WQ0034137_Application (FTSE)_20090611

JENR--
DWQ
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
(FTA 12/07 ver5)
for GRAVITY 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/percs/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-contiquous 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.

O G. 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 need 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(1b). 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 S480 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, Hamett, 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, Allegheny, 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/Collection%20Systems/CollectionSystemsHome.html
or contact the Regional Office serving your county.

' Application Number:
• USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! (tobe completed by oWQ) W00034137
i. Owner/Permittee:
A77�/. 7c i/
r�/��
1a.
Full Legal Na e (compa , m icipali utility, etc.)
Z 1b. , /
Signing Offi ' I Name and Title
i-
Q 1 c. The legal entity who will own this
(Please
system
review 15A NC
p
is: ,
C 2T .
J
Private P
1e.
authorized si fficials!)
.'`� ���''pc'�
■ Individual • Federal • Municipality
■ State/County
nership ■ Corporation ■ Other (specify):
0 Id.
ZMailing Address2/",'
City4 9���- 1f.�/ D 1g.Z
State /i.../.¢- Zip Code
O 1h. /v _ 1i. (9/),1 9�-fe�c-�. U
1j.
1.-Telephon p� W� pZ Facsimiltq,�
a
V 2. Project Facility) Info anon:
9gd jj4 E-mail k.a �,,fle,, 4 ,
/�� / %
2b. l�jhjd//�
2a.
0. Brief Project Name (permit will
0'
Q 3. Contact P rson:
refer to this name) County Where Project is Located
3a. L� /� �/�//�
Q Name and Affiliation of Someone Wh Can Answer Questions About this Application
3b. 9/l) f P ,2�7 3c. C , `'//� �?�l/ ( '
Pon um er / E-mail
1. Project is f' New • Modification
(of
an existing permit)
If Modification, Permit No.:
B(3))
(go to Item 2(a))
2. Owner is • Public (skip to Item
• Private
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,
IN Public Utility
■ Leasing units (lots, townhomes,
• Homeowner
• Selling units (lots, townhomes,
3. OtA/41 004- c -V) 4
Z Owner of Wastewater Treatment cility F) Treating Wastewater From This Project
O 4a. f &o, /ih L�' e 4b. N&O3o9707
Name ofWWT71M"'OA/ ww%/:= WWfF Permit No.
a5a.
5b.
■ Gravity
• Force Main
5c.
re Owner of Downstream Sewer
0 6. The origin of this wastewater is
LL
Z
Receiving
(check
Sewer Size
all that apply):
Permit # of
centers)
Downstream Sewer (Instruction E)
/o % Domestic/Commercial
(Stores, shopping
Home
(specify):
NI Residential Subdivision
MI Retail
% Industrial (attach
~ Apartments/Condominiums
2 Mobile Home Park
• Institution
• Hospital
description.)
(RO: contact your Regional Office
Pretreatment staff)
% Other (specify):
it ■ School
• Church
aIll Restaurant
II Nursing
■ Office
• Other
or permitted for
ai
7. Volume of wastewater to be allocated
this particular
allocations
will be permitted
project: /qiz,(.2
gallons per day
*Do not include future flows
8. If the permitted flow is zero, indicate
or previously
why:
in
of existing
permitted
Line where flow
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

