WQ0041836_Final Permit_20200818

a � tirw STATE",
n
Roy COOPER
Le
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r
Governor
MICHAEL S. REGAN
Secretary
Y""
S. DANIEL SMITH
NORTH CAROLINA
Director
Environmental Quality
August 18, 2020
Todd Taylor, P.E., Executive Director
Orange Water & Sewer Authority
400 Jones Ferry Road
Carrboro, NC 27510
Subject: Permit No. WQ0041836
Orange Water & Sewer Authority
Habitat for Humanity Sanitary Sewer Extension
Wastewater Collection System Extension Permit
Orange County
Dear Mr. Taylor:
In accordance with your application received July 14, 2020, and additional information received on August
10, 2020, we are forwarding herewith Permit No. WQ0041836 dated August 18, 2020 to the Orange Water
& Sewer Authority (Permittee) for the construction and operation upon certification of the subject
wastewater collection system extension. This permit shall be effective from the date of issuance until
rescinded and shall be subject to the conditions and limitations as specified therein. This cover letter shall
be considered a part of this permit and is therefore incorporated therein by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 11.1: This permit shall not be automatically transferable; a request must be made and
approved.
Condition 11.4: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 02T .0403 or any individual system -wide collection system
permit issued to the Permittee.
Condition 11.7: Upon completion of construction and prior to operation of these permitted facilities, the
completed Engineering Certification form with checklist attached to this permit shall be
submitted with the required supporting documents to the address provided on the form.
Permit modifications are required for any changes resulting in non-compliance with
this permit, regulations, or the Minimum Design Criteria. [15A NCAC 02T.0116]
It shall be responsibility of the Permittee to ensure that the as -constructed project meets the appropriate
design criteria and rules. Failure to comply may result in penalties in accordance with North Carolina
General Statute §143-215.6A through §143-215.6C, construction of additional or replacement
wastewater collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to
the licensing board.
North Carolina Department of Environmental Quality Division of Water Resourcc�
Raleigh Reqlonal Office 3800 Barrett Drive Raleluh, North Carolina 27009

Orange Water & Sewer Authority
Permit No. WQ0041836
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This
request must be in the form of a written petition, conforming to Chapter 150E of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this matter, please contact Ted Cashion at [phone]
or via e-mail at [e-mail].
Sincerely,
olzevn
for S, Daniel Smith
Director, Division of Water Resources
by Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
cc: William Akin, P.E., Civil Consultants, Inc. ([e-mail])
Jessica Godreau, OWASA
Nick Parker, OWASA
Joe Leo, OWASA
Regional Office Files
Water Resources Central Files
PERCS (electronic copy)
Victoria Hudson, Orange County Health Department

NORTH CAROLINA
Enviranmenfal Qualify
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
Orange Water & Sewer Authority
Orange County
for the construction and operation of approximately 305 linear feet of 8-inch gravity sewer to serve a
residential project as part of the Habitat for Humanity Sanitary Sewer Extension project, and the discharge
of no additional gallons per day of collected wastewater (flow will be allocated in future permit
applications) into the Orange Water & Sewer Authority's existing sewerage system, pursuant to the
application received July 14, 2020, and additional information received on August 10, 2020 and in
conformity with 15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February
12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump
Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting data subsequently
filed and approved by the Department of Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
for S. Daniel Smith
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0041836
Permit Issued: August 18, 2020
Page 3 of 8

SUPPLEMENT TO PERMIT COVER SHEET
Orange Water & Sewer Authority is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the Mason Farm Wastewater
Treatment Facility in accordance with Permit Number NC0025241.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000 as applicable, unless specifically mentioned herein. Division approval
is based on acceptance of the certification provided by a North Carolina -licensed Professional Engineer in
the application. It shall be the Permittee's responsibility to ensure that the as -constructed project meets
the appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
I. SPECIAL CONDITIONS
NONE
II. STANDARD CONDITIONS
1. This permit shall not be transferable. In the event there is a desire for the wastewater collection
facilities to change ownership, or there is a name change of the Permittee, a formal permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be considered
on its merits and may or may not be approved. [15A NCAC 02T.0116; G.S 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 02T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for
the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and
other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .0110]
4. The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 02T .0403. If an individual
permit is not required, the following performance criteria shall be met:
a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
Page 4 of 8

b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at
least once per week.
e. High -priority sewer lines shall be inspected at least once per every six -months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance
with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina
General Statute §143-215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
Z. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
L Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept for Subparagraphs (a) through (i) of this Rule for a minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staff member at the Raleigh Regional
Office, telephone number [phone], as soon as possible, but in no case more than 24 hours,
following the occurrence or first knowledge -of the occurrence of either of the following:
a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line
blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside normal business hours may also be reported to
the Division of Emergency Management at telephone number [phone] or [phone].
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
Page 5 of 8

knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part 11 of Form CS-SSO (or the most current Division approved
form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)]
6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State. [15A NCAC 02T.0108(b)]
7. Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form with checklist attached to this permit shall be submitted with the
required supporting documents to the address provided on the form. A complete certification is one
where the form is fully executed and the supporting documents are provided as applicable. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Engineer's Certification shall be considered a violation of the permit and shall subject the
Permittee to appropriate enforcement actions.
if the permit is issued to a private entity with an Operational Agreement, then a copy of the Articles
of Incorporation, Declarations/Covenants/Restrictions, and Bylaws that have been appropriately
filed with the applicable County's Register of Deeds office shall be submitted with the certification.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings (plan & profile views of sewer lines & force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media (CD or DVD disk) and are defined as the design drawings that are
marked up or annotated with after construction information and show required buffers,
separation distances, material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing, velocity,
pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge
protection, detention time in the wet well, and force main, ability to flush low points in force
mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or
pump is dedicated to multiple stations, an evaluation of all the pump stations' storage capacities
and the rotation schedule of the portable power source or pump, include travel timeframes, shall
be provided.
c. Changes to the project that do not result in noncompliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including but not limited to pipe length changes of 10% or
greater, increased flow, pump station design capacity design increases of 5% or greater, and
increases in the number/type of connections), regulations, or the Minimum Design Criteria.
Requested modifications or variances to the Minimum Design Criteria will be reviewed on a case -by -
case basis and each on its own merit. Please note that variances to the Minimum Design Criteria
should be requested and approved during the permitting process prior to construction. After -
Page 6 of 8

construction requests are discouraged by the Division and may not be approved, thus requiring
replacement or repair prior to certification & activation. [15A NCAC 02T .0116]
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident prior to completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the individual permit and construction record drawings shall be maintained on file by the
Permittee for the life of the wastewater collection facilities. [15A NCAC 02T .0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted June
1, 2000 as applicable; and other supporting materials may subject the Permittee to an enforcement
action by the Division, in accordance with North Carolina General Statutes §143-215.6A through §143-
215.6C, construction of additional or replacement wastewater collection facilities, and/or referral of
the North Carolina -licensed Professional Engineer to the licensing board. [15A NCAC 02T .0108(b-c)]
11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities.
[15A NCAC 02T .0110; 15A NCAC 02T .0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or Local
government agencies which have jurisdiction or obtaining other permits which may be required by
the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 8

CERTIFICATION CHECKLIST
To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116.
Certifying Engineer:
Certification Review Date:
Project Name:
WQOQ Project County:
1) Has permittee information changed since the permit was issued (or last modified): change of mailing address,
change of ownership, transfer from developer to HOA/POA, etc. ❑ Yes ❑ No
• If yes, please provide either a change of ownership form or new contact information. Note that transfer of
permits from the developer to the HOA/POA must occur with the first certification.
2) Have the as -built drawings have been signed, sealed, and dated by an N.C. PE? ❑ Yes ❑ No
3) Final Engineering certification? ❑ Yes ❑ No
• If Partial Engineering certification, provide detailed narrative including what is being certified in the current
phase, what was previously certified (if applicable), and what is left to be certified.
4) Adequate information related to sewer lines: ❑ Yes ❑ No ❑ N/A
Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed.
Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines.
Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all
intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches).
5) Adequate information related to pump stations: ❑ Yes ❑ No ❑ N/A
• Ensure power reliability option was selected per 15A NCAC 02T.0305(h).
6) Was project construction completed in accordance with all of the following: ❑ Yes ❑ No ❑ N/A
• 15A NCAC 02T, Minimum Design Criteria (MDC) for the Permitting of Gravity Sewers (latest version), and MDC
for the Permitting of Pump Stations and Force Mains (latest version)?
If not, a variance approval is required in accordance with 15A NCAC 02T.0105 b prior to certification and operation.
• Contact the Central Office to discuss the variance to determine a course of action.
• Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other
pertinent information to the Central Office (one hard copy, one digital copy).
• The central office will review the variance request, and if approvable, specific language regarding the variance
will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the
reissued permit with variance language or the variance letter must be maintained with the original documents.
7) Does the project contains high priority lines (15A NCAC 02T .0402(2))? ❑ Yes ❑ No
• If yes, ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC
02T.0403 (a)(5). If the permit does not include this language, the Fast Track reviewer will reissue the permit with
the appropriate language.
8) Are Permit modifications are required for any changes resulting in non-compliance with this permit (including but not
limited to pipe length changes of 10`Yo or greater, change in flow, pump station design capacity design change of 5% or
greater, and/or change in the number/type of connections)? ❑ Yes ❑ No
• If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified
permit with revised certification must be issued prior to certification and operation.
North Carolina Department of Environmental Quality Division of Water Resources
Raleigh Reg anal Office 1628 Mail Service Center, Raleigh, NC 27699-1628
PhvSlfal AdrtrP.SS' 3800RArrPtt DrivF- Ralmoh Nr' ?7Fing g14.7g1.4 )nn

