WQ0043216_Application (FTSE)_20220215

LA
the
L�JNE
GROUP
February 15, 2022
NCDEQ — Division of Water Resources
Winston-Salem Water Quality Regional Operations Section
450 W. HanesMill Road, Suite 300
Winston-Salem, NC 27105
Re: Blessing Drive Stormwater Utility Improvements
Town of Dobson, NC
Dear Sir/Madam:
ertgineeffing
archffectuire
en*nk
Please find enclosed for your review/ processing the following items for the above referenced project:
- original and pne (1) copy of Form FTA 04-16 Fast -Track Sewer System Extension Application
- one (1) copy of the 8.5" x 11" Site Map
check for $480.00 made out to NCDEQ for the application fee
This project includes replacement of approximately 100 LF of existing 42" stormwater culverts and complete associated
street repairs, relocation of approximately 200 LF of 6" water line,replacement/relocation of approximately 1, 200. LF +/-
of 8" - 12" gravity sewer line, and related improvements.
Sincerely,
THE LANE
GROUP
�`x/11YnVtlUAYI
Kevin Heath, P.E.
cc: Laura Neely, Town of Dobson
KH/sct
Engineers • Architects • Surveyors • Planners • Environmental Specialist
119 North Main Street • Galax, Virginia 24333
Phone: [phone] •Pax: 276.236.0458 • www.thelanegroupinc.com

DWR
Division of `4ater Resources
State of North Carolina
Department ofEnvir•onmental Quality
Division of Water Resources
15A NCAC 02T 0300 — FAST TRACI4 SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR. FORMt FTA 04-16 & SIBPPORTING'DOCUMENTATtON
This application is for sewer extensions involving gravity sewers, pump stations and force natty or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of I5A NCAC 02T and the Division's
I Einemum Design Criteria and that plans, specifications and supporting documents bare been prepared in accordance with, ISA
NCAC 02T, ISA NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with I5A NCAC 02T .0305(b), &sign
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 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 require an environmental assessment in accordance with ISA NCAC IC .0100;
i Projects that do notmeet any part of the minimum design criteria (MDC) document,
le Projects that involve a variance from the requirements of 15A NCAC 2T;
'zr:Pressure sewer systems utilizing septic tank -effluent pumps (STEPs) or simplex grinder pumps;
D STEP 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 othenvise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
O Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
O 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.
• If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
Y Payable to North. Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
O 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 1.2 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 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
O The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer.
The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(6).
Per I5A 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).
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3
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
Page 1 of 3

E. Flow Tracking/Acceptance Form .(Form: FISE04-Ji6)(If Applicnble:
• Submit the completed and executed FTSE formfrom the mamas. of doe downstream sewers and treatment facility.
) r Multiple forms maybe required where the downstream sewer own ea and wastewater treatment facility are different.
a.‘ The flow acceptance indicated in form FTSE must not expire prior to permit issuance anti must be dated less than one
year prior to the application date,
Submittal of this application and faint FTSE indicates that orYnaer has adequate capacity and will not violate G.S. 143-
2Il 5_67(a).
y ]ntergovernmental agreements or ct!her contracts w ll not be accepted in lieu of a project -specific FTSE.
Site Maps (All Application Packages):
al Submit an 8.5-inch x 11-inch color copy ofa USC,S Topographic N ap of sufficient scale to identify the en#ire project
area and closest surface waters.
3- Location of the project (gravity sewer, pump stations & forcem
✓ Downstream connection points and permit number (if known) for the receiving sewer
O include a street level map (aerial) showing general project area so that Division staff can easily locate it in the
G. Existing Permit (All Modification Packages):
Submit the most recently issued existing permit.
• Provide a list of any items within the permit the Applicant would like the Division to address dotting the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
ID Per I5A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
Y 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 ofcertification)
1. 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 town existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOAIPOA 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 I5A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations andBy-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 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INC DING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFEf'Pr:
REGIONAL OFFICE
ADDRESS
COUNTIESSIERVEID
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 2i3778
(828) 29696-4500
[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 28301-5094
[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 281 "15
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston; lredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Water Quality Section
Raleigh Regional Office
1628 Mail Service Center
Raleigh. North Carolina 27699-1628
[phone]
[phone] Fax
Chatham, Durham, Edgeconibe, 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, Bettie, Camden, Chowan, Craven,
Currituck, Dare, Gates, Greene, Hertford, Hyde,
Water Quality Section
Jones, Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington, Wayne
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]
Alamance, Allegheny„ Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
Water Quality Section
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 3

