WQ0012559_Application (FTSE)_19960619

1
MEMO TO: State Review Group
FROM: Ricky Revels A)
Environmental Technician IV
A.,A R.,„_.
SUBJECT: Procedure Four (4)
WQ0012559
Capefear Woods
Sewer Extension - Public
PWC/City of Fayetteville
Cumberland County
Division of Environmental
Management
Fayetteville Regional
Office
6/25/96
Date
State Review Group Review
Engineer Matt Williams
Regional Office
Contact Ricky Revels
1) Name of wastewater treatment plant to receive the wastewater:
PWC of Fayetteville - Rockfish Creek Wastewater Treatment Plant
2) WWTP design capacity 12.0 MGD
3) NPDES Permit No.: NC0050105 Expiration Date: 5/31/96
4) Compliance Information:
Present treatment plant performance
for previous 12 months - beginning 6`95
(See attached self -monitoring data)
5) Quantity and type of wastewater from proposed sewers: 20,000 GPD
domestic ; industrial 100% ; other
6) Volume from previously approved projects not yet tributary to
WWTP N/A GPD
7) Regional Recommendations: Approval X Denial
RR/rr
Enclosure

:;•
•
:
4,5
"

.91
State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
June 19, 1996
MR. VICTOR GANJEHSANI
PWGFAYE 1TEVILLE
PO BOX 1089
FAYETTEVILLE, NORTH CAROLINA 28302
Dear MR. GANJEHSANI:
R
i
JUN 24 1998
ENV. MANAGEMENT
FAYETTEVILLE. DREG. OFFICE
Subject: Application No. WQ0012559
Capefear Woods
Sewers -Public
Cumberland County
The Division's Permits and Engineering Unit acknowledges receipt of your permit application and
supporting materials on June 18, 1996. This application has been assigned the number listed above.
Your project has been assigned to Randy Kepler for a detailed engineering review. Should there be any
questions concerning your project, the reviewer will contact you with a request for additional
information.
Be aware that the Division's regional office, copied below, must provide recommendations from the
Regional Supervisor or a Procedure Four Evaluation for this project, prior to final action by the
Division.
If you have any questions, please contact Randy Kepler at [phone] extension 544. If the
engineer is unavailable, you may leave a message on their voice mail and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING
INQUIRIES ON THIS PROJECT.
Sincerely,
Caron D. cCaskill
Supervisor, State Engineering Review Group
cc: Fayetteville Regional Office
OHM Remediation Services, Corp
Pollution Prevention Pays
P.O. Box 29535; Raleigh, North Carolina 27626-0535 Telephone [phone]
An Equal Opportunity Affirmative Action Employer

r
State of North Carolina
Department of Environment, Health and Natural Resources
Division of Environmental Management
Non -Discharge Permit Application
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
GRAVITY SEWER EXTENSION
PUMP STATIONS, AND PRESSURE SEWERS
L GENERAL INFORMATION:
1- Applicant's name (please specify the name of the mnnYi,tiry, eorpc ration, individual. ez Pub 1 i c
Commission of the City of Fayetteville, NC
tea
Cr)
Wo1c5
2. Print Owners or SigningOfl3c'.al's name and title (the person who is legally responsible for the facility and its compliance):
Victor GanJehsani-Chief Water Resource Engineer
3. Main g adt3rezz P. O. Box 1 0 8 9
c- Fayetteville
Telephone Number ( 910
State zip: 28302-1089
483-1401
4. Project Name (please specify the name of the subdivision, facility, or establishment - should be consistent with project
name on plans, specifications, letters of flow acceptance, Operational Agreements. etc.):
Former CapeFear Wood Preserving site - EPA Superfund Project
S. ApplicarionlZiut: May r 1996
6. County where`pro tit loc3icd Cumberland
LI. PERMIT INFORMA''_"ION•
1. Application No. (will be
2 Specify whether project is: X new -
6. FeeSubmitted: $ 2 0 0
cbmplescd by �1 't-5
modification.
3. If this application is being submitted as a result of a modification to an existing permit. please camplett:
existing permit number and the issue date
4. Spce.fy whether the applicant is polices X Private,-USEPA-Remedial Action
III. INFORMATION ON WASTEWATER:
1. Nature of Wastewater. % Domestic/Commercial ; 1 0 0 gt; Industrial:
% Other waste (specify):
2. Please provide a one or two word description specifying the origin of the wastewater. such as school, subdivision, hospital,
commercial, industrial, apartments, etc.: c .),pr,r-Fiinci Site N P L Listed
3. Indicate any parameter(s) (and their concentration) that will be greater than normal domestic levels; No
4. If wastewater is not domestic in nature, what level of prtn cnertthas been provided to ensure protection of the- re eiving
wastewater :r treatment facility? Activated Carbon A b s o r b t i o n
FORM: GSPSA 11/93 ' - Page 1 of 8

