WQ0043140_Application (FTSE)_20220201

W Q0o43140
11,
BLACK&VEATCH
Building a world of difference:
January 20, 2022
Town of La Grange, NC
2021 Water and Sewer Improvements
BLACK & VEATCH INTERNATIONAL COMPANY
319 N. THIRD STREET, SUITE 202
WILMINGTON, NC 28401 USA
[e-mail] I +1.910.550.1605
NCDEQ
Water Quality Section
943 Washington Square Mall
Washington, NC 27889 l_ �/
Attention: Mr. bse^ 1(.�+1d
Subject: Sewer Fast Track Permit
Dear Mr. TfriNgAttet I Ar>e,;+✓v1
Project No. 400407
B&V File 30.2000
ECEIVm/NCDENR/DWR
JAN 2'8 2022
Water ()witty
Regional Operations Section
Washington Regional Office
On behalf of the Town of La Grange, we are submitting the enclosed sewer fast track permit package for
construction of the new 2021 Water and Sewer Improvements: Gravity Sewer, Water Line and Pump
Station project.
The following items are included in this package:
• A check for $480 to cover the review fee
• This cover letter with a brief project narrative
• Fast Track Sewer System Extension Application (FTA 06-21)
• Variance/Alternative Design Request (VADC 10-14)
• USGS Topographic Map and Project Map
• One drawing set and specification set
The work to be performed in this project includes replacing 32,858' of aging gravity sewer lines, sizes 8"
through 12", to reduce the inflow and infiltration (UI) into the system. The wastewater system has
experienced significant inflow and infiltration during and after rainfall events. This will allow the town to
have a sewer moratorium lifted that limits extensions of the wastewater collection system and brings the
town into compliance with their NPDES permit. This project also includes a full replacement of the Lake
Pine Pump Station including two (2) grinder pumps, precast wet well and valve vault, new electrical and
site work. The project also includes, unrelated to this permit, Water System Improvements including
20,150 linear feet of new 8" and 12" water lines to increase pressures throughout the town and provide
services to new customers.
We are requesting a variance in relation to the minimum slope requirement of Minimum Design Criteria
for Permitting of Gravity Sewers (MDCGS) as part of this permit review. The objective of this project is
to reduce the town's significant inflow and infiltration (UI) issue which has negative impacts on the La
Grange WWTP and ability to expand their wastewater collection system. After completing a gravity
sewer system inspection and survey to determine which gravity sewer lines needed replacing, it became
apparent that the lines to be replaced were spread throughout the system and not caused by a singular
problem area. The existing gravity sewer system was constructed before the adoption of the Minimum
Design Criteria for permitting of Gravity Sewers (MDC) legislation and has numerous locations of 8" to
12" gravity sewer not meeting minimum slope requirements. In order to install the replacement lines
BUILDING A WORLD OF DIFFERENCE'
Ste Comm-4, h ' P

JANUARY 20, 2022 I PAGE 2
2021 Water and Sewer Improvements: Gravity Sewer, Water Line and Pump Station
within the minimum slope guidelines specified by the MDCGS, a much larger portion of the sewer
system, which does not have significant PI problems, would have to be replaced to maintain gravity flow
to the plant. Due to the limited funding allocated for this project, we are proposing that each replacement
pipe segment be installed to matching original slope, proximity, depth and diameter to maintain the flow
profile of the existing gravity sewer system, which does not experience surcharging or sanitary sewer
overflows. This will allow this project to replace the pipes throughout the system causing the most I/I
issues, rather than having to allocate financial resources to replacing the connecting gravity sewer system
to meet minimum slope all the way along the outfall to the WWTP. The reductions of inflow and
infiltration into the system will provide a greater efficiency of waste being treated as required by 15A
NCAC 02T .105(n). We believe the alternative design criteria of not meeting minimum slope due to
matching the existing system, while significantly reducing I/I, provides the following:
(1) equal or better treatment of the waste;
(2) equal or better protection of the waters of the state; and
(3) no increased potential for nuisance conditions from noise, odor or vermin.
Please note Engineering Calculations are not included as a part of this variance request, as the
investigation and analysis were performed with the project survey, as-builts and discussions with the
Town. Due to this being a single variance request that is matching the existing gravity sewer system, we
are requesting this permit application to be reviewed under the fast -track process.
Design of this infrastructure was based on the Preliminary Engineering Report prepared by Black &
Veatch in March of 2019 (PER). The PER identified portions of existing sewer lines to be replaced to
greatly reduce the town's infiltration and inflow problem.
