WQ0018753_Application_20030718

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
Department of Environment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included the following list of required application package items by checking the
space provided next to each item. Failure to submit all required items will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
® I. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. 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 1302).
® II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ III. 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(2a) of this application.
❑ IV. Operational Agreements — Submit one original and two copies of a properly executed operational agreement if
the sewer extension is permitted 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
homeowners' association, use Form HOA 02/03. If the applicant is a developer, use Form DEV 02/03. EVEN IF
THE PROJECT WILL BE TURNED OVER TO A MUNICIPALITY, FORM DEV 02/03 IS REQUIRED.
❑ V. Flow Acceptance Letters — If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and name and permit number of the receiving sewers/WWTF. The flow acceptance must not
expire prior to permit issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
® VI. Map — Submit an 8.5-inch by 11-inch COLOR copy of the portion of a 7.5-minute USGS Topographic Map along
with this form. The map should identify the entire project area location as well as the closest downslope surface
waters as clearly as possible. Each map portion must be labeled with the map name and number, the identified
location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project
involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties,
basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location in Section C of the permit application.
❑ VII. Stream Classifications — Section C
• If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)" available from http://h2o.enr.state.nc.us/ndpu or by contacting the appropriate regional
office.
FFA 02/03 - Rev. 1 06/03

FAST -TRACK APPLICATION for GRAVITY, SEWEIZS, PUMP STATIONS, AND FORCE MAINS PAGE 2
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❑ Vill. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C .0500], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
processed 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.
® IX. Certifications — Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE). The applicant signature must match the signing official listed in Item A(1 b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, 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. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral.
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
Avery, Buncombe, Burke, Caldwell,
59 Woodfin Place
Cherokee, Clay, Graham, Haywood,
Asheville, North Carolina 28801
Henderson, Jackson, Macon,
[phone]
Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania,
Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville,N
Faye
Fayetteville, North Carolina 28301
Anson, Bladen, Cumberland, Harnett,
48
Hoke, Montgomery, Moore, Robeson,
[phone] Fax
Richmond, Sampson, Scotland
Mooresville Regional Office
919 N Main Street
Moor
Mooresville,N
Mooresville, North Carolina 28115
Alexander, Cabarrus, Catawba,
66
Cleveland, Gaston, Iredell, Lincoln,
[phone] Fax
Mecklenburg, Rowan, Stanly, Union
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe,
Raleigh, North Carolina 27699-1628
Franklin, Granville, Halifax, Johnston,
[phone]
Lee, Nash, Northampton, Orange,
[phone] Fax
Person, Vance, Wake, Warren,
Wilson
Washington Regional Office
Beaufort, Bertie, Camden, Chowan,
943 Washington Square Mall
Craven, Currituck, Dare, Gates,
Washington, North Carolina 27889
Greene, Hertford, Hyde, Jones,
[phone]
Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington,
Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
Brunswick, Carteret, Columbus,
[phone]
Duplin, New Hanover, Onslow,
[phone] Fax
Pender
Winston-Salem Regional Office
585 Waughtown Street
Alamance, Alleghany, Ashe, Caswell,
Winston-Salem, North Carolina 27107
Davidson, Davie, Forsyth, Guilford,
[phone]
Rockingham, Randolph, Stokes,
[phone] Fax
Surry, Watauga, Wilkes, Yadkin
For more information, visit our web site at. http://h`2o.enr.state.nc.us/ndpu/
FTA 02/03 - Rev. 1 06/03

