WQ0043176_Permit (Issuance)_20220225

Division of Water Resources
State of North Carolina
Department of Ens'ircrninentai Qua.litJ,
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-2.1 & SUPPORTING DOCUMENTATION
Application Number: :u± be completed by DWRl
All items must be completed or the application will be returned
I. APPLICANT Il1'FORMATION:
1. Applicant's name: Town of Carthage (company. municipality. HOA, utility, etc.)
Applicant type: 0 Individual El Corporation
0 Federal 0 State County
General Partnership
Municipal
3. Signature authority's name: Allen Smith per 15A NCAC 02T .0106E bl
Title: Public Works Director
4. Applicant's mailing address: 4.396 Hwy 15-501 (Town Flail) •
City: Carthage State: NC Zip: 28327-
5. Applicant's contact information:
Phone number; [phone] Email Address: dasmith pwdl&townofcarthace.ora
U. PROJECT INFORMATION;
1. Project name: SOUTHBURY SUBDIVISION PHASE 2
2. Application 'Project status: Proposed (New Pertnit)
If a modification, provide the existing permit number: WOO()
0 Privately -Owned Public Utility
0 Other
0 Existing Permit: Project
and issued date:
Fri 0 7 2-7-7
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: Gt,'Q00
3. County where project is located: Moore
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.325926. Longitude: -79.408962.
5. Parcel ID (if applicable): 00001 180 (or Parcel ID to closest downstream sewer)
lll. CONSULTANT INFORMATION:
1. -Professional Engineer: M. Shane Sanders License Number: 36249

G S S
ENGINEERING
V ENGINEERING I SURVEYING I PLANNING
December 28, 2021
Re: Fast Track Sewer Permit
SOUTHBURY SUBDIVISION PHASE 2
Carthage, NC
SNS Project #20119B
Project Narrative
a^
FEB 0 7 Lo1A'
FAME I i'EVf)!_EREGiONjp,i_CFFICE
This site is Phase 2 of the Southbury Subdivision development and consists of 10.06 acres of
wooded and undeveloped land that is being developed as single-family residential lots. This application is
for Phase 2 of the project and consists of 25 three -bedroom homes with a requested flow allocation of
9,000 Gal/Day. All sewer serving this project will be 8" gravity lines that will be connected to an existing
gravity line abutting the southwestern boundary of the property. Once construction is completed, all sewer
lines will be owned by the Town of Carthage and all wastewater will flow to the Moore County Water
Pollution Control Plant (WWTP Facility Permit #: NC0037508).
Respectfully,
M. Shane Sanders, PE, PLS
Principal
180 Perry Drive • Southern Pines, NC 28387 • P: [phone] • License# C-3791
w w w. s n s e n g i n e e r s. c o m

