WQ0035984_Application_20120530

1
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Application Number:
(to be completed by DWQ)
Owner/Permittee:
la.
City of Clinton
Full Legal Name (company, municipality, HOA, utility, etc.)
0
1 b.
John Connet
0
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
Q
1 c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
0
1d.
221 Lisbon Street / PO Box 199
le. Clinton
U.
Mailing Address
City
Z
1f.
North Carolina
1g. 28329
OState
Zip Code PYtorfn EI V E
1h.
[phone] 1i. [phone]
1j. jconnet@cityof li
QTelephone
Facsimile
E-mail
MAY 3 0 2012
L)
2.
Project (Facility) Information:
J
2a.
Eliza Lane Infrastructure Improvements
2b. Sampson
CL
Brief Project Name (permit will refer to this name)
County WAi
a
Q
3.
Contact Person:
3a.
Jeff Vreugdenhil, Public Works & Utilities Director
Q
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
[phone] ext 3052
3c. [e-mail]
Phone Number
E-mail
1.
Project is ® New ❑ Modification (of an existing permit)
If Modification, Permit No.:
2. Owner is 0 Public (skip to Item B(3)) Private (go to Item 2(a))
To
- `•' �'�;r e • �="' "'Tt-tIS DOCUMENT: HAS A COLORED BACKGROUND AND INVISIBLE FLUORESCENT FIBERS -VIEW UNDER BLACK LIGHT - •; '�
CITY OF CLINTON
CLINTON, NORTH CAROLINA 28329
ACCOO M6vM pGQVABL E
Exactly Four hundred eighty and 00/100
PAY
NCDENR
TO THE DIVISION OF WATER QUALITY
ORDER OF 1617 MAIL SERVICE CENTER
RALEIGH NC 27699
FIRST CITIZENS BANK 98965
CLINTON, N.C. 28328
66-30
531
05/16/2012 *****480.00
This disbursement has been approved as required by the
Local Govemmen t and Fiscal Control Act
�a
T�— SIGNATUREhp
AUTHORIZED SIGNATUR
I. VVIU1110 VI VVa CIGVVaLV1 LU UV GIIVt aLGUyl ,.I 1111IIO�A — uuo f/Cbuv wu. r. vtvv.. v �ww.... +..• ...+�
*Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA 12/07

CITY OF CONTON • CLINTON, N.C. 28329
`1400- r NCDENR
A.62coWILWWnber Invoice # Inv Date
4-7-12 4/7/2012
05/16/2012
PO Number Description
APPLICATION FEE
RECEIVED
MAY 3 0 2012
98965
Amount
480.00
DEW-EAYETTEVILLE REGIONAL OFFICE
Check Total
480.00

OF W A TF,Q State of North Carolina
RECEIVED Department of Environment and Natural Resources
FAST -TRACK APPLICATION
� Division of Water Quality
o MAY 3 0 1012
=�
AYfifiEVILLE REGION (FTA 12/07 very)
for GR�� SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included/addressed the following list of required application package items by
checking the space provided next to each applicable item. Failure to submit all required items will lead to your application
being returned as incomplete. Forms are available from the web site or by calling the Regional Office serving your county:
http://Portal.ncdenr.org/web/wq/swp/ps/cs/apps
® A. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. The application should include a project narrative describing the final build -out design (i.e. system and/or
pump station to ultimately serve 500 homes, but flow for only 100 homes being requested now). For modifications,
clearly explain the reason for the modification (i.e. adding another phase, changing line size/length, etc.). Only
include the modified information in this permit application - do not duplicate project information that has already
been included in the original permit.
Any changes to this form will result in the application being returned. The Division of Water Quality (Division) will
only accept application packages that have been fully completed with all applicable items addressed. You do not
need to submit detailed plans and specifications unless you respond NO to Item 1303).
Separate applications should be made for non-contiguous sewer systems.
® B. Application Fee - Submit a check in the amount of $480 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ C. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2)a of this application.
❑ D. Operational Agreements — Submit one original and two copies of a properly executed operational agreement, as
per 15A NCAC 02T .0115, if the application is submitted by a private applicant and will be serving residential or
commercial lots (e.g., houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If
the applicant is a home or property owner's association, use Form HOA 02/03. If the applicant is a developer,
use Form DEV 02/03. EVEN IF THE PROJECT MAY BE TURNED OVER TO A MUNICIPALITY UPON
COMPLETION, FORM DEV 02/03 IS REQUIRED.
® E. Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance — FORM FTSE 10/07 (Flow
Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant
(and owners of downstream sewers, pump stations and/or treatment facilities submitting FORM FTSE-10/07)
certifies that the addition of the volume of wastewater to be permitted in this project has been evaluated along the
route to the receiving treatment plant, and that the flow from this project will not cause capacity related sanitary
sewer overflows or overburden any downstream pump station en route to the receiving wastewater treatment
plant. Where the applicant is not the owner of the downstream sewer, submit two copies of FORM FTSE 10/07
from the owner of the downstream sewer and owner of the WWTF, if different. The flow acceptance indicated in
FORM FTSE-10/07 must not expire prior to permit issuance and must be dated less than one year prior to the
application date. Submittal of this application and FORM FTSE-10/07 indicates that owner has adequate
capacity and will not violate G.S. 143-215.67(a). Intergovernmental agreements or other contracts will not be
accepted in lieu of project -specific FTSE 10/07.
® F Map — Submit an 8.5-inch by 11-inch COLOR copy of a USGS Topographic Map of sufficient scale to identify the
entire project area and the closest surface waters. Each map or maps must show the location of the sewer line
and pump stations and be of reproducible quality. Include a street level map showing the downstream connection
point, and the permit number for the downstream sewer, if known.
FTA 12/07