If you have any questions or need further information, please contact me at 910-550-1605 (email:
[e-mail]).
Sincerely,
BLACK & VEATCH
International Company
atio&1e0 b(- )I,IH ?yCC ,
Matthew Pitzer, P.E.
Civil Engineer
Enclosure[s]
cc: John P. Craft, Town of La Grange
BUILDING A WORLD OF DIFFERENCE'

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300, Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ Simplex S 1'LP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Appllcation Packages, Form FTA 05-21):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
Z The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
Z The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
> Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
El Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
> General location of the project components (gravity sewer, pump stations, & force main)
> Downstream connection points and permit number (if known) for the receiving sewer
® Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump 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 in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 28778-8211
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
Water Quality Section
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301-5095
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
Water Quality Section
Mooresville Regional Office
610 E. Center Avenue
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabanas, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Water Quality Section
Raleigh Regional Office
3800 Barrett Drive
Raleigh, North Carolina 27609
[phone]
[phone] Fax
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Water Quality Section
Washington Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
Beaufort, Bertie, Camden, Chowan, Craven,
Currituck, Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pamlico, Pasquotank,
Perqulmans, Pitt, Tyrrell, Washington, Wayne
Water Quality Section
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pender
Water Quality Section
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, North Carolina 27105
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Gultford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
Water Quality Section
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3

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: (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of La Grange (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: John P. Craft per 15A NCAC 02T .0106Lb)
Title: Town Manager
4. Applicant's mailing address: 203 S. Center St
City: La Grange State: NC Zip: 28551-
5. Applicant's contact information:
Phone number: [phone] Email Address: jperaft lagrangenc.com
II. PROJECT INFORMATION:
1. Project name: 2021 Water and Sewer Improvements: Gravity Sewer, Water Line, and Pump Station
2. Application/Project status:
® Proposed (New Permit) ❑ Existing Permit/Project
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: Lenoir
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.308103° Longitude: -77.790572°
5. Parcel ID (if applicable): (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Matt Pitzer License Number: 049996
Firm: Black & Veatch International Company
Mailing address: 319 N. Third Sheet, Suite 202
City: Wilmington State: NC Zip: 28401-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: La Grange WWTP Permit Number: NC0021644
Owner Name: Town of La Grange
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0034386
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Town of La Grange
FORM: FTA 06-21
Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) 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 15A NCAC 02T.0115(c) been attached?
❑Yes El 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
® 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
❑ Other (Explain in Attachment)
5. Nature of wastewater : 73.67 % Domestic 26.33 % Commercial 0 % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ® No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ['Yes ® No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow °,'
No. of Units
Flow
None — Replacing existing pipe with same
OD.
0 gal/day
0 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
0 GPD
a See 15A NCAC 02T .0114(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 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114)
➢ 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: FTA 06-21
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
30,887
PVC
10
1,097
PVC
12
874
PVC
> Section lI & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing llnes 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 SEPARA I E COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Lake Pine
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.29905° Longitude: -77.79623°
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.2592 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): 180 gallons per minute (GPM) at 41 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6
37
DIP
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump
> Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
> Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
> Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
> If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/altematives found in 15A NCAC 02T .0305(f) & (g)?
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (g), see Section X.1 of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) 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 webpage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation 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 River ❑ 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 coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A 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/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with t5A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
❑ Yes ® No
If no, for projects requiring a single variance, complete and submit the Variance/Altemative 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 Droiects requirine a variance approval may be subject to longer
review times. For proiects reauirine two or more variances or where the variance is determined by the Division to be a
signlfcant portion of the Drolect, the full technical review is required.
2. Professional Engineer's Certifi : 'on:
attest that this application for 2021 Water and Sewer Improvements:
(Professional Engineer's fro Application Item MI.) Gravity Sewer. Water Line. and Pump Station
(Project Name from Application Item IL 1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version1, 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 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:
\\`%�11I'''li
\\)% CAR('
•ss�o
aov
SEAL
049996
40. '.!VGitJEF
/111t'
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, wJBH/�C � �wN 4" /^ atttest that this application for 2021 Water and Sewer Improvements:
(Signature Authority Name from Application Item I.3.) Gravity $ewer. Water Line. and Pump Station
(Project Name from Application Item 11.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, 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:
FORM: FTA 06-21
Date: //�/ 0 Zvi --
Page 5 of 5
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Sch14-1-0 Byfo4
DWR
"DivIslon of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02T .0105 — VARIANCE/ALTERNATIVE DESIGN REQUEST
INSTRUCTIONS FOR FORM: VADC 10-14 & SUPPORTING DOCUMENTATION
Plans, specifications and supporting documents shall be prepared in accordance with, 15A NCAC 02T .0100, 15A NCAC 02T
.0300, Division Policies and good engineering practices. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the request.