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Numbe- tto he completed by DWR)
All items must be completed or the application will be returned
APPLICANT INFORMATION:
1. Applicant's name: Town of Carthage (company. municipality, HOA, utility, etc,)
2. Applicant type: ❑ Individual 0 Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
0 Federal 0 State County ® Municipal n Other
3. Signature authority's name: Allen Smii:h per I5A NCAC 02T.0106(b)
Title: Public Works Director
4. Applicant's mailing address: 4396 Hwv 15-501 (Town Haill
City: Carthage State: NC Zip: 28327-
5. Applicant's contact information:
Phone number: [phone] Email Address: dasmith.pwd(a%townofcarthaW*e,org
II. PROJECT INFORMATION:
I, Project name: SOUTHBURY SUBDIVISION PHASE 2
2. Application ProJect staters:
Proposed (New Permit) EJ Existing Permit/Project
if a modification, provide the existing permit number: WQOO 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: Moore
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.325926. Longitude:-79.408962T_
5. Parcel ID (if applicable): 00001 180 (or Parcel ID to closest downstream sewer)
I11. CONSULTANT INFORMATION:
I. Professional Engineer: M. Shane Sanders License Number: 36249
Firm: SNS En ineerine, Inc.
Mailing address: I08 Perry Drive
City: Southern Pines State: NC Zip: 28387-
Phone number: [phone] Entail Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name; Moore County Water Pollution Control Plant Permit Number: NC0037508
Owner -Name: Moore County Public Utilities
V. R.ECEIVINC DOWNSTREAM SEWER INFORMATION:
1 Perm it Nurn ber(s): NC003 7508
Downstream (Receiving) Sewer Information: inch E Gravity 77 Force Main
3. System Wide Collection System Permit Number(s) (if applicable):
Owner Nante(s): Moore County Public Utilities
FORM: FTA 06-7 1
Page l,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?
0 Yes [f No E NA
2. If the Applicant is a Developer of lots to be sold, has a Developers Operational AoreementSFORM: DEV) been attached?
❑Yes No NNA
3. 1f the Applicant is a Home Property Owners' Association; has an HOA POA Operational Agreement (FORM: HOAI and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
[[Yes .❑No NA
4. Origin of wastewater: (check all that apply):
IZ Residential (Individually Owned) 0 Retail (stores, centers, malls)
0 Residential (Leased) 0 Retail with food preparation service
❑ School preschool day care [] Medical dental veterinary facilities
[] Food and drink facilities ❑ Church
0 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 : ) 00 ° ° Domestic ° ° Commercial °b Industrial (See 15A NCAC 02T.0103(201)
If Industrial, is there a Pretreatment Program in effect? 0 Yes [ No
6. Has a flow reduction been approved under 15A NCAC 02T .01 14(1)? 0 Yes Z No
> If ves, 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 °'b
No. of Units
Flow
3 Bedroom Residential Dwellings
360 gaLunit
25
9,000 GPD
gal
GPD
gal
GPD
gal
GPD
gal
GPD
gal
GPD
Total
9,000 GPD
a See I5A NCAC 02T .0114(b1. till, tea I) and fen2t 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 Watenvay to be used as vacation rentals as defined
n G.S. 42A-4).
b Per I5A NCAC 02T .0114(c), design flow rates for establishments not identified [in table I5A NCAC 02T.01141 shall be
detenn fined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 9.440 GPD (per I5A NCAC 02T .0114)
> Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
1,0 Pump Station Force iviai❑ of Graoity Sewer where tlow will be petmivad in subseyueu peunits that cuuuect iu this lice.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flaw.
0 Plow has already been allocated in Permit Number: _ Issuance Date:
[7 Rehabilitation or replacement of existing sewers with no new flow expected
0 Other (Explain):
FORM: ETA 06-2I
Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
I. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
1,381
PVC
8
462
Ductile iron
Section II & 111 of the MDC for Permitting of Gravity Sewers contains information rela ed to design criteria
• Section III contains information related to minimum slopes for gravity sewer(s)
as. Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force:\lainsl:
PROVIDE. A SEPARATE COPY OF TlIIS PAGE FOR EACH PUMP STATION INCLUDED IN TIiIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - .
3. Total number of punips 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) al feet total dynamic head (TDH)
S- Summarize the force main to be permitted (for this Pump Station):
I
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
MDCPSPM Section 2.0I C. 1 .b. ❑ Grinder Pump n Mechanical Bar Screen ❑ Other (please specify)__
6 Power reliability in accordance with I5A NCAC 02T.0305(h)( I):
U S• tandby powersource or E Standby pmnp
'- MusD have automatic activation and telemetry - 15A NCAC 021'.0305(h)(I)(B)i
o Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
pet manent to tauuty ana inay not oe pottaure
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(I0(I)(C):
Li P• ortable power source with manual activation, quick -connection receptacle and telemetry -
or
P• ortable pumping unit with plugged emergency pump connection and telemetry:
3 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)?
I SA NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems
® Yes ❑ No
Setback Parameter*
Separation Required
Stonn sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class 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, HOW, 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 webnage
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(0 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: ® 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)? E Yes ❑ No
Per I SA NCAC 02T O105(c)(61_ directly related enviromnental 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, stonnwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes Z 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:
Does the submitted system comply with I5A NCAC 02T, the Minimum Desien Criteria for the Permittiti of Pump Stations
and Force Mains t latest version), and the Gravity Sewer Minimum Desien Criteria t latest version] as applicable?
Z Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance Alternative Design Request application
(VA DC 10-14) and supporting documents for review to the Central Office. Aguroval of the request will be issued
concurrently with the approval of the permit and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2 Professional Engineer's Certification:
I, M. Shane Sanders attest that this application for SOIJTHBURY SUBDIVISION PHASE 2
(Professional Engineers name from Application Item 111 I.) (Protect Name from Application Item III )
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 Gravit Sewers (latest version) and the Minimum Desien 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 1 es and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (24AC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per I5A NCAC 02T .0106(h):
1 actecrAtie
(Signature Authority Name from Application Item 13 )
, attest that this application for SOUTHBURY SUBDIVISION PHASE 2
(Project Name from Application Item III )
attest that this application has been reviewed by the and is accurate and complete to the best of my knowledge.
I understand that if all requiredparts 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. 1 will make no claim against the Division
of Water Resources should a condition of this permit he violated. 1 also understand that if all required park of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE In accordance with General Statutes I43-215.6A and 143-215.613. 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: Owl Set
Date: //zt/Zell
FORM: FTA 06-21 Page 5 of 5

