WQ0042651_Application (FTSE)_20210617

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 FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: cm ac completed by DWR)
OONZ6-5-1
All items m.ust.be completed or t application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Fu ua -Varina (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: Jay T. Meyers per 15A NCAC 02T :0106(b)
NC Dept of Environmental Quality
Title: Public Utilities Director
4. Applicant's mailing address: 134 N. Main St. JUN 17 2021
City: Fu ua -Varina State: NC Zip: 27526-
5. Applicant's contact information: Raleigh Regional O#Ece
Phone number: (2l9) 567-3911 Email Address: 'me ers fu ua-varina.or
IL PROJECT INFORMATION:
l . Project name: The Preserves at Holland
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: Wake
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.572464' Longitude:-78.7823670
5. Parcel ID (if applicable): 0666422289 0666428465 066628912 0666439015 0666523374 0666523886
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
I. Professional Engineer: Donald L. Cum+ License Number: 26970
Firm: The Curry Engineering Group,PLLC
Mailing address: 205 S. Fuguay Ave.
City: Fuquay-Varina State. NC Zip: 27526-2212
Phone number: 9 9) 552-0849 Email Address: don c en .com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: North Harnett Regional WWTP Permit Number. NCO021636
Owner Name: Harnett Count/
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0030170 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s)( if applicable): WQCS00193
Owner Name(s): Town of Fuquay-Varina
FORM: FTA 04-16 PROP I 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 ®NIA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational A eement (FORM: DEV) been attached?
❑ Yes [:]No ®NIA
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
❑ SchooI / 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: 100 Residential % Domestic/Commercial % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
4Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .01 14(f) ® Yes ❑ No
➢ If Yes, provide a coyy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 021.0114(f))
Daily Design Flow"
No. of Units
Flow
Single Family Subdivision lots
300 gal/unit
50
15,000 GPD
gal/
GPD
gaV
GPD
gall
GPD
gall
GPD
gal/
GPD
Total
15,000 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. 15,000 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):
FORM: FTA 04-16 Paee 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
1,734
PVC (SDR-35)
8
1,257
PVC (C900)
8
451
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
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:
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 .030S(ii)(1):
❑ Standby power source or pump with automatic activation and telemetry - I5A 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 Paee 3 of 5

1X. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f) & (g)
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systcros:
❑ Yes ® No
Setback Parameter*
Separation Re uired
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 im unded 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
An basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drains e systems and interce for 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(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webPRRe
➢ 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
➢ Seethe 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 ® NIA
➢ 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 02_T.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 ❑ NIA
➢ 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.
PORM- PTA (14-1 F Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the r4linimum Design Critcriu for the Permitting ot` Pump Star ions
and Force Mains latest version and the Gr:tvih- Sewer Minimum Design Criteria I 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 or the request is required prior to submittal of the Fast Track Application and sugRorting
documents.
2. Professional Engineer's Certification:
aZ.PIS71w,
(Professional Engineer's name from Application Item I11.1.)
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 documentation to the best of my knowledge. 1 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 S10,000, as well as civil penalties up to S25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date: _ci
'�
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I,.�avT. 15,��..�vbjt� (%/V&
igriature A'uthority's name & title from Application Item 1.3.)
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, 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 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 exceed $10,000 as well as civil penalties up to $25,000 per violation.

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Fuquay-Varina _
Project Name for which flow is being requested: Th'e Preserves at Holland
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewaterf]'ow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: North Harnett Regional WWTP
b. WWTP Facility Permit #: NCO021636
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the
e. WWTP facility's actual avg. flow
f Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
AI! flows are in MGD
2.600
WWTP 0.634
I.490
0.015
2.139
82.27%
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)
(g)
Design
Pump
Pump
Average
Approx.
Station
Station
Firm Daily Flow"*
Current
(Name or
Permit
Capacity, * (Firm / p fl,
Avg. Daily
Number)
No,
MGD MGD
Flow, MGD
(C)
(D)=(B+C) (E)=(A-D)
Obligated,
Not Yet
Total Current
Tributary
Flow Plus
Daily Flow,
Obligated Available
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); Morgan Creek Ph 6,9,10,11
Downstream Permit Number: 0030170
Page 1 of 6

