NC0086550_FTA Application_20040408

Hobbs, Upchurch & Associates, P.A.
Consulting Engineers
300 S.W. Broad Street • Post Office Box 1737 • Southern Pines, NC 28388
April 8, 2004
Regional Water Quality Supervisor
DENR Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
APR 13 2004
DWQ
Re: Town of Boardman Sewer Improvements
Sewer Interconnection with Town of Fairmont
Columbus County/Robeson County , HUA File No. BD0302.320
Dear: Water Quality Supervisor:
Please find enclosed two (2) copies of the referenced FTA application package,
all required supporting documents and a check for the $400 permitting fee.
We are also sending a copy of the complete application (minus the permitting
fee) to the Fayetteville office as the proposed Boardman collection system is in
Columbus County but the proposed receiving WWTP, (Fairmont NC0086550), is
located in Robeson County.
If you should have any additional questions or need additional information,
please feel free to contact this office at anytime.
Sincerely,
HOBBS, UPCHURCH AND ASSOCIATES, P.A.
19
Gary Griffin" Cox, P.E.
Project Engineer
Governmental Division
cc: _Town of Boardman
DENR_EayetteviIIe_Regional-Office=(225-GGreen:St: Suite 71.4; Fayetteville
�-=NG=28301_)3
Southern Pines, NC • Telephone [phone] • Fax [phone] • e-mail: [e-mail]
Myrtle Beach • Nags Head • Raleigh • Charlotte • Beaufort

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 1
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included the following list of required application package items by checking the
space provided next to each item. Failure to submit all required items will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
® I. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. Any changes to this form will result in the application being returned. The Division of Water Quality
(Division) will only accept application packages that have been fully completed with all applicable items
addressed. You do not need to submit detailed plans and specifications unless you respond NO to Item B(12).
® II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ III. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2a)of'th'is application.
❑ IV. Operational Agreements — Submit one original and/two copies of a properly executed operational agreement if
the sewer extension is permitted by a private ap&cant and will be serving residential or commercial lots (e.g.,
houses, condominiums, townhomes, outparcels,` -tc.) that will be sold to another entity. If the applicant is a
homeowners' association, use Form HOA 02/0 If the applicant is a developer, use Form DEV 02/03. EVEN IF
THE PROJECT WILL BE TURNED OVER TO "'' MUNICIPALITY, FORM DEV 02/03 IS REQUIRED.
® V. Flow Acceptance Letters — If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and name and permit number of the receiving sewers/WWTF. The flow acceptance must not
expire prior to permit issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
® VI. Map — Submit an 8.5-inch by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map along with this
form. The map should identify the entire project area location as well as the closest downslope surface waters as
clearly as possible. Each map portion must be labeled with the map name and number, the identified location,
and be of clear and reproducible quality. For instance, if the project involves 4 miles of interceptor sewer that
traverses over or near several different waterbodies (or counties, basins, etc.), the map should have location ID's
for each different waterbody (where the sewer line is within 100 feet of such waterbody - see Instruction VII).
® VII. Stream Classifications — Section C
• If any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire project area is a minimum of 100 feet away from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)" available from http://h2o.enr.state.nc.us/ndpu or by contacting the appropriate regional
office.

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 2
❑ VIII. Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01 C .0500], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
processed until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS) has been
issued. A copy is to be submitted with that permit application.
® IX. Certifications — Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE). The applicant signature must match the signing official listed in Item A(1 b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, the Gravity Sewer Minimum Design Criteria (most
recent version) and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
(most recent version), as applicable to the project. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral.
THE COMPLETED FTA 02/03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
•
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
59 Woodfin Place
Asheville, North Carolina 28801
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell,
Cherokee, Clay, Graham, Haywood,.
Henderson, Jackson, Macon,
Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania,
Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett,
Hoke, Montgomery, Moore, Robeson,
Richmond, Sampson, Scotland
Mooresville Regional Office
919 N Main Street
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba,
Cleveland, Gaston, Iredell, Lincoln,
Mecklenburg, Rowan, Stanly, Union
Raleigh Regional Office
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
[phone]
[phone] Fax
Chatham, Durham, Edgecombe,
Franklin, Granville, Halifax, Johnston,
Lee, Nash, Northampton, Orange,
Person, Vance, Wake, Warren,
Wilson
Washington Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
Beaufort, Bertie, Camden, Chowan,
Craven, Currituck, Dare, Gates,
Greene, Hertford, Hyde, Jones,
Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington,
Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus,
Duplin, New Hanover, Onslow,
Pender
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, North Carolina 27107
[phone]
[phone] Fax
Alamance, Allegheny, Ashe, Caswell,
Davidson, Davie, Forsyth, Guilford,
Rockingham, Randolph, Stokes,
Surry, Watauga, Wilkes, Yadkin
For more information, visit our web site at: http://h2o.enr.state.nc.us/ndpu/