.,,. State of North Carolina
if •„(. jl 4i Department of Environmental Quality
Division of Water Resources
PE `' 7 Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocat o'hYL l"I LTii h
Project Name for which flow is being requested: Southbury Subdivision Phase 2
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
statlotrs along the route of the proposed wastewater from
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name:
b. WWTP Facility Permit #:
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
0.009
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design
Average Approx. Obligated, Total
Pump Pump Daily Current Not Yet Current Flow
Station Station Firm Flow** Avg. Daily Tributary Plus
(Name or Permit Capacity, * (Firm / pf), Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
Hwy 22 WQ0036420 0.460 0.276 0.145 0.0778 0.2227 0.0532
Cox WQ0036420 0.864 0.400 0.278 0.0778 0.3558 0.0442
McCaskill WQ0036420 0.864 0.4320 0.29 0.1210 0.1210 0.0210
* 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): Moore County Public Utilities
Downstream Permit Number: WQCS00034
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I ade certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official Signature
/Title of Signing Official
/lM/z,41
Date
Page 2 of 6
FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
/2//7/70Z/
Date
Page 3 of 6
FTSE 10-18

Instructions for Flow Tracking form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not vet tributary to the WWTP MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through interlocal
agreements or other contracts not yet contributing flow to the collection system are also included. For POTWs
that implement a pretreatment program, include flows allocated to industrial users who may not be using all of
their flow allocation. Please contact your Pretreatment Coordinator for information on industrial flow tributary
to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years and
reconciled their flow records, to the best of their ability, so it is known how much flow has been obligated and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entity.
e. WWTP facility's actual avg. flow, MGD: Previous 12 month average.
f. Total flow for this specific request MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + f]
h. Percent of permitted flow used: Equals [(g / c)*100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there is 0.5
MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f. = 0.015 MGD
g. = 3.215 MGD
h. = 53.6 %
The next Form FTSE may be npdaterl-like this with a proposed flew erpans1or of 0.102 MGD•
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
f. = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 10-18

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design average
daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow through the
pump station (C) for each pump station that will be impacted by the proposed sewer extension project. Calculate
the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D). Include the proposed flow
for this project with other obligated flows that have been approved for the pump station but are not yet tributary
(C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as per the
Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not less than
2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump station
if the system has future specific plans related to capacity that should be considered in the permitting process.
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Obligated,
Design Approx. Not Yet
Firm Average Current Avg. Tributary
Pump Station Capacity Daily Flow Daily Flow, Daily Flow,
(Name or Number) MGD (Firm / pf) MGD MGD
Kaw Creek PS 0.800 0.320 0.252 0.080
Valley Road PS
Total Current
Flow Plus
Obligated Available
Flow Capacity*
0.332 -0.012
1.895 0.758 0.472 0.135
0.607 0.151
Page 5 of 6
VISE 10-18

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section 1I where available capacity is < 0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated flows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary overflows and must take all steps necessary to complete the project or control
the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned project in
the future not yet funded but in a formal plan adopted by the system. The system should carefully weigh the
certainty of successful timely project completion for any expansion, flow management diversion or infiltration and
inflow elimination projects that are the foundation of a planned solution to capacity tracking and acceptance
compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080 MGD of the
committed flow in Pump Station Kaw Creek• and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with planned
completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project entitled
Kaw Creek Pump Station upgrade with funding planned in July 2014. This project is planned to add 0.100 MGD
to the firm capacity of the pump station by October 2015. Inclusion of thisproposed capital project as a condition
of this Flow Tracking/Acceptance for Sewer Extension Permit Application elevates this project's priority for
funding and construction to be implemented ahead of the activation ofoblgated not yet tributary flows in amounts
that exceed the firm pump station capacities identified in Section I1 above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow this flow
to be permitted, without a significant likelihood of over -allocating capacity in the system infrastructure.
Page 6 of 6
FTSE 10-18

