WQ0043376_Application (FTSE)_20220420

April 19, 2022
Mr. Robert Tankard
Assistant Regional Supervisor
Division of Water Resources
NCDEQ
943 Washington Square Mall
Washington, NC 27889
,Jgoo 43 374
BISSEll
PROFESSIONAL GROUP
TheGoastatExP
RECEIVED/NCDENR/DWR
APR 2 0 2022
Water Quality
Regional Operations Section
Washington Regional Office
RE: Fast Tract Sewer System Extension Application for U Beaners Bakery and Cafe
Dear Robert,
We are submitting one original and one copy of an application and supporting documents for a fast
track sewer system extension (lift station and force main) for a bakery/cafe along with proposed office
and retail uses to be located on Survey Road in Moyock, NC (Currituck County). One existing and one
proposed building will share the grinder pump station as shown on the street level plan.
The following items are included with this cover letter:
1. Fast Track Form FTA 06-21
2. Documentation that the applicant is registered for business with the North Carolina Secretary of
State and the Annual Report
3. Flow Tracking/Acceptance Form FTSE 04-16 from Currituck County
4. 8.5-inch x 11-inch color USGS Topographic Map showing project area
5. Street level map and aerial showing the project area
6. Application fee in the amount of $480.00
We are requesting construction approval for this fast track sewer system extension application, with a
flow allocation of 486 GPD. It is our understanding that this allocation is included in the SOC agreement
between Currituck County and NDDEQ.
Please let me know if you need any additional information in order to authorize this construction.
Sincerely yours,
BISSE L ESSI.NALGROUP
rk S`Bissell,..E,
cc: Mr. Hugh S. Miller, IV
P.O. Box 1068 • 3512 N. Croatan Hwy. • Kitty Hawk, NC 27949
252-261-3266 • Fax: [phone] • E-mail:[e-mail]

RECEIVED/NCDENR/DWF'
State of North Carolina
APR 2 0 2022 Department of Environmental Quality
Division of Water Resources
DVR Water Quality
O
Regional Operations Section FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources Washington' a tONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T. 15A NCAC 02T .0300, Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in I5A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
Qlf Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
pi( List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. A plication Fee (All New and Modification Application Packages):
Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 05-21):
11:.
34
/14
0
Submit the completed and appropriately executed application.
If necessary for clarity or due to space restrictions, attachments to the application may be made.
If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
The Project Name in Item II.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3