DWR
Resources
State of North Cal Ina
DettartnrentofEnvironmental Quality
Division of Water Resources
15A NAC 02T .0300 - FAST TRACIK SEWER SYSTEM EXTENSIONAPPLICAT ION
ETA 04-16 & SUPPORTING1 CIPMENTATION
Application. Number..:
'Octal by DWR)
All items must be completed nr the anplicatiorr will be
1. APPLICANT INFORMATT1ON:
1, Applicant's name: Town of Dobson (company„ man cipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership 0 Privately-Ocned Public UUtili
❑ Federal ❑ StatefCo int}1 El Municipal ❑ Other
3. Signature authority's name: Laura Neely per ISA NCAC 02T_0106(b)
Title: Town Manager
4. Applicant's mailing address: 307 North Main Street
City: Dobson State: NC Zip: 27017-
5. Applicant's contact information:
Phone number: [phone] Email Address: laura,neely@`dobson-ne.com
11. PROJECT INFORMATION:
1. Project name: Blessing Drive Stornwater Utilitylmprovements
2. Application/Project status: ® Proposed (New Permit) 0 Existing Permit/Project
If a modification, provide the existing permit number. WQ00 and issued date:
If new construction but part ofa master plan, provide the existing permit number: WQ00
3. County where project is located: Suny
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.390287' Longitude:-80.726977°
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional. Engineer: Kevin Heath, P.E. License Number: 21204
Firm: The Lane Group
Mailing address: 119 North Main Street
City: Galax State: VA Zip: 24333-
Phone number: [phone] Email Address: kheath(ad7thelanegroupine.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Town of Dobson Wastewater Treatment Plant Permit Number: 0021326
Owner Name: Town of Dobson
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. PertnitNumber(s): WQ33695 Downstream (Receiving) Sewer Size: 12 inch_
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 Page 1 of 5

VII GENERAL 'REt41PIPLEME k'TS
1. If the Applicant is a Privately-Ow/lc
2. if the Applicant is a De eio;per offia
3. If the Applicant is a Houle/Pro
4. igin of wastevvatet {check al
Residential Owned
Residential Leased
❑ School / preschool / day ,care
Food and drink facilities
El Businesses / offices / factories
5. Nature of as ate
lie Utility, has a Certiliicale of Public Convenience and Net s try been attached?
Yes ❑ No to
be sold, has a Developer's Operational Agreement (FORM: D&iit)'be aattached?
En Yes ❑No EIN/A
s" Association, has an Operational Aereement (FORM: HOA) been attached?
❑ Yes QNo [N/A
at apply):
❑ Retail (stores centers, malls)
❑ Retailwith food preparation/service
❑ Medical / dental /veterinary facilities
❑ Chinch
❑ Nursing Home
1 GO°fo Domestic/Commercial % Commerci
% Industrial (See 15A NCAC 02T .0103(20))
Pretreatment Program in effect?
❑ Car Wash
Ej Hotel and/or Motels
❑ Swimming Pool /;Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(1)? ❑ Yes ❑ No
S If ves, provide a coijy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(fl)
Daily Design Flow °°}'
360 gal/house/day
No, of units
Flow
GPD
Residential Home
Coimmercia(Business Employees
25 gal/employee/day
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
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)
Y Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
0 Flow has already been allocated in PermitNumber:
® Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16
Page 2 of 5

