WQ0043485_Application (FTSE)_20220527

110 WithersRavenel
/ Out People. You; Success.
May 20, 2022
Department of Environmental Quality
Winston-Salem Regional Office - Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
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Environr�i, �, , ‘88Ilty"
Received
MAY 2 3 7n22
Winston-Salem
Regional Office
Attn: Jenny Graznak
RE: Town of Liberty Collection System Improvements (ASADRA Project CS370460-04)
Dear Ms. Graznak:
Enclosed you will find the Fast Track Application for the Town of Elbert' Collection System
Improvements project. There will be no flow requested with this applicationJ
The Town of Liberty Collection System Improvements project consists of the relocation of the
Starmount Lift Station out of the 100-year flood plain, including but not limited to, reconfiguration
of existing 8-inch and 12-inch gravity sewers, installation of 8-foot diameter precast concrete wet
well, vault and control piping, manhole mounted comminutor, electrical gear, structure for
electrical gear, propane powered emergency generator, bypass pump connection and connection
to existing 6-inch force main, area fencing and improving the access road.
Included items:
• One original and one paper copy of signed and sealed FTA 04-16 Form
• Two paper copies of USGS Topographic and Aerial Site Map
• $480 Application Fee
Please contact me if you have any questions or need any additional information.
Sincerely,
WithersRavenet
Christoph4f N. Huff, PE
Senior Project Engineer
919-535-5161 direct
115 IvracKenan Drive I Carv. NC 27511
t. 919.469:3340 j f: 919.467.6008 j www.withersravenel.com j License No. i--1479
Asheville I Cary I Charlotte j Greensboro 1 Lumberton Pittsboro j Raleigh j Southern Pines j Wilmington

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: Town of Liberty (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual 0 Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
0 Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: Scott Kidd per I5A NCAC 02T .0106(b)
Title: Town Manager
4. Applicant's mailing address: 239 S. Fayetteville St., P.O. Box 1006 Liberty, NC 27298
City: Liberty State: NC Zip: 27298-
5. Applicant's contact information:
Phone number: [phone] Email Address: townmanagertownoflibertync.org
7a
II. PROJECT INFORMATION:
1. Project name: Town of Liberty Collection System Improvements Contractl - Pump Station Improvements (ASADRA Proiect
CS370460-04)
2. Application/Project status:
J
® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the g7dsting permit number: W000 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: Randolph
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.853°Longitude: -79.584°
5. Parcel ID (if applicable): 81652 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Christopher N. Huff
Firm: WithersRavenel
Mailing address: 115 MacKenan Drive
City: Cary State: NC Zip: 27511-
Phone number: [phone] Email Address: chuff(aiwithersravenel.com
License Number: 024420
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Town of Liberty WWTF Permit Number: W00003090
Owner Name: Town of Liberty
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQCS00280
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00280
Owner Name(s): Town of Liberty
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
CI Yes ❑No ZN/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):
Z Residential (Individually Owned)
Z 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
0 Other (Explain in Attachment)
5. Nature of wastewater : 20 % Domestic 80 % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in 'effect? 0 Yes 0 No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(fl? 0 Yes I No J
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
Total
0 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 I5A 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: 0 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: Permit number was requested from NCDEO. NCDEO could not
locate the existing permit to reference for this application. Issuance Date:
0 Rehabilitation or replacement of existing sewers with no new flow expected
® Other (Explain): The Starmount Pump Station is being relocated out of the 100-year floodplain. No new flow will be
allocated with this project.
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
457
PVC
12
94
PVC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
S. Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Starmount Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.853° Longitude: -79.584°
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.36 million gallons per day (firm capacity)
S. This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 250 gallons per minute (GPM) at 97 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6
107
PVC
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. 0 Grinder Pump 0 Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
S. Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
S. Must be permanent to facility 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):
O 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.
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(t)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (g)? ® Yes ❑ No
15A NCAC 02T.0305(f) 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
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water maths (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 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains I
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (g) see Section X.1 of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
2. Does this project comply with the minimum separation requirements for water mains? ❑ 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
➢ 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 permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
® N/A
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 4 of 5

VI. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T the Minimum Desien Criteria for the Permitting of Pump Stations
and Force Mains (latest version). and the Gravity Sewer Minimum Desien 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
concurrently with the approvalof the permit, and protects requiring a variance approval may be subject to longer
review times. For protects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
f, Christopher N. Huff , attest that this application for Town of Liberty Collection System
Improvements Contractl - Pump Station Improvements (ASADRA Proiect CS370460-04)
(Professional Engineer's name from Application Item 111.1.) (Project Name from Application Item II.1)
has been reviewed by me and is accurate, complete, and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Desien Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting,
of Pump Stations and Force Mains (latest version). Although other professionals mayhave developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies thati 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)
vittwzoro
North Carolina Professional Engineer's seal, signature, and date: , r 1 r
3. Gil Applicant's Certification per 15A NCAC 02T .0106(b): / /
I , .©" /ZtGf L( , attest that this application for C2Lf2, —t--rr `C(L44,Cn
(Signature Authority Name from Application Item 1.3.) (Project Name from Application ltem/WI) /
5 ✓r
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, 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: � ^ i 1 Date: 5/ D /Z Z
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 5 of 5

PROJECT OCA f Ili
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STARMOUNT PUMP STATION
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