NCC221838_FRO Submitted_20220512

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Amhurst Subdivision
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Zion Church Rd N35'22'28.524" WN'55'12.4a"
Highway/Street Latltude(decimaldegrees) LOngltude(decimaldagrees}
3. Approximate date land -disturbing activity will commence: 4/25/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.97 acres
6. Amount of fee enclosed: $ 325 - (5X65=325) The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeremy Huntsman E-mail Address [e-mail]
Phone: Office #
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pulte Home Company LLC 704-543-4922
Name
11121 Carmel Commons Blvd., Ste 450
Current Mailing Address
Charlotte NC
City State
10. Deed Book No. 90
Phone: Office #
Mobile #
11121 Carmel Commons Blvd., Ste 450
Current Street Address
28211 Charlotte NC 28211
Zip City
State
Zip
Page No. 35 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the names) of the owner(s) may be listed as the financially responsible party(ies).
Pulte Home Company, LLC
Company Name
11121 Carmel Commons Blvd, Ste 450
Current Mailing Address
Charlotte NC 28211
City State Zip
Phone: office # 704-543-4922
Jeremy. [e-mail]
E-mail Address
11121 Carmel Commons Blvd, Ste 450
Current Street Address
Charlotte NC 28211
City State Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Jeremy Huntsman
Name of Registered Agent
11121 Carmel Commons Blvd, Ste 450
Current Mailing Address
Charlotte NC 28211
City
[e-mail]
E-mail Address
11121 Carmel Commons Blvd, Ste 450
Current Street Address
Charlotte NC 28211
State Zip City
Phone: Office # Mobile # [phone]
Jeremy Huntsman
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Jeremy Huntsman
Director of Land Development
Type or Title or Authority
Si a Date
a Notary Public of the County of 1'7 �D
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged t at We above form was executed by him/her.
Witness my hand and notarial seal, this 2-Qday of
Seal
Notakyj
My commission expires ,�,,, Zt�zCj
es

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mai[ Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip
Zip

PUBLIC WATER DISTRIBUTION SYSTEM
EXTENSION OR MODIFICATION APPLICATION
INSTRUCTIONS FOR FORM: WDSEM
The City of Concord will not accept this application unless all of the following instructions are adhered to: Prior to the
submittal of an application package for publicly maintained and operated water distribution system
extensions/modifications, the civil engineering design drawings shall be approved through the appropriate technical review
process as required by the Director of Engineering and defined by the City of Concord Development Ordinance. The design
drawings must be prepared in accordance with Subchapter 15A NCAC 18C of the North Carolina Administrative Code,
the Water and Sewer Authority of Cabarrus County's "Standard Specifications for Wastewater Collection and Water
Distribution Construction for Cabarrus County," the City of Concord Code of Ordinances, and good engineering practices.
Failure to submit all: of the required items will lead to additional fees and processing and review time for the application.
A, Application Form: (All Application Packages):
® Submission of an executed application form. Incomplete applications may result in the application being returned. The
City of Concord will only accept application packages that have been fully completed with all applicable items addressed.
® The project name should be consistent with the project name on the plans and supporting data.
N/A ❑ If this project involves a modification of an existing "Authorization to Construct," submit one copy of the existing
"Authorization to Construct." Please note that modifications must meet current design standards.
B. Application Fee: (All Application Packages):
® Each application shall be subject to an Engineering Review fee in the amount as required by the current "City of Concord
Fiscal Year Fees and Charges Schedule" A copy current City of Concord Fiscal Year Fees and Charges Schedule can be
viewed on the City of Concord web page at www.concordtic.gov under "Departments" — "Finance" - "Adopted Fees
Schedule"
C. Digital Copy of Plans (All Application Packages):
® Submit one digital copy of the complete design drawings in PDF format are to be uploaded to the Accela online portal in
the applicable case at https:/laccetal.cabarruscounty.us/CitizeiiAccess/, unless otherwise specified.
D. Detailed Plans and Specifications: (All Application Packages):
© Submission of the final design drawing plan set must be signed, sealed, and dated by a N.C. Professional Engineer. The
Water and Sewer Authority of Cabarrus County's "Standard Specifications for Wastewater Collection and Water
Distribution Construction for Cabarrus County" and the City of Concord Development Ordinance and Code of Ordinances
Utilities Article and Technical Specifications must be adhered to without exception. Use of the Water and Sewer
Authority of Cabarrus County's (WSACC) "Standard Specifications for Wastewater Collection and Water
Distribution Construction for Cabarrus County," and the City of Concord Development Ordinance, Code of
Ordinances Chapter 62 and Technical Standards must be noted on each sheet of the plans.
Design plans must include but shall not be limited to the following mini mum items:
• Water distribution system extensions and/or modifications shall be designed in accordance with all applicable federal, state,
and local regulations and standards.
• Engineering plans shall be sealed by a North Carolina registered professional engineer and submitted on 24-inch by 36-
inch sheets with the approved City of Concord border and logo.
• The horizontal scale shall be one -inch equals 40 feet and the vertical scale shall be one -inch equals 4 feet.
• A general location map, a North arrow, plan and profile views of the water extension as well as the proximity of the sewer
extension to other utilities and natural features, and detail drawings of all items pertinent to the water extension.
• Depict minimum separations on the plans, in accordance with 15A NCAC 18C and the City of Concord's ordinance,
policies, and specifications. Clearly indicate on the plans, the sections where the minimum separations cannot be
maintained and the ferrous pipe material is required.
• Minimum cover over water extensions must also be shown clearly on the plans, in accordance with 15A NCAC 18C and
the City of Concord's ordinance, policies. and specifications.
• Plans and specifications must not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT FOR
CONSTRUCTION, etc.) that indicate that they are anything other than final plans and specifications.
FORM: WDSEM 03/2021 Instructions Page 1 of 2

® Cross connection control in accordance with the City of Concord Water Resource Department's "Backflow Prevention
Ordinance and Cross Connection Control Ordinance" must be specified on the drawings and details provided.
. The City of Concord Backflow Manual and details can be viewed on the City of Concord web page at
www.concordne.gov under "Departments" — "Water Resources" — "Backflow Prevention Documents" or a copy can
be obtained from the Water Resources Department.
E. Engineering Calculations (All Application Packages):
® Hydraulic design calculations signed, sealed, and dated by a N.C. Professional Engineer for the proposed public water
system and domestic service and fire service, as applicable.
® The proposed extension shall be able to produce the required fire flows, including but not limited to any necessary pumping
or storage, throughout the proposed extension without negatively impacting the existing system. Documentation of this
ability shall be submitted to the Director of Engineering or his/ber designee for approval.
P. City of Concord Water Distribution System Technical Design Checklist (WDSTD-Checklist):
® The proposed water distribution system design conforms to the requirements indicated in City of Concord Water
Distribution System Technical Design Checklist.
A DIGITAL COPY OF THE COMPLETED APPLICATION PACKAGE, INCLUDING PLANS, SUPPORTING
INFORMATION AND MATERIALS, SHOULD BE UPLOADED TO ACCELA ONLINE PORTAL IN THE
APPLICABLE CASE AT https://acecial.cabarruscountv.us/CitizenAccess/, UNLESS OTHERWISE SPECIFIED.
For Accela Case Inquiries, Contact:
CITY OF CONCORD
Planning & Neighborhood Development -
Zoning Services
Post Office Box 308
Concord, North Carolina 28026-0308
Telephone Number: [phone]
For Engineering Design Inquiries, Contact:
FORM: WDSEM 03/2021 Instructions Page 2 of 2
CITY OF CONCORD
Engineering Department
Post Office Box 308
Concord, North Carolina 28026-0308
Telephone Number: [phone]