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERM17TEE:
Orange Water & Sewer Authority
PERMIT #:
WQ0041836
PROJECT:
Habitat for Humanity Sanitary Sewer Extension
ISSUE DATE:
August 18, 2020
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMITTEE'S CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name, Title Signature Date
ENGINEER'S CERTIFICATION
I, , as a duI registered Professional En ineer in the State of North Carolina,
having been authorized to observe ([periodically, ❑ weekly, full time) the construction of the
project name and location as referenced above for the above Permittee hereby state that, to the best of
my abilities, due care and diligence was used in the observation of the following construction:
approximately 305 linear feet of 8-inch gravity sewer, such that the construction was observed to be
built within substantial compliance of this permit; 15A NCAC 02T, the Division of Water Resources'
(Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1,
2000 as applicable; and other supporting materials.
North Carolina Professional Engineer's Seal w/signature & date:
❑ Final ❑ Partial (include description)
Certification Comments/Qualifiers (attach if necessary):
North Carolina Department of Environmental Qua ity Divas on of Water Resources
Raleigh Regional Office 1 1628 Mai Service Center, Ralr.�gh, NC 27699.1.628

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEMENTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: Vii/q 00 to bo completed b% DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION: `Q
1. Applicant's name: Orange Water & Sewer Authority (company, municipality, I-IOA, utility, etc.) K G pPee i y # ` "
2. Applicant type: ❑ Indi%idual ❑ Corporation ❑ General Partnership ❑ I ' ately-Owned Public Utility
❑ Federal ❑ StaterCounty ❑ Municipal ® Other
3. Signature authority's name: Todd Taylor PE per 15A NCAC 02T .01061 h)
Title: Executive Director
4. Applicant's mailing address: 400 Jones Fern Road
City: Carrboro State: NC Zip: 27510-_
5. Applicant's contact information:
Phone number: [phone] Email Address: nnarker i'owasa.org
II. PROJECT INFORMATION:
Z
C)
1. Project name: Habitat fir Hurt anity Sanitar% Sewer Extension
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d
2. Application+Project status: ® Proposed (New Permit) ❑ Existing Permit/Projectgo
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If a modification. provide the existing permit number: WQOO and issued date.
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r
If new construction but part of a master plan. pro% ide the existing permit number: WQOO
15•
3. County where project is located: Orange
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3
4. Approximate Coordinates (Decimal Degrees): Latitude:35.965087" Longitude:-79.028125-
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5. Parcel ID (if applicable):
Parcel ID downstream NC Dept of Environmental Quality
n
A
(or to closest sewer)
III. CONSULTANT INFORMATION: JUL 2 I 2020
L,/
1. Prolessional Engineer: William Akin. PE License Number: 45959 Q ��J� y
f�
Firm: Civil Consultants. Inc
Mailing address: 3708 Lvckan Parkway Suite 201 Q
City: Durham State: NC Zip: 27707-�
Phone number: [phone] Email Address: randv.akinircivil-consul tan ts.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Mason Farm Wastewater Treatment Plant Permit Number: NC 0025241
Owner Name: O WASA
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
I. Permit Number(s): WQ NA -'87 installation Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00031
O%%ner Name(s): Orange Water & Sewer Authority
FORM: FTA 04-16 Page I of

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, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality_ Sect ion
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 K SUPPORTING DOCUNIENTATION Page 3 of')

