WQ0035740_Regional Office Historical File Pre 2018

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, PE
Governor Di rector
January 27, 2012
Mr. Bill Schoettelkotte, Director of Construction
Liberty Healthcare Properties of North Caroliina, LLC
2234 South 41st Street
Wilmington, NC 28403
Subject
Dear Mr, Schoettelko te:
Dee Freeman
Secretary
Permit No, WQ0035740
Royal Park Rehabilitation and Nursing
Center
Wastewater Collection System Extension
Mecklenburg County, North Carolina
In accordance with your complete application received on January 23, 2012, we are forwarding
herewith Permit No. WQ0035740, dated January 27, 2012, to Liberty Healthcare Properties of North
Caroliina, LLC for the construction and operation of the subject wastewater collection system extension.
This permit shall be effective from the date of issuance until rescinded, and shall be subject to the
conditions and limitations as specified therein. This cover letter shall be considered a part of this permit
and is therefore incorporated therein by reference,
Please pay particular attention to Permit Condition 3, which requires that the wastewater
collection facilities be properly operated and maintained in accordance with 15A NCAC 2T .0403 or any
individual system -wide collection system permit issued to the Permittee.
Permitting of this project does not constitute an acceptance of any part of the project that does
not meet 1) 15A NCAC 2T; 2) the Division of Water Quality's (Division) Gravity Sewer Minimum Design
Criteria adopted February 12, 1996, as applicable; 3) and the Division's Minimum Design Criteria for
the Fast -Track Permitting of Pump Stations and Force Mains adopted August 1, 2000, as applicable,
unless specifically mentioned herein. Division approval is based on acceptance of the certification
provided by a North Carolina -licensed Professional Engineer in the application. It shall be the
Permittee's responsibility to ensure that the as -constructed project meets the appropriate design criteria
and rules. Failure to comply may result in penalties in accordance with North Carolina General Statute
§143-215.6A through §143-215,6C, construction of additional or replacement wastewater collection
facilities, and/or referral of the North Carolina -licensed Professional Engineer to the licensing board,
1617 Mail Service Center, Raeigh, North Carolina 27699-1617
Location: 512 N, Salisbury St Raleigh, North Carolina 27604
Phone [phone] FAX [phone]
Internet: wncwaterguality,org
One
NorthCarolina
Aaturally
An Equal Opporlunily AffrmaliveAclion Employe

Mir, Bill Schcettelkotte
January 27, 2012
Page Two
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North
Carolina as amended, and other applicable Laws, Rules, and Regulations, permission is hereby
granted for the construction and operation of approximately 3429 linear feet of 8-inch gravity sewer,
and the discharge of 20,470 gallons per day of collected domestic wastewater into the City of Charlotte
existing sewerage system in conformity with 15A NCAC 2T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996, as applicable; the Division's Minimum Design Criteria for
the Fast -Track Permitting of Pump Stations and Force Mains adopted August 1, 2000, as applicable;
and other supporting data subsequently filed and approved by the Department of Environment and
Natural Resources and considered a part of this permit.
The sewage and wastewater collected by this system shall be treated in the McAlpine Creek
WWTP (NPDES No. NC0024970) prior to being discharged into the receiving stream.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have
the right to request an adjudicatory hearing upon written request within 30 days following receipt of this
permit. This request must be in the form of a written petition, conforming to Chapter 150B of North
Carolina General Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service
Center, Raleigh, NC 27699-6714. Unless such demands are made, this permit shall be final and
binding.
If you need additional information concerning this matter, please contact Mr. Michael Parker at
[phone].
Electronic copies: •
Cc:
Sincerely,
for Chuck Wakild, P.E.
Erin Hall, Mecklenburg County Development of Water Quality
Willis Horton, Mecklenburg County
Marcus King, P.E., Site Solutions, PA
Barbara Gross, CMU
Mooresville Regional Office, Collection System Permit File
Surface Water Protection Central Files
PERCS

