WQ0042126_Application (FTSE)_20201117

V%JG' 00 +%).cQ
CAMDEN PLANTATION HOMES, INC.
544 NEWTOWN ROAD, SUITE 128
VIRGINIA BEACH, VIRGINIA 23462
OFFICE [phone] • FACSIMILE [phone]
October 23, 2020
VIA UPS GROUND AND
ELECTRONIC MAIL(davek&issellprofessionalgroup.cont)
David Klebitz
c/o NCDEQ
943 Washington Square Mall
Washington, NC 27889
Re: Camden Plantation — Wastewater Plans
Dear Mr. Klebitz:
9�
oA
Fo
00
/Zoo
Enclosed is a check in the amount of $480.00 in connection with the State application fee
associated with the wastewater plans for Camden Plantation. Please contact Ken Merner at (757)
831-6074 or via email at keiun��;boydhomes.com should you have any questions or concerns.
Sincerely,
Stefanie S. White
Paralegal
cc: Ken Merner (via email)
Enclosure

5632 NCDEQ
BOYD CORPORATIO1V
DATE
10-15-20
INVOICE NO _
CPPNCDEQ101520
-- — - DE.SCRIp (ION -- _— - ------
STATE APP +FEE
I DEDUCTON _
. 0
BAiftNf
_ 480.0�I
i
1
I
I
I
I
CHECK
10-22-20
DATE
CHECK
1NUMSER
311 TOTAL>
n
G0
i
l
i
480.00
BOYD CORPORATION
POST OFFICE BOX 62209
VIRGINIA BEACH VA 23466-2209
PLEASE DETACH AND RETAIN FOR YOUR RECORDS
TOWNEBANK 88.8841514 311
GLEN ALLEN. VA
Pay. hundred eightr dollars and no rents
s
TO
THE NCDEQ
ORDER
OF
1160000003110 s.0 5 140i! 9 t, 940 2!9 10 1 3 6 21,114
DATE 10/22/2020
$ •:`480.00

ill
November 03, 2020
Ms. Sarah Toppen
Environmental Specialist
Water Quality Regional Operations
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Tke Coastalf xGerts RFCF��o
/I/pJj OFH�oN'9
I �0020
Re: Fast Track Application for Wastewater Collection System for Camden Plantation - Phase 1A,
Camden County, NC
Dear Sarah,
We are submitting a Fast Track Application (FTA 04-16) on behalf of Camden County (original and a
copy) for the installation of a wastewater collection system extension to serve Camden Plantation —
Phase 1A, the first phase of Planned Unit Development slated for construction in South Mills, NC. The
system will become part of Camden County's wastewater system.
The gravity sewers for this project will connect to (2) proposed lift stations with force mains that will join
to connect to an existing county force main that was permitted under Permit No. WQ003475. A total
amount of 53,710 gpd is being allocated based on Phase 1A of the development that will include (109)
residential single-family home lots, with 3.5 bedrooms per lot, and a proposed Clubhouse Facility with
Swimming Pool, Golf -Pro Shop, Pavilion and Golf Cart Storage.
Also included is a Flow Tracking for Sewer Extension Application (FTSE 10-18) for the Camden County
WWTP System. The flow from this development was allocated by Camden County through preparation
of a Development Agreement for the project.
Also enclosed are an 11"x 17" color USGS topo map showing the relevant project features and permit
numbers for the existing system and an 24"x36" street level map showing the overall project. The
application fee, in the amount of $480.00, was mailed separately and, pursuant to an email from Heidi
Shasteen, was received in the NCDEQ WARO office on 10-27-2020. Heidi indicated that the fee is being
held in anticipation of this application package.
Please let us know if you need any additional information in connection with this application.
Sincerely yours,
Bissell Professional Group
David M. Klebitz, P
cc: Mr. David Credle
P.O. Box 1068 •3512 N. Croatan Hwy. • Kitty Hawk, NC 27949
252-261-3266 • Fax: [phone] • E-mail:[e-mail]

Hiss[R
-.
The G0agpA1f x1ertg
LETTER OF TRANSMITTAL
Date: November 04, 2020 To: Ken Bowman, Manager
Project #: 4700 Camden County
Project Name: Camden Plantation P.O Box 190
Phase 1A & Golf Camden, NC 27921
HAND DELIVERED I I OVER -NITS MAIL I X I MAILED I I FAXED
We are sending FRI Enclosed Attached Under separate cover via the following items:
As Requested F7For Client Approval F-1 For Bid Submission E-1 For Construction
F]For Your Use F]For Permit Approval F]For Distribution a For Const. Record
0 For Review & Approval F-1 For Your Records F-1 For Release F—I Confidential
COPIES DESCRIPTION DATE
Camden Plantation - Phase 1A Utility Plans
Fast Track Sewer System Extension Application Package
REMARKS:
Mr. Bowman,
11/03/20
11/03/20
The above listed items are being provided to support an application to NCDEQ for a sewer line
extension to serve Phase 1A of Camden Plantation. The plans are for the County's records and the
Fast Track Sewer Application Package is for execution and submission to NCDEQ. Included in the
application package is (1) original and (1) copy of the Application Form FTA 04-16 that need to be
signed by the County as applicant. Sticky notes and sign here tabs are provided for direction. After
you have signed the forms, the package needs to make its way to Sarah Toppen in the DEQ
Washington regional office per the included cover letter. If the County is able to mail the package
on that would be great. If not, please let me know and we will coordinate having the package picked
up. Thank you again for your assistance with this project and if you have any questions please do
Best Regards,
BISSELL PROFESSIONAL GROUP
David Klebitz, P.E.
P.O. Box 1068 -3512 N. Croatan Hwy. - Kitty Hawk, NC 27949
252-261-3266 - Fax: [phone] - E-mail:[e-mail]

