WQ0042628_Application (FTSE)_20210629

TOWN OF FRANKLIN
44982
VENDOR 1988 NC DEQ 06/11/2021 44982
DATE INVOICE# PO# DESCRIPTION GL# AMOUNT
6/8/2021 6821 Fast Track Sewer System Extension Application 60-7400-5970 480.00
tun ofJlranWin
Provielontor the Payment of t is c eck has been made by an Bpproptletlon duly made,.
pursuant to the local Government Budget and Fiscal Control Am
PAY
TO THE
ORDER
OF
---Four Hundred Eighty Dollars and 00/100 Cents ---
NC DEQ
2090 US Highway 70
Swannanoa, NC 28778
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66-162/531
DATE
CHECK TOTAL 480.00
NUMBER 44982
AMOUNT
06/11/2021 $480.00
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TOWN OF FRANKLIN
VENDOR: 1988 NC DEQ
DATE INVOICE# PO# DESCRIPTION
6/8/2021 6821
Fast Track Sewer System Extension Application
06/11/2021
44982
44982
AMOUNT
480.00
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TO REORDER. CALL YOUR LOCAL SAFEGUARDOIBIBIBUTOB AT e00-780-7233 CRNFZKC01O O TM6FAIla1

;% WithersRavenel
Our People. Your Success.
June 21, 2021
North Carolina Department of Environmental Quality
Division of Water Resources
2090 US Highway 70
Swannanoa, NC 28778
Attn: Tim Heim, Engineer
RE: WR Project #08210279.00
Fast Track Sewer System Extension Application
Town of Franklin
Boyd's Pump Station Rehabilitation
Dear Mr. Heim:
Please find enclosed a Fast Track Application for the Town of Franklin Boyd's Pump Station Rehabilitation
Project. The project consists the installation of a new 6' precast wetwell and new submersible pumps with
an operating point of 250 GPM @ 79' TDH to replace the existing Boyd Pump Station, which is aging. The
project will connect the new pump station to the existing sewer system through the installation of
approximately 5 linear feet (LF) of 12-inch DIP gravity sewer and approximately 35 LF of 6-inch DI. The new
pump station will be located on the same parcel. No additional flow is requested with this application.
Items included in this submittal:
• Two copies of Fast Track Sewer System Extension Application
• Two copies of USGS and aerial site maps
• Application fee
If you have any questions about this submittal, please do not hesitate to call me.
Sincerely,
WithersRavenel
Jacob Gray, PE
Assistant Project Manager - Utilities
WithersRavenel
cc: Nathanael Moore, Town of Franklin
JUN 2 4 2021 —J
Water Quality Regional Operations
Asheville Regional Office
84 Croce Avenue, Suite 260 I Asheville NC 28801
t: 828.255.03131 f: 919.467.6008 www.withersravenel.com I License No. C-0832
Asheville I Cary I Greensboro Pittsboro Raleigh I Wilmington

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
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
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.
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 pennit 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 IC .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):.-•-
- • IA% C
la List all items included in the application package, as well as a brief description of the requested pemStig acttotf.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc. cum r.a
➢ If necessary for clarity, include attachments to the application form.
co.
O 0
'm m,
C. Application Fee (All New and Major Modification Application Packages): �-o
m
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submit@Ld
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
to
-C-
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 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 11.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
la The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
a 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 I5A 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):
❑ Submit 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.
S. 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 II -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
® 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):
❑ Per 15A NCAC 02T .0305(h)(I), submit documentation of power reliability for pumping stations.
S. 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(6)) 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 I5A 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 .0115(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 •Wore inr • nation, ' ..it the Division-'s-collectionsys
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

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
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
2090 US Highway 70
Swannanoa, North Carolina 28778
[phone]
[phone] Fax
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 27899-1628
[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

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: Town of Franklin (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership 0 Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Justin Setser per 15A NCAC 02T .0106(b)
Title: Interim Town Manager
4. Applicant's mailing address: PO Box 1479
City: Franklin State: NC Zip: 28744-
5. Applicant's contact information:
Phone number: [phone] Email Address: Isetser(a)franklinnc.com
❑ Other
II. PROJECT INFORMATION:
1. Project name: Boyd's Pump Station Rehabilitation
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
Ifa modification, provide the existing permit number: W000 and issued date:
If new construction but part of a master plan, provide the existing permit number: W000
3. County where project is located: Macon
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.1329° Longitude: -83.3961°
5. Parcel ID (if applicable): 6583621305
(or Parcel ID to closest downstream sewer)
ID. CONSULTANT INFORMATION:
1. Professional Engineer: Jacob Gray License Number: 047761
Firm: WithersRavenel
Mailing address: 84 Coxe Avenue. Suite 260
City: Asheville State: NC Zip: 28801-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Town of Franklin Wastewater Treatment Plant Permit Number: NC0021547
Owner Name: Town of Franklin
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

VI. GENERAL REQUIREMENTS
L If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ENo ®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 ENo ®N/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ENo ®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
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool /Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater: 100% Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
I —Hs there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under l5A NCAC 02T .0114(1)? ❑ Yes ® No
> If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114W)
Daily Design Flow a'b
No. of Units
Flow
No new flow generated by project
gal/
GPD
Rehab of existing pump station
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(6), (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 I5A NCAC 02T .0114(c), design flow rates for establishments not identified [in table I5A 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: 0 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): Rehabilitation or replacement of existing pump station with no new flow expected
FORM: ETA 04-16
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA(IfApplicable)- 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
12
5
DI
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information rela ed 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
L Pump station number or name: Boyd's Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.1329° Longitude: -83.3961°
3. Design flow of the pump station: 0.035 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 250 gallons per minute at 79 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6 -
35
DI
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:
❑ 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)(t)(C):
> It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
anis comps n.
➢ 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(0):
I. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g)
> 15A NCAC 02T.0305(t) contains minimum separations that shall be provided for sewer vstems:
® 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, HOW, 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(t) 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 ❑ N/A
> 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 I5A NCAC 02B .0200? ® Yes ❑ No ❑ N/A
> This would include Trout Buffered Streams per I5A 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
E Yes ® No
5. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ 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-parallelto-streambanks{hat-issubject to erosinn3hatundetminesertleter-ioratesthes
❑ 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:
I. Does the submitted system comply with 15A.NCAC 02'1' the Mininmin Design Critefia fig the Permuting of PUMP Stations
One Form Mains (latest version) and the Gravity Sewer Minirmml Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Anorovnl of Ike rawest is renulretlnrbr to submittal oldie East Track Aminealion and snnna4ng documents
2. Professional Engineer'sCertification:
1, Sat cob ( was//
(Professional $ngineer's name from Application Item 111.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the piths, specifications,
engineering calculations, and all other suppoting 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, sty 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 $I0,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date: S�N CAIRO10 (
:0.
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3. Applicant's Certification per ISA NCAC 02T .0106(h):
attest that this application for
1o6+ 1 .S cT5er Z'n-/et7wi Town i-fQ4f(ger attest that this application For
(Signature Authority's none & title from Application Item 1.3.) J
has been reviewed by me and is accurate and complete to the best of my knowledge. I onderstond 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. 1 understand that any discharge of wastewater front 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 ptnsecution. [will make no claim against the Division of Water Resources should a condition
or this permit be violated. 1 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 rettuned to me as
incomplete.
NOTE - In accordance with General Salutes 143.215.6A and 143-215.6B, any person who knowingly makes any False
statement, representation, or certification in any application package shall he guilty of a Class 2 misdemeanor, which may
Delude a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:.
Date
502
FORM: FTA 04-16 Page 5 oF5

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