WQ0042721_Application (FTSE)_20210730

Vot stimmel 601s` TRADESTREET, SUITE 200
WINSTON-SALEM, NC 27101
www.stimmelpa.com 336.723.1067
July 231d, 2021
NCDEQ
DWR—Winston-Salem Regional Office
NIC Department of
450 W. Hanes Mill Road, Suite 300
Environmental Quality
Winston-Salem, NC 27105
Received
Attn: Ms. Jenny Graznak
e.e-1
Re: Fast -Track Sewer Application
FrontStreet— Wallburg, LLC
Winston-Salem
Wallburg Road — Pump Station
Regional Office
Winston-Salem, NC
Dear Ms. Graznak:
Attached you will find the Fast -Track Application and supporting information for the private pump station, force
main, and gravity sewer that is to serve a proposed commercial building designed by others. Sewer flows are
100% commercial and are estimated at 11,700 gallons per day. The pump station has been designed to
accommodate additional sewer flows in the future but is only being permitted at this time for the anticipated
flow from the single building. The proposed force main will tie into a public manhole at the northeast corner of
Wallburg Road and Sherlie Weavil Road in Winston-Salem, NC. The proposed building will tie into a proposed
manhole (SSMH 100) just upstream of the pump station. An additional manhole (SSMH 101) is proposed just
upstream of SSMH 100 and will serve as the tie-in point for future development to the north of the pump
station. SSMH 101 is being proposed to increase the distance from the pump station and the future tie-in
location to not disturb the pump station (i.e., fencing, gravel, wet well, etc.) when the future tie-in is made.
Wetland and stream impacts are associated with this project and 401/404 permits have been included with the
submittal package.
The following information is included for your review and approval:
# Copies Description
2 Fast -Track Application Form
1 Review fee check in the amount of $480
2 North Carolina Secretary of State Corporation Documentation
2 Flow Tracking/Acceptance Form (FTSE Form)
2 Site Map on 8.5" x 11" USGS Quad Map
2 Site Map on 8.5 x 11" Google Earth Image
2 401/404 Permits
If you have questions or need additional information, please contact me at [phone] or
akeya.stimmelpa.com .
Sincerely yours:
A W 04
Austin Key, P.E.
Stimmel Associates, P.A.
Project Engineer
LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LANDPLANNING

tn-Salem /Forsyth County
r •Wastewater • Solid Waste
Administration, P.O. Box 2511, Winston-Salem, NC 27102
0: 336-727-8000, F: 336-727-8432, cityofws.org/utilities
May 12, 2021
RC Department of
Jenny Graznak, Assistant Regional Supervisor EnVirol�Pental uality
North Carolina Department of Environmental Quality
ceived
n t
Division of Water Resources J�-
450 West Hanes Mill Road, Suite 300
Winston Salem, NC 27105 Winston-`>31em
ftegiolral Office
Dear Ms. Graznak,
Please allow this letterto serve as documentation that Winston-Salem/Forsyth County Utilities has
completed a project at Muddy Creek Wastewater Treatment Plant that addresses future wastewater
capacity needs. Substantial completion for this project was granted on January 61' 2021. The upgrades
included replacement of the existing headworks barscreens, grit removal, and influent pumping
equipment, 7.5 million gallons of storm flow equalization storage, and 2 million gallons of diurnal flow
equalization. The equalization and storage capabilities will reduce treatment impacts due to heavy wet
weather events and provide for more uniform flow through the plant.
The plant upgrades allow excess flow into Muddy Creek W WTP to be transferred to the Archie Elledge
WWTP, to storm, or diurnal equalization facilities. The transfer of flow will be based on hydraulic, best
treatment, and financial considerations. The integrated influent system and flow storage provides
significant reliability, allows us to balance flows between plants, and provides optimum treatment
performance during dry and wet weather.
Please let this letter serve as justification to continue permitting wastewater flows to the Muddy Creek
Wastewater Treatment Plant.
Regards,
Courtney river P.E.
Utilities Director
City Council: Mayor Allen lolnes; Denise D. Adams, Mayor Pm Tampere, North Ward; Barbara Hanes Burke, Northeast Ward; Robert C. Clark, West Ward;
John C. Larson, South Ward; Jeff Macintosh, Northwest Ward; Kevin Murray, Southwest Ward; Annette Scipplo, East Ward; lames Taylor, Jr., Southeast Ward;
City Manager: Lee D. Garrity
County Commissariats: David R. Plyler Chair; Don Martin, Vice Chair; Fleming El Amin; Ted Kaplan; Richard V. Linville; Tanya McDaniel; Gloria D. W hisenhunt;
Call 311 or 336-727-8000
cormymanager: Dudley Watch, Jr.
[e-mail] ofws.or
Winston.Salem/Forsyth County Utility Commission: Randall S.Tuttle, Chair L. Wesley Curtis, Jr., Vice Chair; Harold E. Day; Tom Griffin; Yvonne H. Hines;
l:-
Duane Long; Hugh W. Jernigan; Chris Parker; Donald R.Stewart; Charles Wilson; Allan Younger

State of North Carolina
nWR
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 06-21 & 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 (Gravity Sewer & Pump Stations/Force Mains l 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 immediately 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.0303
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ Simplex 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 (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (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.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form ETA 05-21):
® 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 I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item I.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 Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(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 ISA NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: ETA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3

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 andwill not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
10 Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
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 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 .0115(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
❑ 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 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15ANCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONALOFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Favetteville Reaional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
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
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
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, Fender
[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, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3

