WQ0042975_Application_20211112

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I S A A C S 7:1p RECEIVED/KDEQ/DVVR
CIVIL ENGINEERING DESIGN & LAND SURVEYING NOV 1 G 2021
8720 RED OAK BOULEVARD, STE. 420
CHARLOTTE, N.C. 28217
PHONE [phone] FAX [phone] WQROS
MOORESVILLE REGIONAL OFFICE
Date: October 7, 2021
Re: Chestnut Lane Senior Living
Private Sewer System
Indian Trail, Union County, North Carolina
On behalf of Clover Group, we are hereby requesting a sewer permit for a private gravity sanitary sewer system for a
new 122-unit senior living apartment building located along Chestnut Lane in Indian Trail, Union County, North
Carolina. The subject development is located at parcel ID 07132036.
Approximately 412 linear feet of 8-inch PVC/DIP gravity sewer is proposed to be constructed under this permit. The
proposed private sewer system will tie to a proposed public sewer manhole to be owned and maintained by Union
County. The proposed public extension is also being permitted at this time.
All flows associated with the project are included with the permit for the public extension, no flows are permitted for
the private sewer system. This public extension permits 17,965 GPD of flow to the Crooked Creek WWTF
(NC0069841), and zero flow is permitted as part of this private system.
All other plan approvals and construction permits through NCDEQ, NCDOT, Town of Indian Trail, and Union County
have either been submitted for or have already been approved by these jurisdictions.
Please let me know if there are any additional requests in order to process this application.
Thank you,
Alex Quesenberry, P.E.
The Isaacs Group, P.C.
704-527-3440 ext. 121
THE ISAACS GROUP 8720 RED OAK BLVD, STE. 420 CHARLOTTE, NC 28217 PHONE: [phone] FAX: [phone]

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: kit Q0L4(2t 47 (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Clover Communities Indian Trail LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual
❑ Federal
❑ Corporation
❑ State/County
3. Signature authority's name: Michael L,.Joseph___
Title: Authorized Person
❑ General Partnership
❑ Municipal
❑ Privately -Owned Public Utility
® Other
per 5\ NCAC 02T .d+ 'FIECEiVED/NCDEQ/DWR
4. Applicant's mailing address: 348 Harris Hill Road
City: Williamsville State: NY Zip: 14221 -
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Chestnut Lane Senior Living (Private)
2. Application/Project status:
® Proposed (New Permit)
If a modification, provide the existing permit number: WQ00
NOV 12 2021
WQROS
MOORESVIL LE REGIONAL OFFICE
❑ Existing Permit/Project
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: WOO()
3. County where project is located: Union
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.04.25° Longitude: -80.41.00°
5. Parcel ID (if applicable): 07132036 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Christopher Isaacs, PE
Firm: The Isaacs Group, PC
Mailing address: 8720 Red Oak Blvd, Suite 420
City: Charlotte State: NC Zip: 28217
Phone number: 704-527-3440 Email Address: [e-mail]
License Number: 18947
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Crooked Creek Permit Number: NC0069841
Owner Name: Union County Public Works
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ000160
2. Downstream (Receiving) Sewer Information: 8 inch 0 Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Union County Public Works
FORM: FTA 06-21
Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's }nerational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an
supplementary documentation as required by 15A 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 / day care
❑ Food and drink facilities
❑ Businesses / offices / factories
❑ Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
%POA Operational Agreement (FORM: HOA) and
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic 0 % Commercial 0 % Industrial ( ee 15A NC»
If Industrial, is there a Pretreatment Program in effect? ❑ Yes
6. Has a flow reduction been approved under 15A N<' 11? ® Yes ❑ No
)> Ifves,_provide a copy_of_flow reduction approval letter with this application
7. Summarize wastewater generated by project:
❑ No
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
0 GPD
a See 15A NCAC 02T .01 14(b). (d), (e)(1) and (e)(2) 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 ).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table A NCAC 02T.0114] 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 02T .01 14)
> 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): Private sewer system tied to prop. public system in which flows are included and permitted
FORM: FTA 06-21
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC fG ravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
339
PVC
8
73
DIP
Ya 2
➢ Section II & 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 requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — & "b r} F o rcY
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: ° Longitude: - °
3. Total number of pumps at the pump station:
4. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
5. Operational point(s) per pump(s): _ gallons per minute (GPM) at feet total dynamic head (TDH)
6. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
7. Power reliability in accordance with 3. NCAC0 ?T .()305(h) 1 �:
❑ 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
D. 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)(1)(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