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).
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) New Gravity or Additional
Force Main
/NCH 260 NEW GRAVITY
• 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
W
Pump Station. Location ID (self chosen - as shown on plans/map for reference)
Z
Design Flow Power Reliability Option
Z (MGD) OP GPM @TDHerational 'nt 1 - permanent generator w/ATS; Force Main Size Force Main Length
O 2 - portable generator w/MTS
U
Z
0
QPump Station Location ID (self chosen - as shown on plans/map for reference)
Design Flow Operational Point Power Reliability Option
cc (MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
O 2 - portable generator w/MTS
LL
H
OC
W
a
00
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
❑ Yes X 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 ❑ N/A
Sedimentation and Erosion Control Plan?
Stormwater?
❑ Yes ❑ No ❑ N/A
❑ 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: 0 and provide details
1. Owner/Permittee's Certification: (Signature of Signing Official and Project`Name)e)C/:��
1, (a ij 74 ��/iy attest that this application for //Vc IV/Cfr�/ L% ;/ G has been
reviewed by me and is aco&rate and complete to the best of my knowledge.) understand that if all required parts of this
application are not completed and that if all required supporting documentation and attachments am 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 w nalties up to $2 _ per violation.
1111 1011' • •
Siyn g Offic al ignatur '/
Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
ij TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
'lrk aG-oa G
O 2.
V
F—
W
V
ci
Professional Engineer's Certification: (Signature f Design Engineer
M tfe4S A�wr4' S#L attest that this application for . ��:I‘�!4? , ;%rj t '� v-, 11 r�i has been
G/JU2r'f/r' 26-4t6s74r2
LL G
reviewed by me and is accurate, complete and consistent with the in ': '' ' 'e`' en ns, calculations, and
all other supporting documentation to the best of my knowledge. I further attest that to the best of my knowledge the
proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria
for Gravity Sewers adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump
Stations and Force Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance.
Although 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 hn 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. MYERS A. COLVIN SR
ti
Professional Engineer Name
2b. M.A. COLVIN ENGINEERING & CONSULTING INC.
Engineering Firm
2c. 2547 RAVENHILL DR SUITE 103
Mailing Address
2d. FAYETTEVILLE
City
2g. [phone]
2e. NC 2f. 28303
State Zip
2i. [e-mail]
Telephone Facsimile(910) 223-0804 E-mail
Pi
NC PE Seal, Signature & Date
FTA I2/07

LALCu,C,4.'Clo 4 Or WASTewnT a FG,0(4.)
ld.i o 2-CN '� 4 C. C�'S Ti'l7o L L C
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2tlots..
( pev 0,10-
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Tovv 0 F seCRN . Poet-rC u'i'iL tTit-.5 De- i''

WWTP facility's permitted flow
Estimated obligated flow not yet tributary to the WWTP
WWTP facility's actual avg. flow
Total flow for this specific request
Total actual and obligated flows to the facility
Percent of permitted flow used
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Flow Tratking/Acceptance for Sewer Exteasioe Permit Applications
(r-ISE—10/07)
roject Applicant Name: i if 4-/.'5 //t/4/71A�
roject Name for which flow is being requested: h1l0Y.I-A /1rrf i 5
Ore Arm one F7SE-J O7 may be required far a single project If the owner gfthe WWTP is not nolitonsiblefor all
map stations along the route grilse proposed wastewater f ow.
Complete this section only if you are the owner of the wastewater treatment plant.
WWTP Facility Name: 5pc—t L-414-/ ( i i./ i J j F
WWTP Facility Permit #: t , (DOq 7z2
All flows are in MGD
f-
f>. / i?y4
(-lgoo ir+6
©O . O2.mcD
Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
st pump stations located between the project connection point and the WWTP
imp Station Name Approx. Capacity, MGD Approx. Current Avg.
(Firm/Design) Daily Flow, MGD
1 b !! , certify that, to the best of my knowledge, the addition of the
permitted in this project has been evaluated along the route to the receiving
stewaiv ' , and that the flow from this project is not anticipated to cause any capacity
w ed sanitary sewer overflows or overburden any downstream pump station en route to the receiving
ument plant under normal circumstances. This analysis has been performed in accordance with local
u bfudral pulitias anti p iuce dwra using tiro bust available dant cadticetlon applies to those Items
ed above m Sections I and ! for which I ami ib Signature of this form indicates
eptancefithis ,.
5 ZVd
?ting lalSignature r 1Date

721 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
Google maps Address
http://maps.google.com/maps?h1=en&riz=1T4ADBR enUS264US265&q=221%20Hickor... 6/10/2009

221 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
Google
aps Address
http://maps.google.com/maps?hl=en&riz=1T4ADBR enUS264US265&q=221%20Hickor... 6/10/2009

721 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
aPS Address
http://maps.google.com/maps?h1=en&riz=1 T4ADBR enUS264US265&q=221 %20Hickor... 6/10/2009

221 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
Goog e
aPS Address
http://maps.google.com/maps?h1=en&riz=1 T4ADBR enUS264US265&q=221 %20Hickor... 6/10/2009

