WQ0042677_Application (FTSE)_20210712

DocuSign Envelope ID 98D29C4D-424F-4E39-8870-831AE18810BD
DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: vVQ000 t1obecompletedbyDWR1
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
I. Applicant's name: 'Town of Holly Springs (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Kendra D. Parrish. P.E, per ISA N(":t(' 021 .0100LbJ
Title: Executive Director of Utilities & Infrastructure Services
4. Applicant's mailing address: 128 South Main Street
City: Holly Springs State: NC Zip: 27540-_
5. Applicant's contact information:
Phone number: [phone] Email Address: kendraparrish(@hollvsprinp-snc.us
If. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
I. Project name: Vill�Gate Tract 2
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of master plan, provide the existing permit number: WQ00
3. County where project is located: Wake
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.6345631 Longitude:-78.8379811
5. Parcel ID (if applicable): 0648-86-0360, 0648-86-2276. 0649-85-1962, 0648-86-2150
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Chris Alien License Number: 023029
Firm: Allen Consulting, PLLC
Mailing address: 10609 Old Pine Court
City: Raleigh State: NC Zip: 27613
Phone number: (21-9) 669-3635 Email Address: callena,allencm.com
1V. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Utley Creek Wastewater Treatment Plant Permit Number: NCO063096
Owner Name: Town of Hol I Springs
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0042413 Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (i fappli cable): WQCS00192
Owner Name(s): Town of Holly Springs
v
z
FORM: FTA 04-16 Page I of 5

Docuftn Envelope ID: 98029C4D424F-4E39-8870-831AE1881OBD
VI. GENERAL REQUIREMENTS
L 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 QL%dL)Vcr's (terationa' Agivement (I ORM- D1.. J been attached?
❑ Yes ❑No ®NJA
3. If the Applicant is a 1 lome: PrcI)er % OwRr rs' A.tisog iation..has an Operational Agreement t 1-ORM: I It 1 been attached?
❑ Yes ❑No ®NiA
4. Origin of wastewater: (check all that apply):
❑ Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ® Medical i dental veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial °o Commercial
% Industrial (S" l,5,A NCAC 021-.0103(201)
4Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A. NCAC 02T .01 14t JV ❑ Yes ❑ No
If Yes, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 021.01 14tf))
Daily Design Flow p•6
No. of Units
Flow
Medical/Office
250 gal/day/practitioner
40
10,000 GPD
gall
GPD
gall
GPD
gal/
GPD
gall
GPD
gal/
GPD
Total
10,000 GPD
a See 15A NCAC 02T .01141b). tdl, Le)(I) and lelt2l 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 .01 14(c), design flow rates for establishments not identified [in table 15A NCAC 02'1� 01 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 10,000 GPD (per 15A NCAC 021' .0114)
D Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16 Page 2 of 5

-DocuSign Envelope ID 98D29C4D-424F4E39-8870-831AE18810BD
VII. GRAVITY SEWER DESIGN CRITERIA (if Applicable) -0 &MDC:(GrmvilvSmnne ;
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 416 PVC
D Section 11 & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section Ill contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIII_ PUMP STATION DESIGN CRITERIA (if Applicable)—U2T &305 & MDC (Puma Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: _ Longitude: -
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) I Length (feet) I Material
6. Power reliability in accordance with 15A NCAC 02'1.tM05(hIt 1j:
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It steal I be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

DocuStgn Envelope ID 98D29C4D-424F-4E39-8870-831AE18810BD
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 021�Ill & Irtt
➢ 15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems_
® Yes [:]No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains horizontal
10 feet
Reclaimed water lines vertical - reclaimed over sewer
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
"Any private or public water supply source, including any wells, WS-1 waters of Class I or
Class 11 impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
-high water or tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ I SA NUAC 02'f_0305(2) contains alternatives where separations in Q11:.03051 Il cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surlitce Water Classifications3►g
➢ If noncompliance with 02'1'.030541) or tuk see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes [:]No
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with all setbacks found in the river basin rules per 15A NCAC _02B .0200? ® Yes ❑ No
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes ❑ No
➢ Wetland -related permits shal I be requested, obtained, and adhered to for projects that impact wetlands or surface waters
➢ Information can be obtained from the 401 &,. Buffer Perntittin,, Branch
5. Does project comply with 15A AC 021f.0105ick6) (additional permits/certifications)? ® Yes ❑ No
Per 15A Nk AC 021'.ft 151c k61, directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 1;,IS +1 (12.[.lW4Y' "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

