WQ0042679_Application (FTSE)_20210712

DocuSign Envelope ID 52D3E880-5503-4EFC-9E2E-9E014CODB757
State of North Carolina
Department of Environmental Quality
Division of Water Resources
DW...R
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: a 1 79 (to be completed by DWR)
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 ❑ Privately -Owned Public Utility
❑ Federal ❑ Stateicounty ® Municipal ❑ Other
3. Signature authority's name: Kendra D. Parrish. P.E. per 1 A NCAC 02T .0106(bl
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: kendra.parrish(hollysprin sg ne.us
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11. PROJECT INFORMATION: M
1. Project name: Carolina Springs Phase I, Sub Phase 1-5 9
2. Application?Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
0�4
If a modification, provide the existing permit number: WQ00 and issued date: p' N o
b
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Wake + f + +�, ti 0
4. Approximate Coordinates (Decimal Degrees): Latitude: 35 Longitude: -78 e A
5. Parcel ID (if applicable): 074003625
(or Parcel ID to closest downstream sewer)
35. (0.8048-BlgS'
III. CONSULTANT INFORMATION: i 35 1` 6' 4r At, Is sa 444 tJ
I. Professional Engineer: Debra M FermLicense Number: 028892
Firm: WithersRavenel, Inc.
Mailing address: 115 MacKenan Drive
City: Cary State: NC Zip: 27511-
Phone number: [phone] Email Address: dfermnwithersravenel.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Utley Creek Wastewater Treatment Plan Permit Number: NCO063096
Owner Name: Town of Holly Springs
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0042364 Downstream (Receiving) Sewer Size: 18 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00192
Owner Name(s): Town of Holly Springs
FORM: FTA 04-16 Page 1 of 5

DocuSign Envelope ID: 52D3EB80-55D3-4EFC-9E2E-9EO14CODB757
VI. GENERAL REQUIREMENTS
I. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No OMIA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement t 1'(1Rtv1: DM been attached?
❑ Yes [—]No ®NIA
3. If the Applicant is a I lonoe OrgWtw PwMT5LAs,sqciation, has an Operational AIreemi�nt il'ORM: I-10AI been attached?
❑ Yes ❑No ZMA
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 l preschool / day care ❑ Medical I dental t 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 : % DomesticlCommercial % Commercial
%Industrial (See 15A NCAC 02T.0103120i)
b Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02'f .01 14{ f�? ® Yes ❑ No
D If yes} provide a copv of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 011.0114M)
Daily Design Flow'-e
No. of Units
Flow
Single Family Residential Units
255 galiday
426
108,630 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
108,630 GPD
a See 15A NCAC 021 .01 141l 1_fdl_ieNtIarid (cX21 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 ofthe Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in (i_S_ 42A-4).
b Per 15A NCAC 02T .0I 14(c), design flow rates for establishments not identified [in table 15A NCAC 02TA 1141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
108,630
8. Wastewater generated by project: _ GPD (per 15A NCAC 02T .01 14)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: VTA 04-16 Page 2 of 5

DocuSign Envelope ID 52D3E88O-55D34EFC-SE2E-SEO14CODS757
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" 11,967 PVC
➢ Section 1I & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
Vill. PUMP STATION DESIGN CRITERIA (If Applicable) 02T .0305 & MDC (Puma Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
. Pump station number or name: N1A
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -.
3. Design flow of the pump station. _ millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): _ gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T _0305(h0 l l:
❑ 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 shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

DocuSign Envelope ID- 52D3E880-55D3-4EFC-9E2E-9EO14CODB757
IX. SETBACKS & SEPARATIONS (02B .0200 & l5A NCAC 02T .0305(f)):
. Does the project comply with all separations found in 1IA NCAA .g21 305f I c t l
➢ 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-I waters of Class 1 or
Class I I impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top sloe of embankment or cuts of 2 feet or more vertical height
10 feet
Drain a e systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCA(' 02 r_0305 t contains alternatives where separations in 021 0305Lt) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Clasilications u�ebtxaae
➢ If noncompliance with tx), 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 I $A NCAC' 0,2D _0200' ® Yes ❑ No
➢ This would include Trout Buffered Streams per 15A NCAC 2I3.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes ❑ No
➢ Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
➢ Information can be obtained from the 401 A Buffer Pkrmit.tin& BranL:h
5. Does project comply with I SA NCAC 02I.0105iUA0 (additional permits+certifications)? ® Yes [:)No
Per U&JUL._011�.Q 0 {clt6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02 17.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ®No
➢ 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: 52D3E880-55D34EFC-9E2E-9EO14CODB757
X. CERTIFICATIONS:
I. Does the submitted system comply with 1 s.'� NC.V. 02T, the Mmimum_Dcsiyn CriteriaAr.the Permmign"Illmmn Stations
and force Mains (latest version), and the Gray it%- Seu er Minimum Design Criteria {latest %Ur ion.} as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. A roval of the re uest is reguired gtrior to submittal of the Fast Track Application and supporting documents.
2. Professional Engineer's Certification:
I Debra M Fenn
attest that this application for
(Professional Engineer's name from Application Item I11.1.)
Carolina Sprins Phase 1, Sub Phase 1-5
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, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that 1 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:
Doauftrwd by:
t Lra JFt,m
64e2S7a388754F8.
3. Applicant's Certification per 15A NCAC 02T .0106(b):
Kendra ParrIJAk Director of utilities and Infrastructure
(Signature Authority's name & title from Application Item 1.3.)
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attest that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. 1 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: __
EDocuftned by:
**_ c�1U
Date: 7/8/2021
FORM: FTA 04-16 Page 5 of 5