S. If a pit isrequi red. has CM bean issued? Yes . X No. It yes. please attach a elegy of the
p essmeneat permit If No. when will one be issued
6. Voltage ofwaste water genexated by this ptrojax 4 , 000 gal./ 20 .0 fl0 ga 7 galbos pa day.
IlimlanaOon afhow waste9+atavalumewas h,•^^ 4.000 mil_ �larOr„ 1r A by psr;m1ra .f - 1 »1 -ted
econtamation water, storm water and system drains. -After this phase estimated well
June 1, 1996 (For Soil Treatment)
output total 100gpm.
IV. DESIGN INFORMATION:
i. Srietprojoudato ipaoa: USEPA NPL Superfund site. BECHTEL is EPA's contractor. 6-1-96
to 2-29-97 surface remediation phase soil treatment process will use'p.ipe1inP And
pump station 7-1-96 to year aprox. 2006 will use pump and treat fnr grniindc.Tarcr
Fayetteville PWC-Rockfish Creek T.P.
2. Name of wastewater treatment facility me:lying wastewater.
a. Facility Permit Number: F NC 0050105
r:
b. Engineer should provide statement of his evaluadoa of downstream sewers ability to accept the wastewater:
PWC will allow access to manhole N.E. of Cliffdale
and Reilly Rd.
c. Permit Number fc sewers immediately downstream: Installed before 1 9R5-nn po,-,,.; r req, <nd
d pipe diameter of sewers immediately downstream: 8 inch
3. Summary of sewer pipe to be permined, by diameter size and pipe material:
Dias:neer
On)
Length
(linear feet)
Pipe
Material
SDR 21 •
C'. -p.
N Factor
Valve
Minimum
Slope (%)
Maximum '
Slope (%)
1
ity
CPO
lxi
um
OPs)
Minimum M
Cover (in)
4
4,800
PVC
150
Force MainFotce
Maii-
2.5
2.85
'IA"
A
NOTE: The minimum velocity must not be less than 2 fps.
For public sewers the minimum diameter is .8 Caches.
For private sewers the minimum diameter is ti Inches.
4. Anchors shall be provided for sewers with slopes greater than 20 %. The anchor spacing shall be a maximum of: 36 feet
separation for slopes of 21% to 35%; 24 feet separation for slopes of 36% to SO%; 16 feet separation for slopes greater than
SO%.
For velocities greater than 15 fps. it is strongly recommended that measures be considered which will protect the sewers and
manholes from erosion. For velocities greater than 20 fps, erosion control measures must be specified.
For any excessive slopes or velocities that will occur in any sews lute segment, what measures have been taken is protect
the sewer pipe and manholes?
N/A
FORM: GSPSA 11/93 Page 2 of $