® G. Stream Classifications — Watershed Classification Attachment (Form WSCAS-12/07) If any portion of the
sewer system project is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment
may need to be completed. A variance must be requested for encroachment within required setbacks or buffers
pursuant to 2T .0305 (f) and be indicated in Item B-13 with supporting documentation/justification provided.
❑ H Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application cannot be used. Send the project application on the most current version of Form
PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications
cannot be accepted until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS)
has been issued. A copy is to be submitted with that permit application.
❑ I. Flow Direction — Many wastewater treatment systems are entering into agreements for regionalization efforts
and emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be directed
to more than one treatment facility. If this is the case with this project, please indicate in B(12) and give the permit
number of the second treatment facility.
® J. Certifications — Section C
The application must be certified by both the applicant and the design engineer who is a North Carolina
Registered Professional Engineer (PE). The applicant signature must match the signing official listed in Item
A(1b). The PE should NOT certify the application if he/she is unfamiliar with 15A NCAC Chapter 2T, the Gravity
Sewer Minimum Design Criteria (most recent version) and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (most recent version), as applicable to the project.
THE COMPLETED FTA 12/07 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
DOCUMENTS AND $480 FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
yoU0016 Rglionel Coca /
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell, Davidson,
Winston-Salem, North Carolina 27107
Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone]
Stokes, Suny, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at.
http://portal. ncdenr. orp/web/wp/swplpslcs
or contact the Regional Office serving your county.
FTA 12/07

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
1. Owner/Permittee:
la. City of Clinton
Full Legal Name (company, municipality, HOA, utility, etc.)
Z 1 b. John Connet
H
Q
0
LL
Z
Z
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H
a
V
J
a
a
Q
i
Application Number: (fir? (to be completed by DWQ)
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
1 c. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1 d. 221 Lisbon Street / PO Box 199
Mailing Address
1f. North Carolina
State
le. Clinton
City
1 g. 28329
Zip Code
1h. [phone] 1i. [phone] 1j. jconnet@cityc
Telephone Facsimile E-mail
2. Project (Facility) Information:
2a. Eliza Lane Infrastructure Improvements 2b. Sampson
Brief Project Name (permit will refer to this name) County Where Project is Located
3. Contact Person:
3a. Jeff Vreucidenhil, Public Works & Utilities Director
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. [phone] ext 3052 3c. vreugdenhil@cif
Phone Number E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification Permit No.:
2. Owner is ® Public (skip to Item B(3))
❑ Private (go to Item 2(a))
2a. If private, applicant will be:
❑ Retaining Ownership (i.e. store, church, single office, etc.) or
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Selling units (lots, townhomes, etc. - go to Item B(215))
3. City of Clinton
intonnc.us
ntonnc.us
2b. If sold, facilities owned by a (must choose one)
❑ Public Utility (Instruction C)
❑ Homeowner Assoc./Developer (Instruction D)
Z
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a.
Larkins Water Pollution Control Facility 4b. NCO020117
QName
of WWTF WWTF Permit No.
5a.
City of Clinton 15b. 8" ® Gravity 15c. WQCS00079
Owner of Downstream Sewer ;Receiving Sewer Size:[3 Force Main 1 Permit # of Downstream Sewer (Instruction E)
0
6.
The origin of this wastewater is (check all that apply):
Z
® Residential Subdivision El Retail (Stores, shopping centers) 100 %Domestic/Commercial
❑Apartments/Condominiums ❑Institution % Industrial (attach
❑ Mobile Home Park ❑ Hospital description.)
❑ School ❑ Church
(RO: contact your Regional Office
LLI
0.
❑ Restaurant ❑ Nursing Home
staff
❑ Office El Other(specify):Pretreatment
�
% Other (specify):
7.
Volume of wastewater to be allocated or permitted for this particular project: 57,560 gallons per day
'Do not include future flows or previously permitted allocations
8.
If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA12/07