P 0", WO/
State of North Carolina
Department of Environmental Quality
Division of Water Resources
WO., (1 y Flow Tracking for Sewer Extension Applications
'- (FTSE 10-18)
Entity Requesting Allocation: Town of Carthage
Project Name for which flow is being requested: Southbury Subdivision Phase 2
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: Moore County Water Pollution Control Plant
b. WWTP Facility Permit #: NC 0037508
All flows are in MGD
c. WWTP facility's permitted flow 10.0000
d. Estimated obligated flow not yet tributary to the WWTP 0.67261
e. WWTP facility's actual avg. flow 5.45000
f. Total flow for this specific request 0.00900
g. Total actual and obligated flows to the facility 6.13161
h. Percent of permitted flow used 61.3161
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (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 / pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
* 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 facto'
(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): Moore County Public Utilities
Downstream Permit Number: WQCS00034
Page 1 of 6
FTSE 10-18

III. Certification Statement:
1 Randy G. Gould, PE certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Off
a {�J
//C (41G 4.5 ref%
Title of Signing Official
Page 2 of 6
FTSE 10-18

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ENGINEERING
\f ENGINEERENG
December 28, 2021
Re: Fast Track Sewer Permit
SOUTHBURY SUBDIVISION PHASE 2
Carthage, NC
SNS Project #20119B
Project Narrative
i SURVEYING j PLANNING
FEB 0 7 ID
FAYE "IEVIL''(‘ii::'.(E'-'1:0(:::31\j/j CIFFI
This site is Phase 2 of the Southbury Subdivision development and consists of 10.06 acres of
wooded and undeveloped land that is being developed as single-farnily residential lots. This application is
for Phase 2 of the project and consists of 25 three -bedroom homes with a requested flow allocation of
9,000 Gal/Day. All sewer serving this project will be 8" gravity lines that will be connected to an existing
gravity line abutting the southwestern boundary of the property. Once construction is completed, all sewer
lines will be owned by the Town of Carthage and all wastewater will flow to the Moore County Water
Pollution Control Plant (WWTP Facility Permit #: NC0037508).
Respectfully,
M. Shane Sanders, PE, PLS
Principal
180 Perry Drive • Southern Pines, NC 28387 • P: [phone] • License4 C-3791
w w w. s n s e n g i n e e r s. c a m

Division of Water Reso
FEB 0"I UV
.115-W- rlEvil E
State of North Carolina
Department of Environmental Quality
Division of Water Resources
x 1ii4 Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Carthage
Project Name for which flow is being requested: Southbury Subdivision Phase 2
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: Moore County Water Pollution Control Plant
b. WWTP Facility Permit #: NC 0037508
All flows are in MGD
c. WWTP facility's permitted flow 10.0000
d. Estimated obligated flow not yet tributary to the WWTP 0.67261
e. WWTP facility's actual avg. flow 5.45000
f. Total flow for this specific request 0.00900
g. Total actual and obligated flows to the facility 6.13161
h. Percent of permitted flow used 61.3161
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (1) (C) (D)=(n+C) (E)=(A-D)
Design Obligated,
Pump Pump Average Apptnx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm 1pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
* 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): Moore County Public Utilities
Downstream Permit Number: WQCS00034
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Randy G. Gould, PE certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Date
Page 2 of 6
FTSE 10-18

V
4E:r YEI[EVIL!,
State of North Carolina
Department of Environmental Quality
Division of Water Resources
tow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Carthage
Project Name for which flow is being requested: Southbury Subdivision Phase 2
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:
b. WWTP Facility Permit #:
Al/ flows are in MGD
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request 0.009
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design
Average Approx. Obligated, Total
Pump Pump Daily Current Not Yet Current Flow
Station Station Firm Flow** Avg. Daily Tributary Plus
(Name or Permit Capacity, * (Firm / pt), Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
Hwy 22 WQ0036420 0.460 0.276 0.145 0.0778 0.2227 0.0532
Cox WQ0036420 0.864 0.400 0.278 0.0778 0.3558 0.0442
McCaskill WQ0036420 0.864 0.4320 0.29 0.1210 0.1210 0.0210
* 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
(p0) 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): Moore County Public Utilities
Downstream Permit Number: WQCS00034
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I ar certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
ase
Signing Official Signature
0c✓a 4✓a Grt[t Lehr
/Title of Signing Official
/l07/z2LI
Date
Page 2 of 6
FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
/4 /%7/70Z/
Date
Page 3 of 6
FTSE 10-18

