WQ0042045_Application (FTSE)_20201019

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 ❑ Swimming Pool/Filter Backwash
® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
4Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(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 1,b
No. of Units
Flow
gal/
GPD
gal/
GPD
See attached worksheet
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
E GPD I :
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 .0114(c), 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 by project: 4850 GPD (per 15A NCAC 02T .0114)
➢ 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 04-16 Page 2 of 5

Tributary
Wastewater Flow Calculations
Establishment
Unit Value
(Gal/Day/Unit)
Unit Type
# of Units
Discharge, GPD
Residential (To NEWWTF)
Residential all other Treatment Facilities
Barber Shops
Beauty Shops
Business - General & Office
Business - Factories Excluding Industrial Waste
360
Residence
Residence
0
0
0
210
0
50
Chair
0
125
Booth or Bowl
0
25
Employce per shift
0
25
Employee per shift
0
0
Business or Factories w/showers or food preparation
35
Employee per shift
0
0
Business - Warehouse
100
Loading bay
0
0
Business - Warehouse Self Storage (not including Caretaker Residence)
I
Unit
0
0
Churches without kitchens, day care, or cams
3
Seat
0
0
Churches with kitchens
5
Seat
0
0
Churches providing day care or camp
25
Person child+em to ee
0
0
Fire or Rescue without on -site staff
25
Person
0
0
Fire or Rescue with on -site staff
50
Person per shift
0
0
Food & Drink - Banquet Dining Hall
30
Seat
0
Food & Drink - Bars, Cocktail Lounges
20
Seat
50
1,000
Food & Drink - Caterers
50
100 sf floors ace
0
0
Food & Drink - Restaurants, Full Service
40
Seat
0
0
Food & Drink - Restaurants, Single Service Articles
20
Seat
20
400
Food & Drink - Restaurants, Drive-in
50
car space
0
0
Food & Drink - Restaurants, Carry out only
50
_ _
100 sf floors ace
0
Food & Drink - Institutions, Dining Halls
5
meal
0
0
0
0
Food & Drink - Deli
40
100 sf floors ace
Food & Drink - Bakery
10
100 sf floors ace
0
0
Food & Drink - Meat Dept., Butcher, Fish Market
Food & Drink - Specialty Food Stand or Kiosk
75
50
100 sf floor space
0
0
100 sf floors ace
0
0
Hotels/Motels/B&B without in -room cooking facilities
120
Room
10
1,200
Hotels/Motels/B&B with in -room cooking facilities
175
Room
0
0
Hotels/Motels- Resort Hotels
Hotels/Motels- Cottages, Cabins
200
Room
0
0
200
Unit
0
0
Laundries (Self -Service)
500
Machine
1
500
Medical or Dental offices
250
Practitioner per shift
0
0
Medical - Veterinary offices without boarding
250
Practitioner per shift
0
0
Medical - Veterinary, Kennels, with boarding
20
Pen, Cage, Kennel, Stall
0
0
Medical - Medical Hospitals
300
Bed
0
0
Medical - Mental Hospitals
150
Bed
0
0
Medical - Convalescent, Nursing, Rest Homes without Laundry
60
Bed
0
0
Medical - Convalescent, Nursing, Rest Homes w/ Laundry
120
Bed
0
0
Medical - Residential Care Facilities
60
Person
0
0
0
0
0
0
Parks & Rec. - Campgrounds w/comfort station but without water & sewer hookul
75
Campsite
Parks & Rec. - Campgrounds with water & sewer hood _
100
Campsite
Parks & Rec. - Campground Dump Station facility
50
Space
0
0
Parks & Rec. - Construction, Hunting, or Work camps with flush toilets
60
Person
0
0
Parks & Rec. - Construction, Hunting, or Work camps with chemical or portable tc
40
Person
0
0
Parks & Rec. - Parks with Restrooms
250
Plumbing Fixture
6
1,500
Parks & Rec. -Summer camps without food prepor laund facilitates
30
60
Person
Person
0
0
Parks & Rec. - Summer camps with food prep and laundry facilitates
0
0
Parks & Rec. - Swimming Pools, Bath Houses, Spas 10 Person
Public Access Restrooms 325 Plumbing Fixture
0
0
0