FAST -TRACK APPLICATION fbr GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWO)
1. Owner: ----------._ ___ __
1 a. Town of Polkton
Full Legal Name (company, municipality, HOA, utility, etc.)
Z 1 b. Libby Cameron, Town Manager
0 Signing Official Name and Title (Please review 15A NCAC 2H .0206(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):
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1 d. P.O. Box 99
Street Address
1f. North Carolina
State
1 h. 704-272-7463 1 i.
le. Polkton
City
1 g. 28135
Zip Code
1j.
Telephone Facsimile
2. Project (Facility) Information:
2a. U.S. 74 Sanitary Sewer Improvements 2b.
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. James M. Dennis, PE, PLS
E-mail
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 704-575-3852 3c. [e-mail]
Phone Number E-mail
_ --
1. Project is ❑ New ® Modification (of an existing permit) If Modification, Permit No.: W00018753
___._..__......_. _----- _ _.__.. _ -
For modifications, attach a separate sheet clearly explaining 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 in B(7) and B(10-11) that has already been included in the original permit.
_._.._.... .._...
___�_----___--
2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be. _ - - 26. If sold, facilities owned by a (must choose one
❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction III)
Z ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction IV)
_0 El Selling units (lots, townhomes, etc. - go to Item B(2b))
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3. Anson County
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
0 4a. Anson County WWTF 4b. NCO041408
LL Name of WWTF WWTF Permit No.
____- _-_._ - ..--
Z 5a. Town of Polkton 15b. 8" '5c. W00018753
Owner of Downstream Sewer Receiving Sewer Size i Permit Number of Downstream Sewer (if known)
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision ® Car Wash
LLI ❑ Apartments/Condominiums
f3 El Institution %� %Domestic/Commercial
❑ Mobile Home Park ❑ Hospital
❑ School ❑ Church % Industrial
100
7.
8.
❑ Restaurant ❑ Nursing Home
❑ Office ❑ Other (specify):
Volume of wastewater to be permitted in this project: 3.100 gallons per day
If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted is 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
......... .... __............ _ _ _._.._.
% Other (specify):
FI'A 02/03 - Rev. 1 06/03

FAST -TRACK APPLICATION for GRAVITY, SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
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9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(I) for Item 13(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that in 15A NCAC 2H .0219(1)(1-2) must be approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality, Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(I)(3).
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
8
Length (feet) Gravity or Force Main
(use the pull down menu)
294 Gravity
ENTER TOTAL LINE LENGTH IN MILES
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID Power Reliability Option
(self chosen - as shown on Design Flow Operational Point (1- dual line feed; 2- permanent generator w/ATS; 3-
plans for cross-reference) (MGD) GPM @ TDH portable generator w/telemetry; 4-wet well storage)
12. 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 2H .0200 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
13. Have the following permits/certifications been submitted for approval?
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
FTA 02/03 - Rev. 1 06/03

FAST -TRACK APPLICATION For GRAVITY SEWEYS, PUMP STATIONS, AND FORCE MAINS PAGE 5
1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02/03
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
ZO regional office (see instructions for addresses) OR indicate the following:
® A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
Qwaterbody; AND,
(� ® A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
option for any pump station near a Class C down slope waterbody.
Location ID on Map
(self chosen - as shown on Name of Waterbody Stream Waterbody
Jmap for cross-reference) Waterbody County River Basin Index Classification
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Submit the 8.5" x 11 " COLOR topographic map as required in Instruction VI
regardless of whether a classification is providedl
1. Applicant's Certification:
1, Libby Cameron, attest that this application for U.S. 74 Sanitary 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 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 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.
Signing —Official Signature Date
W 2. Professional Engineer's Certification:
OI attest that this application for the Town of Polkton 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
i— knowledge. I further attest that to the best of my knowledge the proposed design has been prepared in accordance with
Q the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February 12, 1996, and the
V_ Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 and the
LL watershed classification in accordance with Division guidance. Although certain portions of this submittal package may
have been developed by other professionals, 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
LU General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
V certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10,000 as
Q well as civil penalties up to $25,000 per violation.
2a. James M. Dennis, PE, PLS
Professional Engineer Name
2b. Mulkey Engineers and Consultants r
Engineering Firm
2c. 7516 East Independence Blvd. — Suite 100
Address
2d. Charlotte
City
2g. 704-537-7300
Telephone
2h. 704-537-2811
Facsimile
2e. NC 2f. 28227
State Zip
2i. [e-mail]
E-mail
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�ORT H• C., 0-,,�.
OF •O�
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Seal, Signature & Date
FTA 02/03 - Rev. 1 06/03

Addendum
The modification is required due to changes in the previous U.S. 74 Sanitary Sewer Improvements
project (Permit No. WQ0019753). The modifications include a manhole location change and a grade
revision (See plan and profile).

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