WATER DISTRIBUTION SYSTEM
EXTENSION OR MODIFICATION APPLICATION
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
TO BE COMPLETED BY THE CITY OF CONCORD
Planning Project No:
Engineering Project No:
ATC No:
I.) Project Title:
(Project name oftil€cas
Amhurst Subdivision
indicated on the
drawings)
Located on Amhurst St. SW approximately 4,806 ft. NW of the intersection of Highway 49 and SR
Description of
1155 (Zion Church Rd.)
C
project location:
2.
( Example: Site located on f Road name) SR WHO, appr°x 8i### linear feat (Nor111, South, West or East)of the inlersectian of Road name (SR #tf##) and Road Name
(SR #fflt# )
Cabarrus County
Parcelldcntification
5529-84-2776
9.592
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4.) Number:
4a.) Parcel Acreage:__
C
U
5•) Site Zoning and use:
RC -CD
5a.) Min. Fire Flow
(Per NC Fire Code)
1 500 gpm @ 20 psi
O
100
%Domestic
% Commercial
:% Industrial
6a.) Estimated Water Usage:
% Other use (Specify)
Area Commercial or
72,900
6. Industrial Building
(sq. ft.)
Description of Facility
Single Family Homes
39
�• to be served.
y
7b. Number of Lots
7c.) Number of Units
Additional description
d.) information:
Jeremy Huntsman Director of Land Development
(Title) 11121 Carmel Commons Blvd Suite 450
C
(Name of legal owner, hoard, council, and/or authorized offeial with title, as defined in
(Applicant's Street or Box Number)
0
property records and/or a registered agent(s) as listed in the NC Secretary of State Corporation
filings, hereby referred to as the Applicant.)
M
E
Pulte Home Company, LLC
Charlotte NC 28226
(Name of Applicanl's company, city, town, corporation, sanitary district, water company
(Applicant's City, State, Zip Code)
C
or other defined in property records and/or w listed in the NC Secretary of State Corporation
filings. as applicable.1
C
704 972-0752
CL
(Applicant's Phone Number)
(Applicant's Facsimile Number)
Q
m
Jeremy Huntsman (Nan
[e-mail]
ulte rou .com
(Name with Tille and Finail of contact person,
(Applicant's Email Address)
who can answer questions about application)
REQUIRED
Applicant is to attach documentation of their signature authority(' i(signing for a corporation and documentation ofownership ifsigning as owner.
FORM: WDSEM 03/2021 Page 1 of 5

L
Kate Underwood PhD PE CESI
�IWD
(Typed name of North Carolina Professional Engineer) (Company Name)
a, 0
033470 P.O. Box 268
D j M
(NCPE Registration Number) (Street or Box Number)
m E
704-786-5404 Concord, NC 28026
N
(Phone Number) (City, State, Zip Code)
0 _
Kate Underwood PhD PE [e-mail]
d
(Name and affiliation of contact person, (Email Address)
who can answer questions about application)
® New
1.) Project is:
❑ Modification (of an existing Authorization to Construct)
o
If Modification, specify the ATC Number:
2.) City of Concord
OOwner
of Water Distribution System Supplying Potable Water To This Project
IR
3a.) City of Concord Water System 3b.) 01-13-010
Name of Water System Public Water Supply Identification No.
M
3c. 19-00080 3d. February 04 2019 3d. Cabarrus
CL
CL
WSMP No: WSMP Submittal Date: County
Q
3e.)By my signature below, I, M. Sue Hyde,. Director of Fnizineering, certify that the previously submitted WSMP contains the
information required by 15A NCAC 1 SC .0307(c) for the project defined in the attached engineering plans and specifications.
(Signature of Engineering Director) (Date)
E. En ineer's Report
1a.) City of Concord 1b.) 8-inch
Owner of the Existing Water Main at Tie-in(s) Existing Water Main Diameter(s)
2.) Volume of water demand to be allocated for this particular project: gallons per day.
(Do not include future demands or previously allocated water demand.)
For water demand > ZERO: COMPLETE ITEM 4. For water demand = Zero: COMPLETE ITEM 3.
3.) If the water demand is zero, indicate why:
❑ Transmission Mains or hydraulic loops where water demand will be allocated in subsequent approvals that connect to this extension
tL
❑ Water demand previously allocated in ATC Number: or Water demand allocation in NCDEQ water permit.
W
(Documentation of the NCDEQ permit approval must be provided.)
(Y
❑ Rehabilitation or replacement of existing water mains with no new water demand expected (see 15A NCAC 18C to determine if an
V)
application is required)
i
❑ Other:
(D
W
4.) Provide the water demand calculations used in determining the allocated potable water demand in accordance with the value
indicated in Item E(2) AND/OR the design demand for transmission main or hydraulic loop main sizing if zero demand is being
0)
requested in Item E(3). Values other than that in defined in table b(1) or b(2) in15A NCAC 18C 0409 must be supported with actual
G
W
water use data. (Note: All attachments must be sealed in accordance with (NCGS 89C)
400 gal. lot , 39 lots " 400 gal = 15,000 gpd average daily flow
Ui
15,000 gpd 1(16hr/day'60 min/hr) = 16.25 gpm
16.25 gpm ' 2.5 peaking factor = 40.625 gpm pek flow
fire flow: 1,500 ` 4 hr' 60 minlhr = 360,000
FORM: WDSEM 03/202I rage 2 of 6