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! 1 Application Number: —
• (to be completed by DWQ)
1. Owner:
1 a. Town ofsBpardrnan7
Full L gal Name (company, municipality, HOA, utility, etc.)
z !1b. Larry Williamson, Mayor
0 Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
E" lc.
re 1 d.
The
Z4
PO
legal entity
Individual
Box 87
who will
■ Federal
own this system
►� Municipality
is:
■ State/County
II
Private Partnership
Ile. Evergreen
III Corporation
■
Other (specify):_ _
0 ; Street Address 1 City
LL t
Z 1f. NC 11g. 28438
Z State 1 Zip Code
11 h. 910-608-0390 111 910-608-0335 11 j.
I-- j Telephone 1 Facsimile 1 E-mail
2. Project (Facility) Information:
EL 12a. Boardman Sewer Improvements 12b. Columbus(Collection)/Robeson(WWTP)
a
Q'
I Brief t-Name (permit will refer to this name) ! County Where Project is Located
3. Contact Person:
Ql.:• ;3a. /cliff Gox-m-1, a4% -5 Ld`o 1G ,-c_ 11
Name an'tl Affiliation of Someone Who Can Answer Questions About this Application
l.-_-.-------.--_..___.._._.—_—___._•__........_...-----____.__.._.__........_.__ _.._..---._.i.._........_._.---.----..__._....__....-.---_._—._......._...._...__._......._......_.__...._.__._._._._.._.---..__...
fib. 910-692-5616 13c. [e-mail]
Phone Number j E-mail
1. Project iscNew
•
Modification (of an existing permit) If Modification, Permit No.:
-
2. Owner istPaCPublic
(skip to Item B(3))
■
Private (go to Item 2(a))
i2a.
If
■
■
■
private, applicant will be:
Retaining Ownership (i.e. store, church, single office, etc.) or1
Leasing units (lots, townhomes, etc. - skip to Item B(3))
Selling units (lots, townhomes, etc. - go to Item B(2b))
2b.
I
If
•
■
sold, facilities owned by a (must choose one)
Public Utility (Instruction III)
Homeowner Assoc./Developer (Instruction IV)
0 3.
Tow
. 'J
Owner
of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
54,011111WrifoffiRamtnonilAMIEF---i
4b. NC0086550
0
Name
of WWTF I WWTF Permit No.
i
0 5a. Town
of Fairmont 15b. 12" 15c.
LL
Z
Owner
of Downstream Sewer i Receiving Sewer Size .I Permit Number of Downstream Sewer (if known)
H 6. The
origin of this wastewater is (check all that apply):
E
-
esidential Subdivision
Apartments/Condominiums
•
Car Wash
W
3..:
�i
►A
<=School
Mobile Home Park
i
■Institution
II
►eiChurch
1 1i00 °/3Dbmestiis/@oiiii efcia!-
Hospital i
% Industrial
Xi �EI`Restaurant
IPOffice
►/;Nursing Home ! % Other (specify):
■Other (specify):
7.
Vo`�lur'me
of-wastewatefitoliIpe`rmitted-in ttiis'pioiecf-33'000" gallons'per-day
' 8.
If the
•
•
permitted flow is zero, indicate why:
Interceptor Line - Flow will be permitted is subsequent permits that connect to this line
Flow has already been allocated in Permit No.
■ Rehabilitation or replacement of existing sewer with no new flow expected