0.: Maxim= Newer roach length betwe s mast ed= N / A linear fee.
6. This sewer line segment occurs betwom amble no. and manhole era.
7 Does the owner/operator have the ability so clean this length? X Yes _No. Far sewer reach lengths greaser
than 425 feet, please provide a letter from the owner/aperstm staring the ability to desa the apes f ed roach and include the
equipment specificariass.
a.' •Sewers subject to existing or planned untie bearing lords? X Yes No. If yes. what neatens are bdeg sal=
o enable the sewers to withstand the loads?
9- Outside drop manholes are provided where invert separations exceed: N / A tact (provide far separations > ors 2S)
10. Identify (by masbole uuv her) those manholes that have drop connectfoor N / A
I1. Maximum allowable infiltrationlexfilaatioa test rate: 100 GPD/pipe diameter inch/mile of pipe.
NOTE: Must not exceed 100 GPD/pipe diameter inch/cult of pipe.
12 Ianimum separation distances as shown on the plans or addressed in the specifications. If a. b. or a below is no. explain
in an utachmeat (This section must be completed far all collection sysusas including force mains and pressuts=s sewers):
at) 100 ft. horizontal sepal:Ida: from wells or other water supplies? Yes X No
b) 12 in. vertical separation from ,torsi sewer or f&ous pipe sanitary sewer specified? X Yes No *
c 10 ft. beriz. rep. from war mains or 18 In vertical seep. (wate over sewer) a ferrous pipe specified? X Yee _No *
11. Arc manholes subject to flooding? 'tea X Ne. If yes. are manhole rbn elevations 1 foist above 100-year flood
level. (1tXI year flood elevation should be indicated on plans) Yes No: Or. are; manholes watertight and versed 1
foot above the 100-year flood elevation ( should be shown on plansYet; No
14. Identify (by manhole number) those manholes that are vested:
•
15. Does this project involve any stream crossings? Ya X No. If yes. what precautions or special features have been
utilized to ensure protection of the sewer line and not restrict scream Bow? Identify the sheet of the plans and station
numb= where stream crossings are located:
Please note: The Division recommends all sae= crossings be located three (3) feet below the stream bed or ferrous
material pipe be specified. In addition. all aerial steam crossings must be located above the 25-year flood elevation. Both
the 25-year flood elevation and the 100-year flood elevation should be indicated on the plans.
16. Sewers mg. D.41 be installed in WS-I watersheds. Are any of the subject wastewater collection systems located in a WS-1
watershed? Yes X No.
17. Miscclaawuscommenta * Except for under Cliffdale Ave.
FORM: GSPSA 11/93 Page 3 of 8

V. PUMP STATION INFORMATION Wood Preserving Site
1. Rasp Station No. of NuaaFo rme r Cape Fear - (A separate sheet 4 of 8 should be submined for each pump station)
2. Nitsse of doss downsloce s *T waters: Unnamed tributary to Beaver C
3. Can r
scion of closest dowasloQe surface water= C" (as established by the Envi:vamental Manage:neat
Commission At cr.cifi,-4t on sheet 5 of 8 of this vpticaaon).
4. In accordance with 15A NCAC 2A 2219 (h)(3) describe the measures that are being implemented to prevent impacts as
doansiope surface waters. should a power failure otor at this pump statist NOTE Alternative power MUST be
addressed for every pump station in accordance with the above regulation. N / A
S. what Cheerer pumps arc provided: 3" duplex Barnes Gp and bow Panay? 50 GPM x 2 pumps
6. What is the design total dynamic bead? 100 feet
7 How many pumping cycles will occur at average duty flow? 2.0 cycles per bola
NOTE:. 15A NCAC 211 2219 (h)(2) requires 2 to 8 pumping cycles per hour be achieved at average daily flaw.
IL The following items are typically required in the design for pump stations. C2teck the appropriate blank to signify that
these items ba_nkcenprovided is the design plans/sp c it a ion=
Alternate Power Source N/A
Vex Well Vented with Screen X
Fillets in Wet well
Check Valves and Gate Valves
Security Fencing
Lockible Wct Well Cover X
Area Light
1IOV Electrical Convenience Outlet
Fleed/Buoyancy Protedon
high Water Alarm (one choice may be spedfed) X Audible and Visual Auto Dialer
toedby diameter size and trite material:
Diameter
an) .
: Length
(linear feet)
Pipe
Material
High
Elevation
(ft)
Low
Elevation
m)
Minimum
Velocity
(fps)
Maximum
Velocity
«/
Minimum
Coves din)
4
4,800
SDR 21
233.0
226.0
2.5 1
2.85
•
36
*
10. Are air release valves provided at all points along the force main (must be provided where the elevationdifference
dierence
exceeds 10 feet)? yes _ Do
12. Is pomp station subject to flooding? yes X
no. If yes. what measures act being taken to protect against flooding?
12. If subject to flooding. specify the 100-year flood elevation: Feet MSL
13. Are them existing or planned pump stations downstream of this stallon? Yes X No. If yes. the engineer shall
evaluate the ability of those pump stations to adequately handle the subject flows and shall include that evaluation as an
attachment to this applicsaon.
FORM: GSPSA 11/93 Page 4 of 8

