WQ0043010_Application (FTSE)_20211119

DWR
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: 144,730s-N3p\47 (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION;
. Applicant's name: Shelboume Cary, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Mark Hallowell per I5A NCAC 02T .0106(b)
Title: Partner 0.d
o
4. Applicant's mailing address: 123 Wayne Ave. 'do
City: Wayne State: PA Zip: I9087 '�
of 1.- `.3 ?4 -
5. Applicant's contact information: 3' i' ~v
Phone number: [phone] Email Address: [e-mail] �.,P fd9 -6iy
II. PROJECT INFORMATION: a4,�0 -17 �c
I. Project name: She.lbourne Senior Living 0 �. � �,
..
2. Application:Project status: El Proposed (New Permit) 0 Existing Permit/Project ft,
0
If a modification, provide the existing permit number: WQ00 and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Wake
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.728459 Longitude:-78.791 149'
5. Parcel ID (if applicable): 0762202260 (or Parcel ID to closest downstream sewer)
I111. CONSULTANT INFORMATION:
I. Professional Engineer: Ryan Fisher License Number: 039756
Firm: WithersRavenel
Mailing address: 137 S. Wilmington St., Suite 200
City: Raleigh State: NC Zip: 27601
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I . Facility Name; South Cary Water Reclamation Facility Permit Number: NC0065102
Owner Name: Town of Cary
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
I. Permit Number(s): WQCS00013
2. Downstream (Receiving) Sewer Information: 10 inch ® Gravity 0 Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Town of Cary
FORM: FTA 06-21
Page 1 of 5

VI. GENERAL REQUIREMENTS
I. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑Yes No ®NA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement 1 FORM: DEVI. been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA .POA Operational Agreement (FORM; HOA) and
supplementary documentation as required by I 5A NCAC 02T.0I I5(c) been attached?
❑ Yes ❑ No ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls)
❑ Residential (Leased) ❑ Retail with food preparation/service
El School preschool / day care ❑ Medical / dental. veterinary facilities
® Food and drink facilities ❑ Church
❑ Businesses. offices / factories ❑ Nursing Home
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
® Swimming Pool/Filter Backwash
D Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic 0 % Commercial 0 % industrial (See J 5A NCAC 02T ,0103(201)
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ® No
6. Has a flow reduction been approved under 15A NCAC 02T _01 14(f)? ❑ Yes ® No
If ves, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 92T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
Senior Living Facility
120 gal. day
166
19,920 GPD
gal'
GPD
gal/
GPD
gal/
GPD
gal:'
GPD
gal.'
GPD
Total
GPD
a See 1 5A NCAC 02T .01 I4(b}. td1,1elt I .and 1e [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 G.S. 42A-4).
b Per 15A NCAC 02T .01 14(c), design flow rates for establishments not identified (in table I SA NCAC 02T.01 14J shall be
determined using available flow data, water using fixtures, occupancy or ope on patterns, and other measured data.
8. Wastewater generated by project: 19,920 GPD (per 15A N .'AC 02T .01 14) Wept °f Environmental Quality
►� Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
NOV 19 2021
❑ Pump Station, Force Main or Gravity Sewer where flow will be permitted in sub- ent erm its that connect to this line,
Please provide supplementary information indicating the approximate timeframe foi! f xbith flow.
❑ Flow has already been allocated in Permit Number: . Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
I. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
6
300
PVC
7 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)
7 Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations:Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name: N A
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Total number of pumps at the pump station:
3. 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.
4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total dynamic head (TDH)
5. 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 2.0I C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with I _NCAC 02T .0305(h)I I):
❑ Standby power source or 0 Standby pump
• Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)_
7 Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
• Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(l)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
7 ▪ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
7 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(f)):
I. Does the project comply with all separations.alternatives found in ISA NCAC 02T .0302f1 & (0?
15A NCAC 02T.0305(f) contains minimum separations that shall be vrovided for sewer systems:
® Yes ❑ 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 1 or
Class 1I 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, 1-IQW, 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,0305( or (g), see Section X.I of this application
*I5A NCAC 02T.0305W contains alternatives where separations in 02T,0305(fl cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water ClassificatiogLweboage
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,
signedsealed 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
i Please provide supplementary information identifying the areas of non-conformance.
i See the Division's draft separation requirements for situations where separation cannot be met.
> No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ® Yes Basin name: Neuse ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 13A NCAC 02B ,02009 ® Yes ❑ No
> This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage.authorization under a 404 Nationwide.'individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
r Please provide the permit numberpermitting status in the cover letter if coverage,authorization is required.
6. Does project comply with I5A NCAC 02T.0105(c.1(6) (additional permits,certifications)? ® Yes ❑ No
Per 1 5A NCAC 02T.0105(c)16), 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 I5A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
> If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per I5A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-2 l Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria fowth�j'e l tti�y� Pump Stations
and Force Mains (IateHt version), and the Gravity Sewer Minimum Design Criteria (latest ve i t a p e?
® Yes ❑ No
�nici h
If no, for projects requiring a single variance, complete and submit the Variance/Alternative to i ijgffi�4 lication
(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 protect. the full technical review is required.
2. Professional Engineer's Certification:
NC Dept of F..nvirnnmctttel Quality
I, Ryan Fisher PE , attest that this application for Shelboume Senior Living
(Professional Engineer's name from Application Item IILI.) (Project Name front Application Item II.I)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Critena for Gravity Sewers (latest version), and the Minimum Dcsibn 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 1 have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: \'‘\0 C A /t.�i%
-ss'.
�locuS�:
SEAL
0397
5...
11/18/2021
3. Applicant's ' cation per ISA NCAC 02T .0106(b):
I, ►1(, attest that this application for Shelboume Senior Living
(Signature Authority Name from Application item 1.3.) (Project Name from Application Item I1.1)
attest that this application has been reviewed by me and is accurate and complete to the best of niy 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 I43-2I5.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
i
i
v ll �fi ~1_.
Date:
1t Rizf
FORM: ETA 06-21
Page 5 of 5