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4
i1
W
F-
0
Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H
.0219(1) for Item B(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that in 15A NCAC 2H .0219(1)(1-2) must be approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality, Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(I)(3).
Pump Station will serve Boardman, Cerro Gordo & Fair Bluff:
Currently a total of 780 homes at 300 gal/day/home = 234,000 gallons/day
Current Commercial use at 1,627 people at 15 gal/day/person = 24,405 gallons/day
Industrial use at 10% of total = 26,000 gallons/day
Total flow = 284,405 gallons/day: 335,000 gallons -284,405 gallons = 50,595 gallons reserved for future growth
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Gravity or Force Main
Size (inches) Length (feet) (pull down menu)
.Gravitym'
Attyl 2,250 I Gravity
i 2,750., Gravity'
*arm
ark7=50"• >•' 'fForce ai "7
I Gravity
I �Grayity ....--------._
Z . ' ENTER TOTAL LINE LENGTH IN MILES; 111111011WV
F-' 111. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
a
Location ID
0` (as shown on plans)
LLi. _..---.._._. _.. __._.
Z 0� -r.
Design Flow Operational Point
MGD).__..._.._........._.iGPM @ TON
0 8375 r'.fi50�GPM (a��13 TpFll
Power Reliability Option
(dual line feed, permanent generator w/ATS,
ortable generator w/telemetry, wet well storage)
permanent generator w/ATS
002 ! .03001 OIGIVArgtligivliDL,Dt, 1 portable generator wiTelemetry
cL
UJ
a
12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
s ® Yes ❑ No If no, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested:
SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
•
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification? ® Yes ® No ❑ N/A
Sedimentation and Erosion Control Plan? ® Yes ® No ❑ N/A
Stormwater? ® Yes ❑ No ® N/A

' FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5
1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02/03 —
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets as
Z necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
O regional office (see instructions for addresses) OR indicate the following:
H ❑ A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
Q waterbody; AND,
V ❑ A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability
LL. option for any pump station near a Class C down slope waterbody.
CO
Location ID Name of
Q ;._. _._ .....__on.._ Map ..._....------..__._._.__Waterbody
Lumber River
002
Lumber River
County
Columbus
Columbus
Waterbody Stream
River Basin Index
Lumber River 14(13)f
Lumber River 14(13)f
Waterbody
Classification
C SW
C SW
Submit the 8.5" x 11" topographic map as required in Instruction VI regardless of whether a classification is provided!
11. Applicant's Certification:
1, Larry Williamson, Mayor, attest that this application for Town of Boardman Sanitary Sewer Improvements
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. Note: In accordance with North Carolina
General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
certification in any application 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.
-
? Signing Oal ial Signature
2. Professional Engineer's Certification:
f
Date
I attest that this application for Town of Boardman Sewer Improvements has been
reviewed by me and is accurate, complete and consistent with the information in the engineering plans, 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 adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump
Stations and Force Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance.
Although certain portions of this submittal package may have been developed by other professionals, 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 NC General Statutes 143-215.6A and 143-215.6B, any person who
knowingly makes any false statement, representation, or certification in any application 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.
2a. Gary Griffin Cox
Professional Engineer Name
2b. Hobbs, Upchurch and Associates P.A.
Engineering Firm
2c. Post Office Box 1737
Address .........................
2d. Southern Pines
City
2g. 910-692-5616 21i. 910-692-4795
Telephone
Facsimile
12e. NC
State
2f. 28388
Z• ip
i. [e-mail]
E-mail
l i R• tJ›
•
SEAL
A 2 6,13
06' �a �-:'t3i. �
Seal, Signature & Date

Phone: [phone]
March 8, 2004
TOWN OF FAIRMONT
421 South Main Street • P.O. Box 248
Fairmont, NC 28340
Email: [e-mail]
Mi. L arty Williain uu, Mayuc
Town of Boardman
Post Office Box 87
Evergreen, N.C. 28438
Re: Town of Boardman Flow Acceptance/Sanitaiy Sewer Fees
Connection to Regional Wastewater System N00086550
Dear Mr Williamson:
Fax: [phone]
As previously discussed, the Town of Fairmont supports your efforts in providing
sanitary sewer, improvements to your residents. As set forth by the Commissioners of the
Town of Fairmont on May 14, 2002, the Town agrees to accept and treat up to 45,000
gallons per day of wastewater from the Town of Boardman. A.•capacity/impact fee of
S45,000 will be required to purchase and reserve a 45,000 gallon per day, prorated share
in the Town's wastewater treatment plant. It is our understanding that the Rural Center
grant will cover the capacity charges for your Town.
This capacity/impact fee is a one-time charge implemented as a means to offset the costs
associated with capital investments made by the Town in order to provide service to the
Town of Boardman. Such capital costs include the construction of facilities as well as
engineering, surveys, land, financing, legal and administrative costs.
We will accept wastewater flow at the Town's wastewater treatment plant at a rate of
$2.25 per 1000 gallons. This rate will be reviewed annually and may be adjusted up or
down based on actual expenditures. These and.other details will be further addressed in a
future interlocal agreement that is currently being drafted by Hobbs, Upchurch and
Associates. If you should have any questions regarding.these fees and conditions, or if r
may be of fiuther assistance, please feel free to call me.
(i
trina Tatum
Interim Town Manager