DWR
Division of Water Resources
Application Number:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Front Street — Wallburg 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: Robin Team per 15A NCAC 02T .0106(b)
Title: Managing Partner
NC Department of
4. Applicant's mailing address: 450 North Patterson Avenue, Suite 300 EnvironmentalQuality
City: Winston-Salem State: NC Zip: 27101-
Received
5. Applicant's contact information: JUL 3 9 2021
Phone number: 3(3�243-2600 Email Address: [e-mail]„n,`Mnston-Salem
Regional Office
H. PROJECT INFORMATION:
1. Project name: Front Street — Wallburg, LLC Wallburg Road— Pum Station
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000
3. County where project is located: For h
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.039527' Longitude:-80.134793'
5. Parcel ID (if applicable): 6863-55-3421.00 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Austin Key License Number: 043196
Firm: Stimmel Associates, P.A.
Mailing address: 601 N. Trade Street, Suite 200
City: Winston-Salem State: NC Zip: 27101-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Lower Muddy Creek Permit Number: NCO050342
Owner Name: Winston-Salem/Forsyth County Utility Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQCS00003
2. Downstream (Receiving) Sewer Information: 8 inch N Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00003
Owner Name(s): Winston-Salem/Forsyth County Utility Commission
FORM: FTA 06-21 Pagel of 5

V1. GENERAL REQUII2EMENTS
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 Aereement (FORM: DEVI been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually 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: 0 % Domestic 100 % Commercial 0 % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, 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 with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow ',b
No. of Units
Flow
Warehouse
100 gal/loading bay
117
11,700 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
11,700 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: 11700 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: ETA 06-21 Page 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 58 DI
➢ 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 requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Wallburg Road — Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 36. 039527' Longitude:-80.134793'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.117 millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 94 gallons per minute (GPM) at 70 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
3
1,224
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.Lb. ® Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15ANCAC 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 and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant 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
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(fl & (g)? ® Yes ❑ No
15A NCAC 02T.0305(fl contains minimum separations that shall be Drovided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, 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 It impounded reservoirs used as a source of drinking water, and associated wetlands.
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 associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
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
➢ If noncompliance with 02T.0305(fl or (g), see Section X.1 of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(fl cannot be achieved. Please check `Yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webuage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ® Yes ❑ No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. 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 must be 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.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ 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 permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T. the Minimum Design Criteria for the Permitting of Pumn Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
*d�Mum
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the aonroval of the permit, and projects requiring a variance approval may be subject to longer
review times. For vroiects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
Front Street - Wallburg, LLC
I, Austin Key attest that this application for Wallburg Road - Pump Station
(Professional Engineer's name from Application Item 111.1.) (Project Name from Application Item 11.1)
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,
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 143-215.6E, 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. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: ; \`��e �N
if" -SEAL"
04319' _
tIN W • ���
3. Applicant's Certification per 15A NCAC 02T .0106(b): Front Street - Wallburg, LLC
I, Robin Team attest that this application for Wallburg Road - Pump Station
(Signature Authority Name from Application Item 1.3.) - (Project Name from Application Item II.I)
attest that this application 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.
Signature;/_.--�-�� Date: 7 °�5• '
FORM; FTA 06-21 Page 5 of 5

• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online
Add Entity to My Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print
an Amended a Annual Report form
Limited Liability Company
Legal Name
Front Street - Wallburg, LLC
Prev Legal Name
Front Street - Union Cross, LLC
Information
Sosld: 1838177
Status: Current -Active O
Date Formed: 5/2/2019
Citizenship: Domestic
Annual Report Due Date: April 15th
Currentgnnual Report Status:
Registered Agent: Team, Coleman
Addresses
Principal Office Reg Office
450 N. Patterson Avenue, Suite 300 450 N. Patterson Avenue, Suite 300
Winston Salem, NC 27101 Winston Salem, NC 27101
Mailing Reg Mailing
PO Box 21509 PO Box 21509
Winston Salem, NC 27120 Winston Salem, NC 27101
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Member
Coleman Team
P 0 Box 21509

State of North Carolina
Department of Environmental Quality
( Division of Water Resources
DkIsion of Water ftesot u.ces Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Front Street - Wallburg LLC
Project Name for which flow is being requested: 12522 - FSC Wallburg Road
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 wastewater flow.
L Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Muddy Creek
b. WWTP Facility Permit #: NC0050342
All flows are in MGD
c. WWTP facility's permitted flow 21.000000
d. Estimated obligated flow not yet tributary to the WWTP 2.913427
e. WWTP facility's actual avg. flow 16.790000
£ Total flow for this specific request 0.011700
g. Total actual and obligated flows to the facility 19.715127
h. Percent of permitted flow used 93.9%
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 / 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 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 locatelkiiu
between the project connection point and the WWTP where the Available Capacity is < 0. i cr3ived
Downstream Facility Name (Sewer): Muddy Creek ; ";6:
Downstream Permit Number: WQCS00003 1Nin-r
F.;
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Courtney Driver, P.E. 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.
7/28/21
Signing OfLzal Signature Date
Capital Projects Engineer
Title of Signing Official
Page 2 of 6
FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in
d. The following applies:
; and/or
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
Page 3 of 6
Date
FTSE 10-18

