WQ0039887_Application (FTSE)_20180328

RECEDED State of North Carolina
DWR DEQIDWR Department of Environmental Quality
MAR 2 220Q Division of Water Resources
15A NCAC 02r.0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
ROS
FAYETTEVILE RFRO ALOFFICE
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T 15A NCAC 02T .0300, Division policies and good engineering practices.
Division of Water Resources
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC 1C .0100;
> Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
> Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
> Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
> Be specific as to the system type, number of homes served, flow allocation required, etc.
> If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
CO Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
p If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
p If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
• The Project Name in Item I1.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
• The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 3

E. ,flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
e Subnlit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
> The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of this application and form FTSE 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 a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
El Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
D Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
> This alternative is only available for average daily flows less than 15,000 gallons per day
> It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump station."
➢ 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
timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J.
Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .01 15(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

e
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, 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
Water Quality Section
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
Water Quality Section
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
Water Quality Section
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
Water Quality Section
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
Water Quality Section
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pender
Water Quality Section
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, North Carolina 27105
[phone]
Alamance, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
Water Quality Section
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

PROJECT NAME:
NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
SCO Project # 16-12993-01A
NCDENR FAST TRACK SEWER PERMIT APPLICATION PACKAGE:
1. Cover Letter
2. Instructions
3. Permit Application Form (FTA 04-16)
3a. Permit Application Form, (page #5, sign by DOT)
4. Flow Tracking / Acceptance Form (FTSE 08-13)
4a. Flow Tracking (pages #1 and 2, complete and sign by Town of White Lake)
4b. Flow Tracking (pages 3 - 6, n/a and instructions)
5. Power Reliability Plan
6. Maps
7. Project Summary
Please review, notify us of any comments or corrections,
sign where noted, return to
Ken Bright Associates
PO Box 553
Sanford, NC 27330
NCDENR, Fast Track Sewer Permit Application:
Form (FTA 04-16)
Project Name: NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
SCO Project # 16-12993-01A

CIL 1117?
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:0003 [ 41M (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: North Carolina Department of Transportation (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ® State/County 0 Municipal ❑ Other
3. Signature authority's name: Sterling D. Baker, PE per 15A NCAC 02T .0106(b)
Title: Facilities Management Unit
4. Applicant's mailing address: NC -DOT, Transportatioin Bldg. 1557 Mail Service Center, Raleigh, NC 27699 (USPS Mail)
City: Raleigh State: NC Zip: 27699-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
H. PROJECT INFORMATION:
1. Project name: NCDOT Bladen County Maintenance Facility Sewer Line and Lift Station
2. Application/Project status:
® Proposed (New Permit) 0 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: WQ00
3. County where project is located: Bladen
4. Approximate Coordinates (Decimal Degrees): Latitude: 34.653683° Longitude: -78.520448°
5. Parcel ID (if applicable): Prop #062320
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Ken Bright, PE License Number: 17585
Firm: Ken Bright Associates, PLLC
Mailing address: PO Box 553
City: Sanford State: NC Zip: 27331-0553
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: White Lake WWTF Permit Number: NC0023353
Owner Name: Town of White Lake
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: 3"FM inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00136
Owner Name(s): Town of White Lake
FORM: FTA 04-16 Page 1 of 5

VI. , GENERAL REQUIREMENTS
•' 1 : If the'Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential Owned
❑ Residential Leased
❑ School / preschool / day care
❑ Food and drink facilities
® Businesses / offices / factories
❑ Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
5. Nature of wastewater : 100 % Domestic/Commercial 0 % Commercial
0 % Industrial (See 15A NCAC 02T .0103(20))
)Is there a Pretreatment Program in effect?
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool /Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
❑ Yes ® No
Z No
Establishment Type (see 02T.0114(f))
Daily Design Flow Lb
No. of Units
Flow
OFFICE
25 gal/day
45
1,125 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
1,125 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., 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. 42A-4).
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.
8. Wastewater generated by project: 1,125 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 (Explain):
FORM: FTA 04-16
Page 2 of 5