DocuSign Envelope ID. 52D3E880.55D3-4EFC-9E2E-9EO14CODB757
State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
Ivislon of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Lennar Carolinas LLC
Project Name for which flow is being requested: Carolina Springs Phase 1, Sub Phase 1 - 5
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for alt pump
stations along the route of the proposed wastewaterflow.
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 ##: NC 0063096
All flows are in MGD
c. WWTP facility's permitted flow 6.0
d. Estimated obligated flow not yet tributary to the WWTP 0.658 MGD
e. WWTP facility's actual avg. flow 2.426 MGD
f. Total flow for this specific request 0.109 MGD
g. Total actual and obligated flows to the facility 3.193
h. Percent of permitted flow used 5
3.2
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:
(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 i p f), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
Carolina Springs 1 WQ0042364 1.967 0.787 0 0.109 0.109 0.678
* 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): Carolina Springs 1
Downstream Permit Number: WQ0042364
Page 1 of 6
FTSE: 10- 18

DocuSign Enve ape ID 52D3E8W55D3-4EFC-9E2E-9EO14CODB757
III. Certification Statement:
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 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.
UxuSlpnrd by_
7/8/2021
exa�no�cu�e
Signing Off cial Signature Date
Exec Director of utilities and Infrastructure
Title of Signing Official
Page 2 of 6
FTSE 10-18

DocuS?gn Envelope ID: 52D3E880-55D34EFC-9E2E-9EO14CODS757
■■ WithersRavenel
'. Our People. Your Success.
June 28, 2021
Town of Holly Springs
Utilities and Infrastructure
Attn: Rachel Ingham
128 S. Main Street
Holly Springs, NC 27540
RE: Carolina Springs Phase 1, Sub Phase 1 - 5
Sewer System Extension Permit
Dear Ms. Ingham,
On behalf of Lennar Carolinas LLC, please find the attached documentation in support of a Fast -Track
Application (FTA 04-16) for the referenced project. As noted in the application, this project will consist of
11,967 LF 8" PVC sewer and will connect to sewer permitted under separate cover (WQ0042364). The
proposed sanitary sewer lines will serve 426 single family residential units within the Carolina Springs
Phase 1, Sub Phase 1- 5 development.
The proposed project will meet all of DWR's min}mum design criteria for sanitary sewer extensions. The
design flow rate for this project is calculated at 108,630 gpd based on NCAC 2T Rules for wastewater flow
rates. The proposed sanitary sewer line sizes are more than adequate to convey the design flow rates.
Please find attached the following information in support of the application:
• Fast Track Sewer System Extension Application (FTA 04-16)
• Flow Tracking/Acceptance Form for Sewer Extension Applications (FTSE 10-18)
• USGS Map
• Street Level Map
• Check for $480.00 to NC DEQ
If you have any questions regarding this request or if you require any additional information, please feel free
to contact me at 919-238-0368 or [e-mail].
Sincerely
WithersRavenel
A 41
Debra M. Ferm, P.E.
Project Manager
115 MacKenan Drive I Cary, NC 27511
t: 919.469,3340 1 f: 919-467.6008 1 www.withersravenel,com I License No. C-0832
Cary I Greensboro I Pittsboro I Raleigh I Wilmington