W
D
H
0
V
Z
0
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LL
Z
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a
7.0
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for'
the value in Item 13(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in !.
Item 13(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
Volume of wastewater to be tributary to this pump station = 160 houses ' 360 gallons per day / connection = 57,560 gpd
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) New Gravity or Additional
Force Main
8 1,590 Gravity
4 930 Force Main
11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID Eliza Lane Lift Station (self chosen - as shown on plans/map for reference)
Design Flow Power Reliability Option
(MGD) Operational Point 1 -permanent generator Force Main Size Force Main Length
GPM @TDH w/ATS; 2 - portable generator
w/MTS
0.144 MGD 100GPM @ 22' TDH 1 4" 930 feet
Pump Station Location ID
(self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 -permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
Pump Station Location ID
(self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
❑ Yes ® No If Yes, permit number of 2"d treatment facility _
(RO — if "yes" to 13,12 please contact the Central Office PERCS Unit)
13. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T as
applicable?
® Yes ❑ No If No, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
FTA 12/07

14. Have the following permits/certifications been submitted for approval for the system or project to be served?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A
Stormwater? ❑ Yes ❑ No ® N/A
15. Does this project include any high priority lines, [see 15A NCAC 02T .0402 (2)] involve aerial lines, siphons, or interference
manholes)? These lines will be considered high priority and must be checked once every six months
Check if Yes: ❑ and provide details
1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1, John Connet ,attest that this application for Eliza Lane Infrastructure Improvements has been reviewed by me and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting documentation and attachments are not included, this application package
is subject to being returned as incomplete. Note: In accordance with North Carolina General Statutes 143-215.6A and
143-215.6B, any person who knowingly makes any false statement, representation, or certification in any application
shall ilty of a Class 2 misd eanor, which may inclu fine not to exceed $10,000 as well as civil penalties up to
$25, J00 pA violat' n.
1 a. a 2
Signing Offici I Aignature Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY'
y TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
Z
0
Q2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
_V I, David A. McClure, P.E., attest that this application for Eliza Lane Infrastructure Improvements has been reviewed by me
LL and is accurate, complete and consistent with the information in the engineering plans, calculations, and all other
supporting documentation to the best of my knowledge. I further attest that to the best of my knowledge the proposed
design has been prepared in accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for
UJ Gravity Sewers adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump
(� Stations and Force Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance.
ti Although other professionals may have developed certain portions of this submittal package, inclusion of these materials
under my signature and seal signifies that I have reviewed this material and have judged it to be consistent with the
proposed design. Note: In accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly;
makes any false statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor
which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
2a. David A. McClure, P.E.
Professional Engineer Name
2b. Withers & Ravenel, Inc.
Engineering Firm
2c. 111 MacKenan Drive
Mailing Address
2d. Cary 2e. NC 2f. 27511
City State Zip
2g. [phone] 2h. [phone] 2i. dmcclure@withersraven(
Telephone Facsimile E-mail
FTA12/07

OF WA%9 State of North Carolina
\OI'll
PG Department of Environment and Natural Resources
CIO Division of Water Quality
q;
O tAwd
Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE—10/07)
Project Applicant Name: City of Clinton
Project Name for which flow is being requested: JEliza Lane Infrastructure Improvements
More than one FTSE-10107 may be required for a 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: _Larkins Water Pollution Control Facility
b. WWTP Facility Permit #: NCO020117
All flows are in MGD
c. WWTP facility's permitted flow
5.0
d. Estimated obligated flow not yet tributary to the WWTP
None
e. WWTP facility's actual avg. flow
2.66
f. Total flow for this specific request
0.0576
g. Total actual and obligated flows to the facility
2.66
h. Percent of permitted flow used
53%
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
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Finn/Design) Daily Flow, MGD
Eliza Lane Lift Station
0.144
None - New
III. Cert�ficat�,on Statement:
I, �p 1nL� , certify that, to the best of my knowledge, 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. 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 for/vAkch I amAe rcsRon§ible party. Signature of this form indicates acceptance of this wastewater flow.
Signing ()jfcial Signature Date