626 Mont Drive Spring Lake, NC 28390 - Google Maps
Page 1 of 1
C le m s Spring
Address Mont Dr
SprinnggLake,
, NC 28390
Get Googie Maps on your phone
Text the word "GMAPS'to 466453
http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=626+Mont+Drive+... 6/10/2009

221 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
Google maps Address
http://maps.google.com/maps?h1=en&riz=1T4ADBR enUS264US265&q=221%20Hickor... 6/10/2009

221 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
Google maps Address
http://maps.google.com/maps?hl=en&riz=1T4ADBR enUS264US265&q=221%20Hickor... 6/10/2009

221 Hickory Street Spring Lake, NC 28390 - Google Maps Page 1 of 1
Goog
aps
Address
http://maps.google.com/maps?h1=en&riz=1 T4ADBR enUS264US265&q=221 %20Hickor... 6/10/2009

USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
1.
1a.
Full Legal Na r e (compa , m icipali utility, etc.)
z • 1 b.
Signing Offi '-I Name and Title (Please review 15A NCAC 2T .
1 c. The legal entity who will own this system is:
g ❑ Individual ❑ Federal ❑ Municipality ❑ State/County
0
LL 1f.
f MailingAddressZ State
y� �1
j-
Application Number:
(to be completed by DWQ)
Private P
1 e.
z
1 d.
1 g.
O 1h. /v 1i. (9/�!% 90e) ,fe)rey 1j.
(— Telephon p) ' pZ FacsimiltW 90Jti
2. Proiectacility) Infor/nation:
J 2a. 2b.
Et.
Q3. Contact P
3a.
Brief Project Name (permit will refer to this name)
4/ 4-7
fficials!)
/Jyy/J c%'C
nership ❑ Corporation ❑ Other (specify):
City r//
Zip Code
2 3,U
E-mail
County Where Project is Located
Name and Affiliation o Someone WhQ Can Answer Questions About this Application
111 (—a- % I .) ‘7-?/-- /)',/4 q,. /? /.I/., � /-, i ;# "owl
THIS DOCUMENT HAS AN ARTIFICIAL WATERMARK PRINTED ON THE BACK THE FRONT OF THE DOCUMENT
581058 (100/pkg) 4)
40
►till '17.f 1i1J-4it
HAS A MICROPRINT BORDER AND. W FIBERS. ABSENCE OF THESE FEATURES WILL.INDICATE ACOPY.
5-709
110
23492663
Pay To The Order Of
Dollars (Face Value Valid One Year From Issue, Three Years in CA - Money Order Subject to Retum and Service Charge Thereafter)
099620 / M 37173-P
WACHOVIA
AGENT FOR MONEYGRAM /�
DRAWER: MONEYGRAM PAYMENT SYSTEMS, INC. DRAWEE: BOSTON SAFE DEPOSIT & TRUST CO. Not Good For More Than $1,000.00 �rtty Features Back
P.O. BOX 9476, MINNEAPOLIS, MN 55480 BOSTON, MASSACHUSETTS
Purchaser, Signer For Drawer
- i. t
l._It i.i:. t,Jt�i t.:rV
Address
For
It CC?,?.rt . Pi-r;`1
Date
05%15 iL. r,O`)
: t S.
""Pr0.00
PURCHASER, BY SIGNING YOU AGREE TO THE SERVICE CHARGE AND OTHER TERMS ON THE REVERSE SIDE
II. 2 349 266311/ 1:0 L 100709 21:0 L707 L L994383111
ST. CHARLES INVESTMENT GROUP
WORTHY & CO., INC.
6320 LYNETTE CIRCLE
FAYETTEVILLE, NC 28314
TO THE /v .eA/r
ORDER OF
FOR
WACHOVIA
Wachovia Bank, N.A.
wachovia.com

