WQ0043532_Application (FTSE)_20220609

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6/6/22
North Carolina Department of Environmental Quality
Division of Water Resources
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Attn: Mr. Alex Lowe
Re: Fast Track Sewer System Extension Application for
Robinhood Road Baptist Church Sewer Replacement
Winston-Salem, NC 27106
Dear Mr. Lowe:
NC Oenarfmfht of
trivIroornEcital Quality
Not@lverd
JUN 99 21122
Winston-Salem
Regional Office
On behalf of Robinhood Road Baptist Church and West Edge, LP, I am submitting a Fast Track Sewer System Extension
for the above referenced project. The application package includes the following:
• Fast Track Sewer System Extension Application
• Flow Tracking for Sewer Extension Applications
• Site Maps
• Septic System Information
• Permit fee in the amountlof $480
NARRATIVE
The Robinhood Road Baptist Church wastewater is currently treated by a septic system with onsite disposal consisting of
a grease trap, septic tank, dosing tank & pump and a pressure -dosed subsurface disposal field. No other sources of
wastewater are tributary to the septic system. The Church has agreed to sell a portion of their property to West Edge, LP,
developer of the adjacent property. The subsurface disposal field is located on the property being sold for development,
therefore an alternate means of wastewater disposal must be implemented. West Edge has agreed to grant an easement
for a permanent gravity sewer service to extend from the Church to a public gravity sewer main that will be constructed as
part of the development. Ownership of the public sewer main will be conveyed to the City of Winston-Salem upon
completion of construction and acceptance by the City.
The septic system subsurface disposal field will need to be removed early in the construction process and a temporary
force main will be required to convey the septic tank effluent from the Church along the perimeter of the site to be
developed to an existing City of Winston-Salem sewer manhole in Sweetgrass Trail in the adjacent development. West
Edge has agreed to grant an easement for the temporary force main as well. The force main will be 2" diameter PVC with
combination air valves at two high points along the force main. The Church's septic system (grease trap, septic tank and
dosing tank) will remain in service until such time as the new gravity sewer service can be installed. The existing dosing
pump (single pump) has been evaluated for capacity to pump to Sweetgrass Trail. The overall force main slope is
downhill with a couple intermediate high points in the line so friction head in the force main is the primary head to
overcome. The operating point of the pump is well within the pump curve.
The existing sewer service lines from the Church to the grease trap and septic tank are 4" lines. When the public line is
completed, tested and ready to be put into service the existing 4" service lines from the Church will be replaced with 6"
lines as required by the 15 NCAC 02T Rules and extended to the public system. The septic tank and dosing tank will be
pumped out and the tanks removed or abandoned per requirements of the Forsyth County Health Department.
Power Reliability:
Power reliability will be addressed by a portable generator dedicated to the pump system. The developer will purchase as
appropriately sized generator to provide power for the pump in the event of a power outage. The existing power supply
will be modified to provide for disconnection from the Church power feed and plug in to the generator. The generator will
remain in storage onsite for immediate use if needed.
LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LAND PLANNING

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Pump Reliability:
As discussed above the existing septic system dosing tank operates on a single effluent pump. Per 15A NCAC 02T .0305
' (h) (1) (D) an alternative to the standby power source connecting a single building to an alternative sewer system, wet well
storage requirements shall be documented to provide 24-hours worth of storage. The daily wastewater flow is 2,500 gpd.
Per information obtained from the Forsyth County Health Department the system includes a 1,500-gallon septic tank and
a 1,500-gallon pump tank. See the attached septic system information. In the event of a pump outage both the septic
tank and pump tank could be pumped to provide 3,000 gallons of wastewater storage. There are a number of pump
distributors in the area that stock replacement pumps matching the pump currently in use. We are requesting that this
method of reliability be accepted for the project.
If you have any questions or need additional information, please contact me at [phone] or by e-mail at
ntucke & stimmelpa.com,
Sincerely,
Yew
J. Neal Tucker, PE
Vice President / Director of Civil Engineering
Attachments
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LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LAND PLANNING
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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: InX OO'3jS2. (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Robinhood Road Baptist Church (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal X❑ Other
3. Signature authority's name: John E. Hackworth, Jr. per 15A NCAC 02T .0106(b)
Title: Pastor
4. Applicant's mailing address: 5422 Robinhood Road
City: Winston-Salem State: NC Zip: 27106-9761
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
H. PROJECT INFORMATION:
I. Project name: Robinhood Road Baptist Church
2. Application/Project status: X Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing 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: W000_
3. County where project is located: Forsyth
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.1220° Longitude: -80.3722°
5. Parcel ID (if applicable): 5896-45-7740 (or Parcel ID to closest downstream sewer)
IIL CONSULTANT INFORMATION:
1. Professional Engineer: J. Neal Tucker, PE License Number: 14985
Firm: Stimmel Associates, PA
Mailing address: 601. N. Trade Street
City: Winston-Salem State: NC Zip: 27101--
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (W WTF)1NFORMATION:
1. Facility Name: Muddy Creek Treatment Plant Permit Number: NC0050342
Owner Name: City of Winston-Salem
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ00003
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00003
Owner Name(s): City of Winston-Salem
FORM: FTA 06-21
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 X❑N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No X❑ 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 X❑N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned)
❑ Residential (Leased)
❑ School / preschool / day care
❑ Food and drink facilities
O Businesses / offices / factories
❑ Retail (stores, centers, malls)
❑ Retail with food preparation/service
0 Medical / dental / veterinary facilities
X❑ Church
❑ Nursing Home
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic % 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? ❑ Yes X❑ No J
> If vas, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(0)
Daily Design Flow''b
No. of Units
Flow
Church with kitchen
5 gal/seat
260
1,300 GPD
Church with camps (Mothers morning out)
25 gal/person
48
1,200 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
2,500 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.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 2,500 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:
0 Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21
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
6"
792
PVC
> Section II & III of the MDC for Pemiitting of Gravity Sewers contains information related to design criteria
> 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 INCLUD�D IN THIS PROJECT
1. Pump station number or name: Septic system effluent pump
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.1220° Longitude: -80.3722°
3. Total number of pumps at the pump station: 1
3. Design flow of the pump station: 0.0025 millions 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): 31 gallons per minute (GPM) at 25.5 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
1,530
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. ❑ Grinder Pump ❑ Mechanical Bar Screen XD Other (please specify) See attached
Narrative.
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):
> 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):
X❑ 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.
FORM: FTA 06-21 Page 3 of 5