121.
E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
3' Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Si Maps (All Application Packages):
Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
if
the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
DrDownstream connection points and permit number (if known) for the receiving sewer
Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump station."
> If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall
be provided in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 021 .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
O Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 28778-8211
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
Water Quality Section
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301-5095
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Harnett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
Water Quality Section
Mooresville Regional Office
610 E. Center Avenue
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Water Quality Section
Raleigh Regional Office
3800 Barrett Drive
Raleigh. North Carolina 27609
[phone]
[phone] Fax
Chatham. Durham, Edgecombe, Franklin.
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Water Quality Section
Washington Regional Office
943 shington Square Mall
Wa ngton, North Carolina 27889
Beaufort, Bertie, Camden. Chowan, Craven,
Currituck, Dare, Gates, Greene, Hertford, Hyde,
Jones, Lenoir, Martin, Pamlico, Pasquotank.
Perquimans, Pitt, Tyrrell, Washington, Wayne
(7
Water Quality Section (
(' 2) 946-6481
[phone] Fax
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pender
Water Quality Section
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, North Carolina 27105
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
Water Quality Section
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 1)-18)
Entity Requesting Allocation: Miller Homes & Building, LLC
Project Name for which flow is being requested: LJ Beaners Bakery
More than one FTSE may be required for a single project if the owner al the WWTF is not responsible for all pump
stations along the route of the proposed wasteirarer flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WVvTP Facility Name: Mcyeck Regional WWTP
b. WVi,'TP Facility Permit f: WQ3035706
All flows are in MGD
c. WWTP facility's permitted flow 3.99000
d. Estimated obligated flow .to: yet tributary to the WWTP 3.10170
e. WWTP facility's actual avg. flow 3.59640
f. Total flow for this specific request 3.00049
g. Total actual and obligated flows to the facility 170300
h. Percent of permitted flow used 71.0131
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
Statior Station Firm Daily Flow** Current T-ibGtary FIow Pus
(Name or Permit Capacir), ' (Firm / pf), Avg. Daily Daily Flow, Obligated Available
Number; No. MGD MGD Flow, MGC MGD Flow Capacity"*'
Lake
xi:— WQ003875 0.2`9 0.104 0.050 0.0 0.053 0.054
* 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.
*x 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.
x"* A Planning Assessment Addendum shall be attached for each pump station located
between the project connection paint and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer:I: Lake View at Currituck, Pi -JD
Downstream Permit Number: WQ003875
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I l )n cti d j 6 certify to the best of my knowledge that the addition of
the volume of wastewater to be permit ed in this project has been evaluated along the route to the receiving
wastewater treatment facility and that tLe flow from this project _s not ant:c:pated to cause any capacity
relates sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant sr_der normal circun:s'ances, given the implementation of the planned improNements
identified in the planning assessment where applicable. This analysis lrw been performed in accordance
with local established policies and procedures using the best ava::able data. This certification applies to
those items listed above in Sections I and II plus all attached planking assessment addendums for which I
am the responsible party. Signature of this form certifies that the rece:v:r_g collection system or treatment
works ha's dequate capacity to transport and treat the proposed new wastewater.
Sig mg Officiar Signature
/)') d ✓) Q c1 C r
Title of Signing Official
/ zr7/57
Date
Page 2 of 6
FTSE 10-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit E planning assessment ad ler.dam for each pump station listed in Section :I where Availacle Capacity is <
0.
Puma Statior (Name or Number):
Given that:
a. The proportion and amount of Obligati, Not Yet Tributary Daily Flow IC) accounts for
% and MGD of the Available Capacity :E) in Pump Statior
and that
b. The rate of activation of this obligated, not yet tributary capacity is ctrrently approximately
MGD per year; and that
c A funded Capital Project that will provide the required planned capacity, ramely
is in design or t.nde- construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information there _s sufficient justiEcation to allow
this flow to be permitted, without a significant likelihood of over-ailocating capacity in the system
infrastrLc:are.
I unde:stana that this does not relieve the collection system owner from complying with G.S 143-
215.67;a► wnich prohibits the introouction of any waste in excess of the :apacity of the waste disposal
system.
e L.9 Z
n;ng Official Signu ure / Dale
Page 3 of 6
FTSE 10-13

Instructions for Flow Tradang form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a WWTP Facii:ty Name: Enter the name of the WWTP that w:l 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 N?DES or Non -Discharge permit.
d_ Estimated obligated flow not yet ributary to the WWTP, MGD: This inc:udes flows allocated =o other
construction projects not yet contributing flow to the collection sys_em. Flows allocated through interocal
agreements or other cor_trac:s nc-: yet contributing flow to the collec ion seem are also included. Fo' FCTWs
that implement a pretreatmen_ program, include flows allocated to etdistrial 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 POT'W should have reviewed flow alloca-ions made over the last two yars and
reconciled their flow records, to the best of their ability, so it is kncwn how much flow has been obliged and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entiry.
e. WW-TP facilir 's actual avg. flow. MGD: Previous 12 month average.
f. Tcta_ flow for this specific request, MGD: Enter the requested flow volume.
g. Tcta: actual and obligated flows to the facility, MGD Equals [d + e + f]
h. Percent of permitted flow used Equais [(g / c)* 100]
For example:
On January :5 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 low for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.0: 5 MGD.
The first Fora_ FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. = 0.5 MGD
e. = 2.7 MGD
f.=0.013MGD
g. = 3215 MGD
b. = 53.6 %
The next Form FTSE may be updated like this with a proposed flcw expansion 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 °'o
Each subsequent FTSE forn will be updated in the same manner.
Page 4 of 6
FTSE 10-18