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DocuSign Envelope ID: 52D3E880-55D34EFC-9E2E-9E094CODB757
t`a 197G
THE TOWN OF
q.17y. hKTrl`
July 7, 2021
Director, Division of Water Resources
Raleigh Regional Office
Water Quality Operation Section
1628 Mail Service Center
Raleigh, NC 27699-1628
,Polly ptings
Re: Application for Sewer Extension Permit
Project: Carolina Springs Phase 1, Sub Phase 1-5
Dear Sir or Madam:
NCbeptOfEnvironmental Quail(.
Raleigh Regional offi(,,
Please find enclosed the following items in application for a sewer extension permit to the Town of
Holly Springs existing sewer distribution system:
o One original and one copy cover letter including a project narrative
o 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 I 1-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,
DecuSigned by:
03C0.5B89FC34441,
Kendra D. Parrish, P.E., CFM
Executive Director of Utilities and Infrastructure
KP/tr
cc: Project Consultant Engineer, Debra Ferm, PE
Rachel Ingham, Utility Engineer
Drew Johnson, Development Construction Manager
Theresa Randall, Utility Permitting Specialist
Project file/Correspondence #41900
os
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7/8/2021
Rachel Ingham
Utility Engineer
3002
04 17 2018
Utilities and hif astructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.us

Docusign Envelope ID 52D3E880-55D3-4EFC-9E2E-9EO14CODt3757
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 Aoolication for extension to the Town of
Holly Springs Sewer System
Project:
Carolina Springs Phase 1, Sub Phase 1 - 5
Design Engineer: WithersRavenel, Inc. / Debra Ferm, P.E.
Address: 115 MacKenan Drive, Cary, NC 27511
Phone Number: [phone] Email: [e-mail]
withersravenel.com
Date Complete Application Package Received by Town: _
Date Approved 7/8/2021 (by Rl� 7/8/2021 (by KDPdi (by DI)
//t5/ZVZr
As design engineer for this project, I certify the following (please check (x) each applicable box):
M 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;
M 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
o 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 Trackingfor Sewer Extension Applications
0 One color copy of an 8.5-inch by 11-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)
ftmd by:
Design Engineer's Signature Z,
Date 6/6/2021 _
Please contact Theresa Randall at [phone] or theresa randalhr t holl, ss xrinxsnc.gov if you
have any questions.
2003 Sewer Design Application Certification
01.1421
Utilities and Infrastructure Services
P.O. Box 8 • 118 S. Main Street • Hotly Springs, NC 17540 • www.hollyspringsnc.gov
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DocuSign Envelope ID 5203E880-55D34EFC-9E2E-OE014COD13757
State of North Carolina
DW
Department of Environmental Quality
Division of Water Resources
J 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 IAA NA(' 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, IA
NCAC 02T, 15A NCAC O21' .OJ00, 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 .030.5 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 t 5A Nf' 2 L0193.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that require an environmental assessment in accordance with 15A NCAC 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 Secreyn o1' 5tate.
❑ 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 Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with I SA NCAC 02T _0106&-
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: PTA 04-16 & SUPPORTING DOCUMENTATION Page I of 3

DocuSign Envelope ID- 52WEgso-snD3-4EFC-9E2E-9E414C0D8757
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 FTSF, indicates that owner has adequate capacity and will not violate G.S. 14t-
215.67f 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 I I -inch color copy of a k:SGS 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-
0 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 NC AC 02T .p t0 f h)(1 I, 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 .0I 15ja�Jj provide the Certificate of Public Convenience and Necessity from the North Carolina
1-1tilides Commissiran 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 I tili3.ies Commission's VbwF and 5Vwgr Division PubIL;: Slain 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 HOAIPOA and Developers for lots to be sold):
❑ HomelProyettY Owners' Associations
❑ Per 15A NCAC 02T -01 I Stc1, submit the properly executed Operational Agreement IFORM: HOA?.
❑ Per 15A NCAC 02T .0l 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 Openitional Agreement iFORM: DEVI.
For more information, visit the Division's collection systems ►vehsite
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID 52D3E880-55D3AEFC 9EK-9E014=8757
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
Asheville Regional Office
Water Quality Section
Favetteville Reaional Office
Water Quality Section
Mooresville Reaional Office
Water Quality, Section
Raleigh Regional Office
Water Quality Section
Washington Regional Office
Water Quality Section
ADDRESS
COUNTIES SERVED
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
j Rutherford, Swain, Transylvania, Yancey
225 Green Street Suite 714 1 Anson, Bladen, Cumberland, Harnett, Hoke,
Fayetteville, North Carolina 28301-5094 Montgomery, Moore, Robeson, Richmond,
[phone] 1 Sampson, Scotland
[phone] Fax
610 E Center Avenue
Mooresville, North Carolina 28115
[phone]
[phone] Fax
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
(919) 7914200
[phone] Fax
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Beaufort, Bertie, Camden, Chowan, Craven,
Currituck, Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Re-gional Office 127 Cardinal Drive Extension Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section Wilmington, North Carolina 28405 Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Reaional Office 450 W. Hanes Mill Road Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section Suite 300 Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem. North Carolina 27105 Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCl1MENTATION Page 3 of 3