Instructions for Flow Tracking form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not vet tributary to the WWTP, MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through interlocal
agreements or other contracts not yet contributing flow to the collection system are also included. For POTWs
that implement a pretreatment program, include flows allocated to industrial users who may not be using all of
their flow allocation. Please contact your Pretreatment Coordinator for information on industrial flow tributary
to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years and
reconciled their flow records, to the best of their ability, so it is known how much flow has been obligated and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entity.
e. WWTP facility's actual avg. flow, MOD: Previous 12 month average.
f. Total flow for this specific request, MOD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MOD Equals [d + e + f]
h. Percent of permitted flow used: Equals [(g / c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there is 0.5
MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.015 MOD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f. = 0.015 MOD
g. = 3.215 MOD
h. = 53.6 %
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
f. = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 10-18

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design average
daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow through the
pump station (C) for each pump station that will be impacted by the proposed sewer extension project. Calculate
the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D). Include the proposed flow
for this project with other obligated flows that have been approved for the pump station but are not yet tributary
(C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as per the
Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not less than
2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump station
if the system has future specific plans related to capacity that should be considered in the permitting process.
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Design
Approx.
Not Yet
Total Current
Firm
Average
Current Avg.
Tributary
Flow Plus
Pump Station Capacity
Daily Flow
Daily Flow,
Daily Flow,
Obligated
Available
(Name or Number) MGD
(Firm / pf)
MGD
MGD
Flow
Capacity*
Kaw Creek PS 0.800
0.320
0.252
0.080
0.332
-0.012
Valley Road PS 1.895
0.758 0.472 0.135 0.607 0.151
Page 5 of 6
FTSE 10-18

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity is < 0
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated flows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary overflows and must take all steps necessary to complete the project or control
the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned project in
the future not yet funded but in a formal plan adopted by the system. The system should carefully weigh the
certainty of successful timely project completion for any expansion, flow management diversion or infiltration and
inflow elimination projects that are the foundation of a planned solution to capacity tracking and acceptance
compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080 MGD of the
committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with planned
completion in ; and/or
d. The following applies:
The master plan and ten year plan contain recommended scope and funding for a capital project entitled
Kaw Creek Pump Station upgrade with funding planned in July 2014. This project is planned to add 0.100 MGD
to the firm capacity of the pump station by October 2015. Inclusion of this proposed capital project as a condition
of this Flow Tracking/Acceptance for Sewer Extension Permit Application elevates this project's priority for
funding and construction to be implemented ahead of the activation of obligated, not vet tributary flows in amounts
that exceed the firm DumD station capacities identified in Section II above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow this flow
to be permitted, without a significant likelihood of over -allocating capacity in the system infrastructure.
Page 6 of 6
FTSE 10-18

State of North Carolina
T ,.
Division of Water Resources
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Front Street - Wallburg LLC
Project Name for which flow is being requested: 12522 - FSC Wallburg Road
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 wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Archie Elledge
b. WWTP Facility Permit #: NC0037834
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
h. Percent of permitted flow used
All flows are in MGD
30.000000
2.108130
21.270000
0.011700
23.389830
78.0%
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.
MOD 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): Archie Elledge
Downstream Permit Number: WQCS00003
Page I of 6
FTSE 10-18

III. Certification Statement:
I Courtney Driver, P.E. 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 parry. 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 Signature
Capital Projects Engineer
Title of Signing Official
7/28/21
Date
Page 2 of 6
FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
Date
Page 3 of 6
FTSE 10-18

Instructions for Flow Tracking form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MOD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not vet tributary to the WWTP, MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through interlocal
agreements or other contracts not yet contributing flow to the collection system are also included. For POTWs
that implement a pretreatment program, include flows allocated to industrial users who may not be using all of
their flow allocation. Please contact your Pretreatment Coordinator for information on industrial flow tributary
to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years and
reconciled their flow records, to the best of their ability, so it is known how much flow has been obligated and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entity.
e. WWTP facility's actual avg. flow, MOD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + fJ
h. Percent of permitted flow used: Equals [(g / c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there is 0.5
MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f = 0.015 MGD
g. = 3.215 MGD
h. = 53.6 %
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
f. = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 10-18

Section H
List the pump station name or number and approximate pump station firm capacity, approximate design average
daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow through the
pump station (C) for each pump station that will be impacted by the proposed sewer extension project. Calculate
the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D). Include the proposed flow
for this project with other obligated flows that have been approved for the pump station but are not yet tributary
(C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as per the
Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not less than
2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump station
if the system has future specific plans related to capacity that should be considered in the permitting process.
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Design
Approx.
Not Yet
Total Current
Firm
Average
Current Avg.
Tributary
Flow Plus
Pump Station
Capacity
Daily Flow
Daily Flow,
Daily Flow,
Obligated
Available
(Name or Number)
MGD
(Firm / pf)
MGD
MGD
Flow
Capacity*
Kaw Creek PS
0.800
0.320
0.252
0.080
0.332
-0.012
Valley Road PS
1.895
0.758
0.472
0.135
0.607
0.151
Page 5 of 6
FTSE 10-18

