WQ0042201_Application Attachment_20210104

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Mebane (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: David Cheek per 15A NCAC 02T .0106(b)
Title: City Manager
4. Applicant's mailing address: 106 East Washington Street
City: Mebane State: NC Zip: 27302-_
5. Applicant's contact information:
Phone number: 9( 19) 563-5901 Email Address: dcheek(a citvof nebane.com
❑ Privately -Owned Public Utility
❑ Other
IL PROJECT INFORMATION:
1. Project name: Mebane Towne Center Phase T2, T3, T4, A2, A3 &A4
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: W000
3. County where project is located: Alamance
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.070. Longitude:-79.2800
5. Parcel ID (if applicable): 164152, 164335 & 164338
(or Parcel ID to closest downstream sewer)
�l I W1118 ►7`I.`IIl N KWIl lI
1. Professional Engineer: Charles P. Trubv, Jr. License Number: NC 14984
Firm: CPT En ineering and Surveying. Inc.
Mailing address: 4400 TyningStreet
City: High Point State: NC Zip: 27265-
Phone number: 3( 36) 812-8800 Email Address: chuckt(a cotengineerim.com
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
1. Facility Name: Mebane Wastewater Treatment Plant Permit Number: NCO021474
Owner Name: City of Mebane
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): W00040602 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS0021474
Owner Name(s): City of Mebane
c
FORM: FTA 04-16 Page 1 of 5