DWR
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: Shelboume Cary, LLC
Project Name for which flow is being requested: Shelboume Senior Living
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.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: South Cary Water Reclamation Facility
b. WWTP Facility Permit #: NC0065102
c. WWTP facility's permitted flow
Allflows are in MGD
12.80
d. Estimated obligated flow not yet tributary to the WWTP 0.54
e. WWTP facility's actual avg. flow 5.70
f. Total flow for this specific request 0.02
g. Total actual and obligated flows to the facility 6.26
h. Percent of permitted flow used 49%
aaw ° puopa1 gStaiug
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 Pump
Station Station Firm
(Name or Permit Capacity, *
Number) No. MGD
Swift Creek WQ0003010 23.0
(A)
Design
Average
Daily Flow**
(Firm pf),
MGD
(B) (C) (D)=(B+C) (E)=(A-D)
Obligated,
Approx. Not Yet Total Current
Current Tributary Flow Plus
Avg. Daily Daily Flow, Obligated
Flow, MGD MGD Flow
Available
Capacity***
9.2 4.235 0.535 4.77 4.43
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Regency Interceptor
Downstream Permit Number: WQCS00013
Page 1 of 6
FTSE 10-18

I1I. Certiiu:atioa Stateme t.
1 j* $ r" certify to the best of my knowledge that the addition of
th olume of wastewater to 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 11 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 ade s uate c pac y transport and treat the proposed new wastewater.
Title ofSignin,- Official
`l Z
e.rf� s a,r
NC Dept of Environmental Quality
NOV 19 2021
Raleigh Regional Office
Page 2 of 6
FTSE 10-18