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity is < 0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated flows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary overflows and must take all steps necessary to complete the project or control
the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned project in
the future not yet funded but in a formal plan adopted by the system. The system should carefully weigh the
certainty of successful timely project completion for any expansion, flow management diversion or infiltration and
inflow elimination projects that are the foundation of a planned solution to capacity tracking and acceptance
compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080 MGD of the
committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with planned
completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project entitled
Kaw Creek Pump Station upgrade with funding planned in July 2014. This project is planned to add 0.100 MGD
to the firm capacity of the pump station by October 2015. Inclusion of this proposed capital project as a condition
of this Flow Tracking/Acceptance for Sewer Extension Permit Application elevates this project's priority for
funding and construction to be implemented ahead of the activation of obligated, not vet tributary flows in amounts
that exceed the firm pump station capacities identified in Section II above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow this flow
to be permitted, without a significant likelihood of over -allocating capacity in the system infrastructure.
Page 6 of 6
FTSE 10-18

._y
Project Location

wyl
k
001
n I
�' • . -
IiP
31 J'T
She, lie Weaml Rd —
N �
n
>^ x
1000 ft

ROY COOPER
Governor
DIONNE DELL[-CATTI
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
March 14, 2021
DWR # 20210273
Forsyth County
Front Street Wallburg, LLC
Attn: Mr. Robin Team
PO Box 21509
Winston Salem NC 27120
Delivered via email to:[e-mail]
Subject: APPROVAL OF 401 WATER QUALITY CERTIFICATION WITH ADDITIONAL CONDITIONS
Wallburg Road Distribution and Manufacturing Facility
Dear Mr. Team:
You have our approval for the impacts listed below for the purpose described in your application dated
February 17, 2021, received by the Division of Water Resources (Division) February 18, 2021 and
payment received February 18, 2021, with subsequent information on February 19, 2021, March 8, 2021
and March 14, 2021, These impacts are covered by the attached Water Quality General Certification
Number 4139. This certification is associated with the use of Nationwide Permit Number 39 once it is
issued to you by the U.S. Army Corps of Engineers. Please note that you should get any other federal,
state or local permits before proceeding with your project, including those required by (but not limited
to) Sediment and Erosion Control, Non -Discharge, and Water Supply Watershed regulations.
The Division has determined that the proposed project will comply with water quality requirements
provided that you adhere to the conditions listed in the enclosed certification.
The following proposed impacts are hereby approved. No other impacts are approved, including
incidental impacts. [15A NCAC 02H .0506(b)]
Type of Impact
Amount Approved
Permanent
Amount Approved
Temporary
Stream
Site 1
122 (linear feet)
0 (linear feet)
Site 2
92 (linear feet)
0 (linear feet)
Site 3
78 (linear feet)
0 (linear feet)
404/401 Wetlands
Site 1
0.003 (acres)
0 (acres)
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Suite 300 1 Winston-Salem, North Carolina 27105
rwrm anaou�
oov�m"^^m^ni mHn� 336.776.9800

Front Street Wallburg, LLC
DWR# 20210273
401 Certification
Page 3 of 3
Enclosures: GC 4139
cc: Brad Luckey, Pilot Environment at Inc. (via email)
Andrew Williams, USACE Raleigh Regulatory Field Office (via email)
Olivia Munzer, NCWRC (via email)
DWR 401 & Buffer Permitting Unit file

GC4139
Activities meeting any one (1) of the following thresholds or circumstances require written
approval for a 401 Water Quality Certification from the Division of Water Resources (DWR):
a) If any of the conditions of this Certification (listed below) cannot be met; or
b) Any impacts to streams from excavation or dredging other than excavation that is
conducted as preparation for installing permanent fill or structures; or
c) Total temporary and permanent impacts to streams greater than 150 feet; or
d) Any stream relocation or stream restoration; or
e) Complete dewatering and drawdowns to a sediment layer related to pond/dam
maintenance or removal; or
f) Total temporary and permanent impacts to wetlands or open waters equal to or greater
than one -tenth (1/10) acre; or
g) Any high -density project, as defined in 15A NCAC 02H .1003(2)(a) and by the density
thresholds specified in 15A NCAC 02H .1017, which:
L Disturbs one acre or more of land (including a project that disturbs less than one
acre of land that is part of a larger common plan of development or sale); and
ii. Has permanent wetland, stream or open water impacts; and
Ill. Is proposing new built -upon area; and
iv. Does not have a stormwater management plan reviewed and approved under a
state stormwater program' or a state -approved local government stormwater
program2.
Projects that have vested rights, exemptions, or grandfathering from state or locally -
implemented stormwater programs and projects that satisfy state or locally -
implemented stormwater programs through use of community in -lieu programs require
written approval.; or
h) Any permanent impacts to waters, or to wetlands adjacent to waters, designated as:
ORW (including SAV), HQW (including PNA), SA, WS-I, WS-II, Trout, or North Carolina or
National Wild and Scenic River; or
i) Any permanent impacts to coastal wetlands [15A NCAC 07H .0205], or Unique Wetlands
(UWL) [15A NCAC 02H .0506]; or
j) Any impact associated with a Notice of Violation or an enforcement action for
violation(s) of NC Wetland Rules (15A NCAC 02H .0500), NC Isolated Wetland Rules (15A
NCAC 02H .1300), NC Surface Water or Wetland Standards (15A NCAC 02B .0200), or
State Regulated Riparian Buffer Rules (15A NCAC 02B .0200); or
k) Any impacts to subject water bodies and/or state regulated riparian buffers along
subject water bodies in the Neuse, Tar -Pamlico, or Catawba River Basins or in the
Randleman Lake, Jordan Lake or Goose Creek Watersheds (or any other basin or
watershed with State Regulated Riparian Area Protection Rules [Buffer Rules] in effect
at the time of application) unless:
I. The activities are listed as "EXEMPT" from these rules; or
' e.g. Coastal Counties, HQW, ORW, or state -implemented Phase II NPDES
2 e.g. Delegated Phase II NPDES, Water Supply Watershed, Nutrient -Sensitive Waters, or Universal Stormwater
Management Program
Page 2 of 11

