WQ0042138_Application (FTSE)_20201123

State of North C'arolinn
DWR
Department of Environmental Quality
Division of Water Resources
Dlvislon of water Resources 15A NCAC 02T .0300 - FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: �199AW(to be completed by DWR)
All items must he completed or the application will be returned
lf. APPLICANT INFORMATION:
I. Applicant's name: City of Rocky Mount (company, municipality, HOA, utility, etc.)
2• Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately-t)wned Public Utility
❑ Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: William B. Kerr per 15A NCAC 02T .0106(b)
Title: Director of Public Works 2
0
4. Applicant's mailing address: P O Box 1180
City: Rocky Mount State: NC Zip: 27802
0
5. Applicant's contact information:
Phone number: [phone] Email Address: brad.kerr ock mounmc. ov ry y
1111. PR03ECT INFORMATION: r
1. Project name: Rocky Mount Assisted Living © _
2. ApplicationTroject status: ® Proposed (New Permit) ❑ Fxisting Permit Project
If a modification, provide the existing permit number. WQ00 and issued date: r
If new construction but part of master plan, provide the existing permit number: WQ00
3 County where project is located: Nash
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.955322 Longitude:-77.808826'
5 Parcel ID (if applicable): 385010357164
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
l . Professional Engineer: H. Mack Summey Jr. License Number:
Firm: Summev Engineering Associates, PLLC
Mailing address: PO Box_969
City: Asheboro State: NC Zip: 27204-1 106
Phone number: 3E 36) 328-0902 Email Address: mack(asummeyengineering.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Tar River Regional W WTP
Owner Name: City of Rocky ount
Permit Number: NC 0030317
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTFJ:
I. Permit Number(s): WQ Downstream (Receiving) Sewer Si7e: inch
System Wide Collection System Permit Numhe % i_I'appkabl. WOCS,__—
Owner Name(s):
FORM. FTA 04-16 Page I of 5

VI, GENERAL REQUIREMENTS
I . If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes [:]No ®NIA
2. If the Applicant is a DevelolyeT of lots to be sold, has a Develo is Opgrational Affeement FORM: DEV been attached?
❑ Yes []No ®N/A
3. If the Applicant is a Home/Pro Owners Association has an Qperational 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 1 preschool / day care ❑ Medical / dental veterinary facilities ❑ Swimming Pool Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming PooliFilter Backwash
❑ Businesses / offices! factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic'Commercial % Commercial
% Industrial ( See i SA NCAC 02T .0103(20))
- Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114ff)? ❑ Yes ® No
D If Yes, provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(1))
Daily Design Flow
No. of Units
Flow
Nursing Home with washing facility
120 gal/day
60
7200 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gall
GPD
gal/
GPD
T01011
7200 GPD
V
V
a See 15A NCAC 02T .0114(b),(d). (e)(1) and (cX2) for caveats to wastewater design flow rates (i.c., 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,0114 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
S. Wastewater generated by project: 7200 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 (F -,plain)
FORM: FTA 04-16
Page 2 of 5

Vll. GRAVITY SE WER DESIGN CRITERIA (If Applicable) - 02T .0305 &. MDC Gravit Sewers):
I • Summarize gravity sewer to be permitted.
S Section if & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
Z' Section ill 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) — O2T .0305 & MDC(Pump Stations/Force Mains
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: - Longitude:
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(I ):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(hx 1913):
i Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
;o 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 - I SA NCAC 02T
.0305(h)(1)(C )
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(hx IXQ:
i 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.
Y 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 timef-antes. shall be provided
in the case of a multiple station power outage.
FORM. FTA Od- 16
Page 3 of 5

1X• SETgACKS & SEPARATIONS — I • Does the P
(02B .0200 & l5A NCAC 02T.0305(f));
roject comply. with all
P. separations found in ] SA NCAC 02T A305 &
SA NCAC 0?T.0305 contains minimur„ moo...,_.,_- -.
lities
w
MW
® Yes ® No
sewer s stems:
Separation Required
24 inches
l8 inches
-��anea water lines
horizontal -reclaimed over
""Any private or ❑ sewer
Class 11 im ounded public
reservoirs used supplysource,
a source of drinking water
including any wells, WS-I waters of Class I or
"Waters classified WS (except WS-1 or WS_ hi h water or tide elevation V)' B' SA, ORW, H
and wetkands see item 1X.2 Q�', or SB from normal
"Any other stream, lake, impoundment, or
ditches ground water lowering and surface drainage
T
and
Or cuts of 2 feet or
l8 inch
2 feet
50
l0 feet
5 feet
An swimmin ols iu reet
Final earth 5 feet
"0�2T�o
10 feet
CAcontains alternatives where se
"Stream classifications can be identified 36 inches
If noncompliance with 02T, separations in 02T� }� mot be
0305 using the Division's NC Surface Water Classifications web
(for f e► See fiction X of this application
e
50
2. Does the project comply
;. with separation requirements for wetlands?
See the Division's draft separation requirements for situations whereftt °f
►- No variance is required gseparation)
y qu' ed if the alternative design criteria specified is Utilized separation cannot be meet] Yes No ❑ N A
As built documents should reference the location of areas effected
m design and construction
3- Does the project comply with setbacks found in the river basin rules
►• This would include Trout Buffered Streams per !SA NCA Per1SA NCAC OZ n
C 2B. _0.. B A�00_ ®yes ❑ No [I N A
4. Does the project require coverage, authorization under a 4p4
individual permits or 401 Water Nationwide or
Cluality Certificatiuns?
Information can be obtained from the Yes ® No
c
5. Does project comply with ' S-
J-�NCA{' 07T n Inc. -.
Per I SA 'VCA mT c (additional
—�2T 10 c 6 , directlylxifii�certifications)?
lxtn applied for, or have related environmental ®�'es ❑Ala
seen applied
control I• been Obtained Issuance of this permits or certification a
P ans, storm water man Permit is contingent on applications are being prepared, hale
management plans, etc.). issuance of dependent
Permits (erosion and
6 Does this project include any
Per S N (� ���. Y �� collection lines that are deemed .. _CAL ll: 1 O40 -. "high.priorih' sewer" means hr -fit m
positioned paraalllelltto str�yan� it subject to esionny aerial sew er.e sewer contacting surface water, siphon, or sewer
that undermines or detenora1ey the sewer
"Yes- include an ❑ Yes ®No [] N A
attachment with detajls tor
each line, tncludin
High Priority lines shall g hpc taerial line, sire, material, and l
documented r be inspected by the permittee or its re r location)
Per 15A NCAC 02T.0403I2X5) or the permitec• Pindiv tativeat least once eve
ry FORM: FTA 04-16 idual S}stem- si►-months and inspections
V1 ide t ollection permit.

