WQ0042442_Application (FTSE)_20210329

State of North Carolina
Department of Environmental Quality
DWR. Division of Water Resources
{ I5A NCAC 02T .0300— FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dhrlslon of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: "►Lkil (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Liberty Healthcare Properties of Chatham County. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ IndividuaI ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State'County ❑ Municipal ❑ Other
3. Signature authority's name: William B. Purvis per 15A N('AC 02T .0106(b)
INC Dept of Environmental Quality
Title: Chief Development Officer
4. Applicant's mailing address: 2334 S. 41 s' Street MAR 2 9 2021
City: Wilmington State: NC Zip: 28403-
5. Applicant's contact information: Raleigh Regional Office
Phone number: 9{ 10) 815-3122 Email Address: mTurvis(@Iibertyseniorliving.com
II. PROJECT INFORMATION:
I . Project name: Libeqy Senior A artments
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If 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: Chatham
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.8088'- Longitude:-79.0897'
5. Parcel ID (if applicable): AKPAR: 93104
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Gareth Avant License Number: 036348
Firm: McKim & Creed. Inc.
Mailing address: 1730 Varsity Drive, Suite 500
City: Raleigh State: NC Zip: 27606-
Phone number: (919) 23378091 Email Address: gavantamckimcrced.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Briar Chapel Utilities Wastewater Treatment Facili , Phases A and B Permit Number: W00028552
Owner Name: Old North State Water Company,LLC
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0039608 Briar Chapel SD East Lift Station)
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Old North State Water Company. LLC
FORM: FTA 04-16 Page] of 5

VI. GENERAL REQUIREMENTS
I. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No ®NIA
2. If the Applicant is a Developer of lots to be sold, has n Develo eratiana3 eement 1 CxRM: D1 been attached?
❑ Yes [:]No ®NIA
3. If the Applicant is a Home/PTE)p " Owa rs' Associatipn__,,has an Operaliqual A reeyien({FORiN: F10A} been attached?
[:]Yes []No ®NIA
4. Origin of wastewater: (check all that apply):
❑ Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential Leased ❑ Retail with food preparation/service ❑ HoteI and/or Motels
❑ School'' preschool / day care ❑ Medical / dental I veterinary facilities ® Swimming Pool /Clubhouse
® Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses I offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % DomesticlCommercial , ,% Commercial
% Industrial (5cc_ i $A NCAC 02T .01 D3f201)
1Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T _01 14(D? ® Yes ❑ No
It yes, provide a copy of flow reduction aoproval letter
7. Summarize wastewater generated by project:
Establishment Type (see OZT.0114{f1)
Daily Design Flow'"
No, of Units
Flow
Senior Living Apartments
240 gallunit
150
36,000 GPD
Dining Hall
30 gallseat
30
900 GPD
Pool
10 gal/person
50
500 GPD
Fitness Area
50 gall100
1500
750 GPD
gal,'
GPD
gall
GPD
Total
38,150 GPD
a See 15A NCAC 02T .01 14(b1, (d), (e)(1) and (c)(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.01 141 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 38,150 GPD (per 15A NCAC 02T .0114)
D 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
➢ Section If & 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:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T .0305 h I :
❑ 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:
❑ 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

