WQ0042850_Application (FTSE)_20210909

}IC Dept ofEnvironmental Quality
DocuSign Envelope ID: OEC304A3-4E24-4180- A85-B4 941576EC
DWR
Division of Water Resources
SEP 0 5 71171
State of North Carolina
Department of Environmental Quality
Division of Water Resources
1141eigh Regi.. } IFAS1 *ACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: WO OO4 (T SV (to be completed by DWR'
All items must be completed or the application will be returned
i. APPLICANT INFORMATION:
1. Applicant's name: Town of Holly Springs (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: Kendra D. Parrish, P.E. per 15A NCAC 02T .0I06(b)
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.Darrish@hollysprin&snc.us
11. PROJECT INFORMATION:
1. Project name: Woods Creek Road Elementary School Sewage Pump Station
2. Application/Project status: ® Proposed (New Permit)
❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Wake
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.6810 Longitude: -78.8861
5. Parcel ID (if applicable): 0629617801 (or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer: David A. McClure, P.E.
Firm: WithersRavenel
Mailing address: 115 MacKenan Drive
City: State: NC
Zip: 27511-
License Number: NC 030282
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Utley Creek Wastewater Treatment Plan Permit Number: NC0063096
Owner Name: Town of Holly Springs
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
I. Permit Number(s): WQ0042364
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity : Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00I92
Owner Name(s): Town of Holly Springs
FORM: FTA 06-21
Pats 1 of 5

DocuSign Envelope ID OEC304A3-4E24-4180-8A85-B42F941576EC NC Dept of Environmental Quality
VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity b attached?
❑ Yes ❑ No El NIA Raleigh ltegi011 ()Mee
2. If the Applicant is a Developer of lots to be sold, has a psvgl 's O jon 1 Agreement (FORM; D : V 1 been attached?
❑ Yes ❑ No ® NIA
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: l IOA) and
supplementary documentation as required by I5A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned)
❑ Residential (Leased)
® School / preschool 1 day care
® Food and drink facilities
® Businesses ! offices / factories
® Retail (stores, centers, malls)
® Retail with food preparation/service
D Medical ? dental / veterinary facilities
❑ Church
O Nursing Home
SEP 09 2021
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool?Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : 42 % Domestic 58 % Commercial % Industrial (' )
If Industrial, is there a Pretreatment Program in effect? 0 Yesp No
6. Has a flow reduction been approved under l 5A 'AC 021 .011.4(n? ® Yes 0 No
➢ If yes, provide a cony of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(l))
Daily Design Flow j°
No. of Units
Flow
gall
GPD
gal?
GPD
gal?
GPD
gall
GPD
gal?
GPD
gal!
GP D
Total
GPD
a See La ELICNT ,0114(111.. ld), {e)(I ) and {cl(2i 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 S. 42A-4).
b Per I5A NCAC 02T .01 I4(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01 14] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC (12T .0114)
)3- Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
® Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number:... Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21
Page 2 of 5

DocuSign Envelope ID: 0EC304A3-4E24-413D-9A85-B42F941576EC
of
�ny�,o4.e4
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Se ers}: S�Cp Q taJPit4/4
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
20
PVC
8
145
DIP
12
269
DIP
10/
'Rh ji.egig°
fee
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section 111 contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VI1I. PUMP STATION DESIGN CRITERIA (If Applicable) —02T .0305 & MDC (Pump Stations/Force Mains2:
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Woods Creek Road Elementary School Sewage Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.6810 Longitude: -78.8861
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.6192 millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 430 gallons per minute (GPM) at 86 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
8
3,424
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .Q 05(hW I1:
® Standby power source or ❑ Standby pump
➢ Must have 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 and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(I)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

DocuSign Envelope ID OEC304A3-4E24-4180-8A85-B42F941576EC
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
I . Does the project comply with all separations/alternatives found in t A NCAC OZT .0305M &()? ® Yes ❑ No
15A NCAC 02T.0305(f} contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
zWater mains (vertical - water over sewer preferred, including in benched trenches)
I8 inches
2Water 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 1 or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with U21.0301(f) r (xi, see Section X.I of this application
* 155A NCAC: 021-.0305[El contains alternatives where separations in 2T_0305(F) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webme
2. Does this project comply with the minimum separation requirements for water mains? ® Yes 0 No ❑ MA
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No 0 NSA
➢ Please provide supplementary information identifying the areas ofnon-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: Cape Fear
If yes, does the project comply with setbacks found in the river basin rules per 15A N['A[' 02B .1)=007
➢ This includes Trout Buffered Streams per I SA NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is req
® No
❑ Yes ❑ No
® Yes 0 No
uired.
6. Does project comply with 1.5A NC.. C:02 ] .0105(e)() (additional permitslcertifications)? ® Yes 0 No
Per 15A NCAC 02T.9105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stonnwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC: 021.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
❑Yes ®No
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

