WQ0043329_Application (FTSE)_20220406

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
VS294to be completed by DWR)
All Items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Harnett Regional Water (company, municipality, HOA, utility, etc.)
2. Applicant type: D Individual El Corporation D General Partnership
Federal El State/County Eg Municipal
3. Signature authority's ntune: Steve Ward per 15A NCAC 02T .0106411
Title: public Utilities Director
4. Applicant's mailing address: 700 McKinney Parkway
City: J llippfirn State: NC Zip: 27546-
5. Applicant's contact information:
0 Privately -Owned Public Utility
D Other
NC Dept of Environmental Quality
MAR 2 9 2022
Raleigh Regional Office
Phone number (9Ji) 893-7575 Email Address: swardaPharnettorgl scummingsakamettorg
II. PROJECT INFORMATION:
I. Project name: Partridge Village Subdivision
2, Application/Project status: [8] Proposed (New Permit)
El Existing Permit/Project
If a modification, provide the existing permit munber WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WOO,
3. County where project is located: Harnett
4, Approximate Coordinates (Decimal Degrees): Latitude: 35,457472° Longitude: -78.799629°
5. Parcel ID (if applicable): 0662-01-2507 (Harnett Comity PIN)
(or Parcel ID to closest downstream sewer)
IIL CONSULTANT INFORMATION:
1.
Professional Engineer: Tom Spaulding. PE
Finn: The Spaulding Group. PA
Mailing address: 5318 Burning Oak Ct.
City: Raleigh State: ?Lc Zip: 27606-
Phone number (919) 661.07.8. Email Address: tomf4spaulding-grouri.com
License Number: 19375
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Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 —FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: l l W4 13 (to becompleted by DWR)
All Items must be comnleteed��,or��1theee application wW he returned
L APPLICANT INFORMATION:
1. Applicant's name: Harnett Regional Water (company, municipality, ROA, utility, etc.)
2. Applicant type: 0 Individual ❑ Corporation 0 General Partnership
0 Federal 0 State/County ® Municipal
3. Signature authority's name: Stvinyanti per 1 •A NCAC 021.0106(_hl
Title: Public Utilities Director
4. Applicant's mailing address: 700 McKinnev Parkwav
City: rUllington State: NC Zip: 27546-_
5. Applicant's contact information:
Phone number: 910 S93-7575 Email Address: sward(athamettorg/ sr, mmi+ingskharnett.orR
H. PROJECT INFORMATION:
1. Project name: Partridge Vil .ge Subdivision
2. Application/Project status: Proposed (New Permit) 0 Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date:
If new construction but part of a master plan, provide the existing permit number W000
3. County where project is located: Harnett
4. Approximate Coordinates (Decimal Degrees): Latitude: 35A57472° Longitude: -78.799629°
5. Parcel ID (if applicable): 0662-01-2507 (Harnett County PIN)
(or Parcel ID to closest downstream sewer)
HI. CONSULTANT INFORMATION:
1. Professional Engineer: Tom Spaulding. PE License Number: 19375
Firm: The Spaulding Group, PA
Mailing address: 5318 Burning Oak Ct
City: Raleigh State: dljQ Zip: 77606-_
Phone number 919 66Q-1078 Email Address: tomaspaulding-grourkcom
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
1. Facility Name: North Harnett WWTP Permit Number NC0021630
Owner Name: Harnett Regional Water
V. RECEIVING DOWNSTREAM SEWER INFORMATION Of different than W WTF):
1. Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System PeunitNlurnbertg Uf gain icable): WQCS
Owner Name(s): klarnett Regional Water
❑ Privately -Owned Public Utility
❑ Other
NC Dept of Environmental Quality
MAR 2 9 2022
Raleigh Regional Office
FORM: FTA 04-16
Page 1 of 5

VL 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 (1+O1R1v1: DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Hgnne/ ronerty Owners' Association, has an Operational Ayrnement (FORM: }3OAJ been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
�l
Residential Owned
❑ Residential Leased
❑ School / preschool / day care
❑ Food and drink facilities
❑ Businesses / offices / factories
❑ Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
5. Nature of wastewater : 100 % Domestic/Commercial _% Commercial
_ % Industrial (See 15A NOM; 02i 01.Q ,(2Q))
)Is there a Pretreatment Program in effect?
6. Has a flow reduction been approved under 15A NCAC 02T .0114(0? ® Yes
> If yes. provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool /Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
❑ Yes ❑ No
❑ No
Establishment Type (see 02T.0114(fl)
Daily Design Flow a
No. of Units
Flow
Single -Family Residence
400 gal/day
60
24,000 GPD
gal/
GPD
gal/
GPD
gali
GPD
gal/
GPD
gal/
GPD
Total
24,000 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 C ,_S 4244.).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A21ICAC 02T.0114j shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project 24.000 GPD (per 15A NCAti 021:.0.114)
> 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
❑ Flow has already been allocated in Permit Number.
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16
Page 2 of 5