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(1)):
1. Does the project comply with all separations found in 13A NCAC 02T .U305(0 & [q)
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall he nrnvidprl far w-w,-r cvct
® 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 s stems and interceptor drains
5 feet
Any swimm ng pools
10 feet
Final earth Eade vertical
36 inches
➢ 15A NCAC 02T.0305(s) contains alternatives where separations in 02T.0305 cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications web a *c
➢ If noncompliance with 02T.0305 orfZL see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No
➢ 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 all setbacks found in the river basin rules per 15A NCAC 021 .f 7M)'? ® Yes [:]No
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes [:]No
➢ Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
➢ Information can be obtained from the 401 & Buffer Permitting Branch
S. Does project comply with 15A NCAC 02T.0105( L6) (additional permits/certifications)?
® Yes ❑ No
Per 15A N A T.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
➢ 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. CERTIFicxriONS:
1. Does the submitted system comply with 15 A NCAC 02T, the Minimum Design Criteria for the Pormittimyf to#ions
seed Force Mains f latest version], and the vit Sew Inlnlllm Des' riteria 1 t ve in as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternadve Design Request application (VADC I0-14) and supporting documents
for review. Anproval of the reguest is re uired prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification:
I, Gareth Avant attest that this application for
(Professional Engineer's name from Application Item 111.1.)
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.
N01T — In accordance with General Statutes 143-215.6A and 143-215.613, 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 Fngineer's seal, signature, and date: `\\`\\0%%J%11I r 6��i'',/
1�9��'%
036348 _
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fill a tir►S�A``��.
3. Applicant'stC�ertiification per ISA NCAC 02T .0106(b):
I, W •�`�U.l� P�l ?U11 } attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
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, an&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 143-215.613 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: k! I a I �-Q
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
Department of Environmental Quality
R"o Division of Water Resources
Dtvbdon of Water Resources Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Old North State Water Company, LLC
Project Name for which flow is being requested: Liberty Senior Apartments
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 wasiewaterJlow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Briar Chapel Utilities Wastewater Facility Phases A and B
b. WWTP Facility Permit #: WQ0028552
All flows are in MGD
c. WWTP facility's permitted flow 0.318 ranul Quality
d. Estimated obligated flow not yet tributary to the WWTP 0.0
e. WWTP facility's actual avg. flow 0.230
f. Total flow for this specific request 0.038
g. Total actual and obligated flows to the facility 0.293 ffiee
h. Percent of permitted flow used 92.1% RalelgK
H. 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
Film
Flow**
Current Avg.
Tributary
Flow Plus
(Name or
Capacity, "
(Firm 1 pf),
Daily Flow,
Daily Flow,
Obligated
Available
Number)
MGD
MGD
MGD
MGD
Flow
Capacity***
SD East
1.584
0.417
0
0.065
0.065
0.352
* 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 (pl) not less than 2.5.
*** A PIanning 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): Briar Chapel SD East Lift Station
Downstream Permit Number: WQ0039608 Modification
Page l of 6
FTSE 04-16

III. Certification Statement:
I John McDonald 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.
I
Official Signature
Page 2 of 6
FTSE 04-16

vMCKIM&cREED
I M. Division of Water Resources I
Raleigh Regional Office
3800 Barrett Drive
Raleigh, N.C. 27609
ATTENTION Mr. Danny Smith
LETTER OF TRANSMITTAL
DATE: March 261h, 2021
PROlccr NO: 07246-0004
TASK NO: EXP
RE: Liberty Senior %, ar�n� i viroamental Quality
MAR 19 2021
TRANSM11TALNO: eig
qt@� ;lCe
WE ARE SENDING: ® Originals ❑ Prints ❑ Shop Drawings ❑ Samples
❑ Specifications ❑ Calculations ® Other - Fee
Quantity
Drawing No.
Rev
Description
Status
2 EA
Fast Track Application for Gravity Sewers, Pump Stations and
G
Force Mains (FTA 04-16) and FTSE-04-16
2 EA
Project Narrative including:
C
• USGS Map
• Certificate of Public Convenience and Necessity
• Franchise Documents
1 EA
Permit Application Fee ($480.00)
C
Issue Status Code:
Remarks
A. Preliminary B. Fabrication Only C. For Information D. Bid
E. Construction F. For Review & Comments G. For Approval H. See
Action Status Code: 1. No Exceptions Taken 2. Make Corrections Noted 3. Other
4. Amend & Resubmit 5. Rejected -See Remarks
1730 Varsity drive, Sulk 500, Raidgk NC 27606 giga33-8091 Fax 919n-13-8031
Cc: File McKIM & CREED, INC.
Signed
Chris Seamster, RLA
Project Manager