Section 11
List the 'Limp station name or number and approximate pump station firm capacity, approximate design average
daily flow ;A) approximate current average daily flow (B), and the obligates, not yet tributary flow through the
pump station (C) for each pump stativr_ that will be impacted by the proposed sewer extension project. Calcu:ate
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 puma station but are not yet tributary
(C).
Firm capacity is the maximum pumped flew 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 d:viced by a peaking factor (pf) of not less than
2.5.
If the availab'e capacity (E) for any pump station is < 0, then prepare a Dianning assessment for that pump station
if the system has future specific plans -elated to capacity that should be corsiderec in the permitting process.
(A) (B) (C) (D)=(B+C) (E)=(A-D)
0b1.gated,
Design Approx. Nct Yet
Firm Average Current Avg. ribttary
Pump Station Capacity Daily Flow Daily Flow, Dail_ Flow,
(Name Or Number) MGD (Finn/ pf) MGD MGC
Kaw Creek PS 0.800 0.320 0.252 0.080
Total Current
Flow Plus
Obligated
Flow
Available
Capacity*
0.332 -0 012
Valley Road PS 1.895 C.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 it Section II where available capacity is < 0.
A planning assessment for Kaw Creek FS ;see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated Bows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the fow lased on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary over lows and must take all steps necessary to complete the project or control
the rate of flow tc prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or aorstruction, or a planned project in
the future not ye: funded but in a forma plan adopted by the system. Tie 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 :c capacity tracking and acceptance
compliance.
For example:
Given that:
a. The propcnion 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
t. The rate cf activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that w:I1 provide the required planned capacity, namely
is in design or under construction with planned
completion in ; and/or
C. The followmg applies:
The _master plan and ten year capital plan contain recommended scone and finding for a capital proect entitled
Kaw Creek Pump Station upgrade with funding planned in July 2014 This project is planned to add 0.100 MGD
to the firm capac:ty of the pump station by Cctober 2015. Inclusion of this proposed capital project as a condition
of this Flow Tracking/Acceptance for Sewer Extension Permit Application e:evates this project's prority for
funding and 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 :he system infrastructure.
Page 6 of 6
FTSE 10-18

RECEIVED/NCDENR/DWR
DocuSign Envelope ID 89EE553D-9703-4CA5-8B9F-D4C62B4737FD
DWR
Division of Water Resources
APR 2 0 2022
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Water yr �. TRACK SEWER SYSTEM EXTENSION APPLICATION
Regional Operations n Washington Regional Office FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number.W/ QO 43374- (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Miller Homes & Building: LLC (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: Hugh Sam Miller per i 5A NCAC 02T .0106(b)
Title: Member -Mangier
4. Applicant's mailing address: 111 Currituck Commercial Drive, Suite B
City: Moyock State: NC Zip: 27958-
5. Applicant's contact information:
Phone number: (757) 51 -7671 Email Address: smiller p millerhomesandbuildint .com
I1. PROJECT INFORMATION:
1. Project name: LJ Beaners Baker
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Currituck
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.5053' Longitude:-76.1597`
5. Parcel Ill (if applicable): 0015-000-047B-0000 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Mark S. Bissell License Number. 010362
Firm: Bissell Professional Grout
Mailing address: PO Box 1068
City: Kitty Hawk State: NC Zip: 27949_
Phone number: (252) 261-32_0 Email Address: mark a bissell.professionalgroup.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Moyock Reuional WWTP Permit Number: W00035706
Owner Name: Currituck Count\
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0037875
2. Downstream (Receiving) Sewer Information: $ inch Gravity O Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Currituck Count\
FORM: FTA 06-21
Page 1 of 5

DocuSign Envelope ID: 89EE553D-9703-4CA5-8B9F-D4C6264737FD
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: DEN 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)
❑ 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
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : % Domestic 100 % Commercial % Industrial ( See 15A NCAC 02T .0103(0 )
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(I)? ❑ Yes Z No
➢ If Nes, provide a cop'. of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow 1.b
No. of Units
Flow
Bakery
10 ga1/100 sq ft
2,340 sf
236 GPD
Office/Business
25 gal./employee
10 empl
250 GPD
gal/
GPD
_
lial/
GPD
gal/
GPD
gal/
GPD
Total
486 GPD
a See 15A NCAC 02T .0114(b),(d), (e)(1) and (e)(2 ) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: _ 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

•
DocuSign Envelope ID: 89EE553D-9703-4CA5-8B9F-D4C62B4737FD
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1 Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
➢ 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 sew•er(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 & MD( (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: LJ Beaners Lift Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.5053° Longitude: -76.1597°
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.0216 million 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): 15 gallons per minute (GPM) at 21.6 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
1.5
571
PVC SDR 21
if any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.1.b. ® Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
Z Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)
A. 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

