WQ0043119_Application (FTSE)_20211222

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: W �,>>C► (to be completed by DWR)
All items mlist becompletcd or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: DD DP Midrise. 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: Fred Hazel per 15A NCAC 02T .0106(b)
Title: Vice Pr i n
4. Applicant's mailing address: 403 Corporate Center Drive. Suite 201
City: Stockbridge State. GA Zip: 30281
Applicant's contact information:
Phone number: 770 474 - 4345 Email Address: lhazelCa davisdevelpment.com
H. PROJECT INFORMATION:
I . Project name: Davis Park East - POD B (Private)
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: _. ,
For modilieations, 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: Durham
4. Approximate Coordinates (Decimal Degrees): Latitude: 35,882144' Longitude:-78.860012'
5. Parcel ID (if applicable): 157842 (or Parcel ID to closest downstream sewer)
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Ill. CONSULTANT INFORMATION:
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1. Professional Engineer: John C. Martin License Number: Q443217
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Firm: McAdamsy
Mailing address: 2905 Meridian Parkway
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City: Durham State: NC Zip: 27713
Phone number: [phone] Email Address: jmartinQmcadamsco.com
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IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Triangle WWTP Permit Number: NCO026051
Owner Name: Durham County
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0038871
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity f 1 Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00038
Owner Name(s): Durham County
FORM: FTA 06-21 Page I 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 ® NIA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (rORM: DEV) been attached?
❑ Yes ❑ No ® NIA
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.01 15(c) been attached?
❑ Yes []No ® NIA
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential (Leased) ❑ Retail with food preparationtservice ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(29))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes El No
6. Has a flow reduction been approved under I SA NCAC 02T .01 14(M. ❑ Yes ® No
)' If es rovide a cogy of ow reduction anproval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow
No. of Units
Flow
2 bedroom apartments
240 gal/day
86
20,640 GPD
3 bedroom apartments
360 gal/day
10
3,600 GPD
Amenity Center (Pool House -- 2,446 sf)
0.5 gallsf/day
1
1,223 GPD
I pool (2,184 sf— 146 users)
10 gal/user/day
1
1,460 GPD
gal/
-- gall
GPD
GPD
Total
26,923 GPD
a See 15A_NCAC _02'T_.01 I4(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 G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table I?ANQA _Q2T.Q1141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 26,923 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):
FORM: 1:TA 06-21 Page 2 of 5

VI1. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
240
PVC
8
57
DIP
➢ Section Il & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
D 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
Vlll. 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
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: . Longitude: - 4
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 2.01 C.I.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) __
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(I ]:
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(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

IBC. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/alternatives found in ISA NCAC 021' ,0305(f).&�(e)? ® Yes ❑ No
ISA NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
1S inches
2Water 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-1 waters of Class I or
Class 11 impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
•"Waters classified WS (except WS-1 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.0305(f) or (2), see Section X. l of this application
"1.5A_NCAC 02T.0305(contains alternatives where separations in 02T.0305(f1 cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
"Stream classifications can be identified using the Division's NC Surface Water Classifications webntc
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ NIA
➢ If no, please refer to 15A NCAC I8C.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 ❑ NIA
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ Seethe Division's draftseparalion 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: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ 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?
➢ Please provide the permit number/permitting status in the cover letter if coveragetauthorization is required.
6. Does project comply with I5A NCAC 027.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per I5A NCAC 02T.0105 c 6 , directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A 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/contlict 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 02'1', the Minimum Design Criteria for the Pennitting Of Puntp Stations
and Force Mains (latest version), and the Gravity Sewer Minimum D si n 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 protects reguirine a variance anoroval may be subject to loneer
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:
1, John C. Martin , attest that this application for Davis Park East — POD P (Private)
(Professional Engineer's name from Application Item 111,1.) (Project Name from Application Item 11.1)
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. 1 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 Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and farce Mains t 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 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: i .�`t��N CAR04SS
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
[, ��+ , attest that this application for �1 ��„ d
(Signature Au sty . eme from Application Item 13.) roJ'cct Dame from Application Item (H) '
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 143-215.6B, 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 $ I WO as well as civil penalties up to $25,000 per violation.
Signature: Date:
FORM: FTA 06-2 I Page 5 of 5