GC4139
a. Provide a completed Stormwater Management Plan (SMP) for review and approval,
including all appropriate stormwater control measure (SCM) supplemental forms and
associated items, that complies with the high -density development requirements of 15A
NCAC 02H .1003. Stormwater management shall be provided throughout the entire
project area in accordance with 15A NCAC 02H .1003. For the purposes of 15A NCAC
02H .1003(2)(a), density thresholds shall be determined in accordance with 15A NCAC
02H .1017.
b. Provide calculations to document that the project will not cause degradation of
downstream surface waters. Documentation shall include a detailed analysis of the
hydrological impacts from stormwater runoff when considering the volume and velocity
of stormwater runoff from the project built upon area and the size and existing
condition of the receiving stream(s).
Exceptions to this condition require application to and written approval from DWR.
II. GENERAL CONDITIONS:
1. When written authorization is required, the plans and specifications for the project are
incorporated into the authorization by reference and are an enforceable part of the
Certification. Any modifications to the project require notification to DWR and may require
an application submittal to DWR with the appropriate fee. [15A NCAC 02H .0501 and .0502)
2. No waste, spoil, solids, or fill of any kind shall occur in wetlands or waters beyond the
footprint of the impacts (including temporary impacts) as authorized in the written approval
from DWR; or beyond the thresholds established for use of this Certification without
written authorization. [15A NCAC 02H .0501 and .0502]
No removal of vegetation or other impacts of any kind shall occur to state regulated riparian
buffers beyond the footprint of impacts approved in a Buffer Authorization or Variance or
as listed as an exempt activity in the applicable riparian buffer rules. [15A NCAC 02B .0200]
3. In accordance with 15A NCAC 02H .0506(h) and Session Law 2017-10, compensatory
mitigation may be required for losses of greater than 300 linear feet of perennial streams
and/or greater than one (1) acre of wetlands. Impacts associated with the removal of a
dam shall not require mitigation when the removal complies with the requirements of Part
3 of Article 21 in Chapter 143 of the North Carolina General Statutes. Impacts to isolated
and other non-404 jurisdictional wetlands shall not be combined with 404 jurisdictional
wetlands for the purpose of determining when impact thresholds trigger a mitigation
requirement. For linear publicly owned and maintained transportation projects that are not
determined to be part of a larger common plan of development by the US Army Corps of
Engineers, compensatory mitigation may be required for losses of greater than 300 linear
feet per perennial stream.
Page 4 of 11

GC4139
8. An NPDES Construction Stormwater Permit (NCG010000) is required for construction
projects that disturb one (1) or more acres of land. The NCGO10000 Permit allows
stormwater to be discharged during land disturbing construction activities as stipulated in
the conditions of the permit. If the project is covered by this permit, full compliance with
permit conditions including the erosion & sedimentation control plan, inspections and
maintenance, self -monitoring, record keeping and reporting requirements is required. [15A
NCAC 02H .0506(b)(5) and (c)(5)]
The North Carolina Department of Transportation (NCDOT) shall be required to be in full
compliance with the conditions related to construction activities within the most recent
version of their individual NPDES (NCS000250) stormwater permit. [15A NCAC 02H
.0506(b)(5) and (c)(5)]
9. All work in or adjacent to streams shall be conducted so that the flowing stream does not
come in contact with the disturbed area. Approved best management practices from the
most current version of the NC Sediment and Erosion Control Manual, or the NC DOT
Construction and Maintenance Activities Manual, such as sandbags, rock berms,
cofferdams, and other diversion structures shall be used to minimize excavation in flowing
water. Exceptions to this condition require application to and written approval from DWR.
[15A NCAC 02H .0506(b)(3) and (c)(3)]
10. If activities must occur during periods of high biological activity (e.g. sea turtle nesting, fish
spawning, or bird nesting), then biological monitoring may be required at the request of
other state or federal agencies and coordinated with these activities. [15A NCAC 02H
.0506(b)(2) and 15A NCAC 04B .0125]
All moratoriums on construction activities established by the NC Wildlife Resources
Commission (WRC), US Fish and Wildlife Service (USFWS), NC Division of Marine Fisheries
(DMF), or National Marine Fisheries Service (NMFS) shall be implemented. Exceptions to
this condition require written approval by the resource agency responsible for the given
moratorium. A copy of the approval from the resource agency shall be forwarded to DWR.
Work within a designated trout watershed of North Carolina (as identified by the
Wilmington District of the US Army Corps of Engineers), or identified state or federal
endangered or threatened species habitat, shall be coordinated with the appropriate WRC,
USFWS, NMFS, and/or DMF personnel.
11. Culverts shall be designed and installed in such a manner that the original stream profiles
are not altered and allow for aquatic life movement during low flows. The dimension,
pattern, and profile of the stream above and below a pipe or culvert shall not be modified
by widening the stream channel or by reducing the depth of the stream in connection with
the construction activity. The width, height, and gradient of a proposed culvert shall be
such as to pass the average historical low flow and spring flow without adversely altering
flow velocity. [15A NCAC 02H .0506(b)(2) and (c)(2)]
Page 6 of 11