TOWN OF FA IR M O NT
Phone: [phone]
March 8, 2004
Mr. Leon Merritt, Mayor
Town of Cerro Gordo
Post Office Box 26
Cerro Gordo, N.C. 28430
421 South Main Street • P.O. Box 248
Fairmont, NC 28340
Email: fairrnont _ carollna.net
Re: Town of Cerro Gordo Flow Acceptance/Sanitary Sewer Fees
Connection to Regional Wastewater System NC0086550
Dear Mr. Mcn-itt:
Fax: [phone]
As previously discussed, the Town of Fairmont supports your efforts in providing
sanitary sewer improvements'to your residents_ As set forth by the Commissioners of the
Town of Fairmont on May 14, 2002, the Town agrees to accept and treat up to 40,000
gallons per day of wastewater from the Town of Cerro Gordo. A capacity/impact fee of
$40,000 will be required to purchase and reserve a 40,000 gallon per day, prorated share
in the Town's wastewater treatment plant. It is our understanding that the Rural Center
grant will cover the capacity charges for your Town.
This capacity/impact fee is a one-time charge implemented as a means to offset the costs
associated with capital investments made by the Town in order to provide service to the
Town of Cerro Gordo. Such capital costs include the construction of facilities as well as
engineering, surveys, land, financing, legal and administrative costs.
We will accept wastewater flow at the Town's wastewater treatment plant at a rate of
$2.25 per IOC() gallons. This rate will be reviewed annually and may be adjusted up or
down based on actual expenditures. These and other details will be further addressed in a
future intcrlocal agreement that is currently being drafted by Ilobbs, Upchurch and
Associates. If you should have any questions regarding these fees and conditions, or if I
may be of further assistance, please feel free to e_a11 me.
Sincerely,
Ka ina Tatum
Interim Town Manager

Phone: [phone]
March 8, 2004
TOWN OF FAIRMONT
421 South Main Street • P.O. Box 248
Fairmont, NC 28340
Email: faIrmontecarolina.net
Mr. J.B. Evans, Mayor
Town of Fair Bluff
1175 Main Street
Fair Bluff, N.C. 28439
Re: Town of Fair Bluff Flow Acceptance/Sanitary Sewer Fees
Connection to Regional Wastewater System NC0086550
Dear Mr Evans:
Fax: [phone]
As previously discussed, the Town of Fairmont supports your efforts in participating in
the regionalization of sewer services. As set forth by the Commissioners of the Town of
Fairmont on May 14, 2002, the Town agrees to accept and treat up to 250,000 gallons per
day of wastewater from the Town of Fair Bluff A capacity/impact fee of $250,000 will
be required to purchase and reserve a 250,000 gallon per day, prorated share in the
Town's wastewater treatment plant. Other municipalities are using grant funds to cover
some or all of the capacity fees; Fair BIuff may wish to seek similar assistance in this
worthwhile endeavor.
This capacity/impact fee is a one-time charge implemented as a means to offset the costs
associated with capital investments made by the Town in order to provide service to the
Town of Fair Bluff. Such capital costs include the construction of facilities as well as
engineering, surveys, land, financing, legal and administrative costs.
We will accept wastewater flow at the Town's wastewater treatment plant at a rate of
$2.25 per 1000 gallons. This rate will be reviewed annually and may be adjusted up or
down based on actual expenditures. These and other details will be further addressed in a
future interlocal agreement that is currently being drafted by Hobbs, Upchurch and
Associates. Tf ynn should have any questions regarding these fees and conditions, or if T
may be of Irther assistance, please feel free to call me.
S incer
Y.
-ina Tatum
Interim Town Manager