SEp 49 Qualfj7
DocuSign Envelope ID 0EC304A3-4E24-4180-8A85-B42F941576EC 104
Raleigh
X. CERTIFICATIONS: Regional
I. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Scii 1CD
and F y aj ()Blest+'et'sion . and the comity Scwgr Minimum PojgfiCniteriapatest vo-5.ioW as applicable?
®Yes El No
If no, for projects requiring a single variance, complete and submit the Variance/Altemative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subiect to longer
review times. For projects reuuirine two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, David A. McClure, P.E., attest that this application for Woods Creek Road Elementary School Sewage Pump Station
(Professional Engineer s name from Application Item 111 1) Project Name from Application item 1! I)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criter'.a for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
❑ f Pump •rations and Force Mains (laws( 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. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
\\\\"�p411t1lllll rry!llgl,,��
,��{ CARp�
1DOcUSlgfl*d by: _ �pE S'SS lO,r,{c:, -
f `r SEAL `t'
--
C71 030282 i 5
7 L F 1 Cu
� C...
/11111111111110
31)0771B82C9A400...
8/2/2021
3. Applicant's Certification per 15A NCAC 02T .0106(b):
Kendra Parrish
1, , attest that this application for Woods Creek Road Elementary School Sewage Pump Station
(Signature Authonty Name from Application Item 1 3 ; (Project Name from Application Item 11.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 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. 1 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 143-2.i5,6A 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:
41locuSi4gr by
Date:
9/3/2021
FORM: FTA 06-21 Page 5 of 5

DocuSign Envelope ID: DEC304A3-4E24-4180-8A85-B42F941576EC
Division 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: Woods Creek Road Elem Sch Pump Sta
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: 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 0.644
e. WWTP facility's actual avg. flow 2.426
f. Total flow for this specific request 0
g. Total actual and obligated flows to the facility 3.07
h. Percent of permitted flow used 51%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design
Average Approx. Obligated,
Pump Pump Daily Current Not Yet Total Current
Station Station Firm Flow** Avg. Daily Tributary Flow Plus
(Name or Permit Capacity, * (Firm ! pf), Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
Carolina WQ0042364 1.967 0.787 0 0 0 0.787
c-,wo
* 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:ope ID. OEC304A3-4E24-418Q-8A85-B42F941576EC
- • vrroAle�r$l Quality
SEp 0 9 2021
III. Certification Statement:
Raleigh Regional
wee
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.Daciallgrad by 9/3/2021
m Signing Official Signature-
xua Date
Exec Director of utilities and Infrastructure
Title of Signing Official
Page 2 of 6
FTSE 10-18

DocuSign Envelope ID: 0EC304A3-4E24-4180.8A85-B42F941576EC
WithersRavenel
. Our People. Your Success. . Our People, Your Success.
To:
CC:
From:
Date:
Project:
Subject:
North Carolina Department of Environmental Quality - Division of Water Resources
Raleigh Regional Office
1628 Mail Service Center
Raleigh NC 27699 1628
Phone: [phone]
Attn: Fast Track Sewer Extension Applications Review
Town Holly Springs. NC
David A. McClure, PE
September 1 2021
Town Holly Springs. NC
Woods Creek Road Elementary School Sewage Pump Station
Project Number: WR #02200455.00
Fast Track Sewer Extension Application
To whom it may concern,
Attached is an application for a Fast Track Sewer Extension Permit WithersRavenel is submitting on behalf
of the Town of Holly Springs, NC,
The Woods Creek Road Elementary School Sewage Pump Station project is generally located to the south
of Woods Creek Road between US1 and Woodfield Dead End Road. See the attached maps in the submittal
package for project location.
Theproject includes the construction of a submersible sewage pump station and 8-inch force main along
with some onsite gravity sewer for future connections. The pump station will serve two Wake County
schools in addition to other development consisting of approximately 407 residential units and one million
square feet of commercial space.
The 401 Water Quality Certification and Section 404 verification (USACE Action ID. No SAW-2020-00033)
have been obtained.
A permit is requested for the following:
Gravity Sewer
Pipelines
8-inch
Gravity Sewer 8-inch
Gravity Sewer
Force Main
12-inch
8-inch
Pump Station
Pump Station
Woods Creek Road Elementary
School Sewage Pump Station
Pumping Rate
20 ft PVC
145 ft DIP
269 ft DIP
3,424 ft PVC
Total Dynamic Head
430-gpm 86-feet
115 MacKenan Drive I Cary NC 27511
t: 919 469.3340 I f: 919.467.6008 I www,withersravenel.com I License No. C-0832
Cary I Greensboro I Pittsboro I Raleigh I Wilmington