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 Gras i�y Sewer Minimum Design Criteria (latest version) asapplicable'
® 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.
Professional Engineer's Certification.
1. l L aL� SLA,MM C. attest that this application for
(Professional Engineer's Ti
ne from Application Item I11.I.)
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 S 10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineers seal, signature, and date: �*
CA
Q 0 o
26447
'V, Zj
! 'l
3. Applicant's Certification per 15A NCAC 02T .0106(b):
(nJS�LLA,— G 2 Q O Ke(Z2 attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 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. 1 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 clam 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 143-2156B, any person who knowingly makes any false
statement, representation. or certification in any application package shall be guilty of a Class 2 misdemeanor, which ma,,
include a fine not to exceed S 10,000 as well as civil penalties up to $25,000 per violation
Signature �G' Dace: f!.
FORM. FTA 04-16 Page 5 of 5

DWP
State of North Carolina
Department of Environmental Quality
Division of Water Resources
MI,1.11t of %.Szc( Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: City of Rocky Mount
Project Name for which flow is being requested: Rocky Mount Assisted Living
More than one FTSE may be required f )r a single project if the owner of the WWTP is not responsiblefir all pump
stations along the route of the proposed wastewaterflow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: "far River Regional
b. WWTP Facility Permit #: N00030317
All flows are in MGD
c. WWTP facility's permitted flow
21.00
d. Estimated obligated flow not yet tributary to the WWTP 0.6156
e. VVWTP facility's actual avg. flow
10.83
f. Total flow for this specific request
0,007
g. Total actual and obligated flows to the facility
11.453
h. Percent of permitted flow used
54.54%
11. 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)
(C) (D)=(B*C) (E)=(A-D)
Design
Obligated,
Pump Average Daily Approx.
Not Yet Total Current
Station Firm Flow** Current Avg.
Tributary Flow Plus
(Name or Capacity, " (Firm I pf). Daily Flow.
Daily Flow, Obligated Available
Number) MGD MGD MGD
MGD Flow Capacity"""
97 Lift St 30 12 6.5 0.6156 7.116 4.884
* The Firm Capacity of any pump station is defined as the maximum pumped flow that
can he achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking
factor (pf) not less than 2.5.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Tar River Regional
Downstream Permit Number: NC 0030317 ,
Page 1 of 6
FTSE 04-16

.J
11I. Certification Statement:
I William Brad Kerr 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 1I plus all
attached planning assessment addendums for which I am the responsible party. Signature of this
form indicates acceutance of this wastewater flow.
Signing Official
// Or Z-f)
Date
Page 2 of 6
FTSE 04-16

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ew

Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
9% PO Box 968 — Asheboro, NC 27204
[phone] / Fax: [phone] / Mack(gtsummeyengineering.eom
Date: November 04, 2020
To:
Erin Deck
NCDEQ-DWR
1634 Mail Service Center
Raleigh, NC 27699-1634
TRANSMITTAL
We are sending you attached the following items:
❑ Shop Drawings ❑ Samples
❑ Prints ❑ Specifications
El Plans ❑ Disk
# Copies I Drawinq #
1
Description
$480.00 Application Fee
Rocky Mount Assisted Living
Nash County, NC
Sanitary Sewer Extension
Sea Job No. E-6052
2 Fast Track Sewer Application
2 Flow Tracking Acceptance Form
2 USGS Topo Map
2 Aerial Photo
2 Set of Construction Plans
Remarks: Erin,
❑ Copy of Letter
❑ Other
Disposition
�C f )�,,i of r n� �ruT1IT1ent3l
Nov 2 3
cji h Regional off;,.
We have enclosed the information for your review. Please let us know if you have any
questions, or if you need any additional information from us.
Thank you,
Christian Vestal
Christian(cr�summevenaineerina.com /
336-328-0902