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
This permit shall be effective from the date of issuance until rescinded and shall be subject to the
following specified conditions and limitations:
This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 2T; the Division of Water Quality's
(Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996, as applicable; the
Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force
Mains adopted August 1, 2000, as applicable; and other supporting materials unless specifically
mentioned herein.
2. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data.
The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for
the operation and maintenance of these facilities as required by 15A NCAC 2T .0403. If an
individual permit is not required, the following performance criteria shall be met as provided in 15A
NCAC 2T .0403:
a. The sewer system shall be effectively maintained and operated at all times to prevent
discharge to land or surface waters, and any contravention of the groundwater standards in
15A NCAC 21- .0200 or the surface water standards in 15A NCAC 2B .0200.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan shall be developed and implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e.
365 days per year). Pump stations that are connected to a telemetry system shall be
inspected at least once per week.
e. High -priority sewer lines shall be inspected at least once per every six-month period of time.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Inspection and maintenance records shall be maintained for a period of at least three years.
h. Overflows and bypasses shall be reported to the appropriate Division regional office in
accordance with 15A NCAC 2B .0506(a), and public notice shall be provided as required by
North Carolina General Statute §143-215.1 C.

4. This permit is not transferable. In the event there is a desire for the wastewater collection
facilities to change ownership, or there is a name change of the Permittee, a formal permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be
considered on its merits and may or may not be approved.
5. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State.
6. Per 15A N.CAC 2T .0116, upon completion of construction and prior to operation of these
permitted facilities, the completed Engineering Certification form attached to this permit shall be
submitted with the required supporting documents to the address provided on the form. A complete
certification is one where the form is fully executed and the supporting documents are provided as
applicable.
7. A copy of the construction drawings shall be maintained on file by the Permittee for the life of the
wastewater collection facilities.
8. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted
August 1, 2000 as applicable; and other supporting materials may subject the Permittee to an
enforcement action by the Division, in accordance with North Carolina General Statutes §143-
215.6A through §143-215.6C.
9. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including
those as may be required by this Division, such as the construction of additional or replacement
facilities.
10. The issuance of this permit shall not exempt the Permittee from complying with any and all
statutes, rules, regulations, or ordinances that may be imposed by other government agencies
(local, state and federal) which have jurisdiction, including but not limited to applicable river buffer
rules in 15A NCAC 2B .0200, erosion and sedimentation control requirements in 15A NCAC Ch. 4
and under the Division's General Permit NCG010000, and any requirements pertaining to wetlands
under 15A NCAC 2B .0200 and 15A NCAC 2H .0500.
11. Noncompliance Notification:
The Permittee shall verbally report to a Division of Water Quality employee at the Mooresville
Regional Office, telephone number [phone], as soon as possible, but in no case more than
24 hours or on the next working day, following the occurrence or first knowledge of the occurrence
of either of the following:
a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line
blockage or breakage, etc.; or
2

b, Any failure of a pumping station or sewer line resulting in a by-pass directly to receiving waters
without treatment of all or any portion of the influent to such station or facility.
Voice mail messages or faxed information is permissible, but shall not be considered as the
initial verbal report, Overflows and spills occurring outside normal business hours may also be
reported to the Division of Emergency Management at telephone number [phone] or
[phone], Persons reporting any of the above occurrences shalt file a spill report by
completing Part I of Form CS-SSO (or the most current Division approved form), within five days
following first knowledge of the occurrence, This report shall outline the actions taken or
proposed to ensure that the problem does not recur. Part II of Form CS-SSO (or the most
current Division approved form) can also be completed to show that the SSO was beyond
control,
Permit issued this the 27th day of January, 2012,
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Chuck Wakild, P,E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0035740