DocuSign Envelope ID 0EC304A3-4E24-4180-8A85-842F941576EC
■■ WithersRavenel
. Our Peon),!. Your Success.
The permit will be for zero flow as no flow will be coming online at this time. Flow will be permitted 35
development occurs within the basin, The permitting of the upstream sewer flow will begin immediately
with the construction of the Woods Creek Road Elementary School. Additional permitting for the Carolina
Springs Development and others will most likely begin in 2022 and is expected to be built -out in
approximately 20 years.
This Fast Track Application Package includes the following items:
• Fast Track Application (Form FTA 06-21)
• Flow Tracking/Acceptance Form (Form FTSE 10-18)
• Site Maps
Please do not hesitate to contact me at [phone] or [e-mail] should you have
any questions or concerns.
Sincerely,
WithersRavenel
by.
wwww
McClure, David .Dc—w.w .Ol D
0. M. 2021.03 01 16 22 21 O4 I
David A. McClure PE
Project Manager
n
t 5
t. cf) 0
IP 0
CD 1
W• o LP 0
CD
O A
o
Page 2 of 2

DocuSian Envelooe ID: OEC304A3-4E24-4180-13A85-1342F941576EC
Proposed Woods Creek Road
Elementary School Sewage Pump Station
Proposed 8" DR-18 C-900 PVC Force Main
Proposed Discharge to 8" Gravity Sewer
WQ0042364
Woods Creek Road
Elementary School
Sewage Pump Station
Engineers I Planners I Surveyors
115 macKenan Dr I Cary NC. 27511
t: 919.469.1140
license #: C-0832
www.ssiviers4avenei

DocuSign Enveboe ID. OEC304A3-4E24-4180-8A85-B42F941576EC
1 g
124 i.i Proposed Woods Creek Road
1 i' Elementary School Sewage Pump Station
4
Proposed 8" DR-18 C-900 PVC Force Main
4.riN11
,.,posed Discharge to 8" Gravity Sewer
WQ00423h4
Woods Creek Road
Elementary School
Sewage Pump Station
WithersRavenel
Engineers I Planners I Stirveyors
115 MacKenan Dr I Cary 14C, 27511
t; 919.469.3341)
license It: C-0832
www w-ttiersravenel
Emory'B1uffs9
Legend
- Force Main
al

DocuSign Envelope ID: OEC304A3-4E24-4180-8A85-B42F941576EC
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: Woods Creek Road Elementary School Sewage Pump Station
David A. McClure, P.E.
Design Engineer:
Address: 115 MacKenan Drive, Cary, NC 27511
Phone Number: 919. 4 69.3340 Email: [e-mail]
Date Complete Application Package Received by Town:
Date Approved 9/2/2021 (by RI)LL9/3/2021
(by KDP), US (by DJ)
/Z72t12r
As design engineer for this project, I certify the following (please check (x) each applicable box):
I$1 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;
® 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
To be Paid 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 Tracking for 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)
MOO, feud M MOM. Core
McClure, David °"",r, 08 W 08/02/2021
Design Engineer's Signature Date
Please contact Theresa Randall at [phone] or theresa.randall(ghollvspringsnc.gov if you
have any questions.
2003 Sewer Design Application Certification
01 14 21
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

• DocuSign Envelope ID: 0EC304A3-4E24-4180-8A85-B42F941576EC
THE TOWN OF
September 1, 2021
Director, Division of Water Resources
Raleigh Regional Office
Water Quality Operation Section
3800 Barrett Drive
Raleigh, NC 27609
oily & rings
Re: Application for Sewer Extension Permit
Project: Woods Creek Road Elementary School Pump Station
Dear Sir or Madam:
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
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 11-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,
Docusgn.d by
en1ra Parrish, P.E., CFM
Executive Director of Utilities and Infrastructure
KP/tr
cc: Project Consultant Engineer, David McClure, PE
Rachel Ingham, Utility Engineer
Drew Johnson, Development Construction Manager
Theresa Randall, Utility Permitting Specialist
Project file/Correspondence #41913
3002
04 17.2018
{ os
9/2/2021
Rac▪ hel Ingham
Utility Engineer
830301not ag tI8t2xj
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.us
A
14
(1) 0
rn
-0 crs
o �.
co 0
0
4