For more information, visit the Wastewater Branch's website at:
http: //portal. ncdenr. org/web/wq/swp/ps/cs/ext
General — When submitting a request, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Unless otherwise noted, submit one original and one copy of the request and
supporting documentation.
A. Cover Letter (Required for All Request Packages):
® List all items included in the request package and a brief description of the requested permitting action.
® Submit a detailed description of specific criteria that a variance request is submitted for.
15A NCAC 02T, Minimum Design Criteria (MDC) for the permitting of Gravity Sewers, &
Minimum Design Criteria (MDC) for the Permitting of Pump Stations and Force Mains
® Submit a detailed description why the project cannot comply with 15A NCAC 02T or adopted design criteria.
® Submit a detailed description of how the alternative design will meet the requirements of 15A NCAC 02T .0105(n)
B. Request Form (VADC 10-14) (Required for All Request Packages):
® Submit the completed and appropriately executed VADC 10-14 request form.
® The Applicant's certification of the request shall be signed in accordance with 15A NCAC 02T.106(b). Per 15A
NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided
from a person who meets the criteria in 15A NCAC 02T.0106(b).
® The Professional Engineer's Certification of the request shall be signed, sealed and dated by a North Carolina licensed
Professional Engineer.
C. Engineering Plans (Required for All Request Packages):
® Submit one set of detailed plans that have been signed, sealed and dated by a North Carolina licensed Professional
Engineer, pertinent to the variance request. Individual plan sheets related to the request may be submitted instead of
complete plan sets.
® Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY,
NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final plans. However, the plans may be
labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
D. Specifications (Required for All Request Packages):
® Per 15A NCAC 02T .0304(b)(2), submit specifications that have been signed, sealed and dated by a North Carolina
licensed Professional Engineer, pertinent to the variance request.
® Specifications shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW
ONLY, NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However,
the specifications may be labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
E. Engineering Calculations (All Request Packages):
❑ Per 15A NCAC 02T .0305(b)(3), submit engineering calculations that have been signed, sealed and dated by a North
Carolina licensed Professional Engineer, pertinent to the variance request.
F. Applicable Sewer Extension Application and Supporting Documentation
(Required if submitted in conjunction with a variance request)
❑ Submit the completed and appropriately executed application if provided in conjunction with the request.
> This is exclusive to projects requiring a full technical review (ASEA 08-13 & SSEA 08-13).
> Submission of FTA 10-14 and supporting documents to the regional office is only allowed once the variance has
been approved by the Central Office. Submission prior will result in the application being returned.
INSTRUCTIONS FOR FORM: VADC 10-14 & SUPPORTING DOCUMENTATION Page 1 of 2

15A NCAC 02T.0105 — Select Code Related to Variance / Alternative Design Criteria
(b)...The applicant shall provide adequate documentation to the Division to ensure that the proposed system will meet all
design and performance criteria as required under this Subchapter and other applicable rules, be operated as a non -discharge
system, and protect surface water and groundwater standards. Variances to this Subchapter or adopted design criteria must
be specifically requested in the application and, if approved pursuant to Paragraph (n) of this Rule, incorporated into
the permit. The Division may accept certification from a licensed or certified professional (e.g. Professional Engineers,
Licensed Soil Scientist, Licensed Geologist, Technical Specialist) that the design meets or exceeds minimum design criteria
applicable to the project. Division acceptance of certifications by the applicant or by licensed or certified professionals
preparing reports for the application shall not constitute approval of a variance to this Subchapter or applicable minimum design
and performance criteria unless specifically requested in the application and approved in the permit.
(n) The Director shall approve alternative Design Criteria in cases where the applicant can demonstrate that the alternative
design criteria will provide the following:
(1) equal or better treatment of the waste;
(2) equal or better protection of the waters of the state; and
(3) no increased potential for nuisance conditions from noise, odor or vermin.
