WQ0032709_Sewer Extension_20080201

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Application Number:
(to be completed by DWQ)
1.
Owner/Permittee:
1a.
City of Rockingham
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
0
0
1 b.
- _ _ _
Monty Crump, City Manager
_
Signing Official Name and Title (Please review 15A NCAC 2T A106 (b) for authorized signing officials!)
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1 c.
The legal entity who will own this system is:
_
❑ Individual ❑ Federal Z Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify)_
_
O
1d.
514 Rockingham Road 11e. Rockingham
LL
Mailing Address City
Z--
-
1f.
----- - -- --- - -- - - - - - — --- -- - - - — - - ---
NC 1g. 28379
Z
State i Zip Code
1 h.
i1 i. 1j.
Q---
Telephone - Facsimile I E-mail
-- ---- -
2.
Proiect (Facility) Information:
J
2a.
U-3456: US 1 in Rockingham 12b. Richmond
a
Brief Project Name (permit will refer to this name) County Where Project is Located
3.
Contact Person:
3a.
Bo Hemphill
Q
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
[phone] 3c. bohem phill dot. state.nc.us
Phone Number E-mail
1.
Project is Z New ❑ Modification (of an existing permit) If Modification, Permit No.:
2.
Owner is Z 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
❑ Public Utility (Instruction C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
13.
City of Rockingham
Z
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
O
4a.
City of Rockingham Waste Treatment Plant 4b. NCO020427
~
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Name of WWTF WWTF Permit No.
5a.
City of Rockingham 5b. 8" ® Gravity 5c.
11Aain o,.....,i�+t• ,.� rl....,..otrn o.., Cn.°,ter /Inc�n °r4inn F1
'`. NC Department of Transportation
1514 Mail Service Center
Raleigh, NC 27699-1514
66-1059
531
Warrant 2256666
Date 01 /23/2008
Void after One Year
PAY TO THE
ORDER OF $ 480.00
NC DEPT OF ENV & NAT RESOURCES oaunn �� �i �iy ���ayi� �i aoelerT MIDMIDrcelaa mta zteo
nix/ OF WATER QUALITY
1617 MAIL SERVICE CTR
RALEIGH NC 27699-1617
State, Treasurer, Raleigh, North Carolina
Payable at Par Through Federal Reserve System
THIS FOflM CONTAINS MICROPRINTING
Mark L. foster
Chief Financial Officer
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F W A7FR p - State of North Carolina
' Department of Environment and Natural Resources
O G P,001041
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co �`` � + Division of Water Quality
o FAST -TRACK APPLICATION
(FTA 12/07 )
` for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer 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. Forms are available from the web site or by calling the Regional Office serving your county:
http://h2o. enr. state. nc. us/peres/Collection % 20Systems/CollectionSystemApplications. html
® A. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. The application should include a project narrative describing the final build -out design (i.e. system and/or
pump station to ultimately serve 500 homes, but flow for only 100 homes being requested now). For modifications,
clearly explain 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 that has already
been included in the original permit.
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(13).
Separate applications should be made for non-contiguous sewer systems
® B. Application Fee - Submit a check in the amount of $480 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ C. 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(2)a of this application.
❑ D. Operational Agreements — Submit one original and two copies of a properly executed operational agreement, as
per 15A NCAC 02T .0115, if the application is submitted 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 home or property owner's association, use Form HOA 02/03. If the applicant is a developer,
use Form DEV 02/03. EVEN IF THE PROJECT MAY BE TURNED OVER TO A MUNICIPALITY UPON
COMPLETION, FORM DEV 02/03 IS REQUIRED.
❑ E. Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance — FORM FTSE 10/07 (Flow
Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant
(and owners of downstream sewers, pump stations and/or treatment facilities submitting FORM FTSE-10/07)
certifies that the addition of the volume of wastewater to be permitted in this project has been evaluated along the
route to the receiving treatment plant, and that 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. Where the applicant is not the owner of the downstream sewer, submit two copies of FORM FTSE 10/07
from the owner of the downstream sewer and owner of the WWTF, if different. The flow acceptance indicated in
FORM FTSE-10/07 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-10/07 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 project -specific FTSE 10/07.
® F Map — Submit an 8.5-inch by 11-inch COLOR copy of a USGS Topographic Map of sufficient scale to identify the
entire project area and the closest surface waters. Each map or maps must show the location of the sewer line
and pump stations and be of reproducible quality. Include a street level map showing the downstream connection
point, and the permit number for the downstream sewer, if known.
FTA 12/07

t
❑ G. `Stream Classifications — Watershed Classification Attachment (Form WACAS-12/07) If any portion of the
project boundary is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment
must be completed.
❑ H Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application cannot be used. Send the project application on the most current version of Form
PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications
cannot 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.
❑ I. Flow Direction — Many wastewater treatment systems are entering into agreements for regionalization efforts
and emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be directed
to more than one treatment facility. If this is the case with this project, please indicate in 13(12) and give the permit
number of the second treatment facility.
® J. Certifications — Section C
The application must be certified by both the applicant and the design engineer who is 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 Chapter 2T, 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.
THE COMPLETED FTA 12/07 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
DOCUMENTS AND $480 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, Cherokee,
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,
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,
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,
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,
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
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell, Davidson,
Winston-Salem, North Carolina 27107
Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone]
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at: htta://h2o.enr.state.nc.us/Qeres/
or contact the Regional Office serving your county.
FTA12/07