VII. GRAVITY SEWERDESIGN CRITERIA at Applicable) - 02T .03_0 & MDC (Gravity Scwers1:
1, Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
3,036
PVC
8
438
DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
A Section HI contains information related to minimum slopes for gravity sewer(s)
> °vomizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIH. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T,0305 & MDC tMame Stations/Force Mainsl:
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: _
2.
3.
4.
5.
Approximate Coordinates (Decimal Degrees): Latitude: . ° Longitude: -
Design flow of the pump station: _ millions gallons per day (firm capacity)
Operational point(s) of the pump(s): gallons per minute at _ feet total dynamic head (TDH)
Summarize the force main to be permitted (for this Pump Station):
6. Power reliability in accordance with 15A NCA C 02.1 :030a1y11):
❑ Standby power source or pump with automatic activation and telemetry -15A NCAC 02T .0305(hx1)(13);
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
S. 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 - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
> 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 pump, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations found in 15A NCAC O2T .03051f1 & I g
D ISA NCAC 02T 0305t Il contains minimum scparations that shall be provided for sower systems:
® Yes ❑ No
Setback Parameter*
Separation Required
24 inches
Storm sewers and other utilities not listed below (vertical)
Water mains (vertical -water over sewer including in benched trenches)
18 inches
Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
15 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
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands (see item IX.2)
50 feat
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
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 swimmingpools
10 feet
Final earth grade (vertical)
36 inches
➢ I5A NCAC 02T.0305(t) contains alternatives where separations in 02T.0305(f) cannot be achieved.
> **Stream classifications can be identified using the Division's NC Surface Water Cjaskjfl shone SET
➢ If noncompliance with 02T.0305(t) or (g), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No ❑ 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 ) 5A NCAC 02B .0290? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A_NCAC 2)3 0202
4. Does the project require coverage/authorization under a 404 Nationwide or
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 3 {js1r nnit in rti3.raueh
® Yes ❑ No
5. Does project comply with 15A NC A.t02TA 105W1)r (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 021.0105tc t(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 ®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 thepermtttee 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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 025, the ireirnuer Desifoi Criteria fin fhb PcpnittiWt vf•jmp SiAP9ns
oifFinalVaiinilatest versions, and the Gravity Sewer Minimum Design Criteria (latest versionnp as applicable?
®Yes No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and suppordne documents.
2. Professional Engineer's Certification:
I _ attest that this application for
(Professional Engineer's name from Application Item III.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, 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 I43-215.6B, 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 Professional Engineer's seal, signature, and date:
Q'
.e is SEAL r1
a i 19375
h
:•`e 4h
-T
3. Applicant's Certification per 15A NCAC 02T .0106(b):
, 4-c vc /A)a.r (11 /Frye ? or
(Signature Authority's name & title from Application Item I.3.)
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 I43-215.6A and .L4341.5 i1, 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 $10,000 as well as cj$il penalties up to $25,000 per violation.
lii
Signature:
1f-vi-
attest that this application for
Date: " 24 -1 ) Z
FORM: FTA 04-16 Page 5 of 5

Division of Water
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Harnett Regional Water
Project Name for which flow is being requested: Partridge Village Subdivision
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: North Harnett Regional WWTP
b. WWTP Facility Permit #: NC0021636
c. WWTP facility's permitted flow
Fuquay-Varina Allocated Flow
Lillington Allocated Flow
Angier Allocated Flow
d. Estimated obligated flow not yet tributary to the WWTP
FV Obligated Flow NYT
Lillington Obligated Flow NYT
HC Obligated Flow NYT
Angier Obligated Flow NYT
e. WWTP facility's actual avg. flow
FV Actual Flow
Lillington Actual Flow
HC Actual Flow
Angier Actual Flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
FV Actual Avg. + Obligated Flow
Lillington Actual Avg. + Obligated Flow
HC Actual Avg. + Obligated Flow
Angier Actual + Obligated Flow
h. Percent of permitted flow used
All flows are in MGD
7.5 MGD
2.60 MGD
1.20 MGD
1.008 MGD
2.231 MGD
0.685 MGD
0.237 MGD
0.662 MGD
0.647 MGD
5.200 MGD
1.344 MGD
0.642 MGD
2.568 MGD
0.646 MGD
0.024 MGD
7.455 MGD
2.029 MGD
0.879 MGD
3.254 MGD
1.293 MGD
99.4%*
*A PER to expand the NHRWTTP treatment capacity has been completed and design of the
expansion is currently underway.
Page 1 of 4
FTSE 06-13