FAST TRACK SEWER APPLICATION NARRATIVE
NC Dept of Environmental Quality
MAR Z 9 2021
Liberty Senior Apartments Raleigh Regional Offtee
Chatham County, North Carolina
November 12, 2020
Prepared for:
Liberty Healthcare Properties of Chatham County, LLC
2334 S. 41 st Street
Wilmington, NC 28403
Prepared By:
MCICM&CREED
1730 Varsity Drive, Suite 500
Raleigh, North Carolina 27606
Phone: [phone]
Fax: [phone]
M&C Project No. 07128-0002
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Liberty Healthcare Properties of Chatham County, LLC
Liberty Senior Apartments
November 12, 2020
PROJECT NARRATIVE
The purpose of the project is to construct utility infrastructure to support the
proposed Liberty Senior Apartments in Chatham County, NC. The improvements
planned in this phase are internal to the Liberty Healthcare Properties of Chatham
County, LLC (AKPAR 93104) and will connect to previously constructed
infrastructure for Briar Chapel SD East project (WQ0039251). All flows in the
system will ultimately tie to the existing SD East pump station that was approved
through previous permits (WQ0039608 Modification).
The project will construct a total of 150 1 and 2-bedroom senior apartment units,
and will include a swimming pool, kitchen/dining area and recreational/fitness
amenity area. Using the 02T regulations, the estimated flows calculated for this
facility will be 38,150 Rpd.
The per bedroom unit breakdown is as follows:
• 1 bedroom — 69 units (240 gpd/unit)
• 2 bedroom — 81 units (240 gpd/unit)
o 36,000 gpd
The amenity areas breakdown is as follows:
• Kitchen/dining area — 30 chairs @ 30 gal/chair = 900 gpd
• Pool — 50 people @ 10 gal/person = 500 gpd
• Recreational/fitness —1,500 sf @ 50gal/100 sf = 750 gpd
o 20150 gpd
The sewage and wastewater collected by this system will be treated in the on -site
wastewater treatment facility:
WWTP Facility Name: Briar Chapel Utilities Wastewater Facility Phases A&B
WWTP Facility Permit: #WQ0028552

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CPCN & FRANCHISE
DOCUMENTS

STATE OF NORTH CAROLINA
UTILITIES COMMISSION
RALEIGH
DOCKET NO. W-1300, SUB 9
DOCKET NO. W-1230, SUB 1
BEFORE THE NORTH CAROLINA UTILITIES COMMISSION
In the Matter of
Application by Old North State Water Company, )
LLC, and Briar Chapel Utilities, LLC, for Authority to ) ORDER ALLOWING
Transfer Sewer Utility Franchise in Briar Chapel } RECOMMENDED
Subdivision in Chatham County, North Carolina, to ) ORDER TO BECOME
Old North State Water Company, LLC, and for } EFFECTIVE AND FINAL
Approval of Rates )
BY THE COMMISSION: On April 20, 2015, Hearing Examiner Ronald D. Brown
issued in the above -captioned docket a Recommended Order Approving Transfer,
Granting Franchise, Approving Rates, and Requiring Customer Notice. The parties have
jointly requested that the Commission adopt the Recommended Order as a Final Order.
Based upon the foregoing, the Commission is of the opinion that the request that
the Recommended Order be adopted as the Final Order should be granted.
IT IS, THEREFORE, ORDERED that the Recommended Order entered in this
docket on April 20, 2015, is hereby adopted as the Final Order of the Commission.
ISSUED BY ORDER OF THE COMMISSION.
This the loth day of April , 2015.
NORTH CAROLINA UTILITIES COMMISSION
AQ1L l-Moujnc*
Gail L. Mount, Chief Clerk
Commissioners Susan W. Rabon and ToNola D. Brown -Bland did not participate.

STATE OF NORTH CAROLINA
UTILITIES COMMISSION
RALEIGH
APPENDIX A
DOCKET NO. W-1300, SUB 9
BEFORE THE NORTH CAROLINA UTILITIES COMMISSION
OLD NORTH STATE WATER COMPANY LLC
is granted this
CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
to provide sewer utility service
BRIAR CHAPEL SUBDIVISION SERVICE AREA
(including HERNDON WOODS SUBDIVISION)
Chatham County, North Carolina
subject to any orders, rules, regulations,
and conditions nor or hereafter lawfully made
by the North Carolina Utilities Commission
ISSUED BY ORDER OF THE COMMISSION.
This the 201h day of April—, 2015.
NORTH CAROLINA UTILITIES COMMISSION
A(a � •'C bum*
Gail L. Mount, Chief Clerk