Tributary
Wastewater Flow Calculations
Establishment
Unit Value
Gal/Dav/Unit
Unit Type
# of Units
Discharge, GPD
Schools - Preschools & Daycares
25
Person (child+employee)
0
0
Schools with Cafeteria, G , & Showers
15
Student
0
0
Schools with Cafeteria
12
_
Student
0
Schools without Cafeteria, Gym, & Showers
10
Student
0
0
Schools, Boarding
60
Person student+em to ee)
0
0
Service Stations, Gas Stations
250
Plumbing Fixture
0
0
Car Wash Facilities (ifrecycling water, see Rule .0235 of 2T regulations)
1200
Bay
0
0
Sports Centers - Bowling
50
Lane
0
0
Sports Centers - Fitness, Exercise, Karate, Dance
50
100 sf floors ace
5
250
Sports Centers- Tennis, Racquetball
50
court
0
0
Sports Centers - Gymnasium
50
100 sf floors ace
0
0
Sports Centers - Golf Course with only minimal food service
250
Plumbing Fixture
0
0
Sports Centers - Country Clubs
60
Member or Patron
0
0
Sports Centers - Mini Golf, Putt -Putt
250
Plumbing Fixture
0
0
Sports Centers - Go -Kart, Motorcross
250
Plumbing Fixture
0
0
Sports Centers - Batting Cages, Driving Ranges
250
Plumbing Fixture
0
0
Sports Centers - Marinas without Bathhouse
10
Slip
0
0
Sports Centers - Marinas with Bathhouse
30
Slip
0
0
Sports Centers - Video Game Arcades, Pool Halls
250
Plumbing Fixture
0
0
Stadiums, Auditoriums, Theatres, Community Centers
5
Seat
0
0
Stores, Shopping Centers, Malls & Flea Markets:
Auto, Boat, RV dealerships/showrooms with restrooms
125
Plumbing Fixture
0
0
Convenience Stores, with Food Pre aration
60
100 sf floors ace
0
0
Convenience Stores, without Food Preparation
250
Plumbing Fixture
0
0
Flea Markets
30
Stall
0
0
_Shopping Centers and Malls with Food Service
130
1000 sf
0
0
Stores and Shopping Centers without Food Service
100
1000 sf
0
0
Transportation Terminals - Air, Bus, Train, Ferry, Port & Dock
5
Passenger
0
0
Other -
0
Other -
0
Other - 0
Other- 0
From 15A NCAC 02T .0114 Average Daily Flow (gallons per day) 4,850

Ct'tp of Ztzbeboro
146 -Qortb Cllurrb street
V ® )Box 1106
Olzbeboro, -Q. (f. 27204-1106
October 12, 2020
NC Department of Environmental Quality
Division of Water Resources
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
RE: Bicentennial Park at Sunset Ave.
Dear Sir or Madam:
Eel: 336 -626 -1201
f'ax: 336 -626 -1218
The City of Asheboro intends to extend a portion of its sanitary sewer system to support reuse of an
existing downtown building. The building is located within the City Limits of Asheboro along Sunset
Ave. and Bicentennial Park, and was previously occupied by Christians United Outreach Center. The
building is being partitioned for mixed use business with design sewer flow of 4,850 GPD.
Developer plans are to subdivide the upper level (139) into ten (10) short stay hotel rooms without
cooking facilities, and with a common laundry fixture. The lower level will be occupied by a beer tap
room toward the rear of the building (141) with approximately 50 seats, a tea room and bakery at the front
right (137) with a kitchen and one bathroom, and a martial arts studio at the front left (135) with one
bathroom. The sewer extension includes a 4" tap for event based connection of the City's mobile
restroom facility which has a total of six (6) plumbing fixtures.
This sewer extension involves connecting to an existing 8" sewer line and extending a proposed 8" PVC
sewer line approximately 195 linear feet the length of the affected structure. Materials of construction are
in accordance with City of Asheboro standards. The new sewer line will be installed and maintained by
the City of Asheboro.
Please let me know if you should need anything further.
ich
ely,
ael L. Leonard, PE
City Engineer
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State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: City of Asheboro
Project Name for which flow is being requested: Bienctennial Park Area
More than one FTSE may be required fora single project if the owner of the 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: City of Asheboro WWTP
b. WWTP Facility Permit #: NC0026123
All flows are in MGD
c. WWTP facility's permitted flow 9.0
d. Estimated obligated flow not yet tributary to the WWTP 0.467
e. WWTP facility's actual avg. flow 3.952
f. Total flow for this specific request 0.049
g. Total actual and obligated flows to the facility 4.468
h. Percent of permitted flow used 49.6
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
Pump
Average Daily
Station
Firm Flow**
(Name or
Capacity, * (Firm / p fl,
Number)
MGD MGD
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Approx.
Not Yet
Total Current
Current Avg.
Tributary
Flow Plus
Daily Flow,
Daily Flow,
Obligated
Available
MGD
MGD
Flow
Capacity***
* The Firm Capacity of any pump station is defined as the maximum pumped flow 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.
*** 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): N/A
Downstream Permit Number: N/A
Page 1 of 6
FTSE 04-16

