WQ0041928_Application (FTSE)_20200918

Permit Number W00041928
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
dean.hunkele
Coastal SWRule
Permitted Flow
Facility
Central Files: APS _ SWP
9/ 1 /2020
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit Classification
A
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
Davis Independent Living Campus Private Sewer Minor Wilmington
Location Address County
New Hanover
Facility Contact Affiliation
Owner
Owner Name
Cornelia Nixon Davis Inc
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
8/25/2020
Owner Type
Non -Government
Owner Affiliation
Frank H. Hamilton III
1011 Porters Neck Rd
Wilmington NC 28411
LU
Public Notice Issue Effective Expiration

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
11 II
Application Number: I &66 q k \9'0 (to be completed by DW R)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Cornelia Nixon Davis Inc (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership
El Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Frank H. Hamilton III per 15A NCAC 02T 0106(b)
Title: Chairman Board of Trustees
4. Applicant's mailing address: 1011 Porters Neck Road
City: Wilmington State: NC Zip: 28411
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: The Davis Community Independent Living Campus
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Pennit/Project
If a modification, provide the existing permit number: WQ00_ and issued date: _
If new construction but part of a master plan, provide the existing permit number: WQ00_
3. County where project is located: New Hanover
4. Approximate Coordinates (Decimal Degrees): Latitude: 34.2940580 Longitude:-77.773865'
5. Parcel ID (if applicable): R03700-002-00 1 -000, R03700-002-002-000 R03700-001-005-000
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Phillip G. Tripp License Number: 17374
Firm: Tripp En ineering
Mailing address: 419 Chestnut Street
City: Wilmington
Phone number: 910 163-5100
State: NC Zip: 28401-
Email Address: [e-mail]
com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
Facility Name: James A. Loughlin W WTP Permit Number: NCO023965
Owner Name: Cane Fear Public Utility Authority
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS_
Owner Name(s): Cape Fear Public Utility Authority
FORM: FTA 04-16 Page I of 5

VI. GENERAL REQUIREMENTS
1. 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 Developer's Operational Agreement (FORM• DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply)
® Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church
El Businesses / offices / factories El Swimming Pool/Filter Backwash
❑Nursing Home ❑Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T 0103(20))
L-----)-Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T 01 14(fl? ❑ Yes ® No
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f)
Daily Design Flow 0,1
No. of Units
Flow
Residential Unit
240 gal/unit
4
960 GPD
Self Serve Laundry
500 gal/machine
3
1,500 GPD
Warehouse
100 gal/loading bay
2
200 GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
2,660 GPD
a See 15A NCAC 02T 0114(b) (d) (e)(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 east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S.42A-4).
b Per 15A NCAC 02T .0I 14(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 2 660 GPD (per 15A NCAC 02T .01 14)
➢ 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): _
FORM: FTA 04-I6 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T.0305 & MDC (Gravity Sewers):
I. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 930 C-900 PVC
➢ Section 11 & 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 (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name: _
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - °
3. Design flow 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 (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T 0305(h)(I ):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B):
Y Required for all pump stations with an average daily flow greater than or equal to 15,000 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)(1)(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 Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation 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.
FORM: FTA 04-16
Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(t) & (g)
➢ 15A NCAC 02T.0305(fl contains minimum cenaratinnc that chap hP ..rn.,f,ia.i f ...o,.,o. ...,...e.,....
® Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
—
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains horizontal
10 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-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see 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
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ I5A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webuage
➢ If noncompliance with 02T.0305(f) or (e), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No ❑ N/A
➢ See the Division's draft separation requirements for situations where 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 setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No ® N/A
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ® No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have 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 02T.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.
❑ Yes ®No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (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 15A 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 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravitv Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. APoroval of the request is reauired Prior to submittal of the Fast Track Application and su000rtine documents
2. Professional Engineer's Certification:
1 Phillip G. Tripp, P.E.
attest that this application for
(Professional Engineer's name from Application Item III.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering 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 (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). 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 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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
.........................................................................................
` ,XxA ICA%Q 4%,
OFESS%p 9ti ti27'��
a
SEAL
17 74
I I11
Frank H. Hamilton III; Chairman, Board of Trustees attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
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. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement 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. I also understand that if all required parts of this application package are not completed and that if
all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
NOTE — In accordance with 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 $10,000 as well as civil penalties up to $25,000 per violation.
Signature: yl/(�(�tJt��Gtn Date: Z Zo2o
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
3.
V 3.
Division of Miter Resources
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Cornelia Nixon Davis, Inc.
Project Name for which flow is being requested: The Davis community Independent Living campus
More than one FTSE nmy be required for a single project if the owner of fhe WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: James A. Loughlin (Northside) WWTP
b. WWTP Facility Permit #: NPDES NC 0023965
All flows are in MGD
c. WWTP facility's permitted flow 16.000
d. Estimated obligated flow not yet tributary to the
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
WWTP 3.463
10.661
0.002660
14.126
88.3
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
Design
Average
Pump
Pump
Daily
Station
Station
Firm
Flow**
(Name or
Permit
Capacity, *
(Firm / pi),
Number)
No.
MGD
MGD
89
N/A
14.583
5.833
95
WQ0004843
3.021
1.208
135
N/A
1.058
0.423
(B) (C) (D)=(B+C) (E)=(A-D)
Approx.
Obligated,
Current
Not Yet
Total Current
Avg. Daily
Tributary
Flow Plus
Flow,
Daily Flow,
Obligated
MGD
MGD
Flow
4.493
1.449
5.941
0.463
0.483
0.946
Available
Capacity***
-0.108
0.262
0.179 0.178 0.357 0.066
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped Clow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Cape Fear Public Utility Authority
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Jeff Theberge, CFPUA Eng. Mgr certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Sgning Official Signatt
Engineering Manager
Title of Signing Official
8/18/2020
Date
Page 2 of 6
FTSI 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section 11 where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
24.4 % and 1.449 MGD of the Available Capacity (E) in Pump Station
89 ; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
_Blue Clay Road Force Main is in design or under construction with
planned completion in Complete ; and/or
d. The following applies:
The Blue Clay Force Main is able to provide additional caapci at PS 89 b
diverting existing flow that is currently tributaKy to PS 89 directly to NSWWTP
Construction of the force main is complete and was certified 4/5/18 The force main is
available for event management. Administrative procedures are required for full activation
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Official
8/18/2020
Date
Page 3 of 6
FTSE 10-18

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6/8/2020
North Carolina Secretary of State Search Results
• Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings
Non -Profit Corporation
Legal Name
Cornelia Nixon Davis, Inc.
Prev Legal Name
Cornelia Nixon Davis Home. Inc.
Prev Legal Name
The Cornelia Nixon Davis Nursing Home, Inc.
Information
SOsld: 0039095
Status: Current -Active
Date Formed: 12/9/1963
Citizenship: Domestic
Annual Report Due Date:
Currentgnnual Report Status:
Registered Agent: Long, Charles
Addresses
Mailing
1011 Porters Neck Rd
Wilmington, NC 28405
Reg Office
1011 Porters Neck Rd
Wilmington, NC 28411
Reg Mailing
1011 Porters Neck Rd
Wilmington, NC 28411
https://www.sosnc.gov/online_sewices/search/Business_Registration_Results 1/1