WQ0035561_Application_20110902 (2)

' OF IATLcR State of North Carolina
4 Department of Environment and Natural Resources
10
Division of Water Quality
o FAST -TRACK APPLICATION
(FTA 12/07 very)
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewet 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://h2o. enr. state. nc. us/peres/Collection % 20SystemsICollectionSystemApplications. html
® 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 B(13).
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 10107 (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.
v
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
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Hamett, 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, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at.
http://h2o.enr state.nc.us/peres/Collection%20Systems/CollectionSystemsHome.html
or contact the Regional Office serving your county.
FTA 12/07

---
.____ .......
USE THE TAB KEY TO MOVE FROM FIELD TO FIELDI Application Number,
(to be completed by DWQ) 1111. _... �_.....
1.
Owner/Permittee:
la.
Town of Roseboro
Full Legal Name (company, municipality, HOA, utility, etc.)
Z
1 b.
Town of Roseboro Mayor - Roland Hall
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
Q
1c.
The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
0
1 d.
P.O. Box 848 le. Roseboro
U.
Mailing Address City
Z
1f.
NC _ 1g. 28382
Z
State Zip Code
0
11 h.
910-525-4121 1 i. 910-525-3133 1j. [e-mail]
QTelephone
_ Facsimile E-mail
V
2.
Project (Facility) Information:
J'
2a.
Douglas Ave CDBG Sewer Improvements 2b. Sampson
aBrief
Project Name (permit will refer to this name) County Where Project is Located
Q
3.
Contact Person:
3a.
M. Floyd Adams, PE or Bob Mitchell, The Adams Company, Inc.
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b.
910-293-2770 3c. [e-mail] OR [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))
i2a.
... ................
If private, applicant will be: 2b. If sold, facilities owned by a (must choose one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction C)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D)
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3.
Town of Roseboro
ZiOwner
of Wastewater Treatment Facility ('WWTF) Treating Wastewater From This Project
...
4a.
Town of Roseboro 4b. NCO026816
-----
Name of WWTF WWTF Permit No. .....,
................ ---....... _......... _......... ...... _.................. _._..- -- ....._.... ................. _............. .........................._........_........._......_..._..__......._.......- -- ------------..................
5a.
Town of Roseboro b. 8" ® Gravityc. Collection System # WQCS00155
(
Owner of Downstream Sewer Receiving Sewer Size ❑ Force Main Permit # of Downstream Sewer (Instruction E)
0+
6.
The origin of this wastewater is (check all that apply): j
® Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
❑ Retail (Stores, shopping centers)
❑ Institution
❑ Hospital
® Church
❑ Nursing Home
❑ Other (specify):
100 % Domestic/Commercial
% Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify):
Volume of wastewater to be allocated or permitted for this particular project: 5,540 gallons per day
*Do not include future flows or previously permitted allocations
........
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

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).
14 homes at 360 gpd plus 1 Church (5 gpd/seat @ 100 seats) = 5,540 total gallons per day
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) New Gravity or Additional
Force Main
8" Gravity 583 New
4" Force Main 940 New I
11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID Douglas Ave. (self chosen - as shown on plans/map for reference) j
Design Flow Power Reliability Option
(MGD) Operational
,@TDH 1 - permanent generator WATS; Force Main Size Force Main Length
2 - portable generator w/MTS
0.065 100030 1 4" 940
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
Z __r
ip 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
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 6,12 please contact the Central Office PERCS Unit)
........- .
3. 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
FTA12/07

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?
Stormwater?
❑ Yes ❑ No ® N/A
❑ 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 No
Check if Yes: ❑ and provide details
1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1, Roland Hall. Mayor attest that this application for Douglas Ave. Sewer 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 retumed 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 be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000 as well as civil
penaltie up to $25, 000 per violation.
Signing Official Signatufe Date
:ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMIT
TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
F- "•. 2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
1, M. Floyd Adams. PE . attest that this application for Douglas Ave. Sewer Improvements has been reviewed by
me 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
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.
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 rive not to exceed $10,000 as well as civil penalties up to $25,000 per violation: .
M. Flovd Adams
Professional Engineer Name
.........
The Adams Company, Inc.
Engineering Firm
708 Abner Phillips Rd.
Mailing Address
Warsaw 2e. NC 2f. 28398
City State Zip
910-293-2770 2h. 910-293-2766 2i. [e-mail]
Telephone Facsimile E-mail
NC PE Seal. Sianature & Date
FTA 12/07