GC4139
13. Application of fertilizer to establish planted/seeded vegetation within disturbed riparian
areas and/or wetlands shall be conducted at agronomic rates and shall comply with all
other Federal, State and Local regulations. Fertilizer application shall be accomplished in a
manner that minimizes the risk of contact between the fertilizer and surface waters. [15A
NCAC 02B .0200 and 15A NCAC 02B .0231]
14. If concrete is used during construction, then all necessary measures shall be taken to
prevent direct contact between uncured or curing concrete and waters of the state. Water
that inadvertently contacts uncured concrete shall not be discharged to waters of the state.
[15A NCAC 02B .0200]
15. All proposed and approved temporary fill and culverts shall be removed and the impacted
area shall be returned to natural conditions within 60 calendar days after the temporary
impact is no longer necessary. The impacted areas shall be restored to original grade,
Including each stream's original cross sectional dimensions, planform pattern, and
longitudinal bed profile. For projects that receive written approval, no temporary impacts
are allowed beyond those included in the application and authorization. All temporarily
impacted sites shall be restored and stabilized with native vegetation. [15A NCAC 02H
.0506(b)(2) and (c)(2)]
16. All proposed and approved temporary pipes/culverts/rip-rap pads etc. in streams shall be
installed as outlined in the most recent edition of the North Carolina Sediment and Erosion
Control Planning and Design Manual or the North Carolina Surface Mining Manual or the
North Carolina Department of Transportation Best Management Practices for Construction
and Maintenance Activities so as not to restrict stream flow or cause dis-equilibrium during
use of this Certification. [15A NCAC 02H .0506(b)(2) and (c)(2)]
17. Any rip -rap required for proper culvert placement, stream stabilization, or restoration of
temporarily disturbed areas shall be restricted to the area directly impacted by the
approved construction activity. All rip -rap shall be placed such that the original stream
elevation and streambank contours are restored and maintained. Placement of rip -rap or
other approved materials shall not result in de -stabilization of the stream bed or banks
upstream or downstream of the area or in a manner that precludes aquatic life passage.
[15A NCAC 02H .0506(b)(2)]
18. Any rip -rap used for stream or shoreline stabilization shall be of a size and density to
prevent movement by wave, current action, or stream flows and shall consist of clean rock
or masonry material free of debris or toxic pollutants. Rip -rap shall not be installed in the
streambed except in specific areas required for velocity control and to ensure structural
integrity of bank stabilization measures. [15A NCAC 02H .0506(b)(2)]
19. Applications for rip -rap groins proposed in accordance with 15A NCAC 07H .1401 (NC
Division of Coastal Management General Permit for construction of Wooden and Rip -rap
Groins in Estuarine and Public Trust Waters) shall meet all the specific conditions for design
and construction specified in 15A NCAC 07H .1405.
Page 8 of 11

GC4139
27. When written authorization is required for use of this Certification, upon completion of all
permitted impacts included within the approval and any subsequent modifications, the
applicant shall be required to return a certificate of completion (available on the DWR
website https://edocs.deg.nc.gov/Forms/Certificate-of-Completion). [15A NCAC 02H
.0502(f)]
28. Additional site -specific conditions, including monitoring and/or modeling requirements,
may be added to the written approval letter for projects proposed under this Water Quality
Certification in order to ensure compliance with all applicable water quality and effluent
standards. [15A NCAC 02H .0507(c)]
29. If the property or project is sold or transferred, the new permittee shall be given a copy of
this Certification (and written authorization if applicable) and is responsible for complying
with all conditions. [15A NCAC 02H .0501 and .0502]
Ill. GENERAL CERTIFICATION ADMINISTRATION:
1. In accordance with North Carolina General Statute 143-215.3D(e), written approval for a
401 Water Quality General Certification must include the appropriate fee. An applicant for
a CAMA permit under Article 7 of Chapter 113A of the General Statutes for which a Water
Quality Certification is required shall only make one payment to satisfy both agencies; the
fee shall be as established by the Secretary in accordance with 143-215.3D(e)(7).
2. This Certification neither grants nor affirms any property right, license, or privilege in any
waters, or any right of use in any waters. This Certification does not authorize any person
to interfere with the riparian rights, littoral rights, or water use rights of any other person
and this Certification does not create any prescriptive right or any right of priority regarding
any usage of water. This Certification shall not be interposed as a defense in any action
respecting the determination of riparian or littoral rights or other rights to water use. No
consumptive user is deemed by virtue of this Certification to possess any prescriptive or
other right of priority with respect to any other consumptive user regardless of the quantity
of the withdrawal or the date on which the withdrawal was initiated or expanded.
3. This Certification grants permission to the Director, an authorized representative of the
Director, or DWR staff, upon the presentation of proper credentials, to enter the property
during normal business hours. [15A NCAC 02H .0502(e)]
4. This General Certification shall expire on the same day as the expiration date of the
corresponding Nationwide Permit and/or Regional General Permit. The conditions in effect
on the date of issuance of Certification for a specific project shall remain in effect for the life
of the project, regardless of the expiration date of this Certification. This General
Certification is rescinded when the US Army Corps of Engineers reauthorizes any of the
corresponding Nationwide Permits and/or Regional General Permits or when deemed
appropriate by the Director of the Division of Water Resources.
Page 10 of 11