' VII... ' GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
6
481
PVC-SDR 26
--44
144
3
) w A'1 I 2,
➢ Section 11 & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III 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) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: #1, DOT-Bladen-County Maintenance Yard
2. Approximate Coordinates (Decimal Degrees): Latitude: 64.654033° Longitude:-78.51.9697°
3. Design flow of the pump station: 0.001125 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 55 gallons per minute at 58 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
3
915
PVC SCH 40
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
Z Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ 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.
➢ 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 timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX.. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1 Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g)
D. 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Z Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
24 inches
Water mains (vertical -water over sewer including in benched trenches)
18 inches
Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
> 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
> If noncompliance with 02T.0305(f) or (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes 0 No 0 N/A
D. See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
> As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
❑ Yes ® No
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes 0 No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No ❑ N/A
> If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X: CERTIFICATIONS:
1. Does the submitted system comply with 1 5A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
IfNo, 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.
2. Professional Engineer's Certification:
1, Ken W. Bright
(Professional Engineer's name from A plication Item III. I.
NCDOT Bladen County Maintenance Facility Sewer Line and Litt Station
attest that this application for
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 143-215.6B, 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 $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
.‘`���1 S
11111,47
` CAR°
p,
`; �O .�FESSIO
w. Ba\c".,�
'111,,,, , 11t%t.`
3. Applicant's Certification per 15A NCAC 02T .0106(b):
Fuca \.fir, w 1Ylu►w nest that this application for
(Si natur Authority's name & title from Application Item I.3.)
NCDOT Bladen County Maintenance Facility Sewer Line and Lift Station
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. I 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 claim 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 143-215.6B, 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 $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: 3 js-7'c9
FORM: FTA 04-16
Page 5 of 5

State of North Carolina
' ' F Department of Environmental Quality
Division of Water Resources
Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Town of White Lake
Project Name for which flow is being requested: NCDOT Bladen Co. Maintenace Yard
More than one FTSE 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: White Lake WWTP
b. WWTP Facility Permit #: NPDES # NC0023353
All flows are in MGD
c. WWTP facility's permitted flow 0.800
d. Estimated obligated flow not yet tributary to the WWTP 0.000
e. WWTP facility's actual avg. flow 0.520
f. Total flow for this specific request 0.001,125
g. Total actual and obligated flows to the facility 0.521
h. Percent of permitted flow used 65.14%
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:
(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 / pf), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
999
* The Firm Capacity of any pump station is defined as the maximum pumped flow that
can be 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): White Lake, Collection Permit# 00136
Downstream Permit Number: WWTP Permit #NC0023353
Page 1 of 6
FTSE ()-1-16

III. Certification Statement:
I Tim Frush, Public Works Director 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 II plus all
attached planning assessment addendums for which I am the responsible party. Signature of this
form indicates acceptance of this wastewater flow.
3-1C- 20/k
Signing Official S' nature Date
Page 2 of 6
FTSE 04-16

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available
Capacity is < 0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to
allow this flow to be permitted, without a significant likelihood of over -allocating capacity in the
system infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste
disposal system.
Signing Official Signature Date
Page 3 of 6
FTSE 04-16

Instructions for Flow Tracking/Acceptance form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not yet tributary to the WWTP, MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through
interlocal agreements or other contracts not yet contributing flow to the collection system are also
included. For POTWs that implement a pretreatment program, include flows allocated to industrial
users who may not be using all of their flow allocation. Please contact your Pretreatment Coordinator
for information on industrial flow tributary to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years
and reconciled their flow records, to the best of their ability, so it is known how much flow has been
obligated and is not yet been made tributary to the WWTP, in accordance with local policies and
procedures employed by the reporting entity.
e. WWTP facility's actual avg. flow, MGD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + f]
h. Percent of permitted flow used: Equals [(g / c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there
is 0.5 MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7
MGD. There is a proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f. = 0.015 MGD
g. = 3.215 MGD
h. = 53.6 %
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
f. = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 04-16

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design
average daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow
through the pump station (C) for each pump station that will be impacted by the proposed sewer extension
project. Calculate the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D).
Include the proposed flow for this project with other obligated flows that have been approved for the pump
station but are not yet tributary (C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as
per the Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not
less than 2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump
station if the system has future specific plans related to capacity that should be considered in the permitting
process.
(A) (B)
Design
Firm Average
Pump Station Capacity Daily Flow
(Name or Number) MGD (Firm / pf)
Kaw Creek PS 0.800 0.320
Valley Road PS
Approx.
Current Avg.
Daily Flow,
MGD
0.252
1.895 0.758 0.472
(C) (D)=(B+C) (E)=(A-D)
Obligated,
Not Yet Total Current
Tributary Flow Plus
Daily Flow, Obligated Available
MGD Flow Capacity*
0.080 0.332 -0.012
0.135 0.607 0.151
Page 5 of 6
FTSE 04-16