4• WithersRavenel
111 Our People. Your Success.
November 18, 2021
Department of Environmental Quality
Division of Water Resources
Attn: Jason Robinson, PE
3800 Barrett Drive
Raleigh, NC 27609
RE: Shelbourne Senior Living
7000 Regency Parkway, Cary, NC
Private Sewer System Extension Permit
Dear Mr. Robinson,
NC Dept or Environmental Quality
t4OV IS 25ZA
Raleigh Regional Office
On behalf of Shelbourne Cary, LLC, please find the attached documentation in support of a Fast -Track
Application for the referenced project. As noted in the application, this project will consist of 300 LF of 6"
PVC sewer pipe with one (1) manhole and three (3) cleanouts. This private sewer extension is to serve the
proposed senior living, multifamily building located on the subject property.
The proposed project will meet all of DWR's minimum design criteria for sanitary sewer extensions. The
design flow rate for this project is calculated at 21,840 GPD based on NCAC 2T Rules for wastewater flow
rates and the anticipated flow from the 182 bedrooms in this facility. The proposed sanitary sewer line size
is more than adequate to convey the design flow rates.
Please find attached the following information in support of the application:
• Fast Track Sewer System Extension Application
• Flow Tracking/Acceptance Form for Sewer Extension Applications
• USGS Map
• Street Level Map
• $480 Check for payment of Application Fee
If you have any questions regarding this request or if you require any additional information, please feel free
to contact me at 919-535-5175 or [e-mail].
Sincerely
WithersRavlel
Ry Fisher, PJ'
Project Manager
115 MacKenan Drive I Cary. NC 27511
t: 919.469.3340 I f: 919.467.6008 I www.withersravenel.com I License No. C-0832
Caryl Greensboro I Pittsboro I Raleigh I Wilmington

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. Our People Your Success
137 South Wilmington Street, Suite 200
Raleigh, NC 27601
t: 919.469.3340 I f: 919.467.6008
TO: NCDEQ
3800 Barrett Drive
Raleigh, NC 27609
WE ARE SENDING
YOU THE
FOLLOWI NG
ITEMS:
Attached
❑Shop Drawings
❑Copy of Letter
WithersRavenel Letter of Transmittal
, , 11/18/2021
02160190.00
Jason Robinson, PE
Shelbourne Senior Living - Private Sewer
Extension Permit
❑Under Separate Cover Via
:Prints DPlans
❑Samples
❑Specifications
❑Change Order ❑Disk ❑Other
COPIES_
,i, _ DESCRIPTION 'r
2
Cover Letter
2
Fast Track Sewer System Extension Application
NC Dept of Environmental Quality
2
Flow Tracking/Acceptance Form
2
USGS Map
NOV 1 9 2321
2
Street Level/Aerial Map
Raleigh Regional Office
2
LLC Documentation
1
Check # 1377 for $480
THESE ARE TRANSMITTED as checked below;
® For approval DApproved as submitted
❑For your use :Approved as noted
`IResubmit ______copies for approval
❑Submit ____copies for distribution
❑As requested ❑Returned for corrections ❑Return corrected prints
❑For review and comment ❑Other
❑FOR BIDS DUE DPRINTS RETURNED AFTER LOAN TO US
REMARKS:
COPY TO:
SIGNED: Ryan Fisher, PE
QA/QC: Alissa Pelham
if enclosures are not as noted. kindly notify us at once.

11/17/21, 12:36 PM North Carolina Secretary of State Search Results
• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online • Add
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Amended a Annual Report form
Limited Liability Company
Legal Name
Shelbourne Cary, LLC
Information
I-
n
d
Sosld: 1908394 'FP-3
Status: Current -Active 0 0
k.
Date Formed: 10/23/2019 va�
Citizenship: Foreign ` ,
0
State of Incorporation: DE oo.• �p
Annual Report Due Date: April 15th �v,
a
CurrentAnnual Report Status: 0
Registered Agent: Corporat on Service Company
Addresses
Mailing Principal Office Reg Office
123 Wayne Avenue 123 Wayne Avenue 2626 Glenwood Ave Ste 550
Wayne, PA 19087 Wayne, PA 19087 Raleigh, NC 27608
Reg Mailing
2626 Glenwood Ave Ste 550
Raleigh, NC 27608
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Managing Member Controller
James W Kane Al Marianne Menapace
123 W Wayne Ave
Wayne PA 19087-
123 W Wayne Ave
Wayne PA 19087
https:lhwwv.sosnc.gov/online services/search/Business Registration_Resuits 112

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