State of North Carolina
s Department of Environmental Quality
Division of Water Resources
DI
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Division of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: DD DP Midrise, LLC
Project Name for which flow is being requested: Davis Park East Pod B - 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: Triangle Wastewater Treatment Plant
b. WWTP Facility Permit #: NCO026051
A11 flows are in MGD
c. WWTP facility's permitted flow 12
d. Estimated obligated flow not yet tributary to the WWTP 1.905
e. WWTP facility's actual avg. flow 4.227
f. Total flow for this specific request 0.026923
g. Total actual and obligated flows to the facility 6.159
h. Percent of permitted flow used 51.3
Il. 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 : pt), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
NIA
* 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): Durham County Sewer
Downstream Permit Number: WQCS00038
Page 1 of 6
FTSE 10-18

II1. Certification Statement:
I -15' flW �¢ to -- �v LW certify to the best of my knowledge that the addition of
the volum of wastewater to be p rmitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Of'cial Signature Date
In
Title of Signi Ofcial
Page 2 of 6
FTS L 10-18

The John R. McAdams
Company, Inc.
Raleigh r Durham, NC
2905 Meridian Parkway
Durham, North Carolina 27713
[phone]
Charlone, Me
11301 Cannel Commons Blvd,
Suits 111
Charlotte North Carolina 28226
(704)627.08M
McADAMS
December 17, 2021
NC Dept of Environmental Quality
DEC 2 2 2021
NCDENR - DWR Raleigh Regional Office
Raleigh Regional Office
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
Re: Davis Park East -- Pod B — Private Sewer Permit Application
Durham, North Carolina
DDV-18010
The accompanied Fast -Track Application (FTA 04-16) includes the installation
of 240 lineal feet of private 8" PVC and 57 lineal feet of private 8" DIP gravity
sanitary sewer system for the proposed Davis Park East -- Pod B development
located off Merrion Avenue in Durham, NC. This project also includes the
removal of 452 LF 8" sewer from permit WQ0040504 (Davis Park Townhomes
Public Permit) and removal of 329 LF 8" sewer from WQ0038871 (Davis Park
Apartments Permit). The proposed sewer system has two sections, one that
will be publicly owned and one that will be private. The private sewer system
will be owned and operated by Davis Development corporation, located at
403 Corporate Center Drive, Suite 201 in Stockbridge, Georgia. The proposed
development will consist of approximately 381 apartment units (96 units with
the private permit), clubhouse, pool, and the associated parking areas. The
total private wastewater flow generated by this project is 26,923 GPD. The
receiving downstream sewer permit number for this project is WQ0038871.
The sewer flows to the Triangle WWTP (permit no. NC0026051) treatment
facility. The anticipated date for installation completion for the sanitary sewer
system associated with the Davis Park East Pod B development is Spring 2021.
The anticipated date for 15t effluent discharge (certificate of occupancy) is Fall
2022.
Sincerely,
THE JOHN R. MCADAMS COMPANY, INC.
4 C, *�&-,
Joh C. Martin, P.E
Technical Manager, Engineering Services
Enclosures
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1. USGS: SOIL SURVEY SHEET 40, DURHAM COUNTY, NORTH CAROLINA
2. LAT. 35.881428 N, LONG'.-78.855744 W
NRCS SOIL SURVEY
DAVIS PARK EAST - POD B
M c A DA M S DURHAM, NORTH CAROLINA
0 250 500
Feet
1 inch = 919.149965 fee
DATE: 611012019
JOB NO: DDV-18010
DRAWN BY: JFinch
WjectsODM0V-18010Storm%Ke PIanlDesign Fi eslGISSoil Survey mW. 6/1012019 9 42 05 AM. jFinc