5a.) Maximum daily demand of the project: Peak potable water daily demand plus minimum fire flow times
NC Fire Code Duration (hour) 15,600 -h 360,000 =
375,600
(gallons per day)
((Average Water Demand in gpd X Peaking Factor) plus (Minimum fire flow demand X NC Fire Code Duration Fire Demand) in gallons)
5b.) Peak demand of the project: Peak potable water daily demand plus minimum fire flow
1,516
(gallons per minute)
((Average Water Demand X Peaking Factor) plus (Mlnimum lire flow demand in gpm at 20 psi)) 16.25 + 1500 =
6.) If the water system does not provide fire flow, indicate the minimum calculated pressure at domestic peak water demand
(non -fire flow): D7 Psig
Per Title 15A NCAC 18C Rule 0.0901 — A minimum pressure of 30 psi must be maintained throughout the system.
Attach the supporting calculations in confirmation that the calculated system pressure indicated above and the proposed system
complies with the Title 15A NCAC 18C Rule 0.0901.
7.) If the water system does provide fire flow, indicate the minimum calculated pressure at domestic peak water demand
[Potable (Domestic) plus fire flow]: 23.29 Psig
Per Title 15A NCAC 18C Rule 0.0901 — A minimum pressure of 20 psi must be maintained throughout the system.
Attach the supporting documentation and calculations in confirmation that minimum system pressure indicated above complies with
the Title 15A NCAC 18C Rule 0.0901.
8.) Does the project meet the fire flow requirements specified by the public water system?
0 Yes
❑ No
❑ NIA
9.) Summary of water mains to be constructed (Attach additional sheets if necessary)
Diameter (in.)
Length (Ifn. ft.)
(Exciude hydrant legs and services}
Low Elevation (ft.)
High Elevation (ft.)
Quantity of the Main -line Valves
(Exclude blow -off assembly valves)
.-.
81-
1,351.49'
638.91'
654.83"
9
12"
260.14'
638.59,
645.1 g'
0
G
4-1
t=
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C)
.—,
.t
10.) Number of hydrants 11a.)
Number of
11b.) Station location of 11c.)
Elevation of
0
with guard valves
air -release valves
air -release valves
air -release valves
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4
0
Q�
fl)
i.
General Water System Hydraulic Information
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12.) Closest existing fire hydrant - (Include location on hydraulic calculation plans for reference)
-5
Road name/location and distance
Static Pressure
Flow Rate
Residual Pressure
Flow @ 20 psi
C
from project tie-in.
(Pounds per sq. in.)
(gpm)
(Pounds per sq. in.)
(gpm)
LU
Amhurst St. SW - 272 ft.
92 psi
1418 gpm
34 psi
1593gpm
W
13. Applicable Pressure Zone - Elevated Storage Tank
Tank Capacity Elevation
Pressure Zone Elevation
Hydrant Test Report-
Distance from proposed water system
Name
Location
BC Elevation -TInk Floor
Tank pvernow
wafer Level
connection in miles
Speedway Tank - Morehead Road - 850
26.3
5.6 miles
REQUIRED - Attach sealed hydraulic calculation report(s) with Fire Hydrant Flow Test Report and exhibits.
DESIGN COMPLIANCE CERTIFICATION
14.) Does the subject water distribution system comply with the (latest version) of State of North Carolinas' Administrative Code, Subchapter
15A NCAC 18C, the Water and Sewer Authority of Cabarrus County Standard technical Specifications for wastewater Collection and Water
Distribution Construction for Cabarrus County, and the City of Concord Development Code, Code of Ordinances, Policies and Technical
Standards; as applicable?
X❑ Yes ❑ No If No, to City of Concord Design Standards; please reference the pertinent minimum design criteria and
indicate why an exception is requested. SUBMIT TWO COPIES OF SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE EXCEPTION WITH YOUR APPLICATION.
FORM: WDSEM 03/2021 Page 3 of 6

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5.) Have the following permits/encroachments/certifications been submitted for approval for the proposed water system or the
associated project? If "yes," submit a copy of all applicable permits/encroachment forms.
US Army Corp 404 or NCDENR DWO 401wetland permit?
Sedimentation and Erosion Control Plan?
Stormwater Management Permit?
NCDOT Encroachment?
Environmental Assessment?
❑ Yes
❑ No
0 NIA
® Yes
❑ No
❑ NIA
x❑ Yes
❑ No
❑ NIA
❑ Yes
❑ No
0 NIA
❑ Yes
® NIA
(If Yes,
Submit FONSI or EIS)
City of Concord Certification: TO BE COMPLETED BY THE CITY OF CONCORD
These plans and specifications cited in the foregoing application, including any provisos in the approval letter, are approved insofar as the protection of public health
is concerned as provided in the rules, standards and criteria adopted under the authority ofNCGS 130A-315 and 130A-317. This approval does not address all
applicable laws, rules, standards and criteria, and other approvals and licenses that may be required by the local, state or federal government. This approval is given
with the understanding that upon installation of such works, its operation shall be placed under the care of a competent person, and the operation shall be carried out
according to best accepted practice and in accordance with the recommendations of the City of Concord through the delegated authority of Division of
Environmental Health.
Any erasures, additions or alterations of the proposed improvements except those permitted in 15A NCAC 18C .0306 will make this approval null and void. This
approval does not constitute a warranty or the design, construction or future operation of the water system. THE CITY AND ITS STAFF ARE NOT
RESPONSIBLE FOR ERRORS IN DESIGNS, CALCULATIONS, DRAWINGS OR STATEMENTS SUBMITTED BY APPLICANTS, THEIR TECHNICAL
CONSULTANTS, SURVEYORS OR ENGINEERS. THE CITY AND ITS STAFF ARE NOT RESPONSIBLE FOR FINDING OR CORRECTING ANY
ERRORS OR DEFICIENCIES IN PLANS SUBMITTED TO TIME CITY FOR REVIEW AND APPROVAL. THE CITY OF CONCORD DISCLAIMS ANY
LIABILITY FOR ERRORS CONTAINED IN PLANS SUBMITTED TO THE CITY. THE SIGNATURE OF THE CITY ENGINEER MAY NOT BE RELIED
UPON TO ESTABLISH ANY DUTY OR RELATIONS141P (SUCH AS A THIRD PARTY BENEFICIARY) WITH ANY PARTY USING THIS PLAN OR
DRAWING. PARTIES USING THIS DOCUMENT SHOULD CONDUCT THEIR OWN REVIEW AND ANALYSIS FOR MAKING DECISIONS IN
RELIANCE ON THIS DOCUMENT.
The official copies of plans and specifications accompanying this application have been sealed and stamped with the Authorization to Construct
(ATC) number for this application
1, M. Sue Hyde, P.E., attest that this application has been reviewed by me and contains sufficient information to ascertain reasonable grounds to
believe the application package and its contents meet all applicable standards of Subchapter 15A NCAC 18C, the State of North Carolina's
Administrative Code, the Water and Sewer Authority of Cabarrus County Standard Specifications and the City of Concord's ordinance, policies and
specifications as presented. The denial of the issuance of a permit, subject to the provisions in Article 111, Chapter 62 of the City of Concord Code
of Ordinances shall be made in writing and shall contain the reasons for the denial and the City's estimate of the general changes in the applicant's
proposed activities or plan which will be required in order that the applicant may obtain a permit. Nothing in such estimate shall preclude or
otherwise bar the City from denying a permit, which incorporates such changes, based upon changed circumstances or information not previously
known by the Director of Engineering or the applicant.
Signature: Date:
M. Sue Hyde, PE, Director of Engineering
FORM: WDSEM 03I2021 Page 4 of 6