DocuSign Envelope ID: 98D29C4D-424F-4E39-8870 831AE1881OBD
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NC.'AC 02T. the NLrdmiAm Nyg& Clatcria fOF
and Forac Maim flaiEg Yciiion)a and the GFu% m Sewer MinimuM Degiga Criteria [latest versianl as applicable?
2.
® Yes ❑ No
If No. complete and submit the VariancelAltemative Design Request application (VADC 10-14) and supporting documents for
review. •AppEnal of the request is required prior to submittalyi the Fast Track_ Application and supporting docpffl&nlL
Professional E ineer's Certification:
(Professional Engineer's name from Application Item Ill.1.)
that this application for
has been reviewed b) me and is accurate, complete and consistent with the information supplied in die plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -'track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seat signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — in accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation. or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T ,0106(b):
1 Kendra Parrit�*ec Director of Utilities and infrastructure attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of -,asteuater from this non -
discharge system to surface eaters 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 any person who knowingl) makes any false
statement. representation or certification in any application package shall be guilty of a Class 2 misdemeanor, %%Wch may
include a fine not to exceed $10.000 as well as civil penalties up to $25,000 per violation.
Signature:
FORM: FTA 04-16
Date: 7/7/2021
Page 5 of 5

Docuftn Envelope ID: 98D29C4D424F-4E39-8870-831AE18810BD
;)W-flk.
Dlvbdon of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Holly Springs
Project Name for which flow is being requested: Village Gate Tract 2
More than one FTSE maybe required for a single project if tire owner of the WWTP is not responsible far all pump
stations along the route of the proposed wastewater flow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Utley Creek Wastewater Treatment Plant
b. WWTP Facility Permit 4: NCO063096
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
6.0
0.658
2.426
0.01
3.09
51.60
11. 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:
Pump
Pump
Station
Station
Firm
(Name or
Permit
Capacity,
Number)
No.
MGD
HS Basal
WQ0037350M
0.501
(A)
(B)
Design
Average
Approx.
Daily
Current
Flow**
Avg. Daily
(Firm / pf),
Flow,
MGD
MGD
0.200
0.184
(C)
(D)=(B+C)
(E)~(A-D)
Obligated,
"Total
Not Yet
Current
"Tributary
Flow Plus
Daily Flow,
Obligated
Available
MGD
Flow
Capacity***
0.142
0.326
-0.126
* 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
(pi) 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): HS Basal Creek
Downstream Permit Number: WQ00373SOM
Page 1 of 6
F"I'SL- 10-18

Docusign Envelope ID: 98D29C4DA24F-4E39.8870.831AE1881OBD
111. Certification Statement:
I Kendra Parrish 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 11 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.
by;
7/7/2021
Signing O�iaTStg—Wature Date
Exec Director of utilities and infrastructure
Title of Signing Official
Page 2 of 6
FFSE 10-18

b0cuSign Envelope 10 981329C413-424F-4E39 88'.'0 831AE1881OBD
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): HS Basal Creek
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
43.6 % and 0.142 MGD of the Available Capacity (E) in Pump Station
HS Basal Creek PS ; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
N/A MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
HS Basal Creek Phase 2A _ is in design or under construction with
planned completion in July 2021 ; and/or
d. The following applies:
An upgrade to the HS Basal Creek Pump Station will be completed in partnership with a
Developer on a contributing project. It is anticipated that the improvements will be
completed for expanded capacity by July 2021.
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.
F
by
�` z/z/zazl
Signing O tcia ignature Dale
Page 3 of 6
F'I'Sl� 10-18

DocuSign Envelope ID- 98D29C4D424F4E39-8870-831AE1881OBD
Allen Consulting, PLLC
10609 Old Pine Court Raleigh, NC 27613 919-669-3635
Project Name: Village Gate Tract 2
Fast Track Sewer System Extension Application: FTA 04-16 and FTSE 10-18
A. INTRODUCTION
The subject property is a 4.72-acre tract of land located on South Main Street and Ralph
Stephens Road in Holly Springs. The project will consist 60,000 sf of medical/professional office
space.
b
g � �
i
a
no � --
i
V r St
Ry
s' u Av
B. PROJECT DETAILS
• Building Size: 60,000 sf
• Proposed sewer flow: 250 GPD/Practitioner for 40 Practitioners= 10,000 GPD
• Peak Flow 17.36 GPM.
• Project to be served with 415.92 linear feet of 8" PVC sanitary sewer pipe minimum
slope of 1.05% which drains to the Southwest corner of the site.