Instructions for Flow Tracking form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not yet tributary to the WWTP, MOD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through interlocal
agreements or other contracts not yet contributing flow to the collection system are also included. For POTWs
that implement a pretreatment program, include flows allocated to industrial users who may not be using all of
their flow allocation. Please contact your Pretreatment Coordinator for information on industrial flow tributary
to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years and
reconciled their flow records, to the best of their ability, so it is known how much flow has been obligated and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entity.
e. WWTP facility's actual avg. flow, MGD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d+e+f]
h. Percent of permitted flow used: Equals [(g / c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there is 0.5
MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f. = 0.015 MGD
g. = 3.215 MGD
h. = 53.6 %
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
f. = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 10-18

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design average
daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow through the
pump station (C) for each pump station that will be impacted by the proposed sewer extension project. Calculate
the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D). Include the proposed flow
for this project with other obligated flows that have been approved for the pump station but are not yet tributary
(C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as per the
Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pt) of not less than
2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump station
if the system has future specific plans related to capacity that should be considered in the permitting process.
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Obligated,
Design Approx. Not Yet Total Current
Firm Average Current Avg. Tributary Flow Plus
Pump Station Capacity Daily Flow Daily Flow, Daily Flow, Obligated Available
(Name or Number) MGD (Firm / pf) MGD MGD Flow Capacity*
Kaw Creek PS 0.800 0.320 0.252 0.080 0.332 -0.012
Valley Road PS 1.895 0.758 0.472 0.135 0.607 0.151
Page 5 of 6
FTSE 10-18

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity is < 0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated flows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary overflows and must take all steps necessary to complete the project or control
the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned project in
the future not yet funded but in a formal plan adopted by the system. The system should carefully weigh the
certainty of successful timely project completion for any expansion, flow management diversion or infiltration and
inflow elimination projects that are the foundation of a planned solution to capacity tracking and acceptance
compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080 MGD of the
committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with planned
completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project entitled
Kaw Creek Pump Station upgrade with funding planned in July 2014. This project is planned to add 0.100 MGD
to the firm capacity of the pump station by October 2015. Inclusion of this proposed capital project as a condition
of this Flow Tracking/Acceptance for Sewer Extension Permit Application elevates this project's priority for
fundingand construction to be implemented ahead of the activation of obligated, not yet tributary flows in amounts
that exceed the firm pump station capacities identified in Section II above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow this flow
to be permitted, without a significant likelihood of over -allocating capacity in the system infrastructure.
Page 6 of 6
FTSE 10-18

Division of Water Resource` 'r
�_'i 0 7 Z D2 _
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTAT ION
vii
Application Number: _ (io be completed by DWR?
All items must be completed or the application will be returned
APPLICANT INFORMATION:
1. Applicant's name: Town of Carthage (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: Allen Smith per I5A NCAC 02T .010651)
Title: Public Works Director
4. Applicant's mailing address; 4396 Hwy 15-501 (Town Hall)
City: Carthage State: NC Zip: 28327-
5. Applicant's contact information:
Phone number: [phone] Entail Address: dasmith.pwel@townofcarthage,ore
II. PROJECT INFORMATION:
I. Project name: SOUTHBURY SUBDIVISION PHASE 2
2. Application Project status:
Proposed (New Permit)
If a modification, provide the existing permit number: WQ00
❑ Existing PermitiProject
and issued date:
For modifications, also attach a detailed narrative description as described in Item C of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQOO
3. County where project is located: Moore
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.325926. Longitude: -79.408962,
5. Parcel ID (if applicable): 00001 180 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: M. Shane Sanders License Number: 36249
Firm: SNS Engineering, Inc.
Mailing address: 108 Perry Drive
City: Southern Pines State: NC Zip: 283$7-
Phone number: [phone] Email Address: shanefasnsengineers,com
IV, WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1_ Facility Narne: Moore County Water Pollution Control Plant Permit Number: NC0037508
Owner Narne: Moore County Public Utilities
V. RECEIVING DOWNSTREAM SEWER. INFORMATION:
1. Permit Nunzber(s): NC0037508
2, Downstream (Receiving) Sewer information: inch
3. System Wide Collection System Permit Number(s) (if applicable):
Owner Name(s): Moore County Public Utilities
FORM: FTA 06-21
t.7 Gravity 7 Force Main
Page 1 of 5

