WQ0043303_Application (FTSE)_20220323

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: f.= 0'1TSOS (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Mount Airy (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: Mitchell R. Williams per 15A NCAC 02T .0106(b)
Title: Public Works Director
4. Applicant's mailing address: 440 E Pine St
City: Mount Airy State: NC Zip: 27030-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Lebanon Hill Townhouses
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: W000
3. County where project is located: Surry
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.5131° Longitude: -80.6091°
5. Parcel ID (if applicable): 502007697168 (or Parcel ID to closest downstream sewer)
IH. CONSULTANT INFORMATION:
1. Professional Engineer: Jeffrey M Boyles License Number: 018851
Firm: Moore and Associates Engineering and Consulting
Mailing address: 401 S Main St, Suite 200
City: Mount Airy State: NC Zip: 27030-
Phone number: [phone] Email Address: j.boyles(cr�,manda-inc.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: W WTP Permit Number: NC0021121
Owner Name: City of Mount Airy
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00033
Owner Name(s): City of Mount Airy
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 ❑ No ®N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned)
❑ Residential (Leased)
0 School / preschool / day care
❑ Food and drink facilities
O Businesses / offices / factories
0 Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes 0 No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? 0 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(0)
Daily Design Flow a,h
No. of Units
Flow
2-Bedroom Residential Condominiums
240 gal/day
22
5280 GPD
gall
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
5280 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(I) 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: 5280 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

VH. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
827
PVC/DIP
➢ Section II & DI 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 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 (Pomp Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: . Longitude: - . °
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.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, 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 webpage
2. Does this project comply with the minimum separation requirements for water mains?
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and sub
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands?
➢ 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.
® Yes ❑ No ❑ N/A
a separate document,
❑ Yes ❑ No ®N/A
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 0 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 0 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?" 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 15A 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/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the req uest 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, Jeffrey M Boyles , attest that this application for Lebanon Hill Townhouses
(Professional Engineer's name from Application Item 111.1.) (Project Name from Application Item II.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 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. 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 Qgo`,S�tQ ,Q 4
ooa.�q l C1...c.,q.p
a'itss
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Mitchell R. Williams , attest that this application for Lebanon Hill Townhouses
(Signature Authority Name from Application Item I.3.)
(Project Name from Application Item II.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 retumed 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.
Date: 3. l7.2
FORM: FTA 06-21
Page 5 of 5

Lowe, Alexander
From: Lowe, Alexander
Sent: Thursday, March 24, 2022 12:49 PM
To: [e-mail]
Subject: Request for FastTrack Revision - Lebanon Hill Townhouses
Attachments: FTSE-10-18.docx
Good afternoon Mr. Boyles:
Thank you for taking the time to speak with me. As requested in our conversation, please submit a revised copy of page
three of form FTA 06-21. Item VIl.1 should list each material of pipe on a separate line to ensure the precise length of
each is reflected in the permit. For your convenience, you can simply edit the PDF page and send it directly to my email,
and I will add it to the permit application.
In addition to that edit, we will need you to complete and submit form FTSE 10-18 (attached), which should be signed by
a legal representative of the City of Mount Airy (I imagine Mr. Williams would be the appropriate person in this case).
This form certifies that the facility is capable of receiving this volume of waste, and is collected as part of our statewide
flow -tracking efforts. Note that only pages one and two of this form are necessary to complete and submit unless the
available capacity of the WWTP is less than or equal to zero.
As you did with the FTA, please ensure that the signature on the FTSE form is either a wet -ink signature or a secure
digital signature (such as DocuSign or Adobe), as photocopies or scans of signatures can't be accepted.
Thank you for your assistance with this paperwork. Once I receive these updates I can begin to process the forms and
draft a permit.
Best Regards,
Alex Lowe (he/him)
Environmental Specialist II
Division of Water Resources
Department of Environmental Quality
Winston-Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Cell: [phone]
Office: [phone]
1

GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravi
1. Summarize gravity sewer to be pennitted:
®
©
8
Length (feet)
Material
687
PVC
140
DIP
--
Y Section I1 & HI 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)
• 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 Main*
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
l . 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 Winn capacity)
➢ This should reflect the total GPM for thepump station with the largest pump out of service.
4. Operational point(s) per pwnp(s): gallons per minute (GPM) at - feet total dynamic head (1'DH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
If any portion of the force main is less than 4-inches in diameter, please identify the me hod of solids reduction per
MDCPSFM Section 2.0IC.1.b. 0 Grinder Pump 0 Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(I ):
❑ Standby power source or ❑ Standby pump
• Must have automatic activation and telemetry - 1.5A 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):
0 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.
FORM: FTA 06-21 Page 3 of 5

NC Department of
Environmental Quality
Received
MAR 31 2022
Winston-Salem
«Regional Office
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: G tT S m t; oo W-r H i gx
Project Name for which flow is being requested: Lebanon Hill Townhomes
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: City of Mount Airy WWTP
b. WWTP Facility Permit #: Nc 0021121
All flows are in MGD
c. WWTP facility's permitted flow 7.00
d. Estimated obligated flow not yet tributary to the WWTP 0.31
e. WWTP facility's actual avg. flow 1.9
f. Total flow for this specific request .005
g. Total actual and obligated flows to the facility 2.22
h. Percent of permitted flow used 32%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
Pump Pump
Station Station
(Name or Permit
Number) No.
Firm
Capacity, *
MGD
(A) (B)
Design
Average
Daily Flow**
(Firm / pf),
MGD
Approx.
Current
Avg. Daily
Flow, MGD
(C) (D)=(B+C) (E)=(A-D)
Obligated,
Not Yet Total Current
Tributary Flow Plus
Daily Flow, Obligated Available
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):
Downstream Permit Number:
Page l of 6
FTSE 10-18

III. Certification Statement:
I Mitch Williams, P.E. City Engineer 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 Sign
Date
Page 2 of 6
FTSE 10-18

MOORE AND ASSOCIATES
ENGINEERING AND CONSULTING
401 S. Main Street
Suite 200
Mt. Airy, NC 27030
Phone: (336] 41 5-3540
Fax: C336) 719-2020
1 009 East Avenue
North Augusta, SC 29641
Phone: C803] 279-7799
Fax: C603] 279-3848
www.MandA-inc.com
Winston Salem Regional Office
Water Quality Section
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
March 16, 2022
RE: Lebanon Hill Townhouses
Dear Reviewing Agent:
Please find attached the"application for Lebanon Hill Townhouses. The package consists of this
cover letter, the application form, the 8.5 x 11 map, and a check for $480.
NC Depart _. tarn of
RVIFIlitlerltal MI ty
Receive
MAR 2 3 2022
Winston-Salem
Regional Office
The proposed development consists of 22 2-bedroom condominiums on a disturbed area of
4.78 acres that will generate 5,280 gallons per day. An extension of 827 feet of 8" gravity
sanitary sewer line is required to serve this development.
We request a Fast Track Sewer System Extension Permit for this work. Please call me
336-755-4091 (cell) or email me at [e-mail] if you have any questions or
comments.
Sincerely,
Jeffrey M Boyles, PE