WQ0042614_Application (FTSE)_20210702

Permit Number WQ0042614
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
dean.hunkele
Coastal SWRule
Permitted Flow
Facility
Central Files: APS _ SWP _
6/22/2021
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit Classification
A
Individual
Permit Contact Affiliation
Facility Name MajortMinor Region
Shallotte Hwy 17 Chickfila Private Pump Station Minor Wilmington
Location Address County
Brunswick
Owner
Owner Name
Shallotte Retail LLC
Dates/Events
Facility Contact Affiliation
Owner Type
Non -Government
Owner Affiliation
Jeffrey L. Irvin
1340 Harding PI
Charlotte NC 28204
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
6115/2021 Regulated Activities Requested /Received Events

dOj DUDLEY
ARCHITECTURE PLANNINGI'LLC .JuN 15 2021
To: Mr. Dean Hunkele BYE
Environmental Program Consultant
Water Quality Regional Operations Section
Division of Water Resources/Department of Environmental Quality
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
Tele: 910-796-7380
From: James J. Dudley, NCARB I LEED AP
Date: June 14, 2021
Project: Chick-Fil-A Restaurant — Shallotte, NC
DAP Project #: DAP_2020_02
Materials Chick-Fil-A Shallotte — Fast Track Sewer System Extension Application
Transmitted:
Sent Via: Via Express Delivery (copy via e-mail)
Ms. Hunkele,
Attached please find the following information pertaining to the Fast Track Sewer System Extension
Application for the Chick-Fil-A Shallotte Restaurant Project to be located at 2900 Frontage Road in
Shallotte, NC:
• Two (2) copies of the Application Cover Letter dated June 11, 2021
• Two (2) copies of the fully executed Fast Track Sewer System Extension Application
(Form FTA 04-16)
• A check made out to NCDEQ to cover the Application Fee
• Two (2) copies of the Applicant LLC documentation, as filed with the office of the North
Carolina Secretary of State
• Two (2) copies of the Flow tracking/acceptance forms (FTSE 04-18) from both the Town
of Shallotte and Brunswick County
• Two (2) copies of the USGS topographic map
• Two (2) copies of the Aerial Vicinity Map
• Two (2) copies of the Civil Drawing C-3.0 — Utility Plan
• Two (2) copies of the Duplex Grinder Pump Specifications
• Two (2) copies of the Power Reliability Plan — Applicant Letter dated June 11, 2021
DUDLEY ARCHITECURE& PLANNING PLLC I 112 SOUL H TRYON STREET. SUITE 13401 CHARLOTTE. NC28284 IT: 704.940,6904
W W W. DIJDI 1-YAP.C'OM

I would like to apologize again for my oversight at the beginning of the permitting process. By not sharing
an e-mail with my consulting team I got us in this pickle. I really appreciate your assistance in helping us get
the application submitted so quickly. I know you don't owe me anything, but if you could expedite the
review of the application, I would be deeply appreciative.
Best
James J. Dudley,NCARB I LEED AP
DUDLEY ARC 'IIITF:('U RE R PLANNING PLLC 1112 SOUTH TRYON STREEF. SUITE 13401 CI IARLOTTE. NC 28284I T: 704.940,6904
W W W.DUDI_EYAP.COM

CARTER
ENGINEERING
CONSULTANTS
June 11, 2021
Mr. Dean Hunkele
Environmental Program Consultant
Water Quality Regional Operations Section
Division of Water Resources/Department of Environmental Quality
127 Cardinal Drive Extension
Wilmington, NC 28405
RE: Shallotte Chick-fil-A
Fast Track Sewer System Extension Application
Mr. Hunkele,
This cover letter is intended to satisfy the requirements outlined in Item B of the attached "Instructions for
Form: FTA 04-16 & Supporting Documentation" for a fast -track sewer system extension application. A brief
description of the requested permitting action is followed by a list of items included in the permit application
package.
Description of requested permitting action:
Shallotte Retail, LLC — Owner of the proposed Chick-fil-A restaurant located at 2900 Frontage Road in
Shallotte, NC — requests that the State of North Carolina Department of Environmental Quality, Division of
Water Resources review the attached materials and permit application and grant a state permit authorizing
the use of the installed duplex grinder pump as part of the project's sanitary sewerage system. The system
is a private pump serving the Chick-fil-A restaurant only. The pump and associated emergency storm well
are located approximately 60 feet from the southeast corner of the restaurant building, and approximately
five feet north of the southern property line. A 2" PVC forced main will tie the pump into the existing 8"
forced main. The system is designed to accommodate an average daily flow of 2,640 gallons of
wastewater— 20 gallons per seat (per 15A NCAC 02T .0114 — Wastewater Design Flow Rates —
Restaurant, single service articles) x 132 seats,
List of Items Included in the application package:
Cover letter;
Executed fast track application (Form FTA 04-16);
Application fee of $480 (check made out to NCDEQ);
Applicant LLC documentation as filed with the office of the North Carolina Secretary of State;
Flow tracking/acceptance forms (FTSE 04-18) from both the Town of Shallotte and Brunswick County;
3651 Mars Hill Road Suite 2000 Watkinsville, GA 3o677 www.carterengineering, net r: 770.725.1200