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: W00032709
(to be completed by DWQ)
1.
Owner/Permittee:
1 a.
City of Rockin ham
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 2T 0106 (b) for authorized signing officials!)
1c.
The legal entity who will own this system is:
❑ Individual ❑ Federal Z Municpality_❑ State/County Q_ Private Partnership ❑ Corporation_ ❑ Other (specify)_
0
1d.
514 Rockingham Road le. Rockingham
LL
Mailing Address City
—
1f.
NC 11g. 28379
Z
State Zip Code
1h.
1i. 1j.
QTelephone
Facsimile E-mail
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2.
Proiect (Facility) Information:
J
2a.
U-3456: US 1 in Rockingham i2b. Richmond
dBrief
Project Name (permit will refer to this name) County Where Project is Located
Q
3.
Contact Person:
3a.
Bo Hemphill
Q
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
[phone] 3c. bohem hill dot. state. nc.us
Phone Number E-mail
1.
Project is Z New ❑ Modification (of an existing permit) If Modification, Permit No.:
2.
Owner is Z 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 ❑ Public Utility (Instruction C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3.
City of Rockingham
Z
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
O
4a.
City of Rockingham Waste Treatment Plant 4b. NCO020427
QName
of WWTF WWTF Permit No.
5a.
City of Rockingham 5b. 8" IM Gravity 5c.
Owner of Downstream Sewer Receiving Sewer Size Z Force Main Permit # of Downstream Sewer (Instruction E)
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6.
The origin of this wastewater is (check all that apply):
Z
~
Z Residential Subdivision Z Retail (Stores, shopping centers) 100 % Domestic/Commercial
❑ Apartments/Condominiums ❑ Institution % Industrial (attach
❑ Mobile Home Park ❑ Hospital description.)
W
El School ❑ Church
❑ Restaurant ❑ Nursing Home (RO: contact your Regional Office
d
❑ Office ❑ Other (specify): Pretreatment staff)
% Other (specify):
7.
Volume of wastewater to be allocated or permitted for this particular project: 0 gallons per day
*Do not include future flows or previously permitted allocations
8.
If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
Z Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA12/07

9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item B(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item 13(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) j New Gravity or Additional
Force Main
8 570 Gravity
8 495 Force Main
0 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
W _
Pump Station Location ID (self chosen - as shown on plans/map for reference)
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Design Flow Operational Point Power Reliability Option
Z (MGD) GPM @TDH 1 - Permanent generator w/ATS; Force Main Size Force Main Length
0 2 - portable generator w/MTS
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12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
[:]Yes Z No If Yes, permit number of 2"d treatment facility
(RO — if "yes" to 6,12 please contact the Central Office PERCS Unit)
13. 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 Chapter 2T as
applicable?
Z 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
FTA12/07

14. Have the following permits/certifications been submitted for approval for the system or project to be served?
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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
15. Does this project include any high priority lines, [see 15A NCAC 02T .0402 (2)] involve aerial lines, siphons, or interference
manholes)? These lines will be considered high priority and must be checked once every six months
';Check if Yes: ❑ and provide details
Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1, attest that this application for has been
reviewed by me and is accurate and complete to the best of my knowledge. 1 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.
"I a.
Signing Official Signature Date
31NEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
'LICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIM
OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
I, , attest that this application for 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 classilication in accordance with Division guidance.
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 NC 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.
Professional Engineer Name
Engineering Firm
C.
Mailing Address
City
2e. 2f.
State Zip
2i.
Telephone j Facsimile E-mail
NC PE Seal, Signature & Date
FTA12/07

FAST -WRACK 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,
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® 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.
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Location ID on Map
IV)
(self chosen - as shown on Name of Waterbody Stream Waterbody
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for cross-reference)_--;�.._ aterbod�_ County River Basin Index _ Classification
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.map ,W _.....,.._
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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!
1. Applicant's Certification:
1, Monty Crump, attest that this application for U-3456: Us 1 in Rockingham 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 retume s incomplete. Note: In accordance with North Carolina General Statutes 143-215.6A and 143-215.6B,
any person tv knowingly makes any false statement, representation, or certification in any application shall be guilty of
a Class, 2"mi demean,9 ich may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per
viola n. i _.
Signing Mcial Signa Date
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2. Professional Engineer's Certification:
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I attest that this application for U-3456: US-1 in Rockingham 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
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my knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in accordance
Q
with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February 12, 1996,
V
and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000
LL
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
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General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
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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. Bo Hemphill
Professional Engineer Name
2b. NC DOT Project Services Unit
Engineering Firm �!
2C MSC 1591
Mailing Address
2d. Raleigh 2e. NC 2f. 27699-1591
City State Zip
2g. [phone] ; h. [phone] 2i. [e-mail]
Telephone i Facsimile E-mail Seal, Signature &Date
FTA 02/03 - Rev. 3 04/05

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UTM 17 618019E 3868179N (NAD27)
USGS Hamlet (NC) Quadrangle
Projection is UTM Zone 17 NAD83 Datum
G
M=-7.873
G=0.741