WQ0035824_Application (FTSE)_20120312

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
1 (to be completed by DWQ) p
a 6 at4
lAV
1. Owner/Permittee:
1a. Town of White Lake
Full Legal Name (company, municipality, HOA, utility, etc.)
0 1 b. H. Goldston Womble, Jr-, Mayor
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
...Cr ic. The legal entity who will own this system is:
■ Individual ■ Federal ►1 Municipality ■ State/County ■ Private Partnership ■ Corporation ■ Other (specify):
Cr
0 id. 1879 White Lake Drive le. White Lake
ZMailing Address City
1f. North Carolina 1g. 28337
State Zip Code
1 h 910-862-4800 1 i. 910-862-8686 1j. [e-mail]
QTelephone Facsimile E-mail
0 2 Project (Facility) Information:
J 2a. Carolina Bay Sewer Extension 2b. Bladen
Or Brief Project Name (permit will refer to this name) County Where Proms /
a- it V C1 Y` _ ._.._..._.
Q 3. Contact Person:
Q3a. Brian Cox, Engineering Services MAR I 22012
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-662-7272 3c. bgcox© be 11190 4FOFFTEVI LLE REGIONAL OFFICE
Phone Number 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)) ■ Private (go to Item 2(a))
2a. 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))
PAY
AMOUNT
OF
REGAL RESORT INC.„
910-862-2427
1498 WHITE LAKE DR.
WHITE LAKE, NC 28337-6306
WACCAMAW BANK
WHITE LAKE, NC

❑ Pump Station, Outfall or Interceptor Line where now will De perrnnrcu
❑ 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)
66-1215/531
4686
CHECK
AMOUNT

\N\,. A `... State of North Carolina
oG RECEIVED Department of Environment and Natural Resources
1� Division of Water Quality
- MAR 1 ' 2012 FAST -TRACK APPLICATION
(FTA 12/07 ver5)
DENR-FAYEiTEVILLE RETWOUVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer 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%20Systems/CollectionSystemApplications. 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.
0 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 10/07 (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 Tess 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.
FTA12/07

❑ -Car 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 heed 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(1 b). 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
Swannanoa, North Carolina 28778
[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 28301-5094
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
Mooresville Regional Office
610 E. Center Avenue
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,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
For more information, please visit our web site at:
h ttp://h2o. enr.state. nc. us/peres/Collection%20Systems/CollectionSystemsHome. html
or contact the Regional Office serving your county.
FTA12/07

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: ,,,,.1l O pC,
� C n/ q
(to be completed by DWQ) Q l/
1. Owner/Permittee:
1a. Town of White Lake
Full Legal Name (company, municipality, HOA, utility, etc.)
O 1b. H. Goldston Womble, Jr., Mayor
Signing Official Name and Title
'Qlc. The legal entity who will own this
(Please
system
review 15A NCAC 2T .0106
is:
(b)
Partnership
1e.
1g.
1 j.
2b.
for authorized signing officials!)
■ Individual ■ Federal ►5 Municipality
■ State/County ■ Private
• Corporation ■ Other (specify):CC
0 id. 1879 White Lake Drive
White Lake
LL. Mailing Address
Z if. North Carolina
City
28337
Z State
0. ,1 h. 910-862-4800 li. 910-862-8686
Zip Code
[e-mail]
QTelephone Facsimile
V 2 Proiect (Facility) Information:
E-mail
Bladen
INIIM
...11 Carolina Bay Sewer Extension
aBrief Project Name (permit will
4 3. Contact Person:
refer to this name)
County Where Project is Located
a3a. Brian Cox, Engineering Services
Name and Affiliation of Someone Who Can Answer Questions About
3b. 919-662-7272
3c.
this Application
[e-mail]
Phone Number
E-mail
1. Project is 0 New ■ Modification
(of
an existing permit) If Modification,
Permit No.:
B(3))
Item 2(a))
2. Owner is 0 Public (skip to Item
• Private (go to
2a. If private, applicant will be:
2b.
church, single office, etc.) or
etc. - skip to Item B(3))
etc. - go to Item B(2b))
If sold, facilities owned by a (must choose one)
(Instruction C)
Assoc./Developer (Instruction D)
■ Retaining Ownership (i.e. store,
• Public Utility
■ Leasing units (lots, townhomes,
• Homeowner
IN Selling units (lots, townhomes,
3. Town of White Lake
Z Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
0 4a. Town of White Lake WWTP 4b. NC0023353
Name of WWTF
a 5a. Town of White Lake
5b. 8 inch
WWTF Permit No.
5c.
Gravity
CC Owner of Downstream Sewer
0 6 The origin of this wastewater is
LL.
Z
Receiving
(check
Sewer Size ■ Force Main
Permit # of
centers)
Downstream Sewer (Instruction E)
100 % Domestic/Commercial
% Industrial (attach
all that apply):
►Z� Residential Subdivision
• Retail (Stores, shopping
H • Apartments/Condominiums
■ Institution
• Hospital
2 ■ Mobile Home Park
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify):
W ■ School
■ Church
• Restaurant
• Nursing Home
a • Office
■ Other (specify):
Ca
7. Volume of wastewater to be allocated
or permitted for this particular
project: 1.800
gallons per day
*Do not include future flows
8. If the permitted flow is zero, indicate
or previously
why:
in
of existing
permitted allocations
Line where flow will be permitted
Permit No.
in subsequent
permits that connect to this line
NCAC 02T .0303 to determine if a
■ Pump Station, Outfall or Interceptor
■ Flow has already been allocated
• Rehabilitation or replacement
permit is required)
sewer with no new flow expected (see 15A
FTA12/07

Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item B(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item B(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).
5 new Tots @ 360 gal/day/lot = 1,800 gallons
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
0 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
ZPump Station Location ID (self chosen - as shown on plans/map for reference)
New Gravity or Additional
Force Main
Gravity
F Design Flow
Z (MGD)
0
Z
Operational Point
GPM @TDH
Power Reliability Option
1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
0
QPump Station Location ID
2 Design Flow Operational Point Power Reliability Option
IX (MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
0
Z
(self chosen - as shown on plans/map for reference)
OPump Station Location ID (self chosen - as shown on plans/map for reference)
Design Flow
(MGD)
Operational Point
GPM @TDH
Power Reliability Option
1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. 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 2nd treatment facility
(RO — if "yes" to B,12 please contact the Central Office PERCS Unit)
13. 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? ❑ Yes ❑ No ® N/A
Stormwater? ❑ 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
Check if Yes: ❑ and provide details
Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1, _H. Goldston Womble, Jr , attest that this application for Carolina Bay Sewer 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.
la.
Signing Official Signature
3.2• ja
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY;
N TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
0
f- 2.
c)
LL.
H
I Cr
LLJ
C.)
Date
Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
1, Brian Cox , attest that this application for Carolina Bay Sewer Extension _ 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. 1 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 fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
2a. Brian Cox
Professional Engineer Name
2b. Engineering Services, PA
Engineering Firm
2c. 1202 Benson Rd, Suite 200
Mailing Address
2d. Garner 2e. NC 2f. 27529
City State Zip
2g. 919-662-7272 2h. 919-662-7320 2i. [e-mail]
Telephone Facsimile E-mail
2- Zo-LC12--
•itis
NC PE Seal, Signature & Date
FTA12/07

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE —10/07)
Project Applicant Name: _Town of White Lake
Project Name for which flow is being requested: Carolina Bay Sewer Extension
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: _Town of White Lake WWTP
b. WWTP Facility Permit #: NC0023353
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
0.800
0.00156
0.496
0.0018
0.4993
62%
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
(Firm/Design)
Carolina Bay PS #7 0.080
Approx. Current Avg.
Daily Flow, MGD
0.036
RECEIVED
DENR-FAYETTEVILLE FtEGIC 1AL OFFIfF
III. Certification Statement:
I, /�e{S/ ,C. %!ls/e , 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
acce nce of this w to ater flow.
34- 2'/2.
Signing Offi al Signature Date

3839
40'
3837
3836
2
320 000
FEET
14° 37' 304- I 1 ,
78030' KELLY17ML 731
yo).0 Mapped, edited and published by the Geological Survey
t# in cooperation with North Carolina Department of
Natural Resources and Community Development
Control by USGS, NOSMOAA, and State of North Carolina agencies
Topography by pammetric methods from aerial photographs
taken 1980-81. Field checked 1983. Map edited 1986
6-•-..Y.. ..A 1/t. t_ .. . • .. • - -
2 160 000 FEET
MN
GN
V.J
6,0
27' 30"
•

