WQ0032767_Application (FTSE)_20080219

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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
1. Owner/Permittee:
la. Town of Elizabethtown
Full Legal Name (company, municipality, HOA, utility, etc.)
lb. Alton Bryant, Public Works Director
Application Number:
(to be completed by DWQ)
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
5 lc. The legal entity who will own this system is:
❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
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A. APPLICATION
ORMATION
1 d. P.O. Box 716
Mailing Address
1f. North Carolina
State
lh. [phone]
[phone]
Telephone Facsimile
2. Project (Facility) Information:
2a. Martin Luther King Pump Station Upgrade
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Bill Lester, Jr., P.E.
le. Elizabethtown
City
1 g. 28337-0716
Zip Code
1j. [e-mail]
E-mail
2b. Bladen
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. [phone]
Phone Number
3c. [e-mail]
E-mail
Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3))
2a. If private, applicant will be:
❑ Private (go to Item 2(a))
2b. If sold, facilities owned by a (must choose one)
0 Retaining Ownership (i.e. store, church, single office, etc.) or
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
0 Selling units (lots, townhomes, etc. - go to Item B(2b))
3. Town of Elizabethtown
0 Public Utility (Instruction C)
❑ Homeowner Assoc./Developer (Instruction D)
Owner of Wastewater Treatment Facility (WVVfF) Treating Wastewater From This Project
4a. Elizabethtown WWTP
Name of WWTF
5a. Town of Elizabethtown
5b. 18 inch ® Gravity
Owner of Downstream Sewer Receiving Sewer Size !.❑ Force Main
Thrs nrinin of +hie wancfawa+ar is /(-hark all that annlvl'
4b. NC0026671
WWTF Permit No.
5c. Not Known
Permit # of Downstream Sewer
(Instruction E)
IMj
7HOBBS, 71 PC5fZIQC5f die ASSOCIATES, P.L.
CONSULTING ENGINEERS
P.O. BOX 1737, 300 S.W. BROAD STREET
SOUTHERN PINES, NC 28388
[phone]
Exactly Four hundred eighty and no / 100 Dollars
PAY
TO THE
ORDER
OF:
N. C. DENR
NC
BB&T
Branch Banking and Trust Company
66-112/531
DATE
1/28/2008
VOID AFTER 90 DAYS
47331
47331
AMOUNT
$480.00
Details on back.
8
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State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
(FTA 12/07 )
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sever systems are not to be included as part of this application package)
copy
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/Collection SystemA pplications. 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.
❑ 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 less 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.
FTA 12/07

- ®.G. Stream Classifications — Watershed Classification Attachment (Form WACAS-12/07) If any portion of the
project boundary is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment
must be completed.
❑ 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: http://h2o.enr.state.nc.us/peres/
or contact the Regional Office serving your county.
FTA 12/07

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1.
1 a.
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Owner/Permittee:
Town of Elizabethtown
Application Number: (t be Q00327 67
(to be 1N
completed by DWQ) it
Full Legal Name (company, municipality, HOA, utility, etc.)
1b. Alton Bryant, Public Works Director
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
lc. The legal entity who will own this system is:
O Individual 0 Federal ® Municipality 0 State/County 0 Private Partnership 0 Corporation 0 Other (specify):
1 d. P.O. Box 716 le. Elizabethtown
Mailing Address City
1f. North Carolina lg. 28337-0716
State Zip Code
lh. [phone] li. [phone] 1j. [e-mail]
Telephone
Facsimile E-mail
2. Project (Facility) Information:
2a. Martin Luther King Pump Station Upgrade 2b. Bladen
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Bill Lester, Jr., P.E.
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. [phone] 3c. [e-mail]
Phone Number E-mail
1. Project is ® New 0 Modification (of an existing permit) If Modification, Permit No.:
2. Owner is ® Public (skip to Item 8(3))
2a. If private, applicant will be:
❑ Retaining Ownership (i.e. store, church, single office, etc.) or
❑ Leasing units (lots, townhomes, etc. - skip to Item B(3))
❑ Selling units (lots, townhomes, etc. - go to Item B(2b))
3. Town of Elizabethtown
❑ Private (go to Item 2(a))
2b. If sold, facilities owned by a (must choose one)
❑ Public Utility (Instruction C)
❑ Homeowner Assoc./Developer (Instruction D)
Owner of Wastewater Treatment Facility (WVVfF) Treating Wastewater From This Project
4a. Elizabethtown WWTP 4b. NC0026671
Name of WWTF
5a. Town of Elizabethtown
Owner of Downstream Sewer
5b. 18 inch ® Gravity
Receiving Sewer Size ❑ Force Main
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
WWTF Permit No.
5c. Not Known
Permit # of Downstream Sewer (Instruction E)
❑ Retail (Stores, shopping centers)
❑ Institution
❑ Hospital
0 Church
O Nursing Home
® Other (specify):Municipal
100 % Domestic/Commercial
% Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify):
7. Volume of wastewater to be allocated or permitted for this particular project: 0 gallons per day
*Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
O Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
O 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)
FTA 12/07

