WQ0042565_Application (FTSE)_20210524

DocuSign Envelope ID: 4296DE2F-C3F3-4794-9B51 -FBA42041 FAF3
State of North Carolina
Department of Environmental Quality
Division of Water Resources
DWR
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: Walvolizsu,(robecompleted byDWR)
All items must be completed or the aanlication will be returned
1. APPLICANT INFORMATION:
1.
Applicant's name: Town of Holly Springs (company, municipality, HOA, utility, etc.)
2.
Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal r State/County ® Municipal ❑ Other
3.
Signature authority's name: Kendra Parrish per ISA NCAC of .(i Ic lei
Title: Executive Director
4.
Applicant's mailing address: 128 S Main Street
City: Holly Springs State: NC Zip: 27540-
C'�
5.
Applicant's contact information:
rt
Phone number: [phone] Email Address: kendra.par•ishiahollyspringsnc.us
IL PROJECT INFORMATION:
�t
1.
Project name: Carolina Springs Blvd. Section A
2.
Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
o v
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: WQ000
3.
County where project is located: Wake
4.
Approximate Coordinates (Decimal Degrees): Latitude: 70.2592' Longitude:-20.357890
5.
Parcel ID (if applicable): 073533724
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Debra Ferm License Number: 028892
Firm: WithersRavenel
Mailing address: 115 Mackenan Drive
City: CCr r State: NC Zip: 27511
Phone number: [phone] Email Address: cifenn amithersrayenel.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Utley Creek W WTP Permit Number: NCO063096
Owner Name: Town of Holly Springs
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0042364 Downstream (Receiving) Sewer Size: 18 inch
5yslern Wide Collection S} stem PermiI Numbcrl sl 0 Fap::icablc l: WQCS00192
Owner Name(s): Town of Holly Springs
FORM: FTA 04-16 Pagel of 5

DocuSign Envelope ID: 4296DE2F.C3F3-4794-9B5i-FBA42041FAF3
VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes [--]No ®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 ❑No ®NIA
3. if the Applicant is a Home. Proinerty Owners A ciation_ has an Qgerational Agreement (FORM: HQA) 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 preparationlservice ❑ Hotel and:or Motels
❑ School..' preschool day care ❑ Medical i dental veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses.' offices! factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic:'Commercial % Commercial
%Industrial (Scc 15A NCAC 02T .0103(20))
* Is there a Pretreatment Program in effect? ❑ Yes [—]No
6. Has a flow reduction been approved under 15A NCAC 02T .01 14ti ? ❑ Yes ❑ No
➢ If yes, provide a coov of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 211.111A1f13
Daily Design Flow n,b
No. of Units
Flow
0 gal/
0
0 GPD
gall
GPD
gall
GPD
gall
GPD
gall
GPD
gall
GPD
Total
GPD
a See 15A NCAC 002T .01 14 ft (d). {e)i I I and ieli21 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.01141 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 021_01.14)
�o 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

. DocuSign Envelope ID: 4296DE2F C3F3-4794-9B51-FBA42041 FAF3
Vil. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
180
DIP
16
115
DIP
18
866
PVC
18
130
DIP
➢ Section II & 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
Vill. PUMP STATION DESIGN CRITERIA (if Applicable) — 02T .0305 & MDC (Puma Stations. -force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name: N.'A
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 1.5A NCAC 02T .0305AX 11:
❑ 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 - BA 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 5

DomiSign Envelope ID. 4296DF_2K-C3F3-4794-9851 FBA42041FAF3
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 13A NCAC 02T .0305(0 & 6! 1
➢ 15A NCAC 02T,0305(f) contains minimum separations that shall be provided for sewer systems:
® 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-1 waters of Class 1 or
Class 11 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
hip,h 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
Draina e systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T,0305(gi contains alternatives where separations in 02T.0305(o cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classificatit7ns wSkpage
➢ If noncompliance with 02T.0305() or(" see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ 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 15A NCA_C'.02B .0200" ® Yes ❑ No ❑ N."A
➢ This would include Trout Buffered Streams per 15A NCAC 2B4O202
4. Does the project require coverage: authorization under a 404 Nationwide or ® Yes ❑ No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitiinj Branch
5. Does project comply with ISA NCAC 02T.0105(c)t6) (additional permits."certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0 I 05(cX61, 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 ❑ 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

DocuSign Envelope ID: 4296DE2F-C3F3-4794-9B51-FBA42041FAF3
X. CERTIFICATIONS:
1. Does the submitted system comply with 4L&NC'AC,._2T, the Minimum Design Criteria for the Permitting of Pump Stations
aural I-orce Mains llatest version_, and the CrraviN Sewer Minimum Design iteria (latest version4 as applicable?
® Yes ❑ No
If No, complete and submit the Variance Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the reguest is reuired prior to submittal of the Fast Track Application and supporting documents.
2. Professional Engineer's Certification:
I, Debra Ferm, P.E._ _. attest that this application
(Professional Engineer's name from Application Item II1.1.)
for Carolina Springs Blvd Section A 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.
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. ARAM
North Carolina Professional Engineer's seal, signature, and date:
Applicant's Certification per 15A NCAC 02T .0106(b):
1 Kendra Parrish
Exec Director of utilities and Infrastructure
(Signature Authority's name & title from Application Item 1.3.)
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attest that this application for
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, andior 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.
D°cU by.
7
Signature:
Date:
5/19/2021
FORM: FTA 04-16 Page 5 of 5