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity
is<0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether
there is significant likelihood that needed improvements or reductions in obligated flows will be in place
prior to activating the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to
manage the flow without capacity related sanitary overflows and must take all steps necessary to complete
the project or control the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned
project in the future not yet funded but in a formal plan adopted by the system. The system should carefully
weigh the certainty of successful timely project completion for any expansion, flow management diversion
or infiltration and inflow elimination projects that are the foundation of a planned solution to capacity
tracking and acceptance compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080
MGD of the committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01
MGD per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project
entitled Kaw Creek Pump Station upgrade with funding planned in July 2014. This project is planned to
add 0.100 MGD to the firm capacity of the pump station by October 2015. Inclusion of this proposed
capital project as a condition of this Flow Tracking/Acceptance for Sewer Extension Permit Application
elevates this project's priority for funding and construction to be implemented ahead of the activation of
obligated, not yet tributary flows in amounts that exceed the firm pump station capacities identified in
Section II above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
Page 6 of 6
FTSE 04-16

•
Project Name: NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
NCDENR, FAST TRACK SEWER PERMIT APPLICATION
POWER RELIABILITY PLAN:
DATE: 3/15/2018
FROM: Tom S. Poe, PE
KEN BRIGHT ASSOCIATES PLLC
TO: NCDENR, DEQ, DWR FAST TRACK PERMITTING GROUP
TOWN OF WHITE LAKE, Tim Frush
Sterling Baker, PE, Director Facilities Management Unit
NC Department of Transportation
SUBJECT: POWER RELIABILITY PLAN, as required by
15A NCAC 02T .0305(H)(1)
Fast Track Sewer System Extension Application page 3 of 5, Item #6
for the
THE NORTH CAROLINA DEPARTMENT OF TRANSPORTATION
BLADEN COUNTY — WHITE LAKE SEWER PROJECT,
LIFT STATION, GRAVITY SEWER LINES AND FORCE MAIN
LOCATION: NCDOT BLADEN COUNTY MAINTENANCE FACILITY
5749 US-701, WHITE LAKE, N.C. 28337
NCDOT PROJ. NO. 12993
STATE CONSTRUCTION OFFICE, SCO ID# 16-12993-01A
POWER RELIABILITY PLAN
This is a Sewer Lift station and force main which depends on a portable and shared generator for
back-up and emergency power. The contributory flow to this lift station is small, approx. 1125 gal
per day, the storage capacity is large approx. 3500 gal, so the storage time in emergency without
power is almost 3 days. A portable generator is owned by DOT is normally on site or nearby and
can empty the lift station in approximately 30 min. In emergency, the water can be shut off to the
DOT facility and further reduce or eliminate the flow into the wet well and the eliminate the risk of
an overflow. Additional details about the Power Reliability Plan will be provided at the time of
Certification.
Project Name:
SCO Project #
NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
16-12993-01 A
Notes by
Tom S. Poe PE
919-616-4245
[e-mail]

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GRAVITY SEWER, FORCE MAIN, LIFT STATION PROJECT
5749 US-701, WHITE LAKE, NC 28337
STATE CONSTRUCTION OFFICE
SCO PROJECT ID# 16-12993-01A
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5749 US-701, WHITE LAKE, NC 28337
NCDOT PROJECT # 12993
SCO ID # 16-12993-01A
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NCDOT PROJECT
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PROJECT NAME:
NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
SCO Project # 16-12993-01A
NCDENR FAST TRACK SEWER PERMIT APPLICATION PACKAGE:
1. Cover Letter
2. Instructions
3. Permit Application Form (FTA 04-16)
3a. Permit Application Form, (page #5, sign by DOT)
4. Flow Tracking / Acceptance Form (FTSE 08-13)
4a. Flow Tracking (pages #1 and 2, complete and sign by Town of White Lake)
4b. Flow Tracking (pages 3 - 6, n/a and instructions)
5. Power Reliability Plan
6. Maps
7. Project Summary
Please review, notify us of any comments or corrections,
sign where noted, return to
Ken Bright Associates
PO Box 553
Sanford, NC 27330
NCDENR, Fast Track Sewer Permit Application:
Project Summary:
Project Name: NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
SCO Project # 16-12993-01A