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
WATERSHED CLASSIFICATION ATTACHMENT
Any changes made to this form will result in the application being returned.
r' (THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
INSTRUCTIONS:
To determine the classification of the watershed(s) in which the subject project will be located, you are required to
submit this form, with Items 1 through 8 completed, to the appropriate Division of Water Quality Regional Office
Water Quality Supervisor (see Page 2 of 2) prior to submittal of the application for review. At a minimum, you must
include an 8.5" by 11" copy of the portion of a 7.5-minute USGS Topographic Map that shows the surface waters
immediately downslope of the project. You must identify the location of the project and the closest downslope
surface waters (waters for which you are requesting the classification) on the submitted map copy. If the facility is
located in the Neuse River Basin, also include a copy of the soil survey map for the project location. The
corresponding non -discharge application may not be submitted until this form is completed by the appropriate
regional office and included with the submittal.
1. Applicant's name (name of the municipality, corporation, individual, etc.): Town of Boardman
2. Name and complete address of applicant: Post Office Box 87
City: Evergreen State: NC Zip: 28438
Telephone number: [phone] Facsimile number: (9101 608-0335
3. Project name (name of the subdivision, facility or establishment, etc.): Town of Boardman
Sanitary Sewer Improvements
4. County where project is located: Columbus County
5. Name(s) of closest surface waters: Unnamed tributary to the Lumber River
6. River basin(s) in which the project is located: Lumber River Basin
7. Topographic map name and date:
USGS — Evergreen, North Carolina — 1988
8. North Carolina Professional Engineer's seal, signature, and date:
TO: REGIONAL OFFICE WATER QUALITY SUPERVISOR
Please provide me with the classification(s) of the surface waters, wat
these activities will occur, as identified on the attached map segment:
Name(s) of surface waters and river basin(s): G.i%
Classification(s) (as established by the EMC): 5
izlq 1;003
app its t r i e basin(s) where
Proposed classification(s), if applicable:
River basin buffer rules, if applicable:
Signature of regional office personnel:
L- /L.4: dh Date: l fti 1Q3
FORM: WSCA 10/99 Page 1 of 2

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"Vh
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Copyright (C) 1997, Maptech, Inc.

DIVISION OF WATER QUALITY REGIONAL OFFICES
Asheville Regional Office
WQ Supervisor
59 Woodfin Place
Asheville, NC 28801
Phone: [phone]
Fax: [phone]
Avery
Buncombe
Burke
Caldwell
Cherokee
Clay
Graham
Haywood
Henderson
Jackson
Macon
Madison
McDowell
Mitchell
Polk
Rutherford
Swain
Transylvania
Yancey
Raleigh Regional Office
WQ Supervisor
3800 Barrett Drive, Suite 101
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Chatham
Durham
Edgecombe
Franklin
Granville
Halifax
Johnston
Lee
Nash
Northampton
Orange
Person
Vance
Wake
Warren
Wilson
Winston-Salem Regional Office
WQ Supervisor
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax: [phone]
Alamance
Alleghany
Ashe
Caswell
Davidson
Davie
Forsyth
Guilford
Rockingham
Randolph
Stokes
Surry
Watauga
Wilkes
Yadkin
Fayetteville Regional Office
WQ Supervisor
Wachovia Building, Suite 714
Fayetteville, NC 28301
Phone: [phone]
Fax: [phone]
Anson
Bladen
Cumberland
Harnett
Hoke
Montgomery
Moore
Robeson
Richmond
Sampson
Scotland
Washington Regional Office
WQ Supervisor
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Beaufort
Bertie
Camden
Chowan
Craven.
Currituck
Dare
Gates
Greene
Hertford
Hyde
Jones
Lenoir
Martin
Pamlico
Pasquotank
Perquirnans
Pitt
Tyrell
Washington
Wayne
Mooresville Regional Office
WQ Supervisor
919 North Main Street
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Alexander
Cabarrus
Catawba
Cleveland
Gaston
Iredell
Lincoln
Mecklenburg
Rowan
Stanly
Union
Wilmington Regional Office
WQ Supervisor
127 Cardinal Drive Extension
Wilmington, NC 28405-3845
Phone: [phone]
Fax: [phone]
Brunswick
Carteret
Columbus
Duplin
New Hanover
Onslow
Pender
FORM: WSCA 10/99
Page 2 of 2

TopoZone - The Web's Topographic Map
Page 1 of 1
0
1
2
3
4
5 km
0 1 2 3 4 5 mi
Map center is UTM 17 688422E 3812747N (WGS84/NAD83)
Evergreen quadrangle
Projection is UTM Zone 17 NAD83 Datum
M*
M=-7.801
G=1.16
http://www.topozone. com/print. asp?z=17&n=3 812746.97963 685&e=688422.479165689&... 3/12/2004

•
HOBBS, UPCHURCH & ASSOCIATES, P.A.
N.C. DENR
Tran # Invoice
23200 020904
Type Date Reference
Invoice 02/09/04 BD0302
•
13;UPHURCH&'AS,SOCJATE
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Check Number:
Date: 2/10/2004 Check Amt:
Balance Discount
$400.00 $0.00
v03E04 Lo 410 S 3 L011211:186 /000 LE,Lo'
. 38741
38741
$400.00
Pay Amount
$400.00
SECURITY FEATURES: MICRO PRINT TOP & sorrom SORDEFIS COLORED PATTERN - ARTIFICIAL WATERMARK ON REVERSE SIDE - MISSING FEATURE INDICATES A COPY