Professional Engineer's Certification:
As a duty registered Professional Engineer in the State of North Carolina, I certify that this application has been reviewed by me and is accurate,
complete and consistent with the information supplied in the engineering plans, 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 and supporting documentation has been prepared in
accordance with and subject to the Water and Sewer Authority of Cabarrus County's standard specifications; the City of Concord's ordinances,
policies, and standard specifications, and the North Carolina Administrative Code for water distribution systems. In the event of conflict between
the Water and Sewer Authority of Cabarru5 County's standard specifications; the City of Concord's ordinances, policies, and standard specifications,
or the North Carolina Administrative Code, the more restrictive requirements shall apply. 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. Although the attached City of Concord Water System Supplied information report incorporates
data provided by others, inclusion of these materials under my seal signifies that I have reviewed this material and have judged it to be consistent
with the proposed design. Note: In accordance with NC General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application 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, and referral to the State Board of Registered Professional Engineers and Surveyors.
(Signature of North Carolina Professional Engineer)
Kate Underwood, PhD, PE
(Type Name Signed Above)
033470
(NCPE Registration Number)
(Seal & Signature Date)
704.902.6169
(Phone Number)
(Engineer's seal)
CES1
(Company Name)
P.O. Box 268
(Street or Box Number)
Concord, NC 28026-0268
(City, State, Zip Code)
[e-mail]
(Email Address)
ile Num
Applicant's Certification:
This application is made under and in full accord with the provision of NCGS 130A-317, and such other statutes as related to public water systems.
The applicant agrees that no change or deviation from the engineering plans and specifications approved by the Division of Environmental Health
will be made except as allowed by 15A NCAC I8C .0306 or with the written consent and approval of the City of Concord Director of Engineering or
the Directors' authorized representative. The applicant agrees that a professional engineer licensed to practice in the State of North Carolina shall
submit a statement reflecting that adequate observations during and upon completion of construction, by the engineer or by a representative of the
engineer's office who is under the engineer's supervision, indicates that construction was completed in accordance with approved plans and
specifications. I understand that if all required parts of this application 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. Any application package determined incomplete by the
Director of Engineering shall be returned to the applicant. Revised engineering plans and specifications shall constitute a re -submittal, shall be
accompanied by a new fee, and shall require additional time for review. Note: In accordance with NC General Statutes 143-215.6A and 143-215.6B,
any person who known n I makes any false statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor,
which may ' ewde a title not ti teed $10,000 as well as civalties-up to $25,000 per violation.
11121 Carmel Commons Blvd, Suite 450
(Signs a of ter, board, council, and/or authorized official (Applicant's Street or Box Number)
with title; as defined in property records and/or a registered agent(s) as
listed in the NC Secretary of State Corporation filings.)
Jeremy Huntsman! Director of Land Development
(Applicant's Typed Name & Title (Applicant's Signature Date)
of signing entity)
[phone]
(Applicant's Phone Number)
Charlotte, NC, 28226
(Applicant's City, State, Zip Code)
Jeremy. Huntsmanulte rou .com
(Applicant's Email Address)
FORM: VVDSEM 03/2021 Page 5 of 6

City of Concord Water System -Supplied Information Form
(Water System ID No: 01-13-010)
Annual Report 2021
Engineer's Initials: Date of Initials:
Th&forni mustbe initial aiid`;dat6d by the'Gonsultant'En inter
Citt• Use Otrib,: Data Reference - City of Concord Local Water Supply Report 2020
Date ormided: 2125-12021
det City of C�smcoFd Duectvr of I n atzeerau
Nuxnlber of cuavw eonntc ons m water system
t4.764 c�nz:ectialzs $
tR;ft*er�sT F°�t•r,��Pvc2€�t- tu�r: «1ik�a¢-r�"'€�^aurt:��srs��a'i
Appro. ed number ofcormection: in water system
N•A—locaIgovern Ment-, V--tam
Current xmrage and maximtuu day demand of w=ting system Avenge day demand ii the one day average
12_V4 average'fillion •
demand for the ?ate�t calendar bear.
f:ze ,IXaT �p �hrm-3 aee.S .eras -Asv- nvA=4Ukzz P=P,tP_n,Waf-crM"M Lv
EAo'r-Twc 14�ca° ffla:.7 SV,7t,i j? : %ohem3 d Warty 5iff,& c'vs Afgv r.:uilA=v rim AAW, ay'kr, €R"Zirr HVL&J�[s,:
76699ma7rimuin Million ,p3�
Cuntnt maw =un dar_ty treated water supply of en -tiny, -systern
1% axinau n daily treated water supply is the ma.=xum quantityof treated water that can be produced a --A or
purchased the :ysstm _
? a.2 m., mu= Million lei
Total elevated rtonge capacity of existing system
&75 Million plllon=
r.zar asp! 7,24 TOT-11 Fermw.-J(7arely)
Total g-camd storage capacity of existing sy :tern
sat;
NIE1.o gallon~
sair4 :"'? i'+�{.:fr-�t;,.�°L�i :�Sv: �r-F
Total hydropneu matic storage capactty of a rating system
N='A % ilhou mom
Y ;f
Contractual storage with other systems) Attach a copy of the agreement with the providing system
�! %fillion galiot s
Sv_te= -> 300 connections or eyte= --: 300 connections niihout hydropneumadc-tQV3Ze:
• Total stmp zoiume a at least half the average annual daily demand (Rule .0S05(c))
® Yes ❑ No
• Has elevated storage or tweet: high yield aquifer cnterza (IRA0445(d))
® Yes ❑ No ❑ NVA
• For rntun, cipaiities, at least 75,000 gallons elevated storage mcl at least half the average day
® Yes ❑ No ❑ NVA
4,zem rid, combined elevated and pvmd finished water storage (Rule .0905(b))
System-. with hyda-opneurnaiic storage tames up to 300 connectiom:
Not applicable.
• Volume of hydropneumatic storage tail: is sufzictent to meet peal: deman& based on Rule .0802 and
❑ Yes ❑ No ® N,°A
calciLatlom in Appendix B. Figure b
• For residential co=munit , sy stemr, volume of hydropneumatrc storage tank L at least 40 tin the namzber
❑ Ye' ❑ No ®N€A
of connections or 500 gallo, s, uinchev er is greater (Rule .4503)
• For inobtle houw garb systems, volume of hydropneamaatic storage tank is at least 25 tirrse: the nuniber of
❑Yes ❑'vo © NVA
connection or 500 gallons, whichever is greater (Rule .0903)
• For campground system:, volume of hydroptrtunrstic storage tank is at lest 10 time_: flat number• of
❑ Yes []No ® N,A
con tion.. or 5 1..gallons. whichever i. greases (Ryle .0S03)
41te, ®r l:Cat�y�.,J.'i t�i`�J! C.idSSF�1:
ce data 202 Local Watar.Supply planning Pin)'
FORM: WDSEM 03/2021 Page 6 of 6