V1. GENERAL REQUIREMENTS
I. 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 Developers Operational Agreement ( FORM: DI=V) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a llomelPropertw Owners' Association. has an Operational Agreement (FORM: 11(7A) been attached?
❑ Yes ❑No ®NIA
4. Origin of wastewater: (check all that apply): Not Applicable - Flow to be allocated for future upstream development
❑Residential Owned ❑Retail (stores, centers, malls) ❑Car Wash
❑Residential Leased ❑Retail with food preparation?service 01-lotel and;or Motels
❑ School 1 preschool � day care ❑Medical i dental i veterinary facilities ❑Swimming Pool ; Clubhouse
❑Food and drink facilities ❑Church ❑Swimming Pool"Filter Back%%ash
❑ Businesses,' offices? factories ❑Nursing Ilome ❑Other (Explain in Attachment)
5. Nature of wastewater : % Domestic.. -Commercial % Commercial
_ % Industrial (flee 15A NCAC 02"I' _01103(20))
bIs there a Pretreatment Program in effect'? ❑ Yes ® No
6. Has a flow reduction been approved under 15.4 NCAC 021-
,; 0114(t)? [-]Yes ®No
;- If yes. provide a co v of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.011411))
Daily Design Flow "'b
No. of Units
Flow
gale
GPD
gal'
GPD
gal'
GPD
gal/
GPD
e&
GPD
gal..
GPD
Toga!
GPD
a See 15A NCAC 02T .0114(h). (d). (c)(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 cast of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S. 42A-4).
b Per 15A NCAC 02T .0114(e), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns. and other measured data.
8. Wastewater generated b% project: 0 GPD (per I3A NCAC 02T .01 Id)
i 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):Residential flow will be covered under future fast track permit application.
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITV SEWER DESIGN CRITERIA (If Applicable) - 02T .0305&NIDC (Gravity Sewers):
I. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
305 8 DIP
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
Vill. PUMP STATION DESIGN CRITERIA (If Applicable)-02T .0305&MDC (Puma Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Design floe of the pump station: millions gallons per day ( firm capacity)
4. Operational point(s) of the pump(s): _ gallons per minute at feet total dynamic head (TDI-1)
5. Summarize the force main to be permitted ( for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliabilityin accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic actuation and telemetry - 15A NCAC 02T .0305(h)(1)(13):
Required for all pump stations with an a,,crage daily flow greater than or equal to 13,000 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)(l)(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 Di%ision that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible %%ith thestation.
If the portable power source or pump is dedicated to multiple pump stations, anevaluation 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.
17ORM: FTA 04-16 Page 3 of

IN. SETBACKS & SEPARATIONS — (02B.0200&15A NCAC 02T.0305(f)):
I. Does the project comply with all separations found in 15A NCAC 02T .0305 t & g
I3A NCAC 02T.0305(I) contains minimum separations that shall be nrovided for sewer systems:
® Yes ❑ No
Setback Parameter*
Separation Required
Storm servers and other utilities not listed below (vertical)
24 inches
Water mains ( vertical -water over sewer including in benched trenches)
18 inches
Water mains (horizontal)
l0 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, WS-1 haters of Class I or
Class II impounded reservoirs used as a source of drinkin& water
100 feet
**Waters classified WS (except WS-I or WS-V). B. SA. ORW, FIQW, or SB from normal
high water (or tide elevation) and wetlands (sec 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
Anv basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainages stems 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 02'I'.0305(f) cannot be achieved.
*"Stream classifications can be identi lied using the Division's NC Surface Water Classifications wehyge
If noncompliance with 02T.0303 1 or g .see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 lect of separation) ® Yes [:]No
See the Division's draft separation requirements for situations %%here 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 all setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No
This would include Trout Buffered Streams per I5A NCAC 2B.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes [:]No
Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
Y Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0 105(cli 6) (additional permitsicertifications)? ®Yes ❑ No
Per 15A NCAC 02 r.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or harc 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 021'.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.
❑ Ycs ® No
:- If }es, include an attachment with details for each line, including t) pe (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 ISA 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 I5A NCAC 021', the Minimum Desien Criteria liar the Permitting of Pump Stations
and Force plains (latest version)_ and the Corm it% Sewer Minimum Desien Criteria I latest version as applicable?
❑ Yes ❑ No
IfNo. complete and submit the Variance'
'Alternative Design Request application (VADC 10-1/4) and supporting documents
for review.A roval of the request is re uired prior to submittal of the Fast Track Application and su ortin
documents.
2, Professional Engineer's Certification:
I William Akin, PE
(Professional Engineer's name from Application Item 111.1.)
attest that this application far
has been reviewed by me and is accurate, complete and consistent with the iniormation supplied in the plans. specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I t'urther attest that to the best
of my knowledge the proposed design has been prepared in accordance vvith 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 protessionals may have der eloped certain
portions ofthis 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.
. ",,IIn11111,71Ih,1
North Carolina Professional Engineer's seal, signature, and date: ,C A 7 �'•.,�
• �' SEAL i
045959 i
IV G $P j
Applicant's Certification perl5A NCAC 02T .0106(b):
1, Todd Taylor, P.E., Executive Director attest that this application for
(SignatureAuthority's name& title from Application Item 1.3.)
has been reviewed by me and is accurate and complete to the best of my knnwledge.1 understand that Wall required parts of
this application are not completed and that Wall 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 cniorcement 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. 1 also understand that it -all required parts of this application package are not completed
and that it'all required supporting information and attachments are not included, this application package will be returned to
me as incomplete.
NOTE -- In accordance vvith 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 $f 0,000 as well as civil penalties up to $25.000 per violation.
sigRtu Date: 7/10/2020
FORM: FTA 04-16 Page 5 of 3

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