DAVIS PARK EAST - POD B PLAN INFORMATION
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AERIAL MAP FILENAME
e�wr 4�1.36t. 5000 CHECKED BY
a.9�9. xi.rm 341 DAVIS DRIVE DRAWN BY
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M CA DA M S — - - - DURHAM, NORTH CAROLINA SCALE 1" • oa
DATE 06.68.I0I0

41 BUSINESS CORPORATION ANNUAL REPORT
ID-2017
NAME OF BUSINESS CORPORATION: Davis Development, Inc•
SECRETARY OF STATE ID NUMBER: 0886631 STATE OF FORMATION: GA
REPORT FOR THE FISCAL YEAR END: 1 2/31 /2019
SECTION A:
1. NAME OF REGISTERED AGENT: CT Corporation System
2. SIGNATURE OF THE NEW REGISTERED AGENT:
® Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
160 Mine Lake Ct Ste 200
Raleigh, NC 27615-6417 Wake
SECTION B: PRINCIPAL OFFICE INFORMATION
160 Mine Lake Ct Ste 200
Raleigh, NC 27615-6417
1. DESCRIPTION OF NATURE OF BUSINESS: Real Estate Development and Management
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: [e-mail]
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
0.
403 Corporate Center Drive Suite 201 403 Corporate Center Drive Suite 201
Stockbridge, GA 30281-9023 Stockbridge, GA 30281-9023
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: OFFICERS (Enter additional officers in Section E.)
NAME: Lance A Chernow NAME: Mlgueal B. Davis NAME: Migueal B. Davis
TITLE: Secretary TITLE: President TITLE: Treasurer
ADDRESS:
ADDRESS:
403 Corporate Center Drive, Suite 201 403 Corporate Center Drive, Suite 201
Stockbridge, GA 30281
Stockbridge, GA 30281
ADDRESS:
403 Corporate Center Drive, Suite 201
Stockbridge, GA 30281
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business
entity.
SIGNATURE
Form must be signed by an officer listed under Section C of this form.
Print or Type Name of Officer
DATE
Print or Type Title of Officer
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $25
MAIL TO: Secretary of State, Business Registration Division. Post Office Box 29525. Raleigh, NC 27626-0525

SECTION E: ADDITIONAL OFFICERS
NAME- Stephen M Davis
NAME: Fred S. Hazel
NAME:
TITLE: Vice President
TITLE: Vice President
TITLE:
ADDRESS:
ADDRESS:
ADDRESS:
403 Corporate Center Drive, Suite 201
403 Corporate Center Drive, Suite 201
Stockbridge, GA 30281
Stockbridge, GA 30281
NAME:
NAME:
NAME:
TITLE:
TITLE:
TITLE:
ADDRESS:
ADDRESS:
ADDRESS:
NAME:
NAME:
NAME:
TITLE:
TITLE:
TITLE:
ADDRESS:
ADDRESS:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
Name:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:

