WQ0042656_Application (FTSE)_20210610

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
DIvislon of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: W 0 0_047_65_6 (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: BCFL, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ® General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: Kate Tillman Brown per 15A NCAC 02T .0106(bl
Title: Managing Partner
4. Applicant's mailing address: 1004 Wake Forest Road
City: Raleigh State: NC Zip: 27604-
5. Applicant's contact information:
Phone number: 919 872-5702 Email Address: kateaa.commprop.net
II. PROJECT INFOII VAT,-, r'tiwr Q�c `
1. Project name: Food Lion
❑ Privately -Owned Public Utility
❑ Other
2. Application/Project status: ® Proposed (New Permit) ❑ 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: Chatham
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.8136 Longitude:-79.0887'
5. Parcel ID (if applicable): AKPAR: 93299
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Adam E. Freeman License Number. 044644
Firm: McKim & Creed, Inc.
Mailing address: 1730 Varsity Drive, Suite 500
City: Raleigh State: NC Zip: 27606-
Phone number: [phone] Email Address: afreemanQmckimcreed.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Briar Chapel Utilities Wastewater Treatment Facility Phases A and B
Owner Name: Old North State Water Company, LLC
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0038877 (Briar Chapel SD West Phase 2)
System Wide Collection System Permit Numbcr(s) (if applicable): WQCS
Owner Name(s): Old North State Water Company, LLC
Permit Number: W00028552
FORM: FTA 04-16 Pagel 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 Opuratir na] Agroom enI (FQRM: DEV) been attached?
❑ Yes ®No ❑N;'A
3. If the Applicant is a Home -Property OwnM'.Association, has an Operational Agreement (FORM: HOA I 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 i preschool f day care ❑ Medical r dental..' veterinary facilities ❑ Swimming Pool'Ciubhouse
® Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
® Businesses I offices l factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic/Commercial 100 % Commercial
% Industrial (See 15A NCAC 02T _0103(20})
�bIs there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 1 SA NCAC 02T Al 14ff1? ❑ Yes ® No
➢ If yes. provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 021.0114f f1)
Daily Design Flow *,b
No. of Units
Flow
General Business, Offices and Factories
25 gal/Day
58
1,450 GPD
gal'
GPD
gala
GPD
gal!
GPD
gal/
GPD
gall
GPD
Total
1,450 GPD
a See 15A NCAC 02T-0114fb . tdL (e)f 1) and (eX2) 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: 1,450 GPD (per 15A NCAC 02T .01 14)
➢ 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- 1 6 Page 2 of 5

VII.
Vill.
GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 871 PVC
➢ 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
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 .D305(h)(I 1:
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(13)_
➢ 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) & { ® 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-1 waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-1 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.03Q.V
.Llia contains alternatives where separations in QZI-C-�05(n cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Sudco WatcrClassificatioos w0pa&e
➢ If noncompliance with 02T.0305(f) or I" 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 l5A NCAC' 2R.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 N( A(' 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 021, the Minnnum. Design Criteria for the Permitting of f hump 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 orior_to submittal of the Fast Track Application and suppoLijag
documents.
2. Professional Ingineer's Certification:
I, Adam E. Freeman
(Professional Engineer's name from Application Item Ill.].)
attest that this application for
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 dOCnmentatlOn 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 he 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 tine 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: Digitally sig d by
A man
2 4
Q0,12: 7-04'0 '
044644
s\
//'''r�1,•t. FBI d � 1 `, ti,`'•
3. Applicant's Ce iFicatit) n per IS NCAC 02T .0106(h):
l - -�X>v I A6LYyS r L� PL LLB.
_ % _ quest that this apphcasion for
(Signature Authority's game & title from Application ltem 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 mclude 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 parts of this application package arc not completed
and that if all required supporting information and attachments are not included, this application package will he returned to
me as incomplete.
(NOTE — In accordance with General Statutes 143-215.6A and 143-21 !,.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: J. 0 Datc: 6/1/-
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
nWR
Department of Environmental Quality
Division of Water Resources
Division 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: Food Lion LLC
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible far all pump
stations along the route ofthe proposed wastewater flow.
I. 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
0.250
d.
Estimated obligated flow not yet tributary to the WWTP
0.045
e.
WWTP facility's actual avg. flow
0.205
f.
Total flow for this specific request
0.0013
g.
Total actual and obligated flows to the facility
0.206
h.
Percent of permitted flow used
82.4%
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
Average Daily
Approx.
Not Yet
Total Current
Station
Firm
Flow"
Current Avg.
Tributary
Flow Plus
(Name or
Capacity, *
(Firm 1 pt),
Daily Flow,
Daily Flow,
Obligated
Available
Number)
MGD
MGD
MGD
MGD
Flow
Capacity***
SD East
1.584
0.417
0
0.103
0.103
0.314
-'*—The Firm Capacity of any pump station is defined as the maximum pumped slow 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.
*** 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 a 0.
Downstream Facility Name (Sewer): Briar Chapel SD East Lift Station
Downstream Permit Number: W 0039608 Modification
Page i 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.
Signing,kial Signature
X/O X)II
bate
Page 2 of 6
FTSE 04-16

