WQ0038729_Regional Office Historical File Pre 2018

PAT MCCRORY
D©NACD It.. VAN iER VAARTy:
S. JAY ZIMMERMAN
Water Resources
ENVERQNMENrAL QUALITY
September 19, 2016
Suzanne Pugh, President & CEO
Aldersgate United Methodist Retirerent Community, Inc.
3800 Shamrock Drive
Charlotte, NC 28215
Subject: Permit No. WQ0038729
Aldersgate United Methodist Retirement
Community, Inc.
Commons Building Extension - Aldersgate
United Methodist Retirement Community
Wastewater Collection System Extension Permit
Mecklenburg County
Dear Ms. Pugh:
In accordance with your application received September 12, 2016, we are forwarding herewith Permit No.
WQ0038729 dated September 19, 2016, to Aldersgate United Methodist Retirement. Community, Inc.
(Permittee) for the construction and operation upon certification 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 This permit shall be effective from the date of issuance until rescinded and shall be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 the following conditions contained within this permit:
Condition 11.1: This permit shall not be automatically transferable; a request must be made and
approved
Condition 11.4:
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.
It shall be the responsibility of the Permittee 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.
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 150E 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.
State of North Carolina Environmental Quality Water Resources { Water Quality Regional Operations
Mooresville Regional Office} 610 East Center Averme, Suite 301 I Mooresville, North Carolina 28115
704 663 1699

SUPPLEMENT TO PERMIT COVER SHEET
Aldersgate United Methodist Retirement Community, Inc. is hereby authorized
to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the Charlotte Water Sugar Creek
Wastewater Treatment Plant in accordance with Permit Number NC0024937.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996, as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 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.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
SPECIAL CONDITIONS
1. No flow in excess of the quantity permitted herein, 475 GPD shall be made tributary to the subject
sewer system until an application for permit modification for an increase in flow has been submitted
to and approved by the Division. [15A NCAC 02T.0304(b)]
2. This permit shall become voidable unless the agreement between Aldersgate United Methodist
Retirement Community, Inc. and Charlotte Water for the collection and final treatment of wastewater
is in full force and effect. [15A NCAC 02T.0304(h)]
II. STANDARD CONDITIONS
1. 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. [15A NCAC 02T.0104; G.S 143-215.1(d3)]
2. 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'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 June 1, 2000, as applicable; and
other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110]
This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .0110]
4. 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
Page4of8

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: [15A NCAC 02T .0108(b)):
a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been 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 -months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. 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 §143-215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials -shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
i. Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept forSubparagraphs (a) through (i) of this Rule fora minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources 'staff member at the Mooresville
Regional Office, telephone number [phone], as soon as possible, but in no case more than 24,
following the occurrence or first knowledge of the occurrence of either of the following:
Page 5 of 8

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 nrbreakage, etc.;or
b. Any 9SOand/or spill over 1,0QUgallons; mr
c. Any SSOand/or spill, regardless ofvolume, that reaches surface water
Voice mail messages or faxed 'information is permissible, but this shall not be considered as the initial
verba|naport. Overflows and spills occurring outside normal business hours may also bereported to
the Division of Emergency Management at telephone number(80O) 858-0388 or /919\ 733-3300.
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part | ofForm {S~S5O (or the most current Division approved form) within five days following first
knowledge nfthe occurrence. This report must outline the actions taken urproposed tmbetaken 1u
ensure that the problem does not recur. Part ||ofForm [S-SSO(or the most current Division approved
form) can also be completed to show that the 3S{>was beyond control. [G.5. 143-215.1C(aI)]
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
tnthe surface waters nfthe State. [15AN[ACO2T.Q10O/b\]
7. 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 tnthe address provided omthe form. Acomplete certification isone where the form is
fully executed and the supporting documents are provided asapplicable. Any wastewater flow made
tributary to the vvaistevvater collection system extension prior to completion of this Engineer's
Certification shall be considered a violation of the permit and shall subject the Permnittee to
appropriate enforcement actions.
if the permit Is issued to private entity with anOperational Agreement, then acopy of the Articles
ofIncorporation, Declarations/Covenants/Restrictions, and Bylaws that have been appropriately
filed with the applicable County's Register of Deeds office shall be submitted with the certification.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable, Supporting documentation shall include the following�
a. One copy ofthe project constTuctinnrecnrddravvngs(p\an& profile views ofsewer lines @force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media (CD orDVD disk) and are defined as the design drawings that are
marked up or annotated with after construction information and show required buffers,
separation distances, material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing,
velocity, pump cycle times, and level control settings, pump station buoyancy, wet well storage,
surge protection, detention time in the wet well, and force main, ability to flush low points in
force mains with a pump cycle, and downstream sewer capacity analysis. If portable power
source or pump is dedicated to multiple stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, include travel
tinnafranmes,shall beprovided.
Page 6 of 8