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(1)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (g)?
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
®Yes El No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, 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 I 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 02T.03051 T'y or 1 see Section X.1 of this application
*15A NCAC. 02T.0305(.') contains alternatives where separations in 02 f.0305(1) 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 Classifications webpage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
> 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 ❑ N/A
> Please provide supplementary information identifying the areas of non-conformance.
> See the Division's draft separation 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: ® No
If yes, does the project comply with setbacks found in the river basin rules per ti 't ` CAC 02B .0200? ❑ Yes ❑ No
> This includes Trout Buffered Streams per ' S; , NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
> Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with '5A 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per , 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, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per _ , "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).
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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting. of Pump Stations
and the Gravity Sewer Minimum Desitin Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative 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 subject to longer
review times. For projects requiring 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, Christopher Isaacs, P.E. , attest that this application for Chestnut Lane Senior Living
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item II.1)
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 Criteria for Gravity Sewers (latest version), and the ;k Permitting.
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 I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fme 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)
.-• ,9
THE ISAACS
GROUP, P.C.
n ENGINEERING & : 0
%LAND SURVEYING:
NO. C-1089 "
3. Ap 1'cant's Certi cation per A NCAC 02T .010(f%, OFAV
,e,,,`
811/1111111N1
, attest that this application for
North Carolina Professional Engineer's seal, signature, and date:
,,,�11111t//f104
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N-
IGLiose
(Signature Authority Name from Apphcaticji Item I.3.)
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18'47 .:v
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Chestnut ane Senior Living_
(Project Name from Application Item II.1)
attest that this application 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. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6, 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:
Date: 1,0 1JD2-
FORM: FTA 06-21
Page 5 of 5

UNIONCOUNTY
WAT E R
November 4, 2021
Christopher Isaacs, PE
The Isaacs Group
8720 Red Oak Blvd, Ste. 420
Charlotte, NC 28217
Re: Sewer Treatment Capacity
Chestnut Lane Senior Living (Private)
Dear Mr. Isaacs:
Union County Water can accept the additional discharge of 0 gallons per day of domestic
wastewater from this project for transmission to the Crooked Creek Wastewater Treatment Plant
(NPDES permit number NC0069841) for treatment. The flows attributed to the above mentioned
project are being accounted for in the separately permitted public portion of the project.
If you have any questions please don't hesitate to call.
Sincerely:
���-1 G
i
ry al O. Panico, P.E.
New Development Program Manager
COP/br
Union County Water
500 N. Main Street
Monroe, NC 28112
T 704.296.4210
unioncountync.gov/water

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: Union County
Project Name for which flow is being requested: Chestnut Lane Senior Living (Private)
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: Crooked Creek WWTP
b. WWTP Facility Permit #: NC0069841
All flows are in MGD
c. WWTP facility's permitted flow 1.9
d. Estimated obligated flow not yet tributary to the WWTP 0.5306
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
0.951
0.000
1.4816
77.98
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 Obligated,
Pump Pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
N/A
* 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 < O.
Downstream Facility Name (Sewer): Crooked Creek WWTP
Downstream Permit Number: WQ0001158
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Crystal O. Panico, PE 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 capacit i transport and treat the proposed new wastewater.
li 2
Signing Offici. Signature/ — Date
New Development Program Manager
Title of Signing Official
Page 2 of 6
FTSE 10-18

CSC
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v
NORTH CAROLINA
Department of the Secretary of State
CERTIFICATE OF AUTHORITY
I, ELAINE F. MARSHALL, Secretary of State of the State of North Carolina, do hereby
certify that
CLOVER COMMUNITIES INDIAN TRAIL LLC
having filed on this date an application conforming to the requirements of the General
Statutes of North Carolina, a copy of which is hereto attached, is hereby granted
authority to transact business in the State ofNorth Carolina.
Scan to verify online.
Document Id: C202118201310
Verify this certificate online at https://www.sosnc.gov/verification
IN WITNESS WHEREOF, I have hereunto set
my hand and affixed my official seal at the City
of Raleigh, this 2nd day of July, 2021.
Xiao,t, J ra.,,,,fiaie
Secretary of State

State of Delaware
Secretary of State
Division of Corporations
Delivered 03:44 PM 05/13/2021
FILED 03:44 PM 05/13/2021
SR 20211769923 - File Number 6036966
STATE OF DELAWARE
CERTIFICATE OF FORMATION
OF LIMITED LIABILITY COMPANY
The undersigned authorized person, desiring to form a limited liability company pursuant
to the Limited Liability Company Act of the State of Delaware, hereby certifies as
follows:
1. The name of the limited liability company is
Clover Communities Indian Trail LW
2. The Registered Office of the limited liability company in the State of Delaware is
located at 1209 Orange Street (street),
in the City of Wilmington , Zip Code 19801 . The
name of the Registered Agent at such address upon whom process against this limited
liability company may be served isThe Corporation Trust Company
By:
Name: Michael L. Joseph
Print or Type

North Carolina Secretary of State Search Results Page 1 of 2
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Add Entity to My Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print
an Amended a Annual Report form
Limited Liability Company
Legal Name
Clover Communities Indian Trail LLC
Information
Sosld: 2226505
Status: Current -Active O
Date Formed: 7/2/2021
Citizenship: Foreign
State of Incorporation: DE
Annual Report Due Date: April 15th
CurrentAnnual Report Status:
Registered Agent: CT Corporation System
Addresses
Reg Office Reg Mailing Mailing
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200 348 Harris Hill Road
Raleigh, NC 27615 Raleigh, NC 27615 Williamsville, NY 14221
Principal Office
348 Harris Hill Road
Williamsville, NY 14221
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Michael L Joseph
348 Harris Hill Road
Williamsville NY 14221
https://www. sosnc. gov/online_services/search/Business_Registration_Results 11 / 15/2021

LOCATION MAP
PROJECT SITE

USGS TOPO MAP
(NOT TO SCALE)
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