TOWN OF ROSEBORO
Douglas Ave. CDBG Sewer Improvements
Roseboro, NC
Sampson County
8/23/11
NARRATIVE
1. Project Title: Douglas Ave. CDBG Sewer Improvements
2. Location: Douglas Ave., Roseboro, NC
3. Additions/Improvements: 583 LF of 8" Gravity Sewer, 940 LF of 4" Force Main, Duplex
Pump Station with 2 - 5 hp pumps, telemetry and stand-by generator
4. System will currently serve 14 residents and 1 church; total added flow — 5,540 GPD.
5. Waste Water Treatment Facility — Town of Roseboro, NCO026816
6. Future service potential — 25 residents; total potential added flow — 9,000 GPD
7. All gravity and force main lines and pump station to be owned and operated by the Town of
Roseboro.
8. No Historic Sites are a part of this project.
9. There are currently no non-compliance issues with NCDENR.

O� LN A TAR State of North Carolina
�0 WG Department of Environment and Natural Resources
co Division of Water Quality
© Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE-10/07)
Project Applicant Name: -Lxoy�- or- R45 F Q oe-d
Project Name for which flow is being requested: ; 6„�Q �,� e.D
More than one FTSE-10/07 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: TbLvVV OF 1ZoSr�60��
b. WWTP Facility Permit #: 00 26 8 �
All flows are in MGD
c. WWTP facility's permitted flow 0.41td
d. Estimated obligated flow not yet tributary to the WWTP D,ZOU
e. WWTP facility's actual avg. flow 0, 2.00
f. Total flow for this specific request 6 , D D S
g. Total actual and obligated flows to the facility p,2 o s'
h. Percent of permitted flow used `f' 7- %
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.
(pxbPorEO) (Firm/Design) Daily Flow, MGD
Dbk&r, Ls � PAS,-�, o.0's a6es-
III. Certification Statement:
I, 'tA). i I I { cx m C , Am mays , 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 which I am the responsible party. Signature of this form indicates
acceptance of this wastewater flow. J-.
Signing Official Signature Date

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THE AD iCC'*'77 TV INC.
CONSTRUCTION AND DEVELOPMENT
708 Abner Phillips Road.
Warsaw, NC 28398 d
Phone [phone]
Fax [phone]
September 1, 2011
Trent Allen
Surface Water Protection
Fayetteville Regional Office
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Ref Town of Roseboro
Sewer Extension Permit
Dear Trent,
Please find all necessary documents for the application of Sewer Permit for the sewer line
extension for the Town of Roseboro. The Town of Roseboro's Douglas Ave CDBG Sewer
Improvements project will consist of the construction of 583 linear feet of 8" gravity sewer,
940 linear feet of 4" sewer force main and a duplex pump station with generator.
Enclosed please find 2 copies of the following:
- Fast -Track Application
- Narrative
- Flow Tracking Form
- Waste Flow Map to the Roseboro Waste Water Treatment Facility
- USGS Topo Map
- Check for $480.00
Please do not hesitate to call me at 910-293-2770 if you have any questions,.
�M�
Bob Mitchell
The Adams Company, Inc.
Encl.

' 'a " '"'" "' WARNING: DO NOT CASH THIS INTUIT® CheckLockr" SECURE CHECK IF ANY FEATURES LISTED ON BACK :a TAMPERING
THE ADAMS COMPANY,• •
745
1: ABNER PHILLIPS '• •
[phone]
PAY TO THE NCDENR
ORDER OF
9/1 /2011
*'480.00
Four Hundred Eighty and
DOLLARS
NCDENR
Wilmington Regional Office
127 Cardinal Drive Extension
Wilimington, NC 28405

]G.C:aa.^a1G,].a�rft,L3l'l+C:n.=L:,n.SiLLa¢'9�•..G3`r;.S.n..u0.1� td9c;CL:�MJ-�t..ri[.f5..1ar� LIf;[S`a ...� �_dl'::S�L tr,..r. G7:C<SJP..I ,.� 6•iG.e�trisa i-is.t.t THE ADAMS ,1•,•.r �3:L.t=1•..ya �:a.a:.�eJ., 4.>63a.ar; a1 �_.La;sale I �..]l..i:x:�ua ti'.�(.'aaaa6.d I:.;:ITSaut:pf
COMPANY,•
4745
NCDENR
Perriits
Checking-SB&T
Roseboro Sewer
9/1/2011
480.00
480.00