This form lanai be completed by the appropriate DEM regional office and Included as a part of the project
submittal information.
'NSTRUCTIONS TO NC PROFESSIONAL ENGINEER:
The: classification of the doe/aslope atrrface waters (the surface wase=i that any overflow from the facility would flow mward)
in which these sewers will be constructed must be determined by the appropriate DELI; regional office. Therefore, you are
required. prior to submittal of the application package. to utbrait this farm, with items 1 through 7 complete!, to
the appropriate Division of Environmental Management Regional Water Quality Supervisor (see page 8 of 8). At a
minimum. you must include an 8S by 11' copy of the portion of a 7.5 minute USGS Topographic Map which ttttoaz the
joestioon of these sewers and the downslope surface waters in which they will be located. Identify the closest downslope
surface waters on the attached map copy. Once the regional office has completed the classification.
reincorporate this completed page and the topographic map into the complete application form and
submit the application package.
i. Applicant (specify nano of the slunk ipalizy. corp:radon. individual. eie.x RP h to 1 Fnvi_rnamun
Z Name4complacaddressofestgineesin=Sam: OHM Remediation Services, Corp.
5335 Triangle Parkway, Suite 450,,Norcross, GA 30092
Telephone number. ( 770 ) 729-3900
3. P1ojectnarne: Pnrmar ('ape Fear j,1nna Preserving Site
4. Naineofdlo atdownsIopeamfaCewan Thm np i rrihntary to RPavar rrpPk
S. County(:) where sewers and surface watts are located:
6. Map twneand dater See Attached
Cumberland
•
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sou*.,....■....",
7. NC Professional Engineer's Seal. Signature. and Daze: �Z� •C 1RO j ••.;� • :
e..AESsIp�3 1
O
sE a�
19$66 s
TO: REGIONAL WATER QUALITY SUPERVISOR
Please provide me with the classification of the watershed what these sewers will be communed. as identified art the attached
map segment
Name of uaface waters:
Classification (as established by the Environmental Management Commission):
Proposes! riaeiiriration1 if applicable: iJl4
Signatms of regional office personnel: A I ge,,_ r .- Datc eo —/3 — % Co
(All attachments must be signed) �✓ •
Unnamed-*ribukQry 1b @smiler Ct-ee,�
t, C
s. M: GSPSA 11/93 Page 5 of 8