USGS topographic map;
Aerial vicinity map;
Civil drawing C-3.0 — utility plan;
Duplex grinder pump specifications;
Power reliability plan — applicant letter
Should you have any questions or comments concerning the application and attendant materials please
feel free to contact meat 770-725-1200 or James Dudley (Architect of Record). He can be reached at
704.968.8934 or via e-mail at idudleva12345ftmail.com.
Sincerely,
Jeff Carte P.E. — Civil Engineer of Record
Carter Engineering Consultants, Inc.
3651 Mars Hill Road Suite 2000 Watkinsville, GA 3o677 www.carterengineering.net v: 770.725.1200

Shallotte Retail, LLC
1340 Harding Place
Charlotte, NC 28204
June 11, 2021
Mr. Dean Hunkele
Environmental Program Consultant
Water Quality Regional Operations Section
Division of Water Resources/Department of Environmental Quality
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
Tele: 910-796-7380
RE: Shallotte Chick-Fil-A — Power Reliability Plan (Portable Reliability Option)
Mr. Hunkele,
This letter is intended to satisfy the requirements of Item H in the attached Instructions for Form
FTA 04-16 — Power Reliability Plan. The duplex grinder pump serving the building will be
equipped with a portable power generation unit as a means of providing back-up power in the
event that there is a loss of power to the project site. 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. The portable source shall be owned
by Shallotte Retail LLC and shall be compatible with the duplex grinder pump.
If you have any questions concerning the Power Reliability Plan please feel free to contact me or
the Architect of Record, James Dudley, who can be reached at 704.968.8934 or via e-mail at
jdudlgyal2345 ,gmail.com.
Best wishes,
r
effr L.Irvin
Member, Shallotte Retail LLC

State of North Carolina
R Department of Environmental Quality
m""
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources 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: Shallotte Retail. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Jeffrey L. Irvin per 15A NCAC 02T .0106(b)
Title: Member
4. Applicant's mailing address: 1340 Hardin Place
lace
City: Charlotte State: NC Zip: 28204
5. Applicant's contact information:
Phone number: (7-L4) 405-9400 Email Address: Hrvin(a),cD-nc.com
II. PROJECT INFORMATION:
1. Project name: Shallotte Chick-Fil-A
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a 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: Brunswick
4. Approximate Coordinates (Decimal Degrees): Latitude: Pe Longitude: -M.!r8°
5. Parcel ID (if applicable): 182KA035 ��'c�6
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: James J. Carter License Number: 030180
Firm: Carter Engineering Consultants, Inc.
Mailing address: 3651 Mars Hill Road, Suite 2000
City: Watkinsville State: Georgia Zip: 30677-
Phone number: 770)125-1200 Email Address: jeffna.carterengineering.net
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Shallotte WWTF Permit Number: W00000798
Owner Name: Brunswick County
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): W00016693 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable): WQCSN/A
Owner Name(s): Town of Shallotte
FORM: FTA 04-16 Page 1 of 5

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 ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ® Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / 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: % Domestic/Commercial 100 % Commercial
_ %Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ® No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ Yes ®No
➢ If yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f11
Daily Design Flow'"
No. of Units
Flow
Fast Food Restaurant
2,640 gal/per day
1
2,640 GPD
gal/
GPD
gal/
GPD
gaV
GPD
gal/
GPD
gal/
GPD
Total
2,640 GPD
a See 15A NCAC 02T .0114(b), (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 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: Average 2,640 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 Sewersl:
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
➢ Section 11 & 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: 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 33_97° Longitude:-78_38°
3. Design flow of the pump station: 0.00264 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 26.5 gallons per minute at 91.4 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
16
PVC
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)(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

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & M ® Yes ❑ No
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
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 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(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webnage
➢ 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 ❑ 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 NCAC 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
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 Permitting Branch
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 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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum 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. Approval of the request is required Prior to submittal of the fast Track Application and surmortin2 documents
2. Professional Engineer's Certification:
1, James J. Carter 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.
NOTE — In accordance with General Statutes 143-215.6A and 143.215.6B, 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 Engineer's seal, signature, and date:
3. Applicant's Certification per I SA NCAC 02T .0106(b):
I, Jeffrey L. Irvin, Member, Shallotte Retail, LLC attest that this application
(Signature Authority's name & title from Application Item 1.3.)
to] -
has been reviewed by me and is accurate and complete to the best of my knowledge. l 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. 1 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, and/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 pails 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 143.215.6B, 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 bxceed $10,000 as well as civil penalties up to $25,000 per violation.
r
Signature: Date: June 11, 2021
FORM: FTA 04-16 Page 5 of 5