THE COMPLETED REQUEST AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
ATTENTION: PERCS UNIT SUPERVISOR
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY ST. SUITE 925
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM: VADC 10-14 & SUPPORTING DOCUMENTATION
Page 2 of 2
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DWR
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02T .0105 — VARIANCE/ALTERNATIVE DESIGN REQUEST
VADC 10-14 & SUPPORTING DOCUMENTATION
Application Number: (tt applicable, to be completed by DWR)
I. APPLICANT INFORMATION:
1. Applicant's name: Town of La Grange
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State ® Municipal ❑ County
3. Signature authority's name: John P. Craft per 15A NCAC 02T .0106(b)
4. Applicant's mailing address: 203 S. Center St.
City: La Grange State: NC Zip: 28551-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: 2021 Water and Sewer Improvements: Gravity Sewer, Water Line and Pump Station
2. Project status: ® Proposed ❑ Existing (If existing, Permit Number:
III. CONSULTANT INFORMATION:
1. Professional Engineer: Matthew Pitzer License Number: 049996
Firm: Black & Veatch International Company
Mailing address: 319 N. Third Street, Suite 202
City: Wilmington State: NC Zip: 28401-
Phone number: [phone] Email Address: [e-mail]
IV. VARIANCE REQUEST:
Title: Town Manager
1. Provide a detailed list of specific criteria that a variance request is submitted for:
(e.g., NCAC 02T.0305(f) - Separation, MDC for Pump Stations / Force Mains 3.04(A)(1)(b) — Discharge Piping Velocity, etc)
Minimum Design Criteria for Gravity Sewer III.D.1 - Minimum Slope of Gravity Sewer
FORM: VADC 10-14 Page 1 of 2

Applicant's Certification perer15A NCAC 02T .0106fb):
oN 1, J ,v f L ice' 7'- /itili•,fi6f&-
ISIgnature Authority's name & title from Request Rem 1.3.)
Z a 2 / Ps?rd h •• FA' 5yf7rir hem e •(C.sMlti►rJ• • 46, 4 vi iy 4iefor 14
(Project name from Request Item 11.L) 6y / f=?„m,v
attest that this request for
has been reviewed by me and Is accurate and complete to the best of my knowledge. I also understand that if all required parts of
this request package are not completed and that if all required supporting Information and attachments are not included, this
request package will be returned to me as incomplete. I understand that by certifying this variance request, I shall adhere to the
requirements of the variance approval should it be approved and all permit conditions should the permit be approved.
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 request package sha l,• = guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,00 as v enaRies to ,000i •lation.
Date:
Professional Engineer's Certification:
1, /v1o+i-44,•/ (`�'vo/
(Professional Engineer's name from Request Item 111.1.)
//r/2 0 z
attest that this request for
1011 Up / e- S./Apt s�s ✓'^ �� yo1� s ; 67a r `4. y L./w 4"(/i1 n 1 j- 414441crvli
(Project name from Request Item 11.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, spedflcations,
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. in accordance with iSA NCAC 02T,0105(n) will provide: equal or better treatment of the
waste: eaual or better protection of the waters of the state: and no increased potential for nuisance conditions from noise. odor,
or vermin. I further attest as been prepared In accordance with this request package and its instructions, as well as all applicable
regulations and statutes. 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 R to be consistent with the
proposed design.
NOTE — In accordance with General Statutes 143-215.6P and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any request 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.
North Carolina Professional Engineer's seal, signature, and date:
FORM: VADC 10-14
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WARO Week Stormwater Re • ort For 1/31/22
s
Expres !