I
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting in
non-compliance with this permit (including pipe length increases of 10% or greater, increased flow,
pump station design capacity design increases of 5% or greater, and increases in the number/type of
connections), regulations, or the Minimum Design Criteria. Requested modifications or variances to
the Minimum Design Criteria will be reviewed on a case -by -case basis and each on its own merit.
Please note that variances to the Minimum. Design Criteria should be requested and approved during
the permitting process prior to construction. After -construction requests are discouraged by the
Division and may not be- approved, thus requiring replacement or repair prior to certification &
activation. [15A NCAC 02T :0116]
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident prior to completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy of the construction record drawings shall be maintained on file by the Permittee for the life of
the wastewater collection facilities. [15A NCAC 02T .0116]
10. 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 June 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,
construction of additional or replacement wastewater collection facilities, and/or referral of the North
Carolina -licensed Professional Engineer to the licensing board. [15A NCAC 02T .0104; 15A NCAC 02T
.0108(b-c)]
11. 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.
[15A NCAC 02T .0110; 15A NCAC 02T .0108(b)]
12. 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 the Division any other Federal, State, or
Local government agencies which have jurisdiction or obtaining other permits which may be
required by the Division or any other Federal, State, of Local government agencies. [G.S. 143-
215.1(b)]
Page 7 of 8

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE:
PERMIT #:
PROJECT:
ISSUE DATE:
Aldersgate United Methodist Retirement Community, Inc.
WQ0038729
Commons Building Extension a Aldersgate United Methodist Retirement Community
September 19, 2016
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMiTTEE'S>CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name, Title
Signature Date
ENGINEERS CERTIFICATION
I, , as a dul registered Professional En ineer in the State of North Carolina,
having been authorized to observe ([periodically, El weekly, full time) the construction of the
project name and location as referenced above for the above 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; 1SA NCAC 02T; the
Division of Water Resources' (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 June 1, 2000, as applicable; and other supporting materials.
North Carolina Professional Engineer's Seal w/signature & date:
L Final Q Partial (include description)
Certification Comments "Qualifiers (attach if necessary) :
State of North Carolina I Enrarontnental i aua1itY i ter 1
MottrrsvIle Regional Officcl 610
R,
rations
Avenue, Suite 301 I Mooresviliea Nosttr Cato1i 28115