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05/06/1996 16:06 4232202103
BECHTEL ENV PAGE 07
j-
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION OF ENVIRONMENTAL
MANAGEMENT UNLESS ALL OF THE APPLICABLE ITEMS ARE
INCLUDED WITH THE SUBMITTAL
Regidred lams
a. Ooe original said ooc copy of the completed and appropriately executed application form. If modifications to the form are
required as a result of additional information requests by the Division. the additional information must be uansmiued under
the signature of the applicant and the actual modification must be initialed by the NC Professional Engineer.
b. Two (2) sets of detailed plans and specifications signed and Sealed by a North Carolina Professional Engineer. The plans must
Include a general location map, a plan view of the sewer extension, a profile of the sewer extension. and must show the
proximity of the sewer extension to other utilities and natural features. Specifications may be omitted for delegated
authorities. Each sheet of the plans and the first page of the specifications must be signed and sealed. Two (2) copies of the
existing permit if a modification. The plans and specifications must not contain phrases (such as FOR REVIEW ONLY,
NOT FOR CONSTRUCTION, etc.) that indicate that they are anything other than final plans and specifications. However,
the plans and specifications may contain: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
c. Two copies of all calculations, including pump selection. friction calculations, cycle time. pump curves (including system
curves applicable with one pump running. two pumps running, three pumps running, etc.), and evaluation of downstream
pump stations. These items mast be submitted under the signature and seal of the NC Professional Engineer.
d. The appropriate permit processing fee, in accordance with 15A NCAC 2H .0205(cX5). The fee for sewer extensions for
nondelegated municipalities is 5400. The fee for sewer extensions for delegated municipalities (applies only to those
governmental jurisdictions that have specific delegation review authority. as granted by the Environmental Management
Commission) is $200. Name changes without other modifications are S100.
e. If the owner/authority of the wastewater treatment facility (WWIP) that will be accepting the wastewater flow front this
project is different from the applicant of the project, then a letter must be provided Eton the owner/authority of the WWiF
specifying the volume of flow that will be accepted. The lever should be a recent karr and should refer to the project by the
same name as that identified on the application and the piansispecifiations.
f. If the application is being submitted in the name of a privately owned public utility, evidence mur. be subrtiined from the
Utilities Commission which demonstrates that the utility is authorized to hold the franchise for the ara to be served. In the
ease of contiguous service areas, evidence -must be provided from the Utilities Commission acknowledging these areas Ere
Covered under an existing franchise.
A properly executed Operational Agreement (original and one copy - form provided by DE?ei) must be submitted if the sewer
extension will be serving single family residences, condominiums. mobile homes, or town houses and if the subject sewer
extension is owned by the individual residents, a homeowners association, or a developer.
h. 'The downslope surface waters classification must be determined by the appropriate DEM regional office, using page 5 of 8 of
this form, prior to the submittal of the application package to the Water Quality Permits and Engineering Unit. Once the
regional office has completed the classification, page S of 8 should be reincorporated into the application package and the
entire application package may then be submitted to Water Quality Permits and Engineering Unit.
A cover letter, which briefly describes the project, should be included with each application package. If necessary for clarity.
feel free to include attachments to the application form. Such attachments will be considered as part of the application and.
should be numbered to correspond to the section to which they reefer.
All materials and fees submitted in support of this request for a permit become the properry of the Division of Environmental
Management therefore, if the permit is not issued for any reason, the Division will return submitted materials only at ice
option.
FORM: G:,%.:r, 11/93 Page 6 of 8
MAY-06-1996 17:25 4232202103 P.07

lame and
complete Address d Engineering Fun:
OHM Remediation Services, Corp.
5335 Triangle Parkway, Suite 450,
Norcross Stain: GA • 30092 ity:
hfspbooe Numbs: ( 7 7 0
729-3900
Professional Engineer's Certification:
• Keith G. Angell anew that thin application far
has been tt viewed by me and is accurst= and complete to the best of my knowledge. I feather assess that to the best of my knowledge
the proposed design has been prepared in accordance with the applicable regulations. Although certain portions of this submittal
package may have been developed by other professionals, inclusion of these materials tardes my signanue and seal signiftea that 1 have
Reviewed this material and have judged it to be consistent with the proposed design.
North Carolina Professional Engineer's Seal..Signatrzrc. and Date: CAROL
,/R. a ..nws„�
4�..liSS IQ
• • a SEAL
" i 19866
sc,fiZt 4.124:.G1145:1
•
,,47,,
.
Site
Former Cape.Fear Wood Preservin€
Applicant's Certification:
Victor Ganjehsani
has been mimed. by me and is'accurate and compiete w
application are not completed and that if all requited
will be returned tb mess incom
Signature
Site
thatthisapplicatioa f Former Cape Fear Wood Preserving
my taiow{odge. 1 tmdesstand that if all required parts of this -
and t.ttsehtaents are not included. this application package
:2q_gZC
THE COMPLETED APPLICATION PAC 'AG fling
MATERIALS, SHOULDE
ALL SUPPORTING INFORMATION A.ND
FOLLOWING ADDRESS: -
NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGEMENT
WATER QUALITY SECTION
PERMITS AND ENGINEERING UNIT
POST OFFICE BOX 29535
RALEIGH, NORTH CAROLINA 27626-0535
TELEPHONE NUMBER: [phone]
FORM: GSPSA 11/92 Page 7 of 8