'r?+ LIMITED LIABILITY COMPANY ANNUAL REPORT
le/2017
NAME OF LIMITED LIABILITY COMPANY: ShallOtfe Retail, LLC
SECRETARY OF STATE ID NUMBER: 2055025 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2021
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Jeffrey L. Irvin
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
1340 Harding Place 1340 Harding Place
Charlotte, NC 28204 Mecklenburg Charlotte, NC 28204 Mecklenburg
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Commercial Real Estate
2. PRINCIPAL OFFICE PHONE NUMBER: (704) 4059400 x1 3. PRINCIPAL OFFICE EMAIL:
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS 0, M
..
1340 Harding Place 1340 Harding Place a
Charlotte, NC 28204 Mecklenburg Charlotte, NC 28204 Mecklenburg
6. Select one of the following If applicable. (Optional see Instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: ,Jeffrey Lee Irvin NAME: NAME:
TITLE: Member TITLE: TITLE:
ADDRESS:
1340 Hardina Place
Charlotte, NC 28204 Mecklenburg
ADDRESS:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT, Section D must be completed in its entirety by a person/business entity.
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
DATE
Print or Type Name of Company Official Print or Type Title of Company Official
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $200
MAIL TO: Secretary of State, Business Registration Division. Post Office Box 29525, Raleigh, NC 27626-0525

Hunkele, Dean
From: William Pinnix <[e-mail]>
Sent: Friday, July 2, 2021 10:25 AM
To: Hunkele, Dean
Cc: Lillie Childers; Jeff Irvin; James Dudley; [e-mail];
[e-mail]
Subject: Re: [External] FW: Shallotte CFA Fast Track Sewer System Extension Application for
pending WQ0042614
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Dean,
Thanks... yes, we are fine with the proposed connection.
Regards,
Bill Pinnix, P.E.
County Engineer
910.253.2408
Sent from my Verizon, Samsung Galaxy smartphone
Get Outlook for Android
From: Hunkele, Dean <[e-mail]>
Sent: Friday, July 2, 2021 10:08:02 AM
To: William Pinnix <William.Pin [e-mail]>
Cc: Lillie Childers <[e-mail]>; Jeff Irvin <[e-mail]>; James Dudley <[e-mail]>;
[e-mail] <[e-mail]>; [e-mail]
<rwa ri ng@townofshal lotte. org>
Subject: RE: [External] FW: Shallotte CFA Fast Track Sewer System Extension Application for pending WQ0042614
CAUTION: This email originated from outside of Brunswick County Government. Do not click links or open attachments unless you
recognize the sender and know the content Is safe.
211
Please confirm that County approves connection of this pump station to its force main approved under W00016693
which has been identified as the downstream sewer system on the submitted application & flow tracking form. Thi!
permit was transferred from the Town of Shallotte to County on 1-26-2009.
Thanks
Dean Hunkele
Environmental Program Consultant

Division of VJater Resonrccs
Entity Requesting Allocation: Shallotte Retai
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Project Name for which flow is being requested: Chick-Fil-A Restaurant Shallotte, NC
More tlran one FTSE tray be requiredfor a single project if the owner of the WWTP is not responsible jor ell pomp
stations along the route of the proposed wastewater flow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: _
b. WWTP Facility Permit #:
All flows are in MGD
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
It. Percent of permitted flow used
0.00264 MOD
I1. 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 Pump Average
Approx. Not Yet Total Current
Station Station Finn Daily Flow"
Current Tributary Flow Plus
(Name or Permit Capacity," (Firm /pt),
Avg. Daily Daily Flow, Obligated
Available
Number) No. MOD MGD
Flow, MGD MOD Flow
Capacity"*"
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped now
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
(pO not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning 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): US / 7 1t4k-T11
Downstream Permit Number: XN00/6693
Page 1 of 6
RTgR I A -I R

III. Certification Statement:
I Mimi Gaither 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 certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official
Title of Signing Official
Page 2 of 6
b•14.21
Date
FTSE 10-18

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Shallotte Retail
Project Name for which flow is being requested: Shallotte Chic-Fil-A Restaurant
More than one FTSE may be required for a single project tf the owner of titre WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: SHALLOTTE W WTF
b. WWTP Facility Permit #: WQ 0000798
All flows are in MGD
C.
d.
e.
f. Total flow for this specific request 0.00264
g. Total actual and obligated flows to the facility 0.618
h. Percent of permitted flow used 124%
WWTP facility's permitted flow 0.50
Estimated obligated flow not yet tributary to the WWTP 0.423
WWTP facility's actual avg. flow 0.192
II. 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
Pump
Average
Approx.
Not Yet Total Current
Station
Station
Firm Daily Flow**
Current
Tributary Flow Plus
(Name or
Permit
Capacity, • (Firm / pf),
Avg. Daily
Daily Flow, Obligated Available
Number)
No.
MGD MGD
Flow, MGD
MGD Flow Capacity***
* The Firm Capacity (design flow) 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
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning 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):
Downstream Permit Number:
Page 1 of 6
T7=0r. I n 1 a

III.Cerrtificat Statement: e,
I wt• • L inn , , \ �` to Ehe 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 certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Official Signature
Title of Signing Official
Page 2 of 6

- .
1414
•v' �afyC� � Ee
SITE �..t..
.+ry ... " --_ vim. 6+. �~ r•'•f
f'
fn
�a
,.
u
l '
Google Earth
l 1
dU y j V i
.': ]ye ]I[ .iGJ 1,
5/9;ID21