4
Project Name: NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
PROJECT NOTES / SUMMARY:
THE NORTH CAROLINA DEPARTMENT OF TRANSPORTATION
BLADEN COUNTY — WHITE LAKE SEWER PROJECT,
LIFT STATION, GRAVITY SEWER LINES AND FORCE MAIN
LOCATION:
NCDOT BLADEN COUNTY MAINTENANCE FACILITY
5749 US-701, WHITE LAKE, N.C. 28337
NCDOT PROJ. NO. 12993
STATE CONSTRUCTION OFFICE, SCO ID# 16-12993-01A
OWNERSHIP:
DOT is/will be the Owner, the Permittee, and will be responsible for the O&M of the Lift Station,
gravity sewer lines, and force main on their property.
Back up portable generator is owned and available as needed by DOT
WASTEWATER TREATMENT AND COLLLECTIONS:
THE TOWN OF WHITE LAKE HAS THE FOLLOWING PERMITS:
SEWER COLLECTION SYSTEM PERMIT # NC 00136 ?
WASTEWATER TREATMENT PLANT, NPDES Permit # NC0023353
SCOPE OF WORK:
Installation of approximately 635 LF of 4" and 6" gravity sewer mains on DOT property
(481 LF of 6", and 154 LF of 4" PVC Gravity Sewer Lines)
(3) Abandon Septic Tanks
900 LF of 3" PVC Force Main
This new 3" Force Main is on DOT property, and ties into existing 3" Force Main near the street
from Dept. of Corrections facility abandoned approx. 2 years ago.
3) MH, gravity manholes with miscellaneous appurtenances,
1) MH for new Air Release valve, 1) replace old existing Air Release valve.
100 LF of 1" water line, Yard Hydrant, and meter and hot box.
Duplex Lift Station that includes two submersible pumps, precast wet well and precast valve vault,
all piping, valves, meters, electrical, SCADA, grading, fencing, and site work.
Includes start-up, programming, testing, demonstration of performance, training, O&M Manuals
and 1-year warrantee.
Patching, paving, repair and replace, seeding and mulching of disturbed surface areas
All work is on DOT property
Estimated Flow 1125 gpd
WHITE LAKE CONTACTS:
Tim Frush, Public Works Director, (cell 910-874-0439) [e-mail]
Lee Cain, Collections System
Bryan Cox, PE, 919-662-7272 (office), [e-mail]
Engineering Services, PA, 1202 Benson Road #200, Garner, NC 27529
DOT CONTACTS:
Ken Clark, County Maintenance Engineer, 910-862-3396(office),
910-874-1896 (cell), [e-mail]
Bladen County Facility.
Dan O'Connor PE, 919-907-9581 (cell), [e-mail]
Current Authorized Representative per email 3/14/2018,
Baker, Sterling P.E. Director, Facilities Management Unit
919-707-4552
Project Name:
SCO Project #
NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
16-12993-01A
Notes by
Tom S. Poe PE
919-616-4245
[e-mail]

Project Name: NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
[e-mail]
1525 MAIL SERVICE CENTER (MAIL)
RALEIGH NC 27699-1525
Transportation Bldg
1 S. Wilmington St. Room 514 (Delivery)
Raleigh NC 27601
Thomas L. Riddick, Business & Operations Manager, Facilities Management Unit
919-707-4560
[e-mail]
NCDENR CONTACTS:
Christine Furtenbaugh, PE, DENR-PERCS, Collection Systems, Raleigh
Trent Allen, DENR-FRO,
Jonathon Watts, DENR-FRO, jonathan.watts©ncdenr.gov
Hughley White, DENR-FRO, Collections Permitting
NOTES BY:
Tom S. Poe, PE
919-616-4245
[e-mail]
If you have any comments or corrections to these notes please let me know.
Thanks
Project Name:
SCO Project #
NCDOT Maintenance Office Sewer
BLADEN COUNTY -WHITE LAKE SEWER PROJECT
16-12993-01 A
Notes by
Tom S. Poe PE
919-616-4245
[e-mail]