DocuSign Envelope ID 89EE553D-9703-4CA5-8B9F-D4C62B4737FD
FORM: FTA 06-21
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .01O5j & (y)? ❑ Yes ❑ No
I SA NCAC 02T 0305(11 contains minimum 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, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 fect
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 (a), see Section X.1 of this apphcauon
*15A NCAC 02T.0305tej contains alternatives where separations in 02T.0305(I ) 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 wel page
2. Does this project comply with the minimum separation requirements for water mains? Z Yes ❑ No ❑ N/A
> If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N/A
> Please provide supplementary information identifying the areas of non-conformance.
> See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
> This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications'?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ if yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permlttee 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.
Page 4 of 5

DocuSign Envelope ID: 89EE553D-9703-4CA5-8B9F-D4C62B4737FD
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Pc n itt.fl_ ` I.. ip Statione
and Force Mains (latest , 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 request will be issued
concurrentll with the approval of the permit, and projects requirim! a variance approval ma% be subject to Ionizer
review times. For projects requirinr. two or more variances or where the variance is determined b% the Division to be a
si,;nificant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, Mark S. Bissell , attest that this application for LJ Beaners Bakery
(Professional Engineer's name from Application Item III. I.) (Project Name from Application Item 11.1)
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 Gravitt Sewers (latest version), and the Mini, Design Criteria for the Fast -Track Permitting
of Pump Stations and Force MainsIlatest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: i ��\‘.�r� lafj�//� �,
.0i62
�,9N.,ve 171. !, •
-1 ,///9 S.i BA5S1\\V
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, _Hugh Sam Miller , attest that this application for LJ Beaners Bakery
(Signature Authority Name from Application Item 1.3.)
(Project Name from Application Item I1.1)
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. 1 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.
Signature:
cDocile rod by:
ElDE)BADICFB/38...
FORM: VIA 06-21 Page 5 of 5
Date:
4/19/2022 11:49 AM EDT

Certificate Of Completion
Envelope Id: 89EE553D97034CA58B9FD4C62B4737FD
Subject: Please DocuSign: LJ Beaners Application 3-23-22.pdf
Source Envelope:
Document Pages: 5
Certificate Pages: 4
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
4/19/2022 11:43:43 AM
Signer Events
Hugh Sam Miller IV
[e-mail]
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 4/19/2022 11:49:26 AM
ID: f3ac2fff-3a22-4924-820d-2f109eec14ec
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Signatures: 1
Initials: 0
Holder: Diana Brink
dianalbrink@gmail com
Signature
-Oo fled by:
`--- E t DEDBAD4CFB438
Signature Adoption: Drawn on Device
Signed by link sent to
[e-mail]
Using IP Address: 174.206.0.144
Signed using mobile
Signature
Status
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Hashed/Encrypted
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Electronic Record and Signature Disclosure
DocuSign
Status Completed
Envelope Originator:
Diana Brink
102 SOUTH ST
nil
Moyock, NC 27958
[e-mail]
IP Address: 173.22.67.172
Location: DocuSign
Timestamp
Sent: 4/19/2022 11:44:41 AM
Viewed: 4/19/2022 11:49:26 AM
Signed: 4/19/2022 11:49:38 AM
Timestamp
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Timestamps
4/19/2022 11:44:41 AM
4/19/2022 11:49:26 AM
4/19/2022 11:49:38 AM
4/19/2022 11:49:38 AM
Timestamps