Es
ENGINEERING
SERVICES, PA
1202 Benson Road
Suite 200
P.O. Box 1849
Garner, NC 27529
■
Telephone:
919.662.7272
Fax:
919.662.7320
March 9, 2012
NCDENR — Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
RECEIVED
12 2012
DENR -FAYETTEVILIEW4ONAL OFFICE
RE: Town of White Lake
Carolina Bay Sewer Extension Fast Track Permit Application
Engineering Services Project No. 11050
To Whom It May Concern:
Enclosed is one (1) original and one (1) copy of the NCDENR Fast Track Permit
Application for Gravity Sewers, project narrative and the $480 application fee.
If you have any questions, please contact me at Engineering Services, P.A. at
[phone].
Sincerely,
ENGINEERING SERVICES, P.A.
Brian G. Cox, P.E.
Enc:
"A COMMITMENT
TO EXCELLENCE"

PROJECT
Carolina Bay Sewer Extension, White Lake, NC
PROJECT NARRATIVE
The project consists of connecting into an existing 8" gravity sewer system and extending an 8" sanitary
sewer main approximately 320 linear feet. The new sewer main will have five (5) new residential service
connections. The sewer is located outside of 100 feet of any water surface or wetland.

•
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Owner/Permittee:
la. Town of White Lake
Full Legal Name (company, municipality, HOA, utility, etc.)
H. Goldston Womble, Jr., Mayor
Application Number: •es_
(to be completed by DWQ) W 6 0 3 p a,Li
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
1 c The legal entity who will own this system is:
0 Individual 0 Federal ® Municipality 0 State/County 0 Private Partnership 0 Corporation ❑ Other (specify):
CC
• 1d. 1879 White Lake Drive 1e. White Lake
ZMailing Address City
,1g 28337
1f. North Carolina
Z `< State
„ • 1 h. 910-862-4800 1 i. 910-862-8686
QTelephone Facsimile
U 2. Project (Facility) Information:
j 2a. Carolina Bay Sewer Extension
CL Brief Project Name (permit will refer to this name)
0. ° Contact Person:
Brian Cox, Engineering Services
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. 919-662-7272
Phone Number
Zip Code
1j. [e-mail]
E-mail
...._._...__......
2b. Bladen
County Where Proj ECENED
MAR 1 2 2012
3c. bgcox@belIVNIALIIVETTEVILLEREGIONALOFFICE
E-mail
. Project is ® New 0 Modification (of an existing permit) If Modification, Permit No.:
2. Owner is I Public (skip to Item B(3)) ■ Private (go to Item 2(a))
2a. If private, applicant will be:
2b.
church, single office, etc.) or
etc. - skip to Item B(3))
etc. - go to Item B(2b))
If sold, facilities owned by a (must choose one)
(Instruction C)
Assoc./Developer (Instruction D)
■ Retaining Ownership (i.e. store,
■ Public Utility
■ Leasing units (lots, townhomes,
■ Homeowner
• Selling units (lots, townhomes,
3. Town of White Lake
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Town of White Lake WWTP 4b. NC0023353
Name of WWTF
5a. Town of White Lake
5b. 8 inch
WWTF Permit No.
5c.
►1 Gravity
Owner of Downstream Sewer
6 The origin of this wastewater is
Receiving
(check
Sewer Size • Force Main
Permit # of
centers)
Downstream Sewer (Instruction E)
100 % Domestic/Commercial
% Industrial (attach
all that apply):
0Residential Subdivision
IIRetail (Stores, shopping
• Apartments/Condominiums
■ Institution
• Hospital
■ Mobile Home Park
description.)
Pretreatment contact your Regional Office
staff)
% Other (specify):
• School
• Church
• Restaurant
III Nursing Home
• Office
• Other (specify):
7. Volume of wastewater to be allocated
or permitted for this particular project: 1,800
gallons per day
*Do not include future flows
8. If the permitted flow is zero, indicate
or previously
why:
in
of existing
permitted allocations
Line where flow will be permitted in subsequent
Permit No.
permits that connect to this line
NCAC 02T,.0303 to determine if a
IN Pump Station, Outfall or Interceptor
■ Flow has already been allocated
■ Rehabilitation or replacement
permit is required)
sewer with no new flow expected (see 15A