PUBLIC WASTEWATER COLLECTION SYSTEM
EXTENSION OR MODIFICATION APPLICATION
INSTRUCTIONS FOR FORM: WWCSEM 03-2021
The City of Concord will not accept this application unless all of the following instructions are adhered to: Prior to the
submittal of an application package for a public wastewater collection system extension/modification, the engineering
plans and specifications shall be approved through the appropriate technical review process as required by the Director
of Engineering and defined by the City of Concord Development Ordinance. Plans and specifications must be prepared in
accordance with 15A NCAC 2T, the State of North Carolina's Gravity Sewer Minimum Design Criteria, the Water and
Sewer Authority of Cabarrus County's Standard Specifications for Wastewater Collection and Water Distribution
Construction for Cabarrus County, the City of Concord Code of Ordinances, the Concord Regional Water Resources'
Water and Sewer Policy and standard specifications, and good engineering practices.
A. Cover Letter (All Application Packages):
Submit a cover letter, which lists all items and attachments included in the application package as well as a brief project
description. As necessary, include attachments to the application form. Such attachments will be considered part of
the application package and should be numbered to correspond to the section to which they refer.
Bleplication Form (All Application Packages):
Submission of an executed application form. Incomplete applications may result in the application being returned. The
City of Concord will only accept application packages that have been fully completed with all applicable items
Faddressed.
The project name should be consistent with the project name on the plans.
FIf this project involves a modification of an existing "Authorization to Construct," submit one copy of the existing
ve "Authorization to Construct." Please note that modifications must meet current design standards.
C❑Application Fee (All Application Packages):
Each application shall be subject to an Engineering Review fee in the amount as required by the current "City of
Concord Fiscal Year Fees and Charges Schedule" A copy current City of Concord Fiscal Year Fees and Charges
Schedule can be viewed on the City of Concord web page at www.concordnc.gov under "Departments" — "Finance" -
"Adopted Fees Schedule"
D. Detailed Plans and Specifications (All Application Packages):
Submission of the final design drawing plan set must be signed, sealed, and dated by a N.C. Professional Engineer.
The Water and Sewer Authority of Cabarrus County's "Standard Specifications for Wastewater Collection and Water
Distribution Construction for Cabarrus County" and the City of Concord Development Ordinance and Code of
Ordinances Utilities Article and Technical Specifications must be adhered to without exception. Use of the Water and
Sewer Authority of Cabarrus County's (WSACC) "Standard Specifications for Wastewater Collection and
Water Distribution Construction for Cabarrus County," and the City of Concord Development Ordinance,
❑ Code of Ordinances Chapter 62 and Technical Standards must be noted on each sheet of the plans.
✓ Design plans must include but shall not be limited to the following minimum items:
• Wastewater collection system extensions and/or modifications shall be designed in accordance with all applicable
federal, state, and local regulations and standards.
• Engineering plans shall be sealed by a North Carolina registered professional engineer and submitted on 24-inch by 36-
inch sheets with the approved City of Concord border and logo.
• The horizontal scale shall be one -inch equals 40 feet and the vertical scale shall be one -inch equals 4 feet.
• A general location map, a North arrow, plan and profile views of the sewer extension as well as the proximity of the
sewer extension to other utilities and natural features, and detail drawings of all items pertinent to the sewer extension.
• Depict minimum separations on the plans, in accordance with 15A NCAC 2T and the City of Concord's ordinance,
policies, and specifications. Clearly indicate on the plans, the sections where the minimum separations cannot be
maintained and the ferrous pipe material is required.
• Minimum cover over sewer extensions must also be shown clearly on the plans, in accordance with 15A NCAC 2T and
the City of Concord's ordinance, policies, and specifications.
• Plans and specifications must not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT FOR
CONSTRUCTION, etc.) that indicate that they are anything other than final plans and specifications.
E. Digital Copy of Plans (All Application Packages):
�/ Submit one digital copy of the complete design drawings in PDF format are to be uploaded to the Accela online portal
int re applicable case at lrttas:Ilacceiat.cabarruscounty.us/CitirenAccess/, unless otherwise specified.
F. Map (All Application Packages):
FORM: WWCSEM 03-2021 Instructions Page 1 of 2

Submit an 8.5-inch by 11-inch color copy of the portion of a 7.5-minute USGS Topographic Map along with this form.
The map should clearly identify the entire project area location as well as the closest down slope surface waters. Each
map portion must be labeled with the map name and number, the identified location of the sewer line and pump station,
and be of clear and reproducible quality. Projects that traverse over or near several different waterbodies (or counties,
basins, etc.), shall submit topographic maps for each different waterbody.
Submit an 8.5-inch by 11-inch street level map showing all relevant project areas.
G. Stream Classifications (All Application Packages):
[�f / Stream Classifications. Complete the stream classification for the closest down slope surface waters. Include all
points that traverse over or are near different waterbodies (or counties, basins, etc.,) A variance must be requested for
encroachment within required setbacks or buffers pursuant to 2T .0305 (f) and be indicated in Item 8-13 with
supporting documentation/justification provided. For further assistance with determining watershed classification,
contact the NCDEQ Mooresville Regional at 704-663-1699 or the City of Concord Engineering Department for the
guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track Sewer
Systems)." This document is also available on the NCDEQ—Division of Water Quality's web site at
littp:Hh2o.ent-.state.iie.us/iidpu.
H. Design Standards and Hydraulic Calculation Requirements (See 15A NCAC 2T and City of Concord Code of
Ordinance Chapter 62, Article 3)
RI1. Rights-of-way/easements (All utility rights -of way/easements shall meet the following standards. Documentation of off -
site utility easement acquisition must be submitted with the application.)
a. Rights -of -way and easements shall be obtained, granted, dedicated, and recorded in accordance with the eity's
current rights -of -way, easements, and encroachments policy.
b. Wastewater collection lines that are not located within a road right-of-way shall be located within a public utility
right-of-way/easement.
• The minimum utility right-of-way/easement width shall be 30 feet. Rights -of -way greater than 30 feet shall be provided
for pump station lots, access roads, associated appurtenances, and when required by the director of engineering.
• Every portion of the water distribution system extension and wastewater collection system extension or modification
shall be accessible by city maintenance crews and equipment within the utility rights-of-way/casement.
• An all-weather travel surface and a minimum slope of eight percent or flatter and side slopes of two percent or flatter
must be provided within the utility rights-of-way/easement. When access through the utility rights-of-way/easement is
not possible, the director of engineering may approve a maintenance/access easement.
• All maintenance/access easements must be clearly indicated on the plans and legally conveyed to the city. The
maintenance/access easement shall have an all-weather travel surface with a minimum slope of eight percent or flatter
and side slopes of two percent or flatter with a horizontal curve radius that does not exceed the turning capabilities of the
city equipment.
• A vehicle turnaround area shall be provided at the termination of the dead-end easement, at an access impediment, and/or
at the end of a maintenance/access road. At the option of the director of engineering, the vehicle turnaround area may be
omitted if the site access easement or access/maintenance easement length is less than 100 feet.
2. Wastewater Collection Systems (All Application Packages):
• All wastewater collection system mains shall be sized to accommodate potential wastewater [low from the entire
drainage basin based on current zoning and/or land use designations.
• The hydraulics of the proposed manhole with the greatest slope differential (i.e., steep line entering the manhole and a
flat line exiting the manhole) and the tie-in point of the existing system shall be evaluated to determine whether or not the
wastewater will surcharge during peak flow conditions.
WlSubmit two copies of all design calculations that have been signed, sealed, and dated by a NC Professional
Engineer.
Calculations must include the minimum items required by 15A NCAC 2T, the State of North Carolina's
Gravity Sewer Minimum Design Criteria and the City of Concord's ordinance and policies:
• Slope standards: Eight -inch diameter wastewater collection system lines shall be designed and installed at a slope equal
to or exceeding six -tenths of one percent except on dead-end lines and lines where low flows are expected. Minimum
slope on such lines that are IS inch or less in diameter shall be one percent.
• If the sanitary sewer lines entering and exiting a manhole are separated by 225°--270° or 90°--135°, the invert -in and
invert -out elevations shall have a vertical separation of at least five -tenths of one foot.
• Dive -foot diameter inside drop manholes shall be provided where invert separations equal two feet or greater and a 12-
inch diameter pipe or smaller is proposed. If three 12-inch diameter or smaller drops are needed at a manhole, a six-foot
inside drop manhole shall be provided. If the invert separation is two feet or greater and a pipe diameter larger than 12
inches is proposed, an outside drop manhole shall be provided.
• Wastewater collection system manhole rim elevations must be set to conform to the street and shoulder final grade
elevation within public or private road rights -of -way. All other wastewater collection system manhole rim elevations
shall be at least two feet above final grade. Wastewater collection system manholes located within the 100-year flood
elevation shall be set such that the rim elevation is either two feet above the 100-year flood elevation but not more than
three feet above final grade or two feet above final grade and watertight with sealed manhole covers and screened vent
pipes set at least two feet above the 100-year flood elevation.
• Wastewater collection system manholes shall be vented every 1,000 feet or at every other manhole, whichever yields the
greater number of vents.
FORM: WWCSEM 03-2021 Instructions Page 2 of 3