on of Water Resources
State of North Carolina
Department of Environmental Quality
DiViSi011 of Water Resources
15A NC:AC 02T .0300 — FAST 'TRACK SEWER SYSTEM EXTENSION APPLICATION
VIA 04-16 kgz, SUPPORTING DOCIJMENTA,TION
Application Number (...)(3S' '7 3\47 no be completed by DWR)
All items must be completed or the application will be returned
APPLICANT INFORMATION:
1. Applicant's name: Aldersgate United Methodist Retirement Comnumitv, Inc (company, municipality,..110A, utility, etc.)
Applicant type: LJ 1ndivdual
El corporation F.1 General Partnership Privately -Owned Public Utility
El Federal 11 SLate ('ount 111 Municipal i Other
3 Signature .authority's name: Suzanne Pugh per I5A NCAC 02T .0106(h)
Tide: President & CEO
4. Applicant's mailing address: 3800 Shamrock Drive
City: Charlotte State: NC Zip: 28215-
5. Applicant's contact information:
Rhone number: [phone] Email .Address: suzannep(ikildersgatc.tecre.com
IL PROJECT INFORMATION:
1, Project nanve tde g'1707rTruents - A Idersgate United Methodist Retirement CommunityInc
il
2.
Application/Project sta1us Ptoposcd (New Permit) El Existing Permit/Project
RECEIVEDINCIDEVVEYWR
S
tiii0 R. ESV iLLE E N A OFFICE
If a modification, provide the ,existing permit number: and issued date:
If new construction but part of a master plan, provide the existing permit number: 'NVQ00
3. County where project is located: „Mecklenburg
4: Approximate Coordinates (Decimal Degrees): Latitude: 35.2314' Longitude: -80,8963'
5. Parcel ID (if applicable): 10102101
(or Parcel ID to closest downstream sewer)
111. CONSULTANVF INFORMATION:
1. Professional Engineer: Steven S Wilson License Number. .15497
Firm: Landworks Design Group
Mailing address: 7621 Little Avenue
City: Charlotte State: NC Zip: 28226-
Phone number: (704) 8414604 1:1.mail Address: sv. i IsoILjandsVOTkS
IV. "(V ASTEWATER TREATMENT FACitsry (WWTF) INFORMATION:
I, Facility Name: Sugar Creek WWII' Permit Number NC4)(124937
Owner Name: Chat lotte Water
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s ): WQ600-14-542 DO NV ['stream (Receiving) Sewer Size: 10. inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Charlotte Water
FORM:11'A 04-16 Page 1 of

VL GENERAL REQUIREMENTS
If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public '
2. lithe Applicant is a Developer f Iis
E Yes LINo
NIA
.ce and Necessity been attached?
e sold, has a Developer's Operational A.greem , RIM:,DEN) been attached?
LI Ycs ENo MN/A
3; lf the Applicant is a liome/Property Owners Association,has an OpicrationalAgreementIFORM: HOA) been attached?
LI Yes Nr)
4. Origin of wastewater: (check all that apply):
E] Residential Owned
Residential Leased
School / preschool/ day care
El Food and think facilities
Businesses /offices / factories
LJ Retail (stores, centers, malls)
El Retail with food preparation/service
dental veterin.ary facilities
[1 Church
[111 Nursing Horne
5, Nature of wastewater 100 % Domestic/Commercial % Commercial
% Industrial (See I 5A NCAC3(20_1)
Is there a Pretreatment Program in effect?
6, Flas a flos reduction been approved under 15A NCAC 021 .0114(f)? El Yes
If ves, provide a copv of flow reduction approval letter
7, Summarize wastewater generated by project:
_..:stablistunent Type (see 02T.0)14(
Tar Wash
el andlor .Motels
Swimming Pool /Clubhouse
Swimming Poo IfFirter Backwash
Other (Explain in Attachment)
'es No
GPD
GPI)
(iPI)
G PD
7°6iat 475 GPD
a See 15,A NC,A.0 2T 01.14 b and (el(2) for caveats to wastewater design flow rates (i.e.., minimum .flow per
dwelling; proposed unknown nori-residential development uses; public access facilities- located tear high public use areas,
and residential property located south or east or the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4),
b Per 15A NCAC 021' .0114(c), design flow rates for establishments not identified [in table I 5A NCAC 02T.011.41 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 475 GPI) (per I 5A NCA(7_02T .0 4)
Do not include future flows or previously permitted allocations
If permitted flow is zero., indicate why:
LI Pump Station or Gravity Sewer where .fiow N, 611 be permitted in subsequent permits that connect. to this line
Ell Flow has already been allocated in Permit Numbex:,._____.
D Rehabilitation or replacement of existing ses erwith no new flo v expected
[1] Other (Explain): _
FORM: 1-JA 04-16
Page: 2 of 5