State of North Carolina
Department of Environmental Quality
MR -.001 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 I .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 1 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 11-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, staring 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)
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

State of North Carolina
Department of Environmental Quality
MR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: Vy Q W'42 `2% (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: County of Camden, NC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ® State/County ❑ Municipal
3. Signature authority's name: Ken Bowman per 15A NCAC 02T .0106(b)
Title: County Manager
4. Applicant's mailing address: PO Box 190
City: Camden State: NC Zip: 27921-
5. Applicant's contact information:
Phone number: 2( 52) 338-6363 Email Address: kbowman(a camdencountync.gov
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
1. Project name: Camden Plantation Phase IA
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: WQ00
3. County where project is located: Camden
4. Approximate Coordinates (Decimal Degrees): Latitude: 36..50489° Longitude:-76..34344°
5. Parcel ID (if applicable): 017081000362300000
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: David Klebitz License Number: 042639
Firm: Bissell Professional Grout)
Mailing address: P.O. Box 1068
City: Kitty Hawk State: NC Zip: 27949-
Phone number: 252 261-3266 Email Address: davek(&bissellprofessionalgroup.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Camden County WWTP Permit Number: W00029894
Owner Name: County of Camden, NC
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ003475 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): County of Camden, NC
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 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))
bIs there a Pretreatment Program in effect? ❑ �'es ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ 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',e
No. of Cnits
Flmi
109 Residential Lots w/ 3.5 bedrooms/lot
120 galibedroom
381.5 bdrm
45,780 GPD
Cart Storage
25 gal/employee
2 emply
50 GPD
Pavilion
100 gal/1000 sf
4000 sf
400 GPD
Pro Shop
100 gal/1000 sf
4800 sf
480 GPD
Clubhouse
10 gal/patron
300
3,000 GPD
Swimming Pool
10 gal/patron
400
4,000 GPD
Total
1 53,710 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. 42A4).
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: 53,710 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

VH. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
6950
SDR-35
8
1067
SDR-21
8
285
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
VIII. 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: LS-01 s c-L- AIL X T tit=
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.49880 Longitude:-76.3425' fo-Q LS -OZ-
3. Design flow of the pump station: 0.04578 millions gallons per day (fun capacity)
4. Operational point(s) of the pump(s): 207 gallons per minute at 80 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
SDR-21
6. 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
R
6950
SDR-35
S
1067
SDR-21
x
285
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
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: LS-02
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.5021 ° Longitude:-76.3406'
3. Design flow of the pump station: 0.00793 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 385 gallons per minute at 90 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
S
4098
SDR-21
6
1712
SDR-21
6. 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(i)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(fl & (g)
➢ 15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
® 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-I or WS-V), B, SA, ORW, HQW, or SB from normal
hi h 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 swi ing pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webnage
➢ 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 02B .0200? ❑ Yes ❑ No ® N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.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?
® 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 supporting
documents.
2. Professional Engineer's Certification:
attest that this application for
(Professional Engineer's name from Application Item 11I.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.
I,
North Carolina Professional Engineer's seal, signature, and date:
Certification per 15A NCAC 02T .0106(b):
(Signature Authority's name & titre from Aplflication Item I.3.)
\\1r A R OZ ////i
Ire,
z SEAS
p42639
. GI � \~z,
gkjp
//////llll���\
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 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: Date: _1,
ALW— --
FORM: FTA 04-16 Page 5 of 5

4. 1~
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: County of Camden, NC
Project Name for which flow is being requested: Camden Plantation -Phase IA
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for al! 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: Camden County WWTP
b. WWTP Facility Permit #: WQ0029894
AlI lows are in MGD
c. WWTP facility's permitted flow 0.1
d. Estimated obligated flow not yet tributary to the WWTP 0.01
e. WWTP facility's actual avg. flow 0.009963
f. Total flow for this specific request 0.053710
g. Total actual and obligated flows to the facility 0.073673
h. Percent of permitted flow used 73.67
Il. 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)
(B)
Design
Pump
Pump
Average
Approx.
Station
Station
Firm Daily Flow**
Current
(Name or
Permit
Capacity, * (Firm / pf),
Avg. Daily
Number)
No.
MGD MGD
Flow, MGD
(C)
(D)=(B+C) (E)=(A-D)
Obligated,
Not Yet
Total Current
Tributary
Flow Plus
Daily Flow,
Obligated Available
MGD
Flow Capacity***
* The Firm Capacity (design flow) 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, 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):
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Ken Bowman 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 Il 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.
Signing
WOJ
Date
Page 2 of 6
FTSE 10-18