DATE �/ d/
yea.
DOLLARS
3108
66-162/531
BRANCH 30156
Fe.luref
VP

00CUMNItioA AN AFRIRSIAL WATERMARK (*THE BACK imam oF DocumENT
581058 (100/pkg)
4 • 4 .4+
HAS A MICRO -PRINT BORDER ARO UV FIBERS. AMERCE OF THESE FEATURES WILL INDICATE A COPY.
23492663 5-709
110
Pay To The Order Of
Dollars (Face Value Valid One Year From Issue, Three Years in CA - Money Order Subject to Return and Service Charge Thereafter)
T I '3 1)1..L MD oo. GENTS
099620 / M 37173-P
L A
WACHOVIA
AGENT FOR MONEYGRAM
DRAWER: MONEYGRAM PAYMENT SYSTEMS, INC. DRAWEE: BOSTON SAFE DEPOSIT & TRUST CO. Not Good For More Than $1,000.00 Security Features
P.O. BOX

ST. CHARLES INVESTMENT GROUP
WORTHY & CO., INC.
6320 LYNETTE CIRCLE
FAYETTEVILLE, NC 28314
PAY
TO THE
ORDER OF
WACHOVIA.
Wachovia Bank, N.A.
wachovia.com
DATE .5--
FOR

3108
66-162/531
BRANCH 30158
Securlte
Features
DOLLARS

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:
(to be completed by DWQ)
1. Owner: \(a,- - ZEAL,
:S'FA'i.0 . LLtv►- . .
11a. WO k 4 kL- ESIA Vr LAX -
Full Legal Name (company, municipality, HOA, utility, etc.)
WQ0034137
1b. Cu v1I0e t“ ('MAIJ*61►Nc, MM. eL)
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
!lc. The legal entity who will own this system is:
Q Individual 0 Federal ❑ Municipality ❑ State/County Private Partnership ❑ Corporation 0 Other (specify)
11d. /j2,(D Mt7 �
APT'� �T A 1 e. S Pt'.1 N G LA It. E:
Mailing Address . City
1 f. 4 b12- C Irk C A CO L.j 1 g. 2.0
State
Zip Code
.`,. 11h. (0)41(0 02694 1i. 1j. C -Hl.)t)f+Ill y PASA0 C0iM
phone Facsimile E-mail
0 12. Project (Facility) Information:
J
O. i Brief Project Name (permit will refer to this name)
3. Contact Person.
13a. P rt % VVoth''
Name and Affiliation of Someone Who Can Answer Questions About this Application
fib. C°1. (0) li3 ' 0204 3c. IL -- WO e4.1A1 S MSM , wen
▪ Phone Number E-mail
11. Project isp2 New 0 Modification (of an existing permit) If Modification, Permit No.:
For modifications, attach a separate sheet clearly explaining 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 in B(7) and B(10-11) that has already been included in the original permit.
p. Owner is 0 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 am)
0 Retaining Ownership (i.e. store, church, single office, etc.) or 0 Public Utility (Instruction III)
® Leasing units (lots, townhomes, etc. - skip to Item 8(3)) 0 Homeowner Assoc./Developer (Instruction IV)
0 Selling units (lots, townhomes, etc. - go to ftem B(2b))
za. WOa-i p (' (ttou.se. 0241eci 2b. u 12.ev`taf°
County Where Project is Located
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
t 0 eV 0. SO.I.G, t—ft. E i4b. NE 60 "3 m 9 3'f o
Name of WWTF WWTF Permit No.
a• nthl DP 5b. 0-Gravity 5c.
Owner of Downstream Sewer Receiving Sewer Size ❑ Force Main Permit Number of Downstream Sewer (if known)
The origin of this wastewater is (check a- ll that apply):
❑ Residential Subdivision 0 Car Wash
(Apartments/Condominiums 0 Institution
❑ Mobile Home Park 0 Hospital
O School 0 Church
❑ Restaurant 0 Nursing Home
❑ Office 0 Other (specify):
7. Volume of wastewater to be allocated for this particular project: 2 bnp gallons per day
*Do not include previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Interceptor Line - Flow will be permitted in subsequent permits that connect to this line
0 Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected
t' °/a Domestic/Commercial
% Industrial
% Other (specify):
NVN
FTA 02/03 - Rev. 3 04/05