VII. GRAVIIN SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC Seers):
Summarize gravity sewer to be permitted;
Size (inches) Length (-feet)
8
>. Section .11, & 11 I 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 requirement is not allowed and a violation of the NI DC
VEIL PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .030.5 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN TIIIS PROJECT
I. Pump station number or name: _
Approximate Coordinates (Decimal Degrees): Latitude: Longitude:
Design flow of the pump station: millions gallons per day (firm capacity)
feet total dynamic head ppm
2.
3,
4, Operational point(s) of the pump(s). gallons per minute at
5. Summarize the force main to be permitted (for this Pump Station).
Size (inches)
6. Power reliability in accordance with I5A NCAC 021 .0305(h)(1),
El Standby power source or pump \vith automatic activation and telemetry - 1.5A NCAC 02T ,0305(h)(1)(B):.
Required for aI1 pump stations with an average daily flow greater than or equal to 1.5,000 gallons per day
Must be permanent to facility
Or lithe .pump station has an average daily flow less than 15,000 gallons per day:
E Portable power source with manual activation, quick -connection receptacle uid telemetry - I SA NCAC 02T
,0305(h)( 1)(C)
Or
El Portable pumping, unit with plugged emergency pump .connection and telemetry - 15A NCAC 021 .0305(b)(IK):
it shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station,
If the portable [tower source, or pump is dedicated to multiple pump stations, an evaluation °fall the pump stationsstorage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage,
FORM: FTA 04-16 Pic :3 of 5

1X. SFIIRACKS & SEPARATIONS — (02B .0200 & 1S CAC 02T .0305(0):
1., Does the project comply with all separations found in I5A NCAC 02T ,0305(J)& t
15.A, 'NCAC 02T.0305(f) contains minimum separations that shall be provided for sec
Setback- Parameter* Separation Required
torm sewers and other utilities not listed below (vertical) 24 inches
Water mains (vertical -water over sewer including in benched .trenches
ains (horizontal)
.eclaimed water lines 'a reclaimed over sewer)
.eclaimed water lines (ho ontal - reclaimed over sewerj
"Any private or public water supply source, including any wells, WS-1 waters of Class" or
Clas_ I. impounded reservoirs used ,asa source of drinking water
**Waters classified WS (except WS-.I or WS-V), B, SA, ORW,11.QW, or SB from normal
high water (or tide elevation) and wetlands (see item IX.2)
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
Yes ,T1 No
Any buildinfoundation
Any basement
Top slope of embankment or cuts of 2 feet
ina ,eastems and interceptor drains
y swimming pools
Final earth grade (vertical)
o \ ertftat height
S
cl
e„.
10 feet
18 inches
2 feet
00 lcet
50 feet
110 feet
S feet
10 feet
5 feet
10 feet.
36 inches
• I5A 'NCAC 02T,03,95(2) contains alternatives where separations in 02T,03054j) cannot he achieved,
• **Stream classifications can he identified using the Division's NC Surface Water CIaiaiss
• 'If noncompliance with. 02171305iflor (2), sce Section X of this application
2. Does the project comply with separation requirements for wetlands? (5.0 feet of separation)
• See thc Division's draft separation requirements for situations where separation cannot he meet
• No variance is required if the alternative design criteria specified is utilized in design and construction
As built documents should reference the location of areas effected
a Te
Yes [.] No
3, Does the project comply with all setbacks found in the river basin rules per I5A NCACO28 0200? Z Yes .
• This would include 'from Buffered Streams per I5A NCAC 2E3.0202
4,„Does the project comply with an .individual 404 Permit or any 401. Certifications? Z Yes [1 No
• ‘Vetland-related permits shall be requested, obtained,. and adhered to for projects that impact setIands or surface waters
• Information can he obtained from the 401 & Buffer Permitting Branch
5, Does project comply with 15A NCAC 023„ o 105,.(cLcir ) (additional permits/certifications)? E Yes LINo
Per 15A NCAC (12T.0 05(0(6p, directlyrelated environmental permits or certification applications are being, prepared, have
been applied for, or have been obtained. Issuance of this permit is ,contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc:).
6. Doesthis 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 sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
11 Yes -No
s If yes, include an attach erit with details for each 1 ic. including type (aerial line., size, material, and location).
High priority lines shalt be inspected by the permittee or its representative at least once every six -months and inspections
documented per ISA NCAC 021 .0403(a)(5) or the perrnitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Pace 4 of 5