Compensatory Mitigation Responsibility Transfer Form
Permittee: Front Street Wallburg, LLC, Robin Team
Project Name: Wallburg Road
Action ID: SAW-2018-01786
County: Forsyth
Instructions to Permittee: The Permittee must provide a copy of this form to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Division of Mitigation Services (NCDMS), who will then sign the form to verify the
transfer of the mitigation responsibility. Once the Sponsor has signed this form, it is the Permittee's responsibility to ensure
that to the U.S. Army Corps of Engineers (USACE) Project Manager identified on page two is in receipt of a signed copy of this
form before conducting authorized impacts, unless otherwise specified below. If more than one mitigation Sponsor will be
used to provide the mitigation associated with the permit, or if the impacts and/or the mitigation will occur in more than one
8-digit Hydrologic Unit Code (HUC), multiple forms will be attached to the permit, and the separate forms for each Sponsor
and/or HUC must be provided to the appropriate mitigation Sponsors.
Instructions to Sponsor: The Sponsor must verify that the mitigation requirements (credits) shown below are available at the
identified site. By signing below, the Sponsor is accepting full responsibility for the identified mitigation, regardless of
whether or not they have received payment from the Permittee. Once the form is signed, the Sponsor must update the bank
ledger and provide a copy of the signed form and the updated bank ledger to the Permittee, the USACE Project Manager, and
the Wilmington District Mitigation Office (see contact information on page 2). The Sponsor must also comply with all
reporting requirements established in their authorizing instrument.
Permitted Impacts and Compensatory Mitigation Requirements:
Permitted Impacts Requiring Mitigation* 8-digit HUC and Basin: 03040103, Yadkin River Basin
Stream Impacts (linear feet)
i Wetland Impacts (acres)
Warm
Cool
Cold
Riparian Riverine
Riparian Non-Riverine
Non -Riparian
Coastal
292
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
Compensatory Mitigation Requirements: 8-digit HUC and Basin:03040103, Yadkin River Basin
Stream Mitigation (credits) -i
Wetland Mitigation (credits)
Warm
Cool
Cold
Riparian Riverine
Riparian Non-Riverine
Non -Riparian
Coastal
584
Mitigation Site Debited: North Carolina Division of Mitigation Services
(List the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDMS. Ifthe NCDMS
acceptance letter identifies a specific site, also list the specific site to be debited).
Section to be completed by the Mitigation Sponsor
Statement of Mitigation Liability Acceptance: I, the undersigned, verify that I am authorized to approve mitigation
transactions for the Mitigation Sponsor shown below, and I certify that the Sponsor agrees to accept full responsibility for
providing the mitigation identified in this document (see the table above), associated with the USACE Permittee and Action
ID number shown. I also verify that released credits (and/or advance credits for NCDMS), as approved by the USACE, are
currently available at the mitigation site identified above. Further, I understand that if the Sponsor fails to provide the
required compensatory mitigation, the USACE Wilmington District Engineer may pursue measures against the Sponsor to
ensure compliance associated with the mitigation requirements.
Mitigation Sponsor Name:
Name of Sponsor's Authorized Representative:
Signature of Sponsor's Authorized Representative Date of Signature

U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id. SAW-2018-01786 County: Forsyth County U.S.G.S. Quad: Winston-Salem East
GENERAL PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION
Permittee:
Robin Team
Front Street Wallbure, LLC
Address:
PO Box 21509
Winston Salem, North Carolina 27120
Telephone Number:
336-243-2600
Size (acres)
83 (approximately) Nearest Town Winston Salem
Nearest Waterway
Mary Reich Creek River Basin Upper Pee Dee
USGS HUC
03040101 Coordinates Latitude: 36.038609
Longitude:-80.131494
Location description: The site is located immediately East of the Wallbure Road, Enterprise Park Boulevard intersection in
Forsyth Countv, North Carolina.
Description of projects area and activity: This authorization is for permanent impacts to tributary streams and wetlands
associated with the construction of a commercial development as follows: Impact Area 1 (Stream SAA, 122 linear feet, Stream
SA, 92 linear feet and Wetland W 1-4, 0.003 acre); Impact Area 2 (Stream SD, 78 linear feet). (see attached plans).
Applicable Law: ® Section 404 (Clean Water Act, 33 USC 1344)
❑ Section 10 (Rivers and Harbors Act, 33 USC 403)
Authorization: Regional General Permit Number and/or Nationwide Permit Number: NWP 39 Commercial and Institutional
Developments
SEE ATTACHED RGP or NWP GENERAL, REGIONAL AND/OR SPECIAL CONDITIONS
Your work is authorized by the above referenced permit provided it is accomplished in strict accordance with the attached
conditions and your submitted application and attached information dated February 18, 2021, including additional
information provided on February 19, 2021. Any violation of the attached conditions or deviation from your submitted plans
may subject the permittee to a stop work order, a restoration order, a Class I administrative penalty, and/or appropriate legal
action.
Special Conditions:
1. In order to compensate for impacts associated with this permit, mitigation shall be provided in accordance with the
provisions outlined on the most recent version of the attached Compensatory Mitigation Responsibility Transfer Form. The
requirements of this form, including any special conditions listed on this form, are hereby incorporated as special conditions of
this permit authorization.
This verification will remain valid until the expiration date identified below unless the nationwide and/or regional general permit
authorization is modified, suspended or revoked. If, prior to the expiration date identified below, the nationwide and/or regional
general permit authorization is reissued and/or modified, this verification will remain valid until the expiration date identified below,
provided it complies with all requirements of the modified nationwide permit. If the nationwide and/or regional general permit
authorization expires or is suspended, revoked, or is modified, such that the activity would no longer comply with the terms and
conditions of the nationwide permit, activities which have commenced (i.e., are under construction) or are under contract to
commence in reliance upon the nationwide and/or regional general permit, will remain authorized provided the activity is completed
within twelve months of the date of the nationwide and/or regional general permit's expiration, modification or revocation, unless
discretionary authority has been exercised on a case -by -case basis to modify, suspend or revoke the authorization.
Activities subject to Section 404 (as indicated above) may also require an individual Section 401 Water Quality Certification. You
should contact the NC Division of Water Resources (telephone [phone]) to determine Section 401 requirements.
For activities occurring within the twenty coastal counties subject to regulation under the Coastal Area Management Act (LAMA),
prior to beginning work you must contact the N.C. Division of Coastal Management in Morehead City, NC, at [phone].