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) (EFlA-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm / pf), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
SLS 120 14.4 5.76 3.558 2.113 5.693 0.067
* The Firm Capacity 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.
*** 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): North Harnett Regional WWTP
Downstream Permit Number: NC0021636
III. Certification Statement:
I g 2 Ward b i reCtryr 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 adddums for which I am the responsible party. Signature of this
form indicates acceptance of j} • stewater flow.
Signing Official Signature
Date
Page2of4
FTSE 06-13

2'
cni
yf

5
NC Dept of Environmental Quality
THE SPAULDING GROUP, PA
planning • civil engineering
November 23, 2021
Raleigh Regional Office — Water Quality Section
Jason Robinson
3800 Barrett Drive
Raleigh, NC 27609
RE: Partridge Village Subdivision
Town of Lillington, NC
Fast -Track Application
MAR 2 9 2022
Raleigh Regional Office
Dear Mr. Robinson,
Please see enclosed two (2) sets of Fast -Track Applications (FTA 04-16) and an accompanying review
fee check of $480.00 for the subject project for your review and approval.
The proposed Partridge Village Subdivision is located on the East side of NC 210 approximately
1,000 feet South of Harnett Central Road in Harnett County, NC. We are seeking a permit to install a
public sanitary sewer extension to serve 60 proposed single-family and townhome residences.
The proposed sanitary sewer extension consists of 3,036 LF of 8" PVC and 438 LF of 8" DIP
extending from an existing manhole that is part of the Quail Glen phase 6 subdivision to the North.
The proposed sanitary sewer main will be public. The construction of this sanitary sewer extension is
projected to begin in Spring of 2022.
If you have any questions or need any additional information, please contact me at [phone].
Sincerely,
Thomas Spaulding, PE
The Spaulding Group, PA

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
1SA NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A [NCAC 023 and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, j5A
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15t Nc'Ac.Ofl.. _)3Q5 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 021,032.
NC Dept of Environmental Quality
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 15A NCAC 1C .0100;
➢ Projects that do not meet any part of the minimum design criteria (MDC) document; MAR 2 9 2022
➢ Projects that involve a variance from the requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank-effluentpumps (STEPs) or simplex grinder pumps Raleigh Regional Office
A STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
A 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 shalladditionasubmitl
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
> If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
El Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
T. Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
El 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 Np h CaroiinaSecreotly of State.
p If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
El The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
El The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a 1; ; for tl
(awlina licensed Pref'e lional Nieu:we).
El The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15L NCAC 02 I .O 101411.
Per 15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 3

E. Flow Traeldng/Aeceptance Form (Form: FTSE 04-16) Of Applicable):
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
> Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate O.S. 143-
215.67(al.
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USOS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
D Downstream connection points and permit number (if known) for the receiving sewer
Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
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 during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15ANCAC 02T .Q305112 € , submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
> It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump station."
> If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump
stations' storage capacities and the rotation schedule of the portable power source or pump, including travel
timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
L Certificate of Public Convenience and Necessity (All Applicadon Packages for Privately -Owned Public Utilities):
❑ Per JjAh NQA . 022T .01151alit) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Appllcatlons from HOA/POA and Developers for lots to be sold):
❑ Home/Pronerty Owners' Associations
❑ Per 15A NCA.0 02T .01 15is1, submit the properly executed Operational Arpaec pier¢ jl?()RZW,1;IOR 1.
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed ° azUonal. AgreemenUJ 01110.:_DEy).
For more information, visit the Division's collection systems x.et......
INSTRUCTIONS FOR FORM: ETA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Oficg
2090 US Highway 70
Swannanoa, North Carolina 28778
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
Water Qualify Section
Fayetteville Realanai 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 Renlonal Office
610 E. Center Avenue
Mooresville, North Caroline 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Water Quality Section
Raleigh Regional Office
1628 Mall Service Center
Raleigh, North Carolina 27699-1628
[phone]
[phone] Fax
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Water Grielitv Section
Waahinnton Regional Office
943 Washington Square Mali
Washington, North Carolina 27889
[phone]
[phone] Fax
Beaufort, Berge, Camden, Chowan, Craven,
Currltuck, Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington, Wayne
Water Quality Section
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunsvlck, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pander
Water Quality Section.
Winstorn-Sgi m Renionai. A,fyca
450 W. Hanes Mill Road
Suite 300
Winston-Salem, North Carolina 27105
[phone]
Alamance, Allegheny, Agra, 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

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