X, • CERTIFICATIONS:
I. Does the submitted system comply with 15A NCAC 02T. the Nlinimum Design Criteria for the Permit/int, of Pump Stations
and Force Niains fatest versicqij. and the Gras* Sewer Minimum Design Criteria (latest version) as applicable?
Yes 0 No
lfNo, complete and submit the 'Variance/Altemative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast 'Track Application and supporting documents,.
2, Professional Engineer's Certification:
Steven S Wilson, PE
(Professional Engineer's name from Application item 111.1,)
attest that this application for
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 thebest of my knos1edge 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 (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to he 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 S10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
Applicant's Certification per I5A NCAC 021 .0106(b):
1, Suzanne Pugh, President & CEO
(Signature .Authority's name &. title :from Application Item I..3.)
attest that this application for
has been reviewed by me and is accurate and complete to the hest (Amy knowledge 1 understand that if all required parts of
this application are not completed and that if all required supporting d.ocumentation and attachments are not includ.ed„ this
application package is subject to beingreturned as incomplete. 1 understand that any discharge of wastewater front 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. 1 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 m.e as
incomplete.
NOTE — In accordance With General Statutes 143-215,6A and 143-215.6B, any person Who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed 510,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date:
FORM: FTA 04- 6
page 5 of 5

Aldersgate United Methodist Retirement Community - Commons Building Addition - Area Map
NOTES: Data available from US, Geological Survey, National Geospatiat Program,
Wiat
Open n The Na ton Map Viewer
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Aldersgate United Methodist Retirement Community - Connnons BuiidingAddition - Site Map
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APdersgate United
ethodist Retire
en t Come unity — Street Level

August 9, 2016
Mr. Steve Wilson
Landworks Design Group
7621 Little Av
Suite 111
Charlotte, NC 28226
SUBJECT:
CHARLOTTE
WLTER
WATER AND SANITARY SEWER FLOW ACCEPTANCE
ALDERSGATE RETIREMENT COMMUNITY — COMMONS BUILDING ADDITION
3800 SHAMROCK DRIVE, CHARLOTTE NC
CLTWATER TRACKING# 2016803
cos
A flow acceptance study of the subject site has been completed and the following has been determined:
This review has been set to conditional due to capacity concerns at Permanent Flow Monitoring Sites 24
& 25. These capacity concerns should be addressed with the completion of the Briar Creek Relief Sewer
project. All other associated sanitary sewer infrastructure was found to have sufficient capacity to
accommodate the proposed sewer flow of 475 gallons per day (additional 19 employees x 25
gpd/employee) from this project for transmission to the Sugar Creek Wastewater Treatment Plant;
NPDES permit number NC0024937, for treatment. This acceptance of flow is based on the existing
capacity of the designated publicly owned treatments works. Please see attached NC DEQ flow tracking
form.
CLTWater 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, PWS ID # 0160010 on file with the Public Water Supply Section of NC DENR, However, CLTWater
cannot guarantee a constant pressure or quality of flow.
CLTWater does not expect any of the above conditions to preclude water or sewer service to the subject
site. However, the applicant should understand that 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 CLTWater and sewer 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. If the appropriate
authorization to construct permits am not obtained and construction has not stared within one (1) year of
issuance of this flow acceptance; and payment for any service connection(s) have not been received
within (1) year of issuance of this flow acceptance, this flow acceptance approval shall be rescinded and
a new flow acceptance request must be made,. If you have any questions, please do not hesitate to
contact me at [phone], or Alan Gaines (704)-391-4689.
Sincerely,,
Barbara Gross
Engineering Assistant
Charlotte Water 5100 Brookshitr Blvd, Charlotte, NC 8 a i ar or w rer.org
OP Operated by the City of Charlotte

