WQ0042462_Application Attachment_20210421

DWR
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: (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: MSD2 Prosperity Church LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: Michael Ambrosino per 15A NCAC 02T .0106(b)
Title: President
4. Applicant's mailing address: 155 1st Street
City: Mineola State: NY Zip: 11501-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Eastfield Daycare Huntersville
2. Application/Project status: ® Proposed (New Permit)
❑ Other
❑ 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: Mecklenburg
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.374939° Longitude: -80.8024°
5. Parcel ID (if applicable): 02708402
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Michael Theberge License Number: 043610
Firm: Bohler Engineering
Mailing address: 1927 South Tryon St. Suite 310
City: Charlotte State: NC Zip: 28203-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Rocky River WWTF Permit Number: NC0036269
Owner Name: WSACC
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ
Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 Page 1 of 5