1. JGRAVITY SEWER DESIGN CRITERIA (If Applicable) -02T
L S ur mariz gmwity sewer to be permitted:
Size (inch
8
Length (freer)
206
Made19d
PVC and D.I.
'12
100d
PVC and D:1l
r Section 11 & Ill of the MDC for Permitting of Gravity Sewers contains information related to desi
11- Seetion III contains information related to minimum slopes for wavily sev,
Oversizing lines to meet tninimatm slope requirement is not allowed and n violation of the MDC
VIH. PUMP STATION DESIGN CRITERIA Of Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Design flow of She pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Material
b. Power reliability in accordance with 15A NCAC 02T.0305(h)(1):
❑ Standby power source or pump with automatic activation and telemetry 15A NCAC 02T .0305(h)(I)(B)_
v 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
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - I5A NCAC 02T
.0305(h)(1)(C)
or
❑i Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(I)(C):
Y It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable 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 ptunp, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM:'FTA 04-16 Page 3 of 5

'MMTBAcI S i : SEPA13ATION'S — j02B .0200 & I5A NCAC 02T .0305(l?);
Does the project comply with all separations found in ►5A NCAC 02T .0305&5p& (g)
D 15A NCAC 02T,0305(f) contains minimum separations that shall be caviled for sewer systems:
0 es D No
Setback Parameter*
Separation Required
Stonsn Senkecs and other nethties not listed below (vertical)
24 inches
Water 7nams •(vertical -water over sewer including hi benched trenches)
: 18 inches
' 'atcr maatrs ( rzontal)
10 feel
Reclaimed water lines (vertical - reclaimed over sewer)
i 8 caches
Reclaimed water lines {horizontal - reclaimed over sewer)
2 feet
* °`Any private or public water supply source, including any wells, l3+'S-I waters of Class I er
Class II impounded reservoirs used as a source of drinking water
100 feet
*t\Vateis elassflied WS (except WS-1 or WS-,) B, SA, 'ORW,1-IQW, nr SB frotn normal
high rater jer tide elevation) and wetlands (see item IX.2)
50 feet
**Any other stream lake impoundment or ground water lowering and surface drainage
ditches
l 0 feel
Any building foundation
5 feet
Any basemen'[
10 feet
Top slope of embankmet or cuts of 2 feet or more vertieal height
10 feet
Drainage systems and interceptor drams
5 feet
Any swimming pools
10 feet
t
Final earth grade (vertical)
36 inches
Sr 1SA NCAC 02T.0305(g) contains alternatives where separations in 0210305(fl cannot be achieved.
• **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
Y if noncompliance with 02T.0305(f) or (g). see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ❑ Yes 0 No 0 N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 028 .0200? ❑ Yes ❑ No ® N/A
Y This would include Trout Buffered Streams per 15A NCAC 26.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes
individual permits or 401 Water Quality Certifications?
Y Information can be obtained from the 401 &'Buffer Permitting Branch
5. 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 are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes 0 No ❑ N/A
➢ 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 permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

CERTIFICATIONS:
submitted system comply with ISA NCAC 0211 lice vtfnimum EaesiSCt ter a farthe P rmittinaoffPump Stations
ands Rome Mk lts fdhtest version}L and the Gravity Sewer, nimum Desienicrlteriah('latest versaanhas ap7ificable2
Yes No
f No, complete and submit the Variance' Alternative Design Request application (VADC I ) and supporting documents for
nd suiepotting documents.
review. Approval of the request is required prior to submittal of the Fast. Track Appl
2. Professional Engineer's Certification:
l vnf [iglu
(Professional Engineer's n
e from Application It
i
plication for
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to 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, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to 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.
North Carolina Pro' essional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1
LA Uret Nett`s�tame —Gown etl�l�Ciel^
(Signature Authority' & title from Application Item I.3.)
SEAL 1
021204
2/a3/2z
attest that this application for
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:
Cow(flpL1
Date: () (1)aoaa
FORM: FTA 04-16 Page 5 of 5

1
he
ANE
GROUP
344834-44444
4444444444424
BLESSING DRIVE
STORMWATER UTILITY
SURRY COUNTY, NC
STREAM
LOCATION MAP
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2144
84442
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8E020 at act
Page
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12242 0242342022
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