In order for an RFA to be accepted by the Corps, the Corps must determine that it is complete, that it meets the criteria for appeal
under 33 CFR part 331.5, and that it has been received by the Division Office within 60 days of the date of the NAP. Should you
decide to submit an RFA form, it must be received at the above address by: Not Auolicable.
It is not necessary to submit an RFA form to the Division Office if you do not object to the determination in this
correspondence. ! ' Date: 2021.03.11
Corps Regulatory Official: AAd�� w 09:44:1 1-05'00'
Andrew Williams
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete our Customer Satisfaction Survey, located online at
http://corpsmgpu.usace.army.mil/cm apex/f?p=136:4:0.
Copy furnished (via email):
Brad Luckey
Pilot Environmental, Inc.
PO Box 128
Kernersville, North Carolina 27285

601 N. TRADE STREET, SUITE 200
(.'2 stimmel WwwwstoimmelpaMomC336723.1067
LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LAND PLANNING
EXHIBIT
TOTAL STREAM IMPACTS: 292 LF
TOTAL WETLAND IMPACTS: 126 SF
M / /
NCBEES CERT. NO.: C-1347
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date: 02-15-21 job #: 19-112
project: FRONT STREET CAPITAL - WALLBURG ROAD
scale: 1" = 30' sheet 1 of 2
description: STREAM & WETLAND IMPACT EXHIBIT
03-10-21 - REVISION 2
40
/ PERENNIAL
Z STREAM
/ 122 LF IMPACT
/ WETLANDS
126 SF IMPACT / END OF IMPACT ,
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W80.1341863
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TOP OF
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PERENNIAL
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SCALE: 1" = 30'
30 0 30
North

Action ID Number: SAW-2018-01786 County: Forsyth County
Permittee: Robin Team
Front Street Wallburg, LLC
Project Name: Wallburg Rd
Date Verification Issued: March 11, 2021
Project Manager: Andrew Williams
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification and return it to the following address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Attn: Andrew Williams
3331 Heritiage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Please note that your permitted activity is subject to a compliance inspection by a U. S. Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending, modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
Signature of Permittee
Date

E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps
regarding the preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an approved
JD (which may be appealed), by contacting the Corps district for further instruction. Also you may provide new
information for further consideration by the Corps to reevaluate the JD.
SECTION II - REQUEST FOR APPEAL or OBJECTIONS TO AN INITIAL PROFFERED PERMIT
REASONS FOR APPEAL OR OBJECTIONS: (Describe your reasons for appealing the decision or your
objections to an initial proffered permit in clear concise statements. You may attach additional information to
this form to clarify where your reasons or objections are addressed in the administrative record.)
ADDITIONAL INFORMATION: The appeal is limited to a review of the administrative record, the Corps
memorandum for the record of the appeal conference or meeting, and any supplemental information that the
review officer has determined is needed to clarify the administrative record. Neither the appellant nor the Corps
may add new information or analyses to the record. However, you may provide additional information to clarify
the location of information that is already in the administrative record.
POINT OF CONTACT FOR; UESTIONS OR INFORMATION:
If you have questions regarding this decision and/or the
If you only have questions regarding the appeal process you may
appeal process you may contact:
also contact:
District Engineer, Wilmington Regulatory Division,
Mr. Philip Shannin, Administrative Appeal Review Officer
Attn: Andrew Williams
CESAD-PDO
3331 Heritage Trade Drive, Suite 105
U.S. Army Corps of Engineers, South Atlantic Division
Wake Forest, North Carolina 27587
60 Forsyth Street, Room 1OM15
Atlanta, Georgia 30303-8801
Phone: [phone]
EMAIL: PHILIP.A.SHANNIN USACE.ARMY.MIL
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any government
consultants, to conduct investigations of the project site during the course of the appeal process. You will be provided a 15 day
notice of any site investigation, and will have the opportunity to participate in all site investi ations.
Date:
Telephone number:
Signature of appellant or agent.
For appeals on Initial Proffered Permits send this form to:
District Engineer, Wilmington Regulatory Division, Attn: Andrew Williams, 69 Darlington Avenue, Wilmington, North
Carolina 28403
For Permit denials, Proffered Permits and approved Jurisdictional Determinations send this form to:
Division Engineer, Commander, U.S. Army Engineer Division, South Atlantic, Attn: Mr. Philip Shannin, Administrative
Appeal Officer, CESAD, 60 Forsyth Street, Room 1OM15, Atlanta, Georgia 30303-8801
Phone: [phone], EMAIL: PHILIP.A.SHANNINC&USACE.ARMY.MIL