Permit Numbee Review' P.•rmit Status Facility
.Comity
Project Type
• 'rime ry lays
.Reviewer Add into) Waiting I Add Info
Last Request' on I Request
App Rcvd Name s Applicant Date
t I
Irdo DWA I
Rcvd Processi Statutory 1 Add info +
Date riq Days Date 1 35 Days
SW7220103 , No In review Windsor Retail Development
SW7130902 I No In review Dollar General - James City,_
SW7951203 No In review Greenfield Shops Center
SW7220104 ; No In review Cardinal Leasln9 Services
SW7080811 No In review
SW7970812 I No In review
SW7220107 No In review
SW7050125 No j In review
SW7170605 ' No 1 In review
SW7000817 No I In review
SW7220108 • No In review
SW7211215_ No , In review
I SW7211219I No Registered
SW7211001 No j In review
SW7211207 No Rered
Bartle New PruJ s t 1/12/2022 Dunn
Craven Minor modtllcatlon 11/18/2021 Dunn
Craven Minor modlflcatlon 1/3/2022 Dian
Craven New Project I 1/24/2022 Dunn
1
0
CravenCounty Reylorid Alrport_Perldng Lot END _ Craven Minor modif1cedbn 4 1/272022 Dunn 0
Craven Airport - 97 Terminal Improv Craven Minor modification 1 1272022 Dunn 0
Cerotlna Colours Medkal Park-Doctor's Office Out Parcel - Craven New Project I 128/2022 Dunn _0 0
_ .. _� __ . _ _- ._-�-_._ ___ _ _____ -_-- Cunitudt _ Major modification 1 8282021 Dunn 1 1 118 10/72021
ICrrrrtttrdt Minor modification 1 1/72022 Dunn I 0 I 0
Gu muck Major mot:Micatlon 128/2022 Dunn 0 0
Currftudt pp New Project 1282022 Dunn 0 0
Dare New Pro =. 12222021 Dunn 0 0
32 _ 12/30/20211
0
Creekslde Estates •
'Mndswept Pines- Ph 1 & Ph 2
Moyock Middle Scholl - - -
Moyock Middle School Addltlons and Modifications
Retell Building
Oregon Inlet Fishing Center__ _ -__-,
Volcano Restaurant
Sargent Investment Group Driveway and Parking
SW7050808 t No In review Bunn Branty Enterprises -Handy Mart
SW7160802' No In review Lake View at Currttuck, PUD - Residential and Commerical Tract # 1
In review Faml Dollar Curridrek
In review Wenchese Marine Industrial Park WWTP
SW7220102 No Registered Cape Hatteras Court _
Registered N - Seine Seafood Rebuild
In review_, Elizabeth City Airport Apron Expanalon
In review DRS - Phase 2
SW7220105 No
_i
SW7021109 i No
SW7220108 ; No
SW7060532 No
SW7070708 J No
SW7091117 No In review USCG -Replacement MInl-Mart/Exchan{ Sup in Center Elizabeth City
SW7090805 I No In review Dollar General - Lewiston
SW7080407
S W7080518
8W7060803
No
SW7070805 : No •
SW7070916 No
SW7970407 t No
SW7060117 ' No i
SW7080928 L No
No _ In review - Waterford Landing - Express _ _ _.- _ .-- _
No In review Branchslde Commercial Subdivision _Ph III _Express
Vanceboro Bojangles 1 Trade 1/..11co - Express New Bern Toyota - _ -
In review
In review
In review Main Street Sell Storage Expanabn
In review _'Graveyard AtlanticMuseum Bidg _ _
In review Oasts Hotel
In review-jCtm_'n B's Campground
11
0_
0
Dare _ New Project
Pesquotenk _ .New Project T
Beaufort New Project
Craven Minor modiflcatlon
Currttuck ) Minor modification
Cunitudt New Project
Dare _ W
Dare_
Dare I New Project
Peaouotaik ! Renewal
Pasquotank Renewal
Pasquotank 1 Renewal
Bettie
Renewal
New Project
-Dunn
10/42021 Dunn
fi Moore
1/28/2022 I Moore
1242022 Moore
o_ 0
1 73 11 /19/2021 •
1 48 12/14/2021 1'(
-
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124r1yz1 'Moore_ 0 - _ 0 -
822J2020_(Moore
Moore
_.IMoore
122220211Moore
12222021 1 M oore
12/22/2021 'Moore
ewal with major mod 1242022 Home_
Craven Renewal 1/8/2022 Thorpe 0 I 0 i 26 - 4/B/2022
Craven a Renewal 1/8/20224Thorpe A 0 0 �� 26 4/82022
Craven Renwal ._0..-25e�4/62022 j
Craven Renewal_12820221Thorpe 0--1---- - -- L4/26/2022I
3 I
Craven_ ` Renewal _12720 22 Tho_Re_._._-0--; Q� ..--_--- L.. _.4 ! 4272022 -
Dere - _ Renewal _ _ 1/6/2022 jlTtorpe 0 I
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Dare_ ' Renewal i1/11/2022 IThpime _., _ _ - 0 � _ 2b 14/8i1021 20 4/11rnrz1I - _
Daret Renewal + 1/24/2022'Thorpe -It- 0 0 7 4242022
1
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44 2/312022 '
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4/24/2022
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aBLACK&VEATCH
Building a world of difference?
TOWN OF LA GRANGE, NC
2021 WATER AND SEWER IMPROVEMENTS
GRAVITY SEWER, WATER LINE AND PUMP STATION
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iBLACK &VEATCH
Balding • world of dtlr.nc.
TOWN OF LA GRANGE, NC
2021 WATER AND SEWER IMPROVEMENTS - GRAVITY SEWER, WATER LINE AND PUMP STATION - PROJECT MAP
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