DocuSign Envelope ID: 98D2904D-424F-4E39-8870-831AE1881ORD
.H n,,.
111 . « r 7 �� +r7
THE TOWN OF
_,,� - -
July 6, 2021
Director, Division of Water Resources
Raleigh Regional Office
Water Quality Operation Section
1628 Mail Service Center
Raleigh, NC 27699-1628
Re: Application for Sewer Extension Permit
Project: Village Gate Tract 2
Dear Sir or Madam:
NC Dept of Environmental Quality
3� 1 1 13 �
lei A011al Office
R2i
Please find enclosed the following items in application for a sewer extension permit to the Town
of Holly Springs existing sewer distribution system:
0 One original and one copy cover letter including a project narrative
c. A check in the amount of $480.00
0 One original and one copy of the State of North Carolina Fast Track Sewer System
Extension Application (FTA 04-16)
0 Two copies of FTSE 04-16 Flow Tracking/Acceptance Form
0 Two color copies of a 8.5-inch by 1 l -inch portion of a 7.5 minute USGS Topographic
Map showing project area
0 Two copies of a street level map showing all relevant project areas
0 One copy of the locally -required Design and Application Certification
Feel free to contact me at 919-577-3150 should you have any questions or need additional
information in order to process this application.
Sincerely,
eMPT " Parrish, P.E., CFM
Executive Director of Utilities and Infrastructure
KP/tr
cc: Project Consultant Engineer, Chris Allen, PE
Rachel Ingham, Utility Engineer
Drew Johnson, Development Construction Manager
Theresa Randall, Utility Permitting Specialist
Project file/Correspondence #41895
ioslim
Rachel Ingham
Utility Engineer
3002
04 17 2018
Utilities anti Infrastructure Services
P.O- Box 8 - 128 S- Main Street 9 HoIly Springs, NC 27540 • www.ho11Nrspringsnc.us

DocuSign Envelope ID 98D29C40-424F-4E39-8870-831AE18810BD
DO NOT SUBMIT SEWER EXTENSION APPLICATIONS UNTIL
CONSTRUCTION DRAWINGS HAVE BEEN APPROVED BY STAFF!
Sewer Design and Application Certification
Note: This form must be submitted with the Fast Tract Application for extension to the Town of
Holly Springs Sewer System
Project:
Design Engineer:
Village Gate Tract 2
Chris Allen, P.E.
Address: 10609 Old Pine Court Raleigh, NC 27613
Phone Number: 919-669-3635
Email: [e-mail]
Date CompleteApplicationPackage Received by Town: 6.9.2021
Date Approved:l 2- 7/6/2021 (by RI] 7/7/2021 (by KDP DJ 7/6/2021
(by DJ)
As design engineer for this project, ! certify the following (please check (x) each applicable box):
0 That the design of the project is in complete conformance with the Town of Holly
Springs Engineering Design and Construction Standards and NC DEQ Sanitary Sewer
Design Regulations;
0 That each of the following items are completed and enclosed for submittal to the State for
a sewer extension permit:
0 One cover letter that includes a project narrative
o A check in the amount of $480.00 to NC DEQ
* A check in the amount of $200.00 to the Town of Holly Springs
0 One State of North Carolina form FTA 04-16 Fast Tract Sewer System
Extension Application
0 One FTSE 10-18 Flow Tracking for Sewer Extension Applications
0 One color copy of an 8.5-inch by I 1-inch portion of a 7.5-minute USGS
Topographic Map showing project area
0 One copy of a street level map showing all relevant project areas
0 One copy of the locally -required Design and Application Certification (this
form)
Design (Engineer's Signature & Lam"- l Date 5.9.2021
Please contact Theresa Randall at (919) 5674009 or theresa.randal I a hal I}_ taringsnc.t ov if you
have any questions.
2003 Sewer Desi Application C'enif.cation
G1.1421
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 0 www.hollyspringsilc.gov

[DocuSign Envelope ID 98D29C4D424F-4E39-8870-831AE18810BD
State of North Carolina
11WR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of l5A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15.1
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 I5A NCAC 02T .MG5 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 021.0 i0.;
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with ISA NCAC IC.0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation,
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State,
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
® The Project Name in Item 11,1 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 J. njw!L, r.
® 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 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 3

DocuSign Envelope ID 98D29C4D-424E-4E39-8870-831AE18810BD
E. Flow TrackingtAcceptance Form (Form: FTSE 04-16) (If Applicable):
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The Flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G. F43;
.,1_�.67 .
➢ 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 I ]-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include a street level map showing general project area.
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .03O5(h)I 11, submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 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)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per lISA WAC 02T_01 15ta)(1 I provide the Certificate of Public Convenience and Necessity from the North Carolina
ViLilities 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 Waler 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/Pro a Owners' Associations
❑ Per I SA NCAC 02T .0l 15W, submit the properly executed Operational Agreement (FORM:. HOA).
❑ Per 15A NCAC 02T .01 15(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .01 15(b), submit the properly executed Operational Agreement (FORM--DEVI.
For more information, visit the Division's collection systems irehsite
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: 98D29C4D-424F-4E39-8870-831AE188108D
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Reaional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville_ Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredelt, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Re-gional Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mali
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
Wilminaton Reaional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR rORM. I'TA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3