Electronic Record and Signature Disclosure created on: 1/7/2015 11:13:37 AM
Parties agreed to: Hugh Sam Miller IV
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C201502300475
RECEIVED/NCDENRIDWP
APR 0 2022 State of North Carolina
Department of the Secretary of State
Water Quality
Regional Operations Section,
Washington Regional Office
Limited Liability Company
ARTICLES OF ORGANIZATION
SOSID: 1423963
Date Filed: 1/26/2015 12:18:00 PM
Elaine F. Marshall
North Carolina Secretary of State
C2015 023 00475
Pursuant to §57D-2-20 of the General Statutes of North Carolina, the undersigned does hereby submit these
Articles of Organization for the purpose of forming a limited liability company.
I. The name of the limited liability company is: Miller Homes & Building, LLC
(See Item lof the Instructions for appropriate entity designation)
2. The name and address of each person executing these articles of organization is as follows: (State
whether each person is executing these articles of organization in the capacity ofa member, organizer
or both. Note: This document must be signed by all persons listed.)
John S. Morrison, Organizer
Twiford Law Firm, P.C.
POB 669
Moyock, NC 27958 (Currituck County)
3. The name of the initial registered agent is: Hugh S. Miller, IV
The street address and county of the initial registered agent office of the limited liability company is:
Number and Street 111 Currituck Commercial Drive, Suite B
City Moyock State: NC Zip Code: 27958 County: Currituck
5. The mailing address, if different from the street address, of the initial registered agent office is:
Number and Street
City
State: NC Zip Code: County:
6. Principal office information: (Select either a or b.)
a. OThe limited liability company has a principal office.
The principal office telephone number: 252-435-6402
The Street address and county of the principal office of the limited liability company is:
Number and Street 111 Currituck Commercial Drive, Suite B
City Moyock
CORPORATIONS DIVISION
(Revised January 2014)
State: NC Zip Code: 27958 County: Currituck
P.O. Box 29622
1
RALEIGH, NC 27626-0622
(Form L-01)

C201502300475
The mailing address, if different from the street address, of the principal office of the company is:
Number and Street
City State: Zip Code: County:
b. ❑ The limited liability company does not have a principal office.
7. Any other provisions which the limited liability company elects to include (e.g., the purpose of the entity)
are attached.
8. (Optional): Please provide a business e-mail add _
The Secretary of State's Office will e-mail the b above at no
cost when a document is filed. The e-mail provicL wrrr,n ruc vIvwacirE-6rrtnewe6site. For more
information on why this service is offered, please see theinstructions for this document.
Privacy Redaction
9. These articles will be effective upon filing, unless a future date is specified:
This is the 21st day of January
20 15
Miller omes & Building, LLC
Signature
John orrison, Organizer
Type or Print Name and Title
The below space to be used if more than one organizer or member is listed in Item #2 above,
Signature
Signature
Type and Print Name and Title Type and Print Name and Title
Signature Signature
Type and Print Name and Title Type and Print Name and Title
NOTES:
1. Filing fee is $125. This document must be filed with the Secretary of State.
CORPORATIONS DIVISION
(Revised January 2014)
P.O. Box 29622
2
RALEIGH, NC 27626-0622
(Form L-01)

RECEIVED/NCDEN R/Dyhp
LIMITED LIABILITY COMPANY ANNUAL REPORT
APR 2 0 2022
116,2022
NAME OF LIMITED LIABILITY COMPANY:
Miller Homes & Building, LLC
SECRETARY OF STATE ID NUMBER: 1423963
REPORT FOR THE CALENDAR YEAR: 2022
STATE OF FORMATION: NC
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: The Twiford Law Firm, P.C.
Regional •
Washirfgto
• P u;
eratiorf offi
ce Use Only
R rF nual Report
63
CA202209502888
4/5/2022 11 00
nChanges
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
111 Currituck Commercial Drive, Suite B 111 Currituck Commercial Drive, Suite B
Moyack, NC 27958-9086 Currituck County Moyock, NC 27958-9086
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: New Construction
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] x2
4. PRINCIPAL OFFICE STREET ADDRESS
111 Currituck Commercial Dr Ste B
Moyock, NC 27958-9082
3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
5. PRINCIPAL OFFICE MAILING ADDRESS
111 Currituck Commercial Dr Ste B
Moyock, NC 27958-9082
6. Select one of the following if applicable. (Optional see instructions)
The company is a veteran -owned small business
The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Hugh S. Miller , IV
TITLE: Managing Member
NAME:
TITLE:
ADDRESS: ADDRESS:
150 Baxter Estate Rd.
Moyock, NC 27958
NAME:
TITLE.
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Hugh S. Miller IV 4/5/2022
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
Hugh S. Miller IV
DATE
Managing Member
Print or Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State. Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

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PROPOSED UTILITY ADDITIONS
& LANDSCAPING PLAN
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