Locations and Separations:
• The location of all utilities shall meet the following standards and the required horizontal and/or vertical separation
distance shall be noted at the appropriate station on the engineering plans.
• A minimum horizontal separation of five feet shall be maintained between any type of maintenance obstruction and the
city's water distribution lines, wastewater collection lines, and associated appurtenances, unless an exception is granted
as outlined in section 62-100. Greater separation distances may be required as specified by federal, state, or local
regulations.
• A minimum vertical separation of two feet shall be maintained between any type of maintenance obstruction, including
but not limited to any other utility provider's lines or equipment, and the city water distribution lines, wastewater
collection lines, and associated appurtenances, unless an exception is granted as outlined in section 62-100. If an
exception is granted, a minimum vertical separation of one foot must be maintained and the city water distribution lines,
wastewater collection lines, and associated appurtenances shall be constructed of ductile iron pipe or an approved ferrous
material with joints that are equivalent to potable water main standards for a distance of ten feet on either side of the
point of crossing. Greater separation distances may be required as specified by federal, state, or local regulations.
• A minimum horizontal separation of ten feet shall be maintained between the city water distribution system and
wastewater collection lines, and associated appurtenances, unless an exception is granted as outlined in section 62-100.
• In areas where utilities are proposed along new roadways subject to the city's development ordinances, water distribution
lines and wastewater collection lines shall be located in accordance with the city's current utility corridor plan, or as
specified by the director of engineering.
• Manholes and cleanouts shall not be located within any feature conveying or pooling storm water.
Depth of Cover (Calculations may be required):
• Three feet minimum cover small be provided for water distribution systems and wastewater collection systems extensions
and/or modifications unless an exception is granted. If an exception is granted, the water distribution systems and
wastewater collection systems extensions and/or modifications must maintain at least 30 inches of cover and be
constructed of ductile iron pipe or an approved ferrous material.
• Maximum depth cover for PVC pipe shall be limited to eighteen (18) feet. All PVC pipe with a proposed depth of cover
exceeding twelve (12) feet shall require the submission of bearing capacity documentation and the supporting design
calculations from the engineer, The documentation and design calculations shall adequately address the bearing capacity
of the proposed PVC pipe and the pipe's ability to withstand the dead and live loads. The design shall include adequate
documentation and the proposed standard detail, which adequately satisfies the bedding requirements for the pipe.
• Ferrous material shall be provided for all proposed water and sewer system extensions that have a depth of cover
exceeding eighteen (18) feet. All ferrous pipe with a proposed depth of cover exceeding eighteen (I8) feet shall require
the submission of bearing capacity documentation and the supporting design calculations from the engineer. The
documentation and design calculations shall adequately address the bearing capacity of the proposed ferrous pipe and the
pipe's ability to withstand the dead and live loads. The design shall include adequate documentation and the proposed
standard detail, which adequately satisfies the bedding requirements for the pipe,
3. Wastewater Pump Stations & Force Main Projects — For a proposed pump station and/or force main additions and/or
modifications submit two copies of the executed Attachment A - Pump Station and Force Main Form (PSFM:2017). For
�A technical design requirements, please reference the most current version of City of Concord Pump Station and Force Main
Technical Specification. This technical specification can be obtained from City of Concord Engineering Department upon
request.
A DIGITAL COPY OF THE COMPLETED APPLICATION PACKAGE, INCLUDING PLANS, SUPPORTING
INFORMATION AND MATERIALS, SHOULD BE UPLOADED TO ACCELA ONLINE PORTAL IN THE
APPLICABLE CASE AT httRs://accclal.c tbarruscountN,.us/CitizenAccess/ , UNLESS OTHERWISE SPECIFIED.
For Accela Case Inquiries, Contact:
CITY OF CONCORD
Planning & Neighborhood Development -
Zoning Services
Post Office Box 308
Concord, North Carolina 28026-0308
Telephone Number: (704) 920-5I52
For Enuincerine Desien Inquiries, Contact:
CITY OF CONCORD
Engineering Department
Post Office Box 308
Concord, North Carolina 28026-0308
Telephone Number: [phone]
FORM: WWCSEM 03-2021 Instructions Page 3 of 3