> 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.
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(1)):
1. Does the project comply with all separations/altematives found in 15A NCAC 02T .0305(f) & (g)? X❑ Yes 0 No
15A NCAC 02T.0305(fl 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
'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
**My other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
I 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
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? 0 Yes ❑ No X❑ 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? 0 Yes 0 No X❑ 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? 0 Yes Basin name: X❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? 0 Yes 0 No
> This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits X❑ Yes
or 401 Water Quality Certifications?
> Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
USACE Action ID No. SAW-2019-02008 / NCDEQ Certification No. WQC004541
❑ No
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? X❑ Yes 0 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.). 401 & 404 permits have been issued, stormwater
permit has been issued (SWA000140), erosion control has been issued through City of Winston-Salem. See attached
Narrative for explanation.
7. Does this project include any sewer collection lines that are deemed "high -priority?" 0 Yes X❑ No
FORM: FTA 06-21 Page 4 of 5

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.
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version) and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
XQYes No
If no, for projects requiring a single variance, complete and submit the Variance/Altern2tive 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 approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects 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:
I, J. Neal Tucker, PE , attest that this application for Robinhood Road Baptist Church
(Professional Engineer's name from Application Item 111.1.) (Project Name from Application Item E.1)
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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 Gravity Sewers (latest version) and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 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)
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North Carolina Professional Engineer's seal, signature, and date:
14985
6/1/22
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, John E. Hackworth, Jr. attest that this application for Robinhood Road Baptist Church
(Signature Authority Name from Application Item 1.3.) (Project Name from Application Item 11.1)
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 retuned 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
FORM: FTA 06-21 Page 5 of 5

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 143-215.6B, any person who knowingly makes any false
statement, represen ..tion, or cert. 'cation in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not o xceed $1p,op0 as , ell as civil pe y]j ies up to $25,000 per violation.
Date:
FORM: FTA 06-21 Page 6 of 5

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Robinhood Road Baptist Church
Project Name for which flow is being requested: Robinhood Road Baptist Church
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment. plant.
a. WWTP Facility Name: MUDDY CREEK
b. WWTP Facility Permit #: NC0050342
All flows are in MGD
c. WWTP facility's permitted flow 21.000000
d. Estimated obligated flow not yet tributary to the WWTP 2.934654 N j
e. WWTP facility's actual avg. flow 13.930000
f. Total flow for this specific request 0.0025000
g. Total actual and obligated flows to the facility 16.867154
h. Percent of permitted flow used 80.3
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
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
* 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.
** 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.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Muddy Creek
Downstream Permit Number: WQCS00003
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Courtney Driver, P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official Signature
Title of Signing Official
Date
Page 2 of 6
FTSE 10-18

APO",Y" } ��i nhee , Qicuiisi Clt u r In Installer Frc ni c —f icr CLk.
Address of Site 549.9, 'Rot ,inkp.wl rti W•5 • ant Olt, Subdivision
Directions to Site ReLinhoa l nA t11es/ s+ �n ir�i �`<sb
Use of Structure %V-1 i, r-ti- I^
Number of Employees N /A
Daily Flow A d& lab Number of Bedrooms N/A
Number of People Water Supply: Public,
LTAR • 25 Total Sq. Footage — Sys Type -Tr B Sys Classification 6So:L. 4 PI us Aggregate Dpth
Total Trench Length lso'
EMS IP/CA C• C.h.// EHSOP /n,nierreif
Ramp gnc,1 7/20/201 t rani
Septic Tank:
Manufacturer u5HAAF (oNs aecca) STB- S`lD/3&i Gals. 1500 Date 1112912610
Fiter Brand a? Ii - (._cyic Filter Model # P L- (,S ST Marker --
Pump Tank:
Manufacturer SHWA F PT. 35 3 One/Two piece ONit . Gal. I Soo
Date a: ` 1 S -11 Riser (min. 6") G ' Riser Sealed Properly rr Gat. per inch in lank N 'r1 eb
Pump