North Carolina Department of the Secretary of State
Elaine F. Marshall, Secretary
BELOW IS THE CHECK LIST FOR BUSINESS CORPORATION ANNUAL REPORT. Please take a few minutes and read the
Information provided. The Business Cornoration's Annual Report is due by the 15th of the 4th month after the and of the
Business Corporation's fiscal year, with the filing fee of 120.00 If filed online if filed in paper form the fee is $25.00.
Each Business Corporation filing an annual report with the North Carolina Department of Secretary of State must
provide the following Information:
1. NAME OF BUSINESS CORPORATION
2. STATE OF FORMATION
3. ANNUAL REPORT FILING YEAR
4. THE REGISTERED AGENT STREET ADDRESS AND MAILING ADDRESS IF DIFFERENT
5. THE REGISTERED AGENT'S NAME AND SIGNATURE IF CHANGED
6. THE PRINCIPAL OFFICE ADDRESS, COUNTY AND TELEPHONE NUMBER
7. THE NAMES, TITLES AND BUSINESS ADDRESS OF THE PRINCIPAL OFFICERS
6. A BRIEF DESCRIPTION OF THE NATURE OF BUSINESS
IF THE INFORMATION REQUIRED TO BE ENTERED IN SECTION A THROUGH SECTION C HAS NOT CHANGED SINCE THE MOST
RECENTLY FILED ANNUAL REPORT, COMPLETE HEADER SECTION AND SECTION D TO CERTIFY THE ANNUAL REPORT.
SECTION A: REGISTERED AGENT'S INFORMATION
I. The name of the registered agent must be typed or printed.
2, if the registered agent has changed, the new registered agent MUST SIGN CONSENT to the appointment in the space provided. If the registered agent's
name has :hanged due to marriage, or by any other legal means, the business corporation must indicate such change in the space provided and have the
agent sign consent to the appointment under their new name. If the new registered agent is a business entity, then the appropriate representative of that
entity must sign and print their name and title. The registered agent must reside in NC.
3. If the street address of the registered office has changed, indicate the change. The address of the registered office must be a Street Address and NOT a
Post Office Box Address. The street address of the registered office must be a North Carolina address.
4. If the mailing address of the registered office has changed it should be indicated in this item. The registered offices mailing address may be a Post Office
Box The registered Office mailing address must be a NORTH CAROLINA ADDRESS.
SECTION B: PRINCIPAL OFFICE INFORMATION
1. Provide a brief description of the nature of the Business Corporation's business.
2. Enter the principal office telephone number.
3. Enter the principal office E-mail address.
4. The principal office address should reveal the Business Corporation's physical location. The principal office street address must be a street address and
NOT a Post Office Box Address.
5. The principal office mailing address may be a Post Office Box.
6. You may voluntarily report whether the company qualifies as a service -disabled veteran -owned or veteran -owned small business. The annual net receipts
cannot exceed one million dollars ($1,000,000) to report as either veteran -owned small business designation. Choose the designation of a service -disabled
veteran -owned small business if one or more service -disabled veterans owns more than 50% of the business. Choose the designation of veteran -owned small
business if one or more veteran owns more than 50% of the business. For further definitions see N.C.G.S. §55-I AO; §57D-1-03; or §59-32.
SECTION C: OFFICERS
Provide the names and addresses of each officer. Use Section E or a plain 8 l :2 X I I sheet of paper if more space is needed. A person listed in this section
must sign the annual report and is then authorized to sign on other documents filed with this office.
SECTION D: CERTIFICATION OF ANNUAL REPORT
Check the annual report carefully to ensure all information required for filing has been provided. Only an officer listed on this report or past completed and
filed report may sign. Complete the signature, date, title and typed or printed name in the space provided on the form to certify that the information is accurate
and current. If the Officer of the business corporation is another business entity then the appropriate representative of that business entity must certify the
annual report.
SECTION E: ADDITIONAL OFFICERS
Provide the names and addresses of each additional officer. A person listed in this section is then authorized to sign on other documents filed with this
office.
Mail the annual report to: Secretary of Slate, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525, For information or assistance, contact
the Business Registration Division at [phone] or Toll Free 1-888-246-7636. The uri address is httu:.. www.susnc.eov. (Revised 1012017)

NC Dept of Environmental Quality
TI MCA DA MS DEC 2 2 2021 LETTER OF TRANSMITTAL
Raleigh Regional Office
Date: December 22, 2021 HAND DELIVER
To: NCDENR Division of Water Resources Re:
3800 Barrett Drive
Raleigh, North Carolina 27609
919 791 4200
I am sending you the following items:
❑ Drawings ❑ Letter
❑ Specifications ® Submittal
❑ Plans ❑ Prints
Davis Park POD B — Private Sewer
Job *I: DDV-18010
❑ Statement of Qualifications
❑ Other
QUANTITY
UNIT
DESCRIPTION
2
Original/Copy
Signed FTA 04-16 Package for Private Sewer
t
Check
$480 for application fee
Transmitted as checked below:
® For approval
❑ For your use
❑ As requested
Remarks:
Copy to:
❑ For review + comment
❑ Other
❑ Other
Signature:
Joh Martin, PE / and
Te - nical Manager, Residential
t ras rip experiences through experience 2905 Mer;dian Parkway, Durham, NC 27713 / 919. 361. 5000