WASTEWATER COLLECTION SYSTEM
EXTENSION OR MODIFICATION APPLICATION
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
TO BE COMPLETED BY THE CITY OF CONCORD
Project T
Amhurst Subdivision
(Project nameoflilelas
1)
indicated on the drawings)
Located on Amhurst St. SW approximately 4,806 ft. NW of the intersection of Highway 49 and SR 1155 (Zion Church
Description of
Rd.)
project locution.
( Example: Site located on (Road name) SR ####, approx #### linear feet (North, South, %Vest or F.ast)of the intersection of Road name (SR 04 04) and Road
�•
Name (SR #### )
Cabarrus County
Parcel Identification
5529-84-2776
9.592
3.)
Number:
3a.
Parcel Acreage:
RC -CD
Area Commercial or Industrial
72 900
4•
Site Zoning and use:
5.)
Building
(sq. ft.) r
Description of Facility
Single Family Homes
3
Ga,
to he served.
6b. Number of hots
6c. Number of Units
Additional description
7
7d.)
information:
Jeremy Huntsman Director of Land Development
{Title}
(Name orlegal owner, board, council, and?or authorized official with title; as defined in property
records andlor a registered agent(s)as listed in the NC Secretary of State Corporation filings, hereby
referred to as the Applicant.)
Pulte Home Company LLC
{Name of Applicant's company, city, lowly corporation, sanitary district, water company or
other defined in property records and/or as listed in the NC Secretary of State Corporation filings.
[phone]
(Applicant's Phone Number)
Jeremy Huntsman [e-mail]
(Name)
(Name with Title and Email of contact person,
wbo can answer clucstions about application)
is to attach
REQUIRED
Nick Buysse, PE
name of ]North Carolina Professional
047977
[phone]
Nick Buysse, PE
(Name and affiliation of contact person, who can answer questions about
application & designs)
11121 Carmel Commons Blvd, Suite 450
or Box
Charlotte, NC, 28226 I
(Applicant's City, State, Zip Code)
(Applicant's Facsimile Number)
[e-mail]
(Applicant's Email Address)
CEST
PO Box 268
et or Box Nun
Concord, NC, 28026-0268
[e-mail]
(Engineer's Email Address)
as owner.
FORM: WWCSEM 03-2021 Page I of 5

❑wl New
p.;.t.:
Project is:
❑ Modification of an existing Authorization to Construct Permit.
A :
Specify the ATC or DWQ/DWR Permit No. and Issuance Date:
L) Name of Water and Sewer Authority of Cabarrus County WWTF:
.O
Rocky River Wastewater Treatment Facility (RRW WTF - Pennit No: NC0036269)
rA :,
❑Muddy Creek Wastewater Treatment Facility (MCWWTF -Pennit No: NC0081 G21)
A
2.) City of Concord
3) 8"
0 Gravity
4.)
Owner of Downstream Sewer
permit # of Downstream Sewer
W
Receiving Sewer Size
❑Farce Main
❑ rump Station
1.) The origin of this wastewater is (check ail that apply):
2.) The type of wastewater is (indicate percentage):
❑
Residential Subdivision
❑
Retail (Stores, shopping centers)
100
% Domestic
❑
Apartments/Condominiums
❑
Institution
% Commercial
Mobile Home Park
❑
Hospital, nursing home, dental
% Industrial
❑
School, preschool, daycare
Church
%Other use
(Specify)
❑Restaurants
❑
Sports Centers
3.) Pretreatment required:
(Food or drink facilities)
QNp
Hotels or motels
❑
Business, offices factories
yes (Specify or attach effluent documentation)
p
l„f
(Provide documentation of'4VSACC's pre-treatment approval.)
ElOther(specify):-
4.) Volume of wastewater flow to be allocated for this particular project: 9,360 gallons per day
1~
"Wastewater discharge volume shall be calculated in accordance with values defined in Title 15A NCAC 2T .0114
Do not include future wastewater discharge projections that are outside of the scope of the project or previously allocated wastewater flow.
t�
5.) If the wastewater flow is zero, indicate why:
v
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
A
❑ Flow has already been allocated in Pen -nit #.
Z
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a permit is required.)
❑ Other (explain):
6.) Summarize wastewater flow generated by project in the table below: The wastewater flow calculations used in determining the permitted flow in
accordance with 15A NCAC 2T .0114
a) See 15A NCAC 2T.0114(b), (d), (e)(2) for caveats to wastewater flow rates (i.e., minitmum flow per dwelling, proposed unknown non-
residential development, uses; public access facilities located near high public use areas; as defined in G.S. 42A-4).
�+
b) Per 15A NCAC 02T.0114(c), design now rated for establishments not identified [in Table 15A NCAC 02T.0I14] shall be
determined using available now data, water using fixtures, occupancy or operation patterns, and other measured data.
{Flow rates NOT listed in table 15A NCAC 2T .0114 must be supported with actual water use or wastewater discharge data in accordance with I SA
NCAC 2T .0114 (I) and must be attached to this application and sealed by a NC licensed professionaI engineer.)
Established Type See 02T.0114(f)
Daily Design Flow a.b
No, of Units
Flow
Single Family Home
SD al/ Bedroom
39 units x 3 bedrocIM
GPD 9,360
al/
GPD
all
GPD
al/
GPD
al/
GPD
al/
GPD
Total
GPD 9,360
FORM: WWCSEM 03-2021 Page 2 of 5

1.) Summary of Sanitary Gravity Sewer Mains to be constructed (attach additional sheets if necessary)
Diameter Length Material Manholes
(Inches) (Linear feet) (Primary pipe material type) Number Diameter
PVC or ODI 6 4-ft
8"
1,334.07 Or Other 5-ft
con.. OPVC or (DDI 4-ft
Or Other 5-ft
u
^? ; OPVC orODI 4-ft
U Or Other 5-ft
� PVC or ODI -ft
Or Other -ft
Pulnp Station and Force Mains'— N
2.) Pump Station?
(additions/modifications) Yes.(Complete and include attachment A: PSFM 2017 Form)
Complete the stream classification for the closest down slope surface waters. Include all points that traverse over or are near different
waterbodies (or counties, basins, etc.,) A variance must be requested for encroachment within required setbacks or buffers pursuant to 2T .0305 (f) and
�p be submitted by thm e City of Concord to NCDEQ DWR with supporting docuentationljustiffcation provided. For further assistance with determining
watershed classification, contact the NCDEQ Mooresville Regional at 704-663-1699 or NCDEQ—Division of Water Resources's web site at
www.rimvater.org or the City of Concord Engineering Department 704-920-5425.
r%]
Location ID on QUAD Map Name of Waterbody County River Basin Waterbody Stream Waterbody
(self choscn - as shown on rnap for cross-rcrcrcnce) Index Classification
V City of Concord Quad Map Irish Buffalo Creek Cabarrus Yadkin Pee•�ee 13-17-g-12\ C
Cabarrus ` 1
Does the subject sanitary sewer system comply with the (latest version) of State of North Carolinas' Administrative Code, Subchapter 15A NCAC 2T
y .0305(f) & (g), the Water and Sewer Authority of Cabarrus County Standard technical Specifications for wastewater Collection and Water Distribution
Construction for Cabanus County, and the City of Concord Development Code, Code of Ordinances, Policies and Technical Standards; the more
restrictive as applicable?
© QYes QNo If No, to City of Concord Design Standards; please reference the pertinent minimum design criteria and indicate why an
Sexception is requested. SUBMIT TWO COPIES OF SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE
U EXCEPTION WITH YOUR APPLICATION.
k
t16 Urn
A
Have the following permits/certifications been submitted for approval for the proposed water system or the associated project to be
served by the water system? If "yes," submit a copy of all applicable permits.
a. US Arm Corp04 or NCDEQ DWQ 401 wetland permit? Q Yes) No 0 NIA
� ) y p
FZw b.) Sedimentation and Erosion Control Plan? Q Yes 0 No Q NIA
c.) Stormwater Management Permit? Q Yes Q No O NIA
d.) NCDOT Utility Encroachment? 0 Yes 0 No a NIA
e.) Environmental Assessment? Q Yes (D NIA
(If Yes, Submit FONSI or EIS)
Does this project include any high priority lines (15A NCAC 02T .0402 (2)) involve aerial lines, siphons, or interference manholes? "High -
priority sewer" means any aerial sewer, sewer contacting surface waters, siphon, or sewer positioned parallel to stream banks that is
a subject to erosion that undermines or deteriorates the sewer.
t..
Check if YesEl
provide details:
xa'.' : WWCSEM 03-2021 Page 3 of 5