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 4
. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(1) for Item B(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than j
that in 15A NCAC 2H .0219(1)(1-2) must be supported with actual water or wastewater use data in accordance with 15A
NCAC 2H .0219(1)(3).2-0
_._/.__/D'°f ...._..._.(See _._.....!1iror (to ,/q �� ,//
?e2 D /1-4- f ew : I .. t £ , " S p.; t a,
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Length (feet)
ENTER TOTAL LINE LENGTH IN MILES
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID
(self chosen as shown on
plans for cross-reference)
Design Flow
(MGD) _
Operational Point
GPM @ TDH
/A
Gravity or Force Main
(use the pull down menu)
Power Reliability Option
(1- dual line feed; 2- permanent generator w/ATS; 3-
portable generator w/telemetry; 4-wet well storage)
112. Does the sewer system comply with the Minimum Design Criteria for the. Fast Track Permitting of Pump Stations and Force!
Mains (latest version); the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
NYes ❑ 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
. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? Yes 0 No 0 N/A
Sedimentation and Erosion Control Plan? 51 Yes 0 No 0 N/A
Stormwater?
® Yes ❑ No 0 N/A
14. Does this project involve aerial lines or siphons? 0
These lines will be considered high priority and must be checked once every ix months
FTA 02/03 - Rev. 3 04/05

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 5
Use the
1. Division's 9 "DETERMINING
tSTREAM
CLASSIFICATIONSsFOR MFTAh e3
(FAST -TRACK SEWER SYSTEMS)" to collocument ect d record he ssteamason data below (attach additional sheets as,
necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
regional office (see instructions for addresses) OR indicate the following:
A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
waterbody; AND
A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
option for any pump station near a Class C down slope waterbody.
Location ID on Map
(self chosen - as shown on E Name of
,map for cross-reference) Waterbody
Waterbody Stream
River Basin Index
Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
Applicant's Certification:
Waterbody
Classification
I, SIGNING OFFICIAL NAME, attest that this application for PROJECT NAME No a_TH j/ u:rrivreLL4
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
General Statutes 143-215.6A and 143-215.68, 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 palps to $25, 000 per violation.
gnmg atur
Professional Engineer's CertifL'uati/on: W
1 attest that this application for o2--n-{ L ,G 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. I further attest that to the best of my knowledge the proposed design has been prepared in
accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February
12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June I
1, 2000 and the watershed classification in accordance with Division guidance. Although certain portions of this submittal
package may have been developed by other professionals, inclusion of these materials under my signature and seal
signifies that I have reviewed this.material and have judged it to be consistent with the proposed design. Note: In
accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed $10, 000 as well as civil penalties up to $25, 000 per violation.
2a. f 4 `t' e s A AIoa t/ CO!.'I +' so,
Professional Engineer Name
.2b r A. Col —sit( 1464t\) ;a G CoNsvc-nivk,.
i 4C
Engineering Firm
Vic.__ -Ito
___...-._.__..- ..__...__ ...
'LI r? ekit!NRILL t Ski!f'tt 10-•
Mailing Address
2d....._FArt-rrtvt L•LE
2e. INK,. 2f. 2&3('-0
City State Zip
9 72ai00$1. 2hgt())223 Aif0it• 21. GOtt/tvlP_ItalCfrj ,e4'vlbtty
Telephone Facsimile Email .J
..�—._/ Date
7
0
6e4111,641 05-H-d
Seal, Signature & Date
FTA 02/03 - Rev. 3 04/05

Permit Number WQ0034137
Central Files: APS SWP
06/16/09
Permit Tracking Slip
Program Category
Non -discharge
Permit Type ;:01:;1:
Gravity Sewer Extension, Pump Stations, & Pressure Sewer
Extensions
Primary Reviewer
trent.allen
Coastal SW Rule
Permitted Flow
1920
Facility
Facility Name
Worthy Townhouse Project
Location Address
Owner
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Major/Minor Region
Major Fayetteville
County
Cumberland
Facility Contact Affiliation
Owner Name Owner Type
Worthy Real Estate LLC Non -Government
Owner Affiliation
Curtis Worthy
626 Mont Dr
Spring Lake
Dates/Events
NC 28390
Orig Issue
06/16/09
App Received Draft Initiated
06/11/09
Scheduled
Issuance
Public Notice Issue
06/16/09
Regulated Activities Requested/Received Events
Wastewater collection Additional information requested
Additional information received
Outfall NULL
Effective Expiration
06/16/09
Waterbody Name Stream Index Number Current Class Subbasin