VI. CENERALREQUIREMENTS
L 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 Developers Operational Agreement i FORM: DEVI been attached?
❑ Yes ❑ No ® N'A
3. If the Applicant is a Home Property Owners' Association, has an HOA POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 1 5A NCAC 02T.0115(c) been attached?
❑Yes ❑No MINA
4. Origin of wastewater: (check all that apply):
C
Residential (Individually Owned)
❑ Residential (Leased)
❑ School preschool: day care
❑ Food and drink facilities
❑ Businesses officesfactories
❑ Retail (stores, centers. malls)
❑ Retail with food preparationrservice
❑ Medical dental ' veterinary facilities
Church
❑ Nursing Horne
❑ Car Wash
❑ Hotel and/or Motels
0 Swimming PoolClubhouse
❑ Swimming Pool Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : IQ0 ° ° Domestic ° 0 Commercial 'lb industrial (See I5A NCAC 02T .0103(201)
If Industrial, is there a Pretreatment Program in effect? ❑ Yes No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(0? ❑ Yes No
> If ves, 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
3 Bedroom Residential Dwellings
360 gal/unit
25
9,000 GPD
galr
GPD
gal'
GPD
gal'
GPD
gale
GPD
gal'
GPD
Total
9,000 GPD
a See I5A NCAC 02T .0114(b). (d). (ei(1) and (e)(2) for caveats to wastewater des gn 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 I5A NCAC 02T .0114(c), design flow rates for establishments not identified [in table I5A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
S. Wastewater generated by project: 19,440 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 thts une.
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
1,381
PVC
8
462
Ductile iron
S Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
a 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
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Maine):
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:
3 Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day (firm capacity)
S This should reflect the total GPM for the pump station with the largest purnp out of service.
4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total dynamic head (TOM)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet)
If any portion of the force main is less than 4-inches in diameter, please identify the me hod of solids reduction per
MDCPSFM Section 2,0IC. I.h. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Oth m (please specify)
6. Power reliability in accordance with 15ANCAC 02T.0305(h)(1):
❑ Standby power source or ❑ Standby pump
Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(I )(B)
3 Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
r Must he 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.
Y 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 purnp, including travel timeframes_ shall be provided
as part of this permit application in the case of a multiple station power outage.
FOR Ft A 06-21 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(11 & (g)? Z Yes 0 No
i SA NCAC 02T.0305(fl contains mininmm separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
?Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
?Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class 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, HOW, 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 embankrnent 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
*I5A 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 0 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? Z Yes 0 No 0 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? 0 Yes Basin name: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? 0 Yes 0 No
• This includes Trout Buffered Streams per I5A 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)? Z Yes ❑ No
Per I5A NCAC 02T 0105(c)(6) directly related envirnnmental 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?" 0 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 I5A NCAC 02T, the Minimum Design Criteria for the Permittinc of Pump Stations
and Force Mains (latest version) and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
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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 projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
1, M. Shane Sanders attest that this application for SOUTHBURY SUBDIVISION PHASE 2
(Professional Engineer's name from Application Item 111 1.) (Project Name from Application Item II I)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge, 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 Force Mains (latest versionl. 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 143-2I5.6A and 143.-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable ' .es and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (24.AC 56.0701)
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North Carolina Professional Engineer's seal, signature, and date:
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, „erGe1 , attest that this application for SOUTFBURY SUBDIVISION PHASE 2
(Signature Authority Name from Application Item 13 i (Project Name from Application Item II I)
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 front this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and'or criminal prosecution. 1 will make no claim against the Division
of Waker Resnnrres ehpnld a rnnrlirinn of this permit he vinlarrd 1 also understand that if all required parts of this application
package are not completed and that if all required supporting infomaation and attaclunents are not included. this application
package will be returned to me as incomplete.
NOTE In accordance with General Statutes I43-215.6A 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: c•�'""^-.,e!� r...�e
Date: /2,
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FORM'. ETA 06-21 Page 5 of 5

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1 inch = 400 feet