III. Certification Statement:
I John N. Ogburn, III 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 indicates acceptance of this wastewater flow.
Signing Official
Date
Page 2 of 6
FTSE 04-16

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC IC .0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page I of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE 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 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 a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x I1-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

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 Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

� l �
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Asheboro (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: John N. Ogburn, III per 15A NCAC 02T .0106(b)
Title: City Manager
4. Applicant's mailing address: P.O. Box 1106
City: Asheboro State: NC Zip: 27204-1106
5. Applicant's contact information:
Phone number: 336 626-1201 Email Address: jogburnna,ci.asheboro.nc.us
II. PROJECT INFORMATION:
1. Project name: Bicentennial Park at Sunset Ave.
❑ Privately -Owned Public Utility
❑ Other
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/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: W Q00
3. County where project is located: Randolph
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.705732' Longitude:-79.815406'
5. Parcel ID (if applicable): 7751728528
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Michael L. Leonard License Number: PE-037440
Firm: City of Asheboro
Mailing address: P.O. Box 1106
City: Asheboro State: NC Zip: 27204-1106
Phone number: [phone] Email Address: mleonard@,ci.asheboro.nc.us
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: City of Asheboro Permit Number: NC-0026123
Owner Name: City of Asheboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 Page 1 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 A14reement 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 ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
4 Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(1)? ❑ 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 s,b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
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 .0114(c), 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 by project: 0 GPD (per 15A NCAC 02T .0114)
➢ 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): Reuse of existing building; anticipated flow is equal to existing flow
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
VIII.
1
2
3
4
Size (inches) Length (feet) Material
8 195 PVC
➢ 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
PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
Pump station number or name:
Approximate Coordinates (Decimal Degrees): Latitude: 0Longitude: - °
Design flow of the pump station: millions gallons per day (firm capacity)
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):
R
Size (inches) Length (feet) Material
Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B)_
➢ 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(1) & (g) ® Yes ❑ No
➢ 15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
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-I 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
➢ 15A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(fl or (g), 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 0213.0200? [-]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 Gravity Sewer Minimum Design Criteria (latest version) as applicable?
Z Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and supportinE documents.
2. Professional Engineer's Certification:
I, l�tIs2}AsL_ L. Lea iAr—p 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:
Applicant's fication per 1 A NCAC 02T .0106(b): `
(Siena re Authontv's name & title from ADDIica�tionitem I.3.
%%A 1111
h. fi
P.3�7,4
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40
Vlk
that this application for
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. 43-215.6A and 143-215.6B, any person who knowingly makes any false
statemelt, r7not
'on, or c ifcation m y a plication package shall be guilty of a Class 2 misdemeanor, which may
inclu e a finx ed ,000 as w ill a civi penalties up to $25,000 per violation.
Signature: Date: C V
FORM: FTA 04-16 Page 5 of 5