Permit No. WQ0035740
January 27, 2012
Owner!WQCS
Bill Schoettelkotte
Liberty Healthcare Properties of North Caroliina, LLC
2234 South 41 s1 Street
Wilmington, NC 28403
PE
Marcus King, P.E.
Site Solutions, PA
2320 West Morehead Street
Charlotte, NC 28208
Complete and submit this form to the permit issuing regional office with the following:
• One copy of the project record drawings (plan & profile views of sewer lines) of the wastewater collection
system extension
• Supporting design calculations (selected pumps, system curve, operating point, available storage if
portable generator(s) or storage greater than longest past three year outage reliability option selected)
for any pump stations permitted as part of this project
• Changes to the project should be clearly identified on the record drawings or in written summary form.
Permit modifications are required for any changes resulting in non-compliance with this permit,
regulations or minimum design criteria.
This project shall not be considered complete nor allowed to operate until this Engineer's Certification and all
required supporting documentation have been received by the Division. Therefore, it is highly
recommended that this certification be sent in a manner that provides proof of receipt by the
Division.
ENGINEER'S CERTIFICATION
❑ Partial ❑ Final
I, , as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observe (❑ periodically, ❑ weekly, ❑ full time) the construction of Royal Park
Rehabilitation and Nursing Center, a Mecklenburg County project for the Permittee, hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance of this permit; 15A NCAC 2T; the Division
of Water Quality's (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable;
the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
adopted November 1, 2000 as applicable; and other supporting materials.
North Carolina Professional Engineer's seal, signature, and date:
SEND THIS FORM & SUPPORTING DOCUMENTATION
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS
MOORESVILLE REGIONAL OFFICE
SURFACE WATER PROTECTION
610 EAST CENTER AVENUE, SUITE 301
MOORESVILLE NC 28115
The Permittee is responsible for tracking all partial certifications up until a final certification is received. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion of this
Engineer's Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions.
4

0
z
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
neriPermittee:
rty Healthcare Properties of+!t4etthessdi7?s+c
Full Legal Nance (company, municipality, HOA, utility, etc.)
Ib, PI11 Schoettelkotte - Director of Construction
ning Official Name and Tide (Please review 15A NCAC 2T .0105 (b) for authorized signing officials!)
lc, The legal entity who will own this system is:
Municipality ❑ State/County 0 Private Partnership Corpora
1 d.
individual © Federal
2234 South 41 '4 Street
Mailing Address
North Carolina
State
1 h, 910-815-3122
Telephone
Wilmington
City
1g. 28403
Zip Code
i, bschoettelkottenlip, tyt
Facsimile E-mail
2, Project (Facility) Information:
2a. Royal Park Rehabilitation and Nursing Canter 2b, Meck
Brief Project Name (permit will' refer to this name)
Contact Person;
a. Marcus King - Site Solutions
Name and Affiliation o
3b. 704-943-3172
Phone Number
Project is
nburg
Where Project is
Who Can Answer i uestions About this Application
3c. making@sitesolutionspa,corn
odiftcation iof an existing
2. Owner is ❑ Public (skip to Item 8(3))
2a, If private, applicant will be:
Retaining Ownership (i.e_ store„ church, single once, etc
❑ Leasing units (lots, townhomes, etc.. - skip to item 8(3))
Q Selling units (lots, townhomes, etc. go to Item 8(2b))
Email
ad* f on. Permit No,:
Private (go to Item 2(a))
Charlotte Mecklenburg Utilities
0
2b. If sold, faciIitles owned by a (must ch
0 Public Utility (instruction C)
❑ Homeowner Assoc./Developer (instruction D)
Owner of Wastewater Treatment Fadlity (WWTF) Treating Wastewater From This Project
McAlpine Creek Wastewater Treatment Plant
4b. NC0024970
Name of WWTF WWTF Permit No.
Charlotte Mecklenburg Utilities5b,
Owner of Downstream Sewer Receiving Sewer Siz
The origin of this wastewater is (check all that apply):
❑ Residential Subdivision
Apartments/Condominiums
© Mobile Home Park
❑ School
0 Restaurant
Office
Permit # of Downstream
Retail (Stores, shopping centers)
Institution
❑ Hospital
❑ Church
Nursing Home
❑ Other (specify):
7. Volume of wastewater to be allocated or permitter) for this particular project
"Do not include future flows or previously permitted allocations
If the permitted flow Is zero, indicate why:
Ej Pump Station, Dutfall or Interceptor Line where flow will be permitted in 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 (see 15A NCAC 02T ,0303 to determine if a
permit is required)
nstructton E)
omestic/Comr
% Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
Other (specify):
0,470 gallons per day
FT'A 12/07

. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
• the value in Item B(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item B(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
169 bed skilled nursing facility X 120 gpd/bed plus 1 single-family lot X 190 gpd/lot
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches)
Length (feet)
New Gravity or Additional
Force Main
8
3429
Gravity
ji 1. Summary of Pump Stations w! associated Force Mains to be Permitted (attach additional sheets as necessary)
W
M
Pump Station Location ID (self chosen - as shown on plans/map for reference)
Z
Design Flow
(MGD)
Operational Point
GPM ©TDH
Power Reliability Option
t - permanent generator w!ATS;
. 2 - portable generator wlMTS
Force Main Size
Force Main Length
Z :1
E
Pump Station Location ID
(self chosen -
as shown on plans/map
for reference)
411.
M
re
O ,
Design Flow
(MGD)
Power Reliability Option
Operational Point; 1 - permanent generator w/ATS;
GPM �TDH 2 - portable generator wiNITS
Force Main Size
Force Main Length
F-
M
re
Pump Station Location ID (self chosen - as shown on planslmap for reference)
W
O.
.
I
I Design Flow
(MGD)
1
Power Reliability Option
Operational Point; 1 - permanent generator %WATS;
GPM @TDH 2 - portable generator wIMTS
Force Main Size
Force Main Length
112. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
0 Yes 0 No If Yes, permit number of 2nd treatment facility
(RO — if `yes" to B,12 please contact the Central Office PERCS Unit)
13. Does the
Mains (latest
applicable?
® Yes
sewer
■
system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T as
..
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
FTAI2/07

1 t. Have the following permits/certifications been submitted or approval for the system or project to be served?
Wetland/Stream Crossings - General Permit or 401Certificatton? © Yes 0 No N/A
Sedimentation and Erosion Control Plan? © Yes © No N/A
Stormwater? El Yes a No El NIA
15, des this project include any high priority lines, {see 15A NCAC 02T .0402 (2)) involve aerial lines, siphons, or in rferen
manholes)? These lines will be considered high priority and must be checked once every six months
Check If Yes: 0 and provide details
Owner/Perrmittee's Certification: (Signature of Signing Official and Project Name)
i, 8111 Schoettelkotte attest that this application for Royal Park Rehabilitation and Nu r inq Center 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. 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 p ie up to $25,000 per violation.
Signing Ofhcl gnature
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITYI
(I) TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
Z
0
2, Professional Engineer's Certifivatlon: (Signature of Design Engineer and Project Name)
Marcus King, PE , attest that this application for Royal Park Rehabilitation and Nursing Center 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, 1 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 other professionals may have developed certain portions of this submittal package, inclusion of these materials
under my signature and seal signifies that I have reviewed this material and have judged it to be consistent with the
proposed design. Note: 1'n accordance with NC General Statutes 143-215,6A and 143-215,68, any person who knowin
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, Marcus King
Professional Engineer Name
2b, Site Solutions, PA
Engineering Firm
2c, 2320 West Morehead Street
Mailing Address
2d, Charlotte
City
2g. 704-521-9880 2h. 70-52
Telephone
Facsimile
2e. NC 2f, 28208
State Zip
2i. mkingc sitesolutionspa.com
E-mail
NC PE Seal, Signature
FTA1','07

CHARd.O'I"I'E.
CHARLOTTE-MECKLENBURG
UTILITIES
January 31, 2011
Mr_ Phillip Hobbs
Site Solutions
2320 West Morehead Street
Charlotte, NC 2B208
SUBJECT: WATER AND SEWER FLOW ACCEPTANCE
ROYAL PARK REHABILITATION & NURSING CENTER
TAX PARCEL# 215-102-06, -14
C-MU TRACKING# 600-11-502
A flow acceptance study of the subject site has been completed and the following has been determined:
Charlotte -Mecklenburg Utilities agrees to 'accept the gravity sewage flow of 20,470 gallons per day (169
bed skilled nursing facilityx 120 gpd/bed; 1 single-family lot x 190 gpd/lot) from this protect for
transmission to the McAlpine Creek Wastewater Treatment Plant; NPDES permit number NC0024970, for
treatment. This acceptance of flow is based on the existing capacity of the designated publicly owned
treatments works. Please see attached NCDENR Flow Tracking form. •
Charlotte -Mecklenburg Utilities agrees to furnish water to the subject project. The water quality to the
subject project Is regulated by the State Drinking Water Act Amendments of 1986, and The Water Supply
Management Plan, dated October 2005, (WSMP # 05-01702 & PWS ID # 0160010), on file with the
Public Water Supply Section of NCDENR. However, Charlotte -Mecklenburg Utilities cannot guarantee a
constant pressure or quality of flow.
Due to the involvement of other agencies and continuing growth of the water and sewer system, the
ability to provide service for future projects cannot be guaranteed nor reserved. Connection to the
Charlotte -Mecklenburg Utilities —system is accepted -on a first -come, first served basis.
The applicant should understand that this letter is not authorization to construct private water or sewer
systems, as the appropriate local or State permits are required prior to construction. lfthe appropriate
authorization to construct permits are not obtained and construction has not started within one (1) veer of
issuance of this flow acceptance letter, and payment for service connection(s) has not been received
within (1) year of the issuance of this flow acceptance letter, this flow acceptance approval shall be
rescinded and a new flow acceptance study must be made. If you have any questions, you may contact
me at [phone].
Sincerely,
Barbara Gross
Engineering Assistant
New Services Section
CHARLOTTE-MECKLENBURG UTILITIES
Customer Service Division • New Services Section
www.cmutilities.com
5100 Brookshire Boulevard
Charlotte, NC 28216
'" ' "'" " -Ph: 704/399-2221- --'—
Fax: [phone]