T1C Dept
vicu�„nC�t�l Quality
v � MCIQM&CREED
Commercial
PrQperties
CPDG Developm
Development
Group
Fast Track Sewer Application Narrative
Briar Chapel — Food Lion
Date: May 10, 2021
Digit Ily signed by dam
eman
2 4
09:13: -04'0 '
044644 -
pt4 i q 20
gateWO P1e910nal pg�'ice
Prepared for:
Food Lion, LLC
2110 Executive Drive
Salisbury, NC 28147
Prepared by:
McKim & Creed, Inc.
1730 Varsity Drive
Suite 500
Raleigh, NC 27606
McKim & Creed Project #00741-0011

Food lion, LLC
Grocery Store
May 10, 2021
PROJECT NARRATIVE
yenta, Q�a1�ty
Crept °f �n��Con
a 00ce
1$hRcgl°�a1
.gale
The purpose of the project is to construct utility infrastructure to support the
Food Lion grocery store within in the Briar Chapel Development in Chatham
County, NC. The improvements planned in this phase are internal to the Food
Lion, LLC parcel (AKPAR 93293) and will connect to previously constructed
infrastructure for Briar Chapel SD West Phase 2 project (WQ0038877). 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 35,929 s.f. grocery store. Using the 02T regulations,
the estimated flows calculated for this facility will be 1,452 gpd. The breakdown
is as follows:
• 58 employees @ 25/gpd/employee
The sewage and wastewater collected by this system will be treated in the on -site
wastewater treatment facility:
WWTP Facility Name: Briar Chapel Utilities, LLC
WWTP Facility Permit #WQ0028552

MAPS

15
, vv.
a ' i-'VT-'mq W
N'tIT"
Nz kw
lc%T,

v
n
c
x
Om
3x10 m��3
c co o � Ro, it �p �° m M
x ar x 0 �v
� � A E8
�1 mg o
C m o
�3�mg�. �mCOP
3�',�°
Q i $ a Q m
�so
7 D N
a3oR—'^R- p
m o R w w w m m m 3 m a o $ E $ m w S GIag
m g e a aD $ H v m
40 i3� �Ng 7w� ��� n 9 m m v' g m s
$m 30 !"aania�m v°�� a c+a'�g—"
�n3�n°m 3jON�D a"n `0�� m�Qg�xo
who m p m c m 0 �5 c - - 9 � 9R Comm 3k q
Sr gm�`-- m n. om c m m a m a$ = 0 a r+ o moo k ii
gm S �v m m e3 �' ' F+ H Jaen �°m $
_ Ic a r- o a Q 3
c��oQ Win° 3 a 1 c/ ?R nR m m m `° ' v -- o Amy m p Y c Q y�
3 R7 o miPi $ N� m rn S R O m g
$m w ° �a '° s n r- F
�'Im0° 3�m °^a p n ?a�Sr m
pm n .0 vr` a m `0 mmafa 3

f�
°uo�5 ..
I

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 20th day of April , 2015.
NORTH CAROLINA UTILITIES COMMISSION
sail l.'!'(loum*
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
in
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 20th day of Aril , 2015.
NORTH CAROLINA UTILITIES COMMISSION
Gail L. Mount, Chief Clerk

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources 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 permit from the Division) are explained in 15A NCAC 02T,Q303.
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 I .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):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
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 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina SmreLary of Slate.
❑ If the Applicant Type in Item 1.2 is a partnership or dlb,:a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item 1I.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 021.0106fb1.
Per 15A NCAC 02T A 106(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 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Paget of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
E Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ MuItiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ 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(a1.
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
E Submit an 8.5-inch x 11-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
E Include a street level map showing general project area.
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)(1), submit documentation of power reliability for pumping stations.
➢ 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(b)) 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
dmeframes, 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):
E Per 15A NUAC 02T .0115(a)f l )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
E 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 I SA NCAC 02T .01 15(c}, submit the properly executed O"rational AAgr=U)ent (FORM: HOA).
❑ Per 15A NCAC 02T .01 l 5(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .01 15(b), submit the properly executed Oaerational Agreement ORM: DEV,).
For more information, visit the Division's collection systems website
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
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality, Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Reaional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality_ Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washinaton Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Re ional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

v���t�,cizEsD 3
TO. Division of Water Resources
Raleigh Regional Office 5
ls:
3800 Barrett Drive c
a
Raleigh, N.C. 27609 q
ATTENTION: Mr. Danny Smith
WE ARE SENDING: ❑ Originals
❑ Specifications
LETTER OF TRANSMITTAL
U
DATE: aVne 9, 2021
00JECr e: 00741-0011
TASK NO: REIMB
E: '§.riar Chapel Multi -Family Apartments
x
04
TRADISMITTAL. NO:
PAGE 1 OF 1
❑ Prints
❑ Calculations
❑ Shop Drawings ❑ Samples
® 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 (� Nk�KC� ( C
FT
Issue Status Code: A. Preliminary B. Fabrication Only C. For Information D. Bid
E. Construction F. For Review & Comments G. For Approval H. See
Remarks
Action Status Code: 1. No Exceptions Taken 2. Make Corrections Noted 3. Other
4. Amend & Resubmit 5. Rejected -See Remarks
1730 Varsity Drive, Suite W Raleigh, NC 276D6 919j233-8091 Fax [phone]
Cc: File McKIM & CREED, INC.
4 40
Signed
Don Bataille
Senior Civil Designer