WQ0043349_More Information (Received)_20220425

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Novant Health Inc. (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: Matt Stiene per 15A NCAC 02T .0106(b)
Title: Senior Vice President
4. Applicant's mailing address: 2085 Frontis Plaza Blvd
City: Winston-Salem State: NC Zip: 27103-
5. Applicant's contact information:
Phone number: [phone] Email Address: mhstiene@u,novanthealth.org
II. PROJECT INFORMATION:
1. Project name: Novant Health Critical Care Tower
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: Forsyth
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.075186° Longitude: -80.298525°
5. Parcel ID (if applicable): 6814-68-8340 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brian CraffordLicense Number: 044053
Firm• Stimmel Associates
Mailing address: 601 N. Trade Street, Suite 200
City: Winston-Salem State: NC Zip: 27101-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Archie Elledge WWTP Permit Number: NC0037834
Owner Name: Winston-Salem/ Forsyth County Utilities Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQCS00003
2. Downstream (Receiving) Sewer Information: 18" inch Z Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00003
Owner Name(s): Winston-Salem/ Forsyth County Utilities Commission
FORM: FTA 06-21
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