9. 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).
No additional flow will result from this project. Work is for rehabilitation of an existing pump station.
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet)
4-inch
8-inch
50
40
New Gravity or Additional
Force Main
Force Main
Gravity Main
0 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
W
M Pump Station Location ID MLK P.S. (self chosen - as shown on plans/map for reference)
Z
Design Flow Operational Point Power Reliability Option
Z (MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
Q 2 - portable generator w/MTS
V
... 0.092 160@137.76 1 4-inch 3,538
Z
0
17,
Pump Station Location ID (self chosen - as shown on plans/map for reference)
2 Design Flow Power Reliability Option
Operational Point
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
Q 2 - portable generator w/MTS
LL
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B. PERMIT
•
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
FTA 12/07

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? 0 Yes 0 No Z N/A
Sedimentation and Erosion Control Plan? ❑ Yes 0 No Z N/A
Stormwater? 0 Yes ® No D 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
1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1, Alton Bryant, Public Works Director, attest that this application for Martin Luther King Pump Station Upgrade 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 retumed as incomplete. Note: In accordance with North Carolina Genera;
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 $le ()00
as well as civil penalties up to $25,000 per violation.
l a.
Signing Official Signature Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
u) TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
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Q2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
1, Bill Lester, Jr., P.E., attest that this application for Martin Luther King Pump Station Upgrade has been reviewed by
LL me and is accurate, complete and consistent with the information in the engineering plans, calculations, and all other
F:. 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
LLJ 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
V under my signature and seal signifies that 1 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. Bill Lester, Jr., P.E.
Professional Engineer Name
2b. Hobbs, Upchurch & Associates, P.A.
Engineering Firm
2c. P.O. Box 1737
Mailing Address
2d. Southern Pines 2e. NC 2f. 28388
City State Zip
2g. [phone] 2h. [phone] 2i. [e-mail]
Telephone Facsimile E-mail
NC PE Seal, Signature & Date
FTA 12/07

FORM WSCAS-12/07
WATERSHED CLASSIFICATION ATTACHMENT
FOR SEWER SYSTEMS
Applicant Name
Project Name
Town of Elizabethtown
Martin Luther King Pump Station Upgrade
Professional Engineer Name
Engineering Firm Name
Bill Lester, Jr., P.E.
Hobbs, Upchurch & Associates, P.A.
Location
ID
Name of Waterbody'
County
River
Basin
Waterbody Stream
Index No.
Waterbody
Classification
MLK P.S.
Browns Creek
Bladen
Cape Fear
18-45
C
MLK P.S.
UT to Browns Creek
Bladen
Cape Fear
NA
NA
1
If unnamed, indicate "unnamed tributary to X", where X is the named waterbody to which the unnamed tributary joins.
I certify that as a Registered Professional Engineer in the State of
North Carolina that I have diligently followed the Division's instructions
for classifying waterbodies and that the above classifications are
inclusive of the stated project, complete and correct to the best of my
knowledge and belief.
PE Seal, Signature and Date
*** END OF FORM WSCAS-12/07 ***
FORM: WSCAS-12/07
Page 1 of 1

F W A TF State of North Carolina
QG Department of Environment and Natural Resources
co`r 1 .�€ Division of Water Quality
-c Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE —10/07)
Project Applicant Name: Town of Elizabethtown
Project Name for which flow is being requested: Martin Luther King Pump Station Upgrade
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 Elizabethtown WWTP
b. WWTP Facility Permit #: NC0026671
All flows are in MGD
c. WWTP facility's permitted flow 1.225
d. Estimated obligated flow not yet tributary to the WWTP 0.060
e. WWTP facility's actual avg. flow 0.666
f. Total flow for this specific request 0.000
g. Total actual and obligated flows to the facility 0.726
h. Percent of permitted flow used 59.3%
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 Approx. Current Avg.
(Firm/Design) Daily Flow, MGD
0.550 0.445
Locks Road Pump Station
Note: Locks Road Pump Station is currently being upgraded to the noted capacity.
III. Certification Statement:
1, Alton Bryant, Public Works Director, 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
acceptance of this was ater flow.
Signing Official Signature
Date