NVA1 , State of North Carolina
9 Department of Environment and Natural Resources
r Division of Water Quality
Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FI SE —10/07)
Project Applicant Name: Site Solutions
Project Name for which flow is being requested:
Royal Park Rehabilitation & Nursing Center, Phase t
More than one FTSE-10/07 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 wastewaterflow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: McAlpine Creek, Irwin Creek, Sugar Creek WWTP
b. WWTP Facility Permit #: NC0024970, NC0024945, NC002' 937
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
99.0
8.652
66.0
0.020
76.208
77.0
II. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
List pump stations located between the project connection point and the WWTP
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Firm/Design) Daily Flow, MGD
Heathers 0.671 0_103
11I. Certification Statement:
I, la, cry S k ea fin , certify that, to the best of my knowledge, 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 tllis.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. 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 for which I am the responsible party. Signature of this form indicates
acceptance of is wastewater flow.
1/2 7/II
Signing 0 cial Signature Date

.r I: SCAE
ARt ITE. TORE
C Vil . r r I I l.lttri.
SITE PLANNING
2320 W, Morehead St.
Charlotte, NC 28208
Phane:104.521,9880
Fax: 704,521.8955
sitle s [t trt�f5pa.cosn
January 20, 2012
Ms. Dee Browder
NCOENR
Mooresville Regional. Office
610 E. Center Avenue
Mooresville, NC 28115
RE: Royal Park Rehabilitation and Nursing Center
Fast Track Application
Dear Ms. Browder:
Attached please find our Fast Track Application, application fee, downstream sewer
WTTF capacity and flow tracking/acceptance form and color map. In addition to
the above listed items we offer the following narrative generally describing the
project.
Narrative
The purpose of this project is to serve the new Royal Park Rehabilitation and
Nursing Center in Matthews, North Carolina.
As part of this project, a new "Skilled Nursing Facility" (SNF) is proposed along with
relocation of an existing historic farmhouse that is required to be preserved as part
of the rezoning agreement.
There is an existing 8" sanitary sewer located at the rear of this property that this
project will tie into. Our onsite sewer will be 8" PVC and connect to the Sr* and
historic farmhouse and transport all onsite wastewater to the McAlpline Creek
Wastewater Treatment Plant owned by Charlotte Mecklenburg Utilities.
Please accept and process this application at your earliest possible convenience. If
you have any questions or if we can assist you further, please feet free to call.
Sincerely,
SITE SOLUTIONS
Marcus J. King, PE, MBA