State of North Carolina
ent of Environmental Quality
Division of Water Resources
Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Landworks Design Group
Project Name for which flow is being requested: Aldersgate Retirement Community - Commons Building
More than one FTSE may be required for a single project a the pion r of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: McAlpine Creek, Irwin Creek, Sugar Creek
b. WWTP Facility Permit #: N00024970, NC0024945, NC0024937
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
11.037
71.262
0.00048
82.300
83.1%
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) (b)=(B ) (E) A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flaw Plus
(Name or Capacity, * (Firm / pt), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
* The Firm Capacity of any pump station is defined as the maximum pumped flow tltat
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.
*** 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): 15-inch Sanitary Sewer Replacement
Downstream Permit Number: WQ0002809
Page 1of6
FTSE 04-16

III. Certification Statement:
Carl Wilson 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 orm indicates acceptance of this wastewater flow.
Signing 0
Otikeko
Signature Date
Page 2 of 6
FTSE 04-16

Lan lll erks Design Group, P.A.
7621 Little Avenue, Suite 1111
Charlotte, NC 28226
Memorandum
Date: September 12, 2016
To: NCDEQ — Mooresville Regional Office
610 E. Center Ave,
Mooresville, NC 28115
From: Landworks Design Group, PA.
Steven S. Wilson, PE.
Telephone: [phone]
Facsimiles 70484i-1604
Project: Commons Building Extension — Aldersgate United Methodist Retirement Community, Inc
Job #: 14040 CMMNS
Re: Commons Building Extension Private Sanitary Sewer
On behalf of Aldersgate United Methodist Retirement Community, inc, we are submitting Fast -Track
Application (FTA) for gravity sewers for the construction of "Commons Building Extension" private
sanitary sewer and related appurtenances.
(2) Copies of completed application FTA, Project Narrative, Flow Acceptance letter and form
FTSE, and Site Maps. Appropriate forms have been signed by the proper representatives.
(1) Review Fee
We look forward to your favorable review and approval of the proposed construction. Should you have
any questions or if we may aid in your review, please feel free to contact me at 704.841.1604.
Regards,
Landworks Design Group, PA.
Steven S. Wilson, PE
P: L2014 Jobs114040 - Aldersgate Expansion CDslPermit Submittats9COMMONSIUtibity CommonslPrivatelSanitary Sewer41_ 14040 CIU MNS -
DENR Private Sewer Submittal Memo.docx

Landworks Design Group, P.A.
7621 Little Avenue, Suite 111
Charlotte, NC 28226
Project Narrative
Date: September 12, 2016
To: NCDEQ
From: Landworks Design Group, PA
Steven S, Wilson, PE
Telephone: [phone]
Facsimile: 704-841-1604
OO ESVH NAL. OF ,C:E
Project: Commons Building Extension — Aldersgate United Methodist Retirement Community, Inc
Job #: 14040 - CMMNS
Re: Commons Building Extension Private Sanitary Sewer Narrative
The proposed Commons Building Extension is a planned building extension to serve office space.
This project will consist of approximately 4/-555LF- 8" private gravity sewer and related appurtenances,
which will connect to an existing 8" private gravity sewer located southeast of existing drop-off area for
the Commons Building on parcel 10102101.
The estimated sewage flow from this project is 475 gpd based on the following calculations: 19 office
staff x 25 gpd/office staff = 475 gallons per day.
Regards
Landworks Design Group, P.A.
Steven S. Wilson, PE
P 12t?14 Jobsl14040 - Aldersgate Expansion CDsPermrt Submtttals'C©MMONS1Utility Commons\PrivateSani'tary Sewer\2_ 14040 CMMNS -
D►NQ - Fast Track Narrative_docx