III. Certification Statement:
I Jay T Meyers, PE _ 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.
7�;ffcial Si at:rre
h,
Title of Signing Official
-�Ko4e--Zo7-1
Date
Page 2 of 6

CurryENGINEERING
June 15, 2021
NC Department of Environment Quality
Division of Water Resources
Raleigh Regional Office
Water Quality Section
1628 Mail Service Center
Raleigh, NC 27699 1628
19191791-4200
RE: The Preserves at Holland Subdivision
Sewer Fast Track San tary Sewer Application Cover Letter
To Whom It May Concern,
Enclosed please find documentation, design data, application fee and other resources necessary to
review the Fast Track Application for the public sanitary sewer system of The Preserves at Holland
Subdivision in Fuquay-Varina, NC The development consists of a 50-lot single family home
subdivision. The wastewater generated by this site totals 15,000 GPD. Construction of the sanitary
sewer lines will connect to two existing public sewer ,Ines at the north and west side of the property,
which feed to the North Harnett Regional Waste Water Treatment Plant. The Preserves al Holland
development is located at 820 Holland Road in Fuquay-Varina. The property involved is located within
the Town of Fuquay-Varina, NC planning jurisdiction.
The sanitary sewer system consists of 2991 feet of 8" PVC and 451 feet of DIP gravity service
connecting to existing public gravity main lines. There are twenty-one (211 new manholes to be
installed in the development.
At the completion of construction, the system will be certified by a licensed professional engineer in
accordance with NCDEQ and State and local regulations.
Sincerely,
-19
Ed Loeffler, Project Manager
1r 1919) 552-0849 205 S. Fuquay Avenue
F (9191552-2043 Fuquay-Varina, NC 27526
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State of North Carolina
Department of Environment
and Natural Resources A
Division of Water Quality 'A410
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Gregory J. Thorpe, Ph.D., Acting Director
November 7, 2001
Mr. Michael A. Allway, Assistant Town Manager
Town of Fuquay-Varina
401 Old Honeycutt Road
Fuquay-Varina, North Carolina 27526
Dear Mr. Allway:
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
'MCEN
NOV 0 8 2001
U= at -Vert
Subject: Town of Fuquay-Varina
Flow Reduction Approval
Wake County
On September 10, 2001, the Division of Water Quality Non Discharge Permitting Unit received your
flow reduction request for future and present, but not yet tributary, single-family dwellings in the Town of
Fuquay-Varina. The letter requests approval of a residential flow value of 220 GPD/residence for these
dwellings.
The information provided water use information for 2000 and actual daily waste water flow recordings
for their peak month of May. Other supporting data was provided. The evaluation covered 90 homes that are
representative of the subdivisions in Fuquay-Varina in accordance with 15A NCAC 2H .0219(1)(3).
Based on the information submitted, the Division hereby approves the use of 75 GPD per bedroom
per dwelling for residential units (225 GPD per three bedroom home) in all applicable non -discharge permit
applications for future sewer line extensions and present, but not yet tributary projects for the Town of Fuquay-
Varina. The Division did note that the average flow per residence in February 2000 was 271 GPD. Regardless
of the adjusted design day wastewater flow rate at no time shall the wastewater flows exceed the effluent
limits defined in the Town's NPDES errnit for the treatment facility or exceed the capacitycgpagity of the sewers
downstream of anynew sewer extension.
Please submit a separate letter to the Raleigh Regional Office that requests now reductions for
Specific previously permitted projects (indicate permit number, project name, permitted flow, new flow
under reduction and the difference between them). If you have any questions or comments regarding this
matter, please contact Marie Doklovic at [phone] ext. 371.
Since ,
L!
Gregory J. Thorpe, Ph.D.
cc: Raleigh Regional Office
Flow Reduction File
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] Fax [phone]
An Equal Opportunity Affirmative Action Employer 50% recycied/10% post -consumer paper