KEN BRIGHT ASSOCIATES, PLLC
Consulting Engineers
March 15, 2018
Mr. Trent Allen
North Carolina Division of Environmental Management
Division of Water Quality
225 Green Street, Suite 714
Fayetteville, North Carolina 28301-5043 WQROs
FAYETTE L1E REGIONAL OFFICE
Re: NCDOT Bladen Co. Maintenance Facility
5749 US 701, White Lake, NC 28337
Lift Station, Gravity Sewer, and Force Main, (SCO Project # 16-12993-01A)
DEQ/Dttp
MAR 282018
Enclosed please find the following:
1. Cover Letter
2. Fast Track Sewer Application Instructions/Checklist
3. Fast Track Sewer Application, (FTA 04-16, with NCDOT as the Applicant)
4. Flow Tracking / Acceptance Form, (FTSE 04-16, by City of White Lake receiving this WW)
5. Power Reliability Plan, ( DOT, owner portable back-up generator, responsible for O&M)
6. Maps
7. Project Summary & check in the amount of $ 480.00 payable to NCDEQ
(one original, one copy, and electronic-pdf files are provided)
This NCDOT facility is currently served by 3 septic tanks with drain field lines and sewer
lines connecting various buildings. The proposed project consists of the of a new
duplex lift station, approximately 535 LF of 6" & 4" PVC gravity lines, 900 LF of 3" force
main which will tie into the city's existing 3" force main in the ROW of Hwy 701 in front
of the NCDOT site. A 3,000 gallon wet well / pump tank is proposed as emergency
storage. The NCDOT has portable generator to provide emergency power when
needed, and the Town of White Lake also provides emergency assistance and staff
support when needed.
If you have any questions please feel free to contact me.
Sincerely,
Ken W. Bright, P.E.
cc, NCDOT, Sterling Baker, Director Facilities Management Unit
Town of White Lake, Tim Frush, Public Works Director
NCDOT - Bladen County Maintenance Facility Sewer System
SCO Project ID # 16-12993-01A
P.O Box 553 1 Phone: [phone]
2305 Carthage Street
Sanford, NC 27330 e-mail: [e-mail]

State of North Carolina
Department of Environmental Quality
Division of Water Resources
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: North Carolina Department of Transportation (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation
❑ Federal ® State/County
❑ General Partnership
❑ Municipal
❑ Privately -Owned Public Utility
❑ Other
3. Signature authority's name: Sterling D. Baker, PE per 15A NCAC 02T .0106(b)
Title: Facilities Management Unit
4. Applicant's mailing address: NC -DOT, Transportatioin Bldg. 1557 Mail Service Center, Raleigh, NC 27REetiiigkiiiii
City: Raleigh State: NC Zip: 27699-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: NCDOT Bladen County Maintenance Facility Sewer Line and Lift Station
2. Application/Project status:
DEC)113WR
MAR 2 8 2018
WS
FAYETTEVILE REGIONAL OFFICE
® Proposed (New Permit) ❑ Existing Permit/Project 15'. 3 v
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: WQ00
3. County where project is located: Bladen
4. Approximate Coordinates (Decimal Degrees): Latitude: 34.653683° Longitude: -78.520448°
PAY TO THE
ORDER OF
NC Department of Transportation
1514 Mail Service Center
Raleigh, NC 27699-1514
NC DEPT OF ENVIRONMENTAL QUALITY
PUBLIC WATER SUPPLY SECT
1634 MAIL SERVICE CENTER
RALEIGH NC 27699-1634
State Treasurer, Raleigh, North Carolina
Payable at Par Through Federal Reserve System
Owner Name(s): 1 own of bite Lake
66-1059
531
Check 3919705
Date 03/16/2018
Void after One Year
$ 480.00
136W1101
Evan Rodewald
Chief Financial Officer
FORM: FTA 04-16
Page 1 of 5

Central Files: APS _ SWP
4/3/2018
Permit Number WQ0039887 Permit Tracking Slip
Program Category Status Project Type
Non -discharge Active New Project
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
johnathan.watts
Coastal SWRuIe
Permitted Flow
1,125
Facility
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Facility Name
NCDOT Bladen County Maintenance Facility Sewer Line and Lift Station
Location Address
Owner
Major/Minor Region
Minor Fayetteville
County
Bladen
Facility Contact Affiliation
Owner Name
North Carolina Department of Transportation
Dates/Events
Owner Type
Government - State
Owner Affiliation
Sterling D. Baker
NC -DOT Transportation Bldg
Raleigh NC 27699
Orig Issue
4/3/2018
Scheduled
App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
3/28/2018 4/3/2018 4/3/2018
Regulated Activities Requested /Received Events
Wastewater collection Additional information requested
Additional information received
Outfall
Waterbody Name Streamindex Number Current Class Subbasin