. Central Files: APS _ SWP
9/19/2016
Permit Number WQ0038729 Permit Tracking Slip
Program Category Status Project Type
Non -discharge Active New Project
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
barry.love
Coastal SWRuIe
Permitted Flow
475
Facility
Version Permit Classification
1.00 Individual
e
Permit Contact Affiliation
Facility Name
Commons Building Ext-Aldersgate Independent Living Apt.
Location Address
Owner
MaJorlMinor Region
Minor Mooresville
County
Mecklenburg
Facility Contact Affiliation
Owner Name
Aldersgate United Methodist Retirement Community
Dates/Events
Owner Type
Non-Govemment
Owner Affiliation
David High
Director Operations Plant of
3800 Shamrock Dr
Charlotte
NC 28215
Orig Issue
9/19/2016
App Received Draft initiated
9/1212016
Scheduled
Issuance Public Notice issue Effective Expiration
9/19/2016 9/19/2016
Regulated Activities Requested !Received Events
Office
Wastewater collection
Outfall
Additional information requested
Additional information received
Waterbody Name Streamlndex Number Current Class Subbasin

Water Resources
Environmental Quality
January 25, 2017
Suzanne Pugh, President & CEO
Aldersgate United Methodist Retirement Community, Inc.
3800 Shamrock Drive
Charlotte, NC 28215
SUBJECT: Final Engineering Certification Acknowledgement
Project: Commons Building Extension — Aldersgate
Retirement Community
Permit No. WQ0038729
Permittee: Aldersgate United Methodist Retirement
County: Mecklenburg
Dear Ms. Pugh:
WO' Y COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZIMMERMAN
Director
United Methodist
Community, Inc.
The Division of Water Resource's Mooresville Regional Office received the final engineering
certification with record drawings for the subject sewer extension project on January 24, 2017.
Enclosed is a certification page for your records. A full review of the certification materials may
or may not be conducted. It is assumed that receipt of this certification indicates compliance with
all regulations, design criteria and the permit. However, if a full technical review is conducted,
you will be notified of any items of non-compliance.
Please be reminded that the Permittee is responsible for keeping a copy of the final record drawings
for the life of the project. If you have not received such copy from your consultant, please contact
them immediately to obtain a copy.
Lastly, you are receiving this letter because the Division has you listed as the responsible party. If
this permitted system is no longer owned by you or your company, please complete Form PNOCF
since the permit is not automatically transferable. Form PNOCF can be downloaded from
http://portal.ncdenr.org/web/wq/swp/ps/cs/pnoc from the Collection Systems Applications page.
Should you have any questions, please do not hesitate to contact me at [phone].
Sincerely,
Barry Love
Environmental Specialist
cc: Steven S. Wilson, P.E., (Landworks Design Group, P.A., 7621 Little Ave., Suite' 111,
Charlotte, NC 28226)
Central Files
MRO
ixluthing Compareslc.l_.
State of North Carolina I Environmental Quality 1 Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 301 1 Mooresville, North Carolina 28115
704-663-1699