05/0b/1996 16:06 423220210J BECHTEL ENV
•
PAGE e9
DIVLSION OF ENVIRONMENTAL MANAGEMENT REGIONAL OFFICES (11193)
Asheville Regional WQ Supervisor
$9 Wood& Place
Asheville. NC 28801
(704) 251 a62O8
Fax [phone]
Avery Maw=
Buncombe Madison
Nuke McDowell
Caldwell Mitchell
Cherokee Polk
Clay Rutherford
Graham Swain
Haywood Transylvania
Henderson Yam"
Jar -loan
Fayetteville Regional WQ Supervisor
Wachovia Building, Suite 714
Fayetteville, NC 28301
[phone]
Fax [phone]
Anon
BLden
Cumberland
Harnett
Holm
Montgamery
Moore
Robeson
Richmond
Sampson
Scotland
Washings= Regional WQ Supervisor
Post Office Box 1507
Washington, NC 27889
[phone]
Fax [phone]
Beaded
Bettie
Camden
Chowan
Owen
Currituck
• data
Greene
Bert%d
Winston-Salem Regional WQ Supervisor
8025 North Point Boulevard, Suite 100
Winston-Salem, NC 27106
[phone]
Fax [phone]
Alamaa:e
AIleghany
Ashe
Caswell
Davidson
Davie
Forsyth
Guilford
Rockingham
Randolph
Stokes
Surry
Watauga
Wilkes
Yadkin
Joss
Lenoir
Mania
Pamlico
Pasquceank
Paqttimans
Pitt
Then
Washington
WVe
Mooresville Regional WQ Supervisor
919 North Main Street
Mooresvile, NC 28115
[phone]
Fax [phone]
Akx#nda
c
Catawba
Gaston
lbodeD
Li ncolu
Mecklenburg
Rowan
Stanly
UioU/�nevrnnr`�d
FORM: GSPSA 11/93 v :: Page 8 of 8
MAY-06-1996 17:26 4232202103
Raleigh Regional WQ Supervisor
Post Mee Box 27687
Raleigh. NC 27611
[phone]
Fax [phone]
Chatham Nash
Durham Northampton
Edgecomhe Orange
Franklin Pen=
Granville Vance
. Halifax Wake
Johnston Warier
Ia Wilson
Wilmington Region. WQ Supervisor
127 Cardinal Drive Extension
Wilmington, NC 28405.3845
[phone]
Fax ;910) 350-2004
Drmswldc New Hanover
Ctuer Onslow
Columbus Raider
D+rpliu'
P. 09

-.
State of North Carolina
Departtnent of Environment. Health, and Natural Itcsm,t-ce;
Division o[• Environmental Management
512 North Salisbury Street • Ralei,,h. North Carolina: (Ct', t157,5
;ames G. Marun. Governor
\' ttt:am W. Cobey, Jr.. Secretary
Memorandum
To: Delegated Municipalities
From: Steve W. Tedder. Chief(`
Water Quality Section k)
Subject: Delegated sM•tunic:_r_•iiiies Ch•_ckiist for Revised Non•Dischar•le Permit .Appiication:.
The Division of Environmental Management's Water Quality Section has 'revised the
Gravity Sewer Non -Discharge Permit Application Form. The form now incorporates the basic
information that the Division feels is necessary in order for the delegated municipalities to perform
review on a gravity sewer project for the Division; therefore, the Division will no longer require
the "Delegated Municipalities Gravity Sewer Design Checklist" be completed and submitted. We do.
however, require that the delegated municipality perform the same type of review as always required
and complete the bottom portion of this page and attach it as the last page of all gravity sewer
applications that are being submitted as a delegated municipalities project. If you have any questions
on this matter, please contact Mr. Randy Jones at 919/733-5083.
DELEGATED MUNICIPALITY GRAVITY SEWER CERTIFICATION'
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
Applicant: P[[RI TC WORKS CO fTcSTO`r OP THFITTY n� FAYFTTFLT[ F :DRY--CAP.III 1-1-'l,—
/n� pD S' ••{•e, - EPA Sot''Cq�'d t�roJ eeF
Project Name: �prn'l�r (� Fear' Tfe.SerVit% t
Delegated Municipality Reviewer's Certification:
I, VICTOR CAN TFHSANT , attest that the subject plans and
specifications have been reviewed under my supervision and that those plans and specifications ar=
consistent with the information that has been specified on the Non -Discharge Application and th.:
Division of Environmental Management's minimum design requirements for gravity sewer projects
Delegated Municipality Reviewer's NC Prc essional Engineer's Registration Nc. ,1436R
M a y 1, 1991
Seal and Siunature (specify daze)
FORM: WAGS 4/9 i
PAGE 1 OE 1