WQ0029576_Application_20051209

T-TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
...........
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
1. Owner:
la. Town of White Lake
Application Number: W00029 57 6
(to be completed by DWQ)
Full Legal Name (company, municipality, HOA, utility, etc.)
1b. Tim Frush, Public Works Director
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
lc. The legal entity who will own this system is:
0 Individual 0 Federal ® Municipality 0 State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
Id. 1849 White Lake Dr.
Street Address
le. White Lake
City
1f. NC
State
1 h. 910-862-4800
Telephone
1 i. 910-862-8686
Facsimile
lg. 28337
1j
Zip Code
E-mail
2. Project (Facility) Information:
a. 2a. Carolina Bay Sanitary Sewer Extension
d Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Brian Cox, Engineer, Engineering Services, PA
2b. Bladen
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-662-7272
Phone Number
3c. becoxcbellsouth.net
E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
2. Owner is Z Public (skip to Item 8(3)) 0 Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold. fa._
rilitiPc nwnarl a i\
ENGINEERING SERVICES, PA
518 VILLAGE COURT
P.O. BOX 1849
GARNER, NC 27529
PAY TO THE NC-DENR
ORDER OF
Four Hundred and 00/100**********,*****,k***********,,,.*.***************,.,.*,k***,.****** *,.,t;,..**************,.,*,k********** DOLLARS -
WACHOVIA BANK
OF NORTH CAROLINA, N.A.
RALEIGH, NC 27611
66-763/531
10858
11/15/2005
**400.00
NC-DENR
MEMO
Permitting Fee

. 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
FTA 02/03

VV ATF R
State of North Carolina
`0�� AG DENR—Fartment of Environment and Natural Resources
n Division of Water Quality
il%%iwv: FAST -TRACK APPLICATION
for GROEWERS, 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 B(12).
Z 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 will be serving residential or commercial lots (e.g., houses, condominiums, townhomes,
outparcels, etc.) that will be owned by a homeowners' association or developer (Item B(2b)). If the applicant is a
homeowners' associationI, 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 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,
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
for each different waterbody (where the sewer line is within 100 feet of such waterbody - see Instruction VII).
® VII. Watershed 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.
INSTRUCTIONS FOR FORM FTA 02/03

❑ VIII. 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 T
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
59 Woodfin Place
Asheville, North Carolina 28801
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell,
Cherokee, Clay, Graham, Haywood,
Henderson, Jackson, Macon, Madison,
McDowell, Mitchell, Polk, Rutherford, Swain,
Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
Mooresville Regional Office
919 N Main Street
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Raleigh Regional Office
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
[phone]
[phone] Fax
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
Beaufort, Bertie, Camden, Chowan, Craven,
Currituck, Dare, Gates, Greene, Hertford,
Hyde, Jones, Lenoir, Martin, Pamlico,
Pasquotank, Perquimans, Pitt, Tyrrell,
Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pender
Winston-Salem Regional
Office
585 Waughtown Street
Winston-Salem, North Carolina
27107
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell,
Davidson, David, Forsyth, Guilford,
Rockingham, Randolph, Stokes, Surry,
Watauga, Wilkes, Yadkin
For more information, visit our web site at: http://h2o.enr.state.nc.us/ndpu/
INSTRUCTIONS FOR FORM FTA 02/03

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 1
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
1. Owner:
la. Town of White Lake
Application Number;
(to be completed by DWQ
G10029576
Full Legal Name (company, municipality, HOA, utility, etc.)
1 b. Tim Frush, Public Works Director
1
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
. The legal entity who will own this system is:
❑ Individual 0 Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
Id. 1849 White Lake Dr.
Street Address
1e. White Lake
City
If. NC
State
1 h. 910-862-4800
Telephone
1i. 910-862-8686
Facsimile
1g. 28337
1j.
Zip Code
E-mail
2. Project (Facility) Information:
2a. Carolina Bay Sanitary Sewer Extension
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Brian Cox, Engineer, Engineering Services, PA
2b. Bladen
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-662-7272
Phone Number
_........ .
. Project is ® New 0 Modification (of an existing permit)
3c. becoxcbellsouth.net
E-mail
If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3))
2a. If private, applicant will be:
❑ Retaining Ownership (i.e. store, church, single office, etc.)
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
. Town of White Lake
12 Private (go to Item 2(a))
2b. If sold, facilities owned by a (must choose one)
❑ Public Utility (Instruction III)
❑ Homeowner Assoc./Developer (Instruction IV)
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Town of White Lake WWTP
Name of WWTF
4b. NC23353
WWTF Permit No.
CO 5a. Town of White Lake
z
Owner of Downstream Sewer
b. 8 inch
Receiving Sewer Size
6. The origin of this wastewater is (check all that apply):
W!
L1
❑ Residential Subdivision
0 Apartments/Condominiums
® Mobile Home Park
❑ School
❑ Restaurant
O Office
❑ Car Wash
O Institution
O Hospital
❑ Church
❑ Nursing Home
❑ Other (specify):
5c. Unknown
Permit Number of Downstream Sewer
10Q % Domestic/Commercial
% Industrial
% Other (specify):
7. Volume of wastewater to be permitted in this project: 14.400 gallons per day
8. 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
FTA 02/01

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 2
Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(1) for Item B(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(I)(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).
60 lots times 240 gal per lot = 14,400 gallons per day
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet)
8 1270
Gravity or Force Main
(pull down menu)
Gravity
Gravity
Gravity
Gravity
ENTER TOTAL LINE LENGTH IN MILES 0.24 miles
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID
(as shown on plans)
Design Flow
(MGD)
Operational Point
GPM @ TDH
Gravity
Gravity
Gravity
Power Reliability Option
(dual line feed, permanent generator,
portable generator, 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 0 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 0 No ® N/A
Sedimentation and Erosion Control Plan? 0 Yes ❑ No ® N/A
Stormwater? ❑ Yes 0 No ® N/A
FTA 02/01

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3
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
regional office (see instructions for addresses) OR indicate the following:
❑ A Watershed Classification is not needed because all parts of the project are at least 100 feet away from any down
slope waterbody; AND
® A Watershed 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
Site
Name of
Waterbody
Colly Creek
County
Bladen
River Basin
Cape Fear
Waterbody Stream Waterbody
Index Classification
18-68-17 C
Submit the 8.5" x 11" topographic map as required in Instruction VI regardless of whether a classification is provided)
1. Applicant's Certification:
/ attest that this application for the Carolina Bay sanitary sewer line extension 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.
1
ic' Signature '
2. Professional Engineer' Certification:
I attest that this application for the Carolina Bay sanitary sewer line extension has beery
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 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 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.
2a. Brian G. Cox
Professional Engineer Name.
2b. Engineering Services, PA
Engineering Firm
2c. P. O. Box 1849
Address
2d. Garner 2e. NC
City State
2f. 27529
Zip
2g. 919-662-7272 2h. 919-662-7320
Telephone
Facsimile
2i. [e-mail]
E-mail
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FTA 02/01

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