RECERIEDINCOENRIDWR
FAST TRACK SEWR EGNEEfflNG CERTIFICATION WOROs
MOO R ESVi Li„ E REG 0 NAL OFF-10E
PERMITT'EE: Aldersgate United Methodist Retire Comrnmity, Inc.
PERMIT tt: WQ0038729
PROJECT: Commons Building Extension - Alclersgate United Methodist Retirement Community
ISSUE DATE: September 19, 2016
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt Send the required documentation
the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to compietion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERINI EE'S CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or porUon5 thereof.
Suzanne Pugh, President & CEO
Printed Name, Title Sgnature
ENGINEER'S CERTIFICATION
I, Steven S. Wilson as a djy registered Professional Enjneer he State of North Carolina,
haying been authorized to bserve (J periodically, ED weekly, J full time) the construction of the
project name and location as referenced above for the above Permittee hereby state that, to the best of
rny abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial corn pliance of this permit; 15A NCAC 02T; the
Division of Water Resources' (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 June 1, 2000, as applicable; and other supporting materials.
North Carolina Professional Engineer's Seal w/signature & date:
Final Li Partial (include description)
Certification Comments/Qu rs (attath if necessary}; )7/2 6
Stste of North Carolina Eofeiroornurgal Quality Wafer Rrrrourcrfs I Water Quh Regional ()prralious
lvtoortsville Ragiolaal 001 10atLsl[ Con,' Averfar, Solic .301 I futoomf,vilte.r, Curolina ?RI IS.
"104663 1099

lnd rks Desigit Group, P.A.
7621i. ttie Ave, Suite 111 Telephone: 70 4604
Charlotte, NC 28226 Facsimile: imiie: 7004
J nu rr 0 2017
Barry Love
NCDEQDivision of Water Resources
610 E. Center Avenue
Suite 301
Mooresville, NC 11
FRe Commons Building Extension — Aldersgste United ethodist Retirement Corn unity
Mecklenburg County, NC
Landworks Project No, 100
Permit N. W00038729
As -Built Certification
Dear Mr. Love:
Please find enclosed the Permittee'slEngineer's Certification and one set ofas-bull t drawings for the subject
project, This certification covers all of the private sewer within the boundaries of this project. Please do not
hesitate to contact me if you have any further questions or concerns.
increiy,
Landworks Des Group, P.A.
Steven S. 1`ilson, P.E.
obat44040 - Aide g Expan srrr to -bcsid tComm znst 'n ine rs Certdfire a Cower Letter«Sewer Final 1-20-17.doc

POY C.:700'ER
°t1C11AF:I.. . RERAN
SC( rC''F 7ry
S. JAY ZIMMERMAN
As built check list (reference 2T .0300)
Reviewed By: Barry Love
Review Date: 01 /24/2017
Project Name: Commons Building Extension m Aldersgate United Methodist Retirement
Community
WQ#: WQ0038729
County: Mecklenburg
1) As built has been signed, sealed; and dated by an N.C, PE ' Yes * No
) Adequate information related to sewer lines .
Note that per the 2T and MDC, there is a minimum 8" for public gravity or minimum 6" for
private gravity, °Three (3) feet minimum cover shall be provided for all sewers unless ferrous
material pipe is specified. Manholes shall be installed: at the end of each line, at all changes in
grade, size, or alignment, at all intersections, and at distances not greater than 425 feet, minimum
diameter of manholes shall be 4 feet (48 ,inches). Yes fl No ri N/A
) Adequate information related to pump stations:
Ensure power reliability' option is selected (1.5A NCAC 02T.0305(h)).Yes No N/A
4) Is Project design is in accordance with (see section B.13 of ETA. 12-12)
I5A NCAC 02T Gravity Sewer Minimum Design Criteria (latest version), Minimum Design.
Criteria for Permitting of Pump Stations and Force Mains (latest version). Yes P1 No N/A
a variance approval is required per the requirements of 15A NCAC 02T.0105(b)
Applicant must submit TWO copies of"the plans, specifications, and calculations
Contact the Central Office to discuss the variance request to determine a course f action.
The central office will review the variance request, and if approvable, specific language
regarding the variance will be forwarded to the Regional Office reviewer to incorporate into the
permit. A copy of the variance letter (or email correspondence) should be kept with the
application file.
5) Project contains high priority lilies (1.SA NCAC 02T .0402(2))
Yes Z No
If Yes, insure that the pertnit contains the necessary condition related to high priority lines 15A
NCAC 02T0403 (a)(5)
6) Is the Sewer As -built length within 10% of the fast track applied Length?
( I Original length of pipe — As built length / Original length) < 10%. Yes 1 No
lino application need to be modified
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