DocuSign Envelope ID: 4296DE2F-C3F3-4794-9B51-FBA42041FAF3
■■ WithersRavenef
N. Oui People. Your Success.
May 10, 2021 NC
DEQ
1628 Mail Service Center
Raleigh, NC 27699-1628
RE: Carolina Springs Blvd Section A
Dear Sir or Madam:
This letter is to serve as a request to permit the collection system of a project in Holly Springs. The proposed
development consists of infrastructure only and 0 flow. Approximately 866 LF of 18" PVC sewer, 115 LF of
16" DIP sewer, 130 LF of 18" DIP sewer, 180 LF of 8" DIP sewer. Please find attached the application with
fee, an original and a copy of the FTSE04 16, and site maps for your review and approval.
If you have any questions or need any additional information, please feel free to contact me at 919-337-
2837.
Sincerely
WithersRavenel
Debbi Ferm
Project Manager
115 MacKenan Drive I Cary, NC 27511
t: 919,469.3340 1 f: 919.467.6008 1 wwwAthersraveneLcom I License No. C-0832 C

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DocuS?gn Envelope ID: 4296DE2F-C3F3-4794-9851-F13A42041FAF3
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"^ THE TOWN OF
May 13, 2021
Director, Division of Water Resources
Raleigh Regional Office
Water Quality Operation Section
1628 Mail Service Center
Raleigh, NC 27699-1628
Aol'�'ily �f'Prings0
NC Dept of Environmental Quality
Re: Application for Sewer Extension Permit MAY z * 2021
Project: Carolina Springs Blvd., Section A Ralcigh Regional Office
Dear Sir or Madam:
Please find enclosed the following items in application for a sewer extension permit to the Town
of Holly Springs existing sewer distribution system:
0 One original and one copy cover letter including a project narrative
o A check in the amount of $480.00
0 One original and one copy of the State of North Carolina Fast Track Sewer System
Extension Application (FTA 04-16)
0 Two copies of FTSE 04-16 Flow Trackinge"Acceptance Form
0 Two color copies of a 8.5-inch by 11-inch portion of a 7.5 minute USGS Topographic
Map showing project area
0 Two copies of a street level map showing all relevant project areas
0 One copy of the locally -required Design and Application Certification
Feel free to contact me at 919-577-3150 should you have any questions or need additional
information in order to process this application.
Sincerely, Da
f
5/19/2021°1f3i'arrish, A.E., CFM Rachel Ingham
Executive Director of Utilities and Infrastructure
Utility Engineer
KP `tr
cc: Project Consultant Engineer, Debra Ferm, PE
Rachel Ingham, Utility Engineer
Drew Johnson, Development Construction Manager
Theresa Randall, Utility Permitting Specialist
Project f le?Correspondence #41889
3002
04 172018
Utilities and Infrastructure Services
P-O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www-hollyspringsnc.us

e
Docu9ign Envelope ID: 4296DE2F-C3F3-4794.9B51 FBA42041FAF3
DO NOT SUBMIT SEWER EXTENSION APPLICATIONS UNTIL
CONSTRUCTION DRAWINGS HAVE BEEN APPROVED BY STAFF!
Sewer Design and Application Certification
Note: This form must be submitted with the Fast Tract Application for extension to the Town of
Holly Springs Sewer System
Project:
Design Engineer:
Address:
Carolina Springs Blvd Section A
Debra Ferm
221 Hidden Farm Ln, Holly Springs, NC 27540
Phone Number: 919-337-2837
Email: [e-mail]
Date Complete Application Package ReceiveTown:
Date Approved � 1/19/2021 (by RI CO' r 5/19/2021 (by KDP a% 111112121.. (by DJ)
As design engineer for this project, I certify the following (please check (x) each applicable box):
® That the design of the project is in complete conformance with the Town of Holly
Springs Engineering Design and Construction Standards and NC DEQ Sanitary Sewer
Design Regulations;
That each of the following items are completed and enclosed for submittal to the State for
a sewer extension permit:
0 One cover letter that includes a project narrative
o A check in the amount of $480.00 to NC DEQ
o A check in the amount of $200.00 to the Town of Holly Springs
0 One State of North Carolina form FTA 04-16 Fast Tract Sewer System
Extension Application
0 One FTSE 10-18 Flow Tracking for Sewer Extension Applications
0 One color copy of an 8.5-inch by I I -inch portion of a 7.5-minute USGS
Topographic Map showing project area
0 One copy of a street level map showing all relevant project areas
0 One copy of the locally -required Design and Application Certification (this
form)
DocuSiomd W.
Design Engineer's Signature. l,1r'a Ft^
94623743M754FB
Date 05-07-21
Please contact Theresa Randall at [phone] or theresa.randallrii>hollysvringsnc.gov if you
have any questions.
2003 SeNer Design Application Certification
01.14.21
s
O
S
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC27540 • www.hollyspringsnc.gov