Curr
ENGINEERING
TRANSMITTAL FORM
TO: NC Dept. of Environmental Quality
Div. of Water Resources
Raleigh Regional Office
Water Quality Section
1628 Mail Service Center
Raleigh, NC 27699-1628
919-791-4200
SUBJECT: The Preserves at Holland
CURRY PROJECT NO: 2019-042
We are sending you the following items:
DATE: June 15, 2021
SENT BY: Ed Loeffler
COPIES ITEM DI
2 Application Fast Track Sewer Application - The Cr
2 Forms FTSE 06-13 [Town of Fuquay-Vannal
1 Check $480,00 Fee, Sewer Application
These are transmitted as checked below:
NC Dept of Environmental Quality
JUN 17 2021
Raleigh Regional Office
For information Approved as Noted - Revise and Resubmit
As Requested Not Approved - Revise and Resubmit
For Review and Comments For Record and File
For Revision Submittal
x For Approval For Recording
Approved _ For Signature, then return to:
REMARKS:
Attached please find the signed Fast Track Sanitary Sewer Application for the Preserves at Holland
Subdiviss�n, at 820 Holland Road in Fuquay-Varina. Please contact me with any questions. Thank you.
T (9191552-0849 205 S.Fuquay Avenue
F 1919) 552-2043 Fuquay-Varina, NC 27526
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Cover Page Language:
Condition I.1: An alternative design is granted for the installation of gravity sewer as well as
manholes being located within the 100-ft radius of a nearby private well, in
accordance with 15A NCAC 02T.0105(n). Please see Condition l.1 for more
details
Special Condition Language:
Per the submitted variance request as received on May 19, 2021 by The Curry Engineering
Group, PLLC on behalf of the Town of Fuquay-Varina for the subject project, the Division will
grant the variance request with the following conditions:
• As specified in the provided plans, where the gravity sewer does not meet separation
requirements for private wells; materials, testing methods, and acceptability standards meeting
water main standards (15A NCAC 18C) shall be specified, per 15A NCAC 02T.0305(g).
• Manholes located within the 100-foot radius of existing well (STA 10+00, STA 10+18.77 and STA
11+44.56) shall be designed, constructed, and tested in accordance with the plans, general notes,
and cover letter as submitted to and approved by the Division as part of this variance request.
• The minimum separation for any portion of the sewer system shall not be less than 25 feet from
a private well or 50 feet from a public well.
Regardless of the variance approval, in the event that the wastewater collection facilities fail to
perform satisfactorily, including the creation of nuisance conditions, the Permittee shall take
immediate corrective action, including those as may be required by this Division, such as the
construction of additional or replacement facilities.
All other elements of this project shall be constructed in accordance with all applicable rules and
statues including, 15A NCAC 2T; the Division of Water Resources' (Division) Gravity Sewer
Minimum Design Criteria adopted February 12, 1996 as applicable; and the Division's Minimum
Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1,
2000 as applicable. Approval of the variance request does not constitute approval of the permit.

State of North Carolina
nWR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dlvlslon 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 1 SA 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 I SA NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
7 Projects that require an environmental assessment in accordance with 15A NCAC I C .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;
7 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.
i► 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.
i 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 SecretM 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 II.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 EnZineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .010fri 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 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page] of3

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.
> 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-
215.67La).
> Intergovernmental agreements or other contracts will not be accepted in lieu of project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x I ]-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 (Ali 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)f 11, 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 I SA 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
timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
1. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .01 15(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
Cl 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/PropertyOwners' Associations
❑ Per 15A NCAC 02T .01 15(c), submit the properly executed Operational Agreement (FORM: HOA1.
❑ Per 15A NCAC 02T .01 15(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 Operational Agreement (FORM. DEV).
For more information, visit the Division's collection systems wehsite
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 Regional 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
Washington 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 Regional 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, Sury, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3