Clinton North - Quad Map
M„ • � N
�i� fi • kF
• t •
•
r
1 • j t
Proposed Pump Station 15? •
Proposed Sewer Lines �
ftl Proposed Force Mainw
• ••• • ft s
IWO
too
. •
Pk low
•
} r •
i
120
0 250 500 1,000 1,500 2,000
Feet

FORM WSCAS-03/2012
WATERSHED CLASSIFICATION ATTACHMENT
FOR SEWER SYSTEMS
oiqiii� �c
Applicant Name
Project Name
City of Clinton
Eliza Lane Infrastructure Improvements
Professional Engineer Name
Engineering Firm Name
David A. McClure, P.E.
Withers & Ravenel, Inc.
Location
ID
Name of Waterbody'
County
River
Basin
Waterbody
Stream Index No.
Waterbody
Classification
1
LIT to William Old Mill
Branch (Mill Branch)
Sampson
Cape Fear
18-68-1-10
C:SW
' If unnamed, indicate "unnamed tributary to V, where X is the named waterbody to which the unnamed tributary joins.
/ certify that as a Registered Professional Engineer in the State of
North Carolina that / have diligently followed the Division's
instructions for classifying waterbodies and that the above
classifications are inclusive of the stated project, complete and
correct to the best of my knowledge and belief.
PE Seal, Signature and Date
*** END OF FORM WSCAS-03/2012 ***
�'.0
ri 0022
iO91 jO'•:VGINEEQ''
FORM: WSCAS-03/2012 Page 1 of 1

as s •• o •• a e o•
CITY OF CLINTON FIRST CITIZENS BANK 98965
CLINTON, NORTH CAROLINA 28329 CLINTON, N.C. 28328
531
QI�OOUHVSS pGQ"�7ML�C ss-
Exactly Four hundred eighty and 00/100
PAY
NCDENR
TO THE DIVISION OF WATER QUALITY
ORDER OF 1617 MAIL SERVICE CENTER
RALEIGH NC 27699
MAY 302012
DENR—FAYETTEVILLEREGIONAL OFRCE
05/16/2012 *****480.00
This disbursement has been approved as required by the
Local Governmen t and Fiscal Control Act
i� ,-_,P
THORIZ SIGNATURE
Z � z
AUTHORIZED SIGNATUR

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Application Number:
(to be completed by DWQ)
1.
Owner/Permittee:
la.
City of Clinton
Full Legal Name (company, municipality, HOA, utility, etc.)
1b.
John Connet
0
Signing Official Name and Title (Please review 15A NCAC
2T .0106 (b) for authorized signing officials!)
Q
1 c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
0
1d.
221 Lisbon Street/ PO Box 199
le. Clinton
LL.
Mailing Address
City
Z
1f.
North Carolina
1g. 28329
O
State
Zip CodeI` `Ed
EQE �/
_
1h.
[phone] 11. [phone]
1j. jconnet@cityof li
V2.
Telephone Facsimile
E-mail
MAY O 2012
Project (Facility) Information:
J
2a.
Eliza Lane Infrastructure Improvements
2b. Sampson
G.
Brief Project Name (permit will refer to this name)
County Wh r i ERL;J010NAL ME
Q
3.
Contact Person:
3a.
Jeff Vreugdenhil Public Works & Utilities Director
Q
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
[phone] ext 3052
3c. [e-mail]
Phone Number
E-mail
1.
Project is ® New ❑ Modification (of an existing permit)
If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
so 9 e • a -e • e • e - - _-----
CITY OF CLINTON FIRST CITIZENS BANK 98965
CLINTON, NORTH CAROLINA 28329 CLINTON, N.C. 28328
ACCOUKTO PAVACo LE 66-30
531
Exactly Four hundred eighty and 00/100
PAY
05/16/2012 *****480.00
NCDENR This disbursement has been approved as required by the
Local Govemm t and Racal Control Act
TO THE ORDER DIVISION OF WATER QUALITY %d
OF 1617 MAIL SERVICE CENTER
RALEIGH NC 27699 � �/SIGNATURE
nr
AUTHORIZED sIGNATUR
t. VVIU1110 V1 vvaotcvvatci w uc auut,a tvu vi PVIIIU L15I! w• I.— P.—u u, N,..�...... .. y..••.-••.- r-..• ....�
*Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA12/07