North Carolina Secretary of State
Page 1 of 1
���,_ °e,�. North Carolina
)} �DEPARTMENT OF THE
F' y Elaine F. Marshall
1 '; SecretarySECRETARY ©� STATE
::
PO Box 29022 Raleigh, NC 27626-0622 [phone]
Date: 1/24/2012
Click here to:
View Document Filings i Sign Up for E-Notifications i
�J Pre -populated Annual Report Fillable PDF Form i File an Annual Report
Corporation Names
Name
NC LIBERTY HEALTHCARE
PROPERTIES OF NORTH
CAROLINA, LLC
Limited Liability Company Information
Name Type
LEGAL
SOSID: 0643724
Status: Current -Active
Effective Date: 8/28/2002
Dissolution Date:
Annual Report Due Date:
Citizenship: DOMESTIC
State of Inc.: NC
Duration: PERPETUAL
Annual Report Status: CURRENT
Registered Agent
Agent Name:
Office Address:
BALTER, YOEL
2334 S. 41ST ST.
WILMINGTON NC 28403
Mailing Address: 2334 S. 41ST ST.
WILMINGTON NC 28403
Principal Office
Office Address: 2334 S. 41ST ST.
WILMINGTON NC 28403
Mailing Address: 2334 S. 41ST ST.
WILMINGTON NC 28403
Officers
Title: MANAGER
Name: LIBERTY REAL PROPERTIES, LLC
Business Address: 2334 S. 41ST ST.
WILMINGTON NC 28403
This website is provided to the public as a part of the Secretary of State Knowledge Base (SOSKB) system. Version:
1995
http://www.secretary.state.nc.us/corporations/Corp. aspx?PitemId=5 517251 1/24/2012

Permit Number WQ0035740
Central Files: APS SWP
01/27/12
Permit Tracking Slip
Program Category Status Project Type
Non -discharge Active New Project
Permit Type Fast Track Version Permit Classification
Gravity Sewer Extension, Pump Stations, & Pressure Sewer 1.00 Individual
Extensions
Primary Reviewer Permit Contact Affiliation
michael.parker
Coastal SW Rule
Permitted Flow
20470
Facility
Facility Name
Royal Park Rehabilitation and Nursing Center
Location Address
Owner
Major/Minor Region
Minor Mooresville
County
Mecklenburg
Facility Contact Affiliation
Owner Name Owner Type
Liberty Healthcare Properties of North Carolina LLC Non -Government
Dates/Events
Owner Affiliation
Bill Schoettelkotte
Construction Director of
2234 S 41 st St
Wilmington NC 28403
Orig Issue App Received Draft Initiated
01/27/12 01/23/12
Scheduled
Issuance
Public Notice Issue Effective
01/27/12 01/27/12
Regulated Activities Requested/Received Events
institution, other
Nursing Home
Wastewater collection
Outfall NULL
Additional information received
Additional information requested
Expiration
Waterbody Name Stream Index Number Current Class Subbasin

Permit No. WQ0035740
January 27, 2012
OwnerIWQCS
Bill Schoettelkotte
Liberty Healthcare Properties of North Carolina, LLC
2234 South 41st Street
Wilmington, NC 28403
PE
Marcus King, P.E.
Site Solutions, PA
2320 West Morehead Street
Charlotte, NC 28208
Complete and submit this form to the permit issuing regional office with the following:
• One copy of the project record drawings (plan & profile views of sewer lines) of the wastewater collection
system extension
Supporting design calculations (selected pumps, system curve, operating point, available storage if
portable generator(s) or storage greater than longest past three year outage reliability option selected)
for any pump stations permitted as part of this project
• Changes to the project should be clearly identified on the record drawings or in written summary form.
Permit, modifications are required for any changes resulting in non-compliance with this permit,
regulations or minimum design criteria.
This project shall not be considered complete nor allowed to operate until this Engineer's Certification and all
required supporting documentation have been received by the Division. Therefore, it is highly
recommended that this certification be sent in a manner that provides proof of receipt by the
Division.
ENGINEER'S CERTIFICATION
0 Partial td Final
I, MARk AAWALrexi as a duly registered Professional Engineer jn the State of North Carolina, having
been authorized to observe ('i' periodically, © weekly, ❑ full time) the construction of Royal Park
Rehabilitation and Nursing Center, a Mecklenburg County project for the Permittee, hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance of this permit; 15A NCAC 2T; the Division
of Water Quality's (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable;
the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
adopted November 1, 2000 as applicable; and other supporting materials.
North Carolina Professional Engineer's seal, signature, and date:
SEND THIS FORM & SUPPORTING DOCUMENTATION
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS
MOORESVILLE REGIONAL OFFICE
SURFACE WATER PROTECTION
610 EAST CENTER AVENUE, SUITE 301
MOORESVILLE NC 28115
The Permittee is responsible for tracking all partial certifications up until a final certification is received. Any
wastewater flow made tributary to the wastewater collection system extension prior to completion of this
Engineer's Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions.
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