-(41)).-772-5393
Fax:O_9) 772-1176 [e-mail]
9.
Street Address: P Q Box
97 City: Garner State: NC_ Zip: 2 7 5 2 9
1140 Benson Hwy., Bldg, 2
ro'ect Information:
(Note: Metric Information will NOT be accepted)
10,
Is this installation: CkNew
❑ Revision to e-risting ❑ Attachment to existing ❑ Upgrade -_X19 ln9
11.
If not a new installation, furnish existing Agreement Number:
12.
If this installation is to be a supplement to your master (general) agreement, furnish:
Agreement Number
Date:
13.
Your Reference Number:
G (14 0 9 5
14.
Work to be performed by:
❑ Applicant's employees
Is Applicant an Aegis member? ❑ Yes ❑ No
f) Contractor Contractor
Name:
15.
Town Location: 34owwAymif
Dobbins County: Richmond State/Province: NC
Heig is
(Form continued on Page 2)

U0/11/U0 JL rnd aio ... ....
C_� X - ()'fxlob ' ( t�UFX U; M 1- /4:)]-.KL'V. 11ru11W (rage 2 or 2)
Information
16. Product to be Conveyed: wastewater Flammable: ❑ Yes fXNo
Temperature: N I A
17. - Maximum Working Pressure: u / A Field Test Pressure: N / A Type Test: N ( A
18. Location of Shut -Off Valves: N LA
19. Number: IR Manh.oles,_Q__ 0 Other (describe)
to be located within Railroad corridor. Manholel shall be flush with -top of ground and dimensions
of ancillary structures are requlhed on drawing.
20, Distance .from manholes/other to nearest track: 1Z f per
21. Angle of Crossing: • 68 degrees Number of Tracks to be crossed: 2
22. PIPE SPECH ICATIONS: CARREER PIPE: CASING PIPE:
Material Ductile Iron Steel
Material Specifications & Grade AWWA C 151 Class 350 AWWA C 2 0 0
Minimum Yield Strength of Material PSI 42,000 35,000
Inside Diameter 8.55 i n . 17.38 in.
Wall Thickness 0.25 in. 0.312 in.
Outside Diameter 9.05 in.- 18 . 0 0 i n.
Type of Seam Seamless Butt -welded or s
Kind of Joints Mechanical Joint Butt -welded
Total Length Within Railroad R/W 54 feet 54 feet
Tunneling (Liner Plates) Note: Attach manuracturer's shoe detail and computations that
include plate thickness and Ease.
Vents: Number 0 Size Height above ground
Seals: ❑ One End ❑ Both Ends
Bury depth: Base of rail to top of casing; 12 feet 8 inches
Not beneath tracks: 11 feet 0 inches
(Below ditches) 10 feet, 0 inches
Cathodic Protection: ❑ Yes 1KNo Protective Coating; ❑ Yes (Kind) XXNo
23. Method of installation; D r v Bore & Jack
24. Temporary track support or riprapping required? 0 Yes Q1No (Describe and Detail on Drawing)
25. Wires, poles, obstructions to be relocated? 0 Yes IN No (Describe and Detail on Drawing)
26. Is this both a Crossing and Parallelism? ❑ Yes :9XN0
27. Crossing location: 2 03 6 ' f r;- 2 0 3 7feet North (direction) from Railroad Milepost: 5251
If known: Valuation Station: Valuation Map Number:
If known: Latitude/Longitude:
If known: Street Address of Crossing/Parallelism:
28. - Parallelism location: Beginning: feet (direction) from RR Milepost:
and Ending: feet (direction) from RR Milepost:
29. Total length on Railroad R/W. Length Crossing: Length Paralleling:
30. Will line be eumely within apublic road R/W? 0 Yes 1XNo DOT/AAR Crossing No.-
** If you answered yes, road name, number, and width of public right-of-way are required on drawing
31. a) Will this occupancy connect to an existing facility within Railroad corridor? I Yes ❑ No
b) If Yes, name facility owner(s): City of R o e k i n g h am
GRailroad Use Only:
Division F�-OKEVr .-- Subdivision ��'►' L� 1 � tti1��No. of toss' g9:
Absolute. No.: OVR Valuation Section/Map No.: 1%1(MC Lq S"t-ZI-a
Valuation Station: a 0 -,r 3 �-,
Milepost: S — OAS 0 - 6 1
Roadtnaster No.: N � d,_ Contr. Type: V l S W X — Fiber?
ml es

1► 56 L.F. Ir STEEL CASING PIPE W/
4()O, 78 JG 6 W _y , NI' D.1.P. CLASS 350 CARRB PIPE
•INSTALLT BY DRY BOK JACK
LD
w PRONM INDUSTRIAL SIDETRACK
a•
PROPOSED 40'01 &ORE PIT
U
N
z
-
m
N
N
ti
0
wi
of
oil
o.
ti
ii
SANITARY SEATER
DUSTING INDUSTRIAL
PROPOSED MANHOLE
rA N 40s 70, W,
CV
TO �NlTlay ro°"ilr
PROPOSED IC PVC
SANITARY SEWER
PROPOSED MANHOLE
5
0W DR FORMERLY
COUNTY OF RIO ND
E)DSTiNC INDUSTRIAL LEAD 1RACK
PLAN
SCALE: 1" 50
"`+ lir STEEL CA!HIC PIPE �+'�
FTNSRED GRADESDE- LEAD g ' D,I,P, CLASS 350 CARRIER PIPE
PROPOSED MANHOLE
- PRELIMINARY:
SECTION A— A NOT FOR CONSlRUC11ON
SCALE: 1" _ 2V 4/4/05
4
u
5