Notice
These plans and specifications cited in the foregoing application and attachments, including any provisos in the
approval letter, are approved insofar as the protection of public health is concerned as provided in the rules, standards
and criteria adopted under the authority of NCGS 143-215.1(f) and 15A NCAC 2T. This approval does not address all
applicable laws, rules, standards and criteria, and other approvals and licenses that may be required by the local, state or
federal government. This approval is given with the understanding that upon installation of such works, its operation
shall be placed under the care of a competent person, and the operation shall be carried out according to best accepted
practice and in accordance with the recommendations of the City of Concord through the delegated authority of North
Carolina Environmental Management Commission and the Division of Water Quality.
Any erasures, additions or alterations of the proposed improvements except those pennitted in 15A NCAC 2T will
make this approval null and void.
This approval does not constitute a warranty of the design, construction or future operation of the wastewater collection
system.
THE CITY AND ITS STAFF ARE NOT RESPONSIBLE FOR ERRORS IN DESIGNS, CALCULATIONS,
DRAWINGS OR STATEMENTS SUBMITTED BY APPLICANTS, THEIR TECHNICAL CONSULTANTS,
SURVEYORS OR ENGINEERS. THE CITY AND ITS STAFF ARE NOT RESPONSIBLE FOR FINDING OR
CORRECTING ANY ERRORS OR DEFICIENCIES IN PLANS SUBMITTED TO THE CITY FOR REVIEW AND
APPROVAL. THE CITY OF CONCORD DISCLAIMS ANY LIABILITY FOR ERRORS CONTAINED IN PLANS
SUBMITTED TO THE CITY. THE SIGNATURE OF THE CITY ENGINEER MAY NOT BE RELIED UPON TO
ESTABLISH ANY DUTY OR RELATIONSHIP (SUCH AS A THIRD -PARTY BENEFICIARY) WITH ANY
PARTY USING THIS PLAN OR DRAWING. PARTIES USING THIS DOCUMENT SHOULD CONDUCT THEIR
OWN REVIEW AND ANALYSIS FOR MAKING DECISIONS IN RELIANCE ON THIS DOCUMENT.
City of Concord Certification: TO BE COMPLETED BY THE CITY OF CONCORD
The official copies of plans and specifications accompanying this application have been sealed and stamped with the
Authorization to Constrict (ATC) number for this application
1, M. Sue Hyde, P.E. attest that this application has been reviewed by me and contains sufficient information to ascertain
reasonable grounds to believe the application package and its contents meet all applicable standards of Subchapter 15A NCAC 2T,
the State of North Carolina's Administrative Code, the Water and Sewer Authority of Cabarrus County Standard Specifications and
the City of Concord's ordinance, policies and specifications as presented. The denial of the issuance of a permit, subject to the
provisions in Article III, Chapter 62 of the City of Concord Code of Ordinances shall be made in writing and shall contain the
reasons for the denial and the City's estimate of the general changes in the applicant's proposed activities or plan which will be
required in order that the applicant may obtain a permit. Nothing in such estimate shall preclude or otherwise bar the City from
denying a penmit, which incorporates such changes, based upon changed circumstances or information not previously known by the
Director of Engineering or the applicant.
Signature:
M. Sue Hyde, P.E., Director of Engineering
FORM: WWCSEM 03-2021 Page 4 of 5

Professional Engineer's Certification:
As a duly registered Professional Engineer in the State of North Carolina, I certify that this application has been reviewed by me and is accurate, complete
and consistent with the information supplied in the engineering plans, 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 and supporting documentation has been prepared in accordance with and subject to the
applicable regulations; NCDEQ Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February 12, 1996; NCDEQ the Minimum Design
Criteria for Fast -Track Permitting of Pump Stations and Force mains adopted June 1, 2000; the watershed classification in accordance with the Division
Guidance; the Water and Sewer Authority of Cabarrus County's standard specifications and technical details: the City of Concord's ordinances, policies,
details and standard specifications; and the North Carolina Administrative Code 15A NCAC 2T for wastewater collection systems. In the event of conflict
between the Water and Sewer Authority of Cabarrus County's standard specifications; the City of Concord's ordinances, policies, and standard
specifications, or the North Carolina Administrative Code, the more restrictive requirements shall apply. 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 NC General Statutes 143-215.6A and 143-215.613, any person who
knowingly makes any false statement, representation, or certification in any application 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, and referral to the State Board of Registered Professional Engineers and
Surveyors.
CESI
(Signature of North Carolina Professional Engineer)
(Company Name)
Nick Buysse, PE
PO Box 268
(Type Name Signed Above)
(Street or Box Number)
047977
Concord, NC, 28026-0268
(NCPE Registration Number)
(City, State, Zip Code)
nickbuysseacesicgs.com
(Seal & Signature Date)
(Email Address)
[phone]
(Phone Number)
(Engineer's seal)
(Facsimile Numbers)
Agnlicant's Certification:
This application is made under and in full accord with the provision of NCGS 143-215.3(a)(1);143-215.1 and such other statutes as related to wastewater
collection systems. The applicant agrees that no change or deviation from the engineering plans and specifications approved by the Division of Water Resources
will be made except as allowed by 15A NCAC 2T or with the written consent and approval of the City of Concord Director of Engineering or the Directors'
authorized representative. The applicant agrees that a professional engineer licensed to practice in the State of North Carolina shall submit a statement reflecting
that adequate observations during and upon completion of construction, by the engineer or by a representative of the engineer's office who is under the
engineer's supervision, indicates that construction was completed in accordance with the applicable regulations, ordinances, policies, approved plans and
specifications. I understand that if all required parts of this application 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. Any application package determined incomplete by the Director of Engineering shall be
returned to the applicant. Revised engineering plans and specifications shall constitute a re -submittal, shall be accompanied by a new fee, and shall require
additional time for review. Note: In accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application 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 $251000 tion.
11121 Carmel Commons Blvd, Suite 450
(Signature o egat otir � aard r , andlor authorized official with title; as (Applicant's Street or Box Number)
defined in praprffy record nd/or a registered agent(s) as listed in the NC Secretary
of State Corporation filings.)
Jeremy Huntsman iDirector ofLand Development Charlotte, NC, 28226
(Applicant's Typed Name & Title of (Applicant's Signature Date) (Applicant's City, State, Zip Code)
signing entity)
[phone] Jeremy.HuntsmanOpultegroup.com
(Applicant's Phone Number)
(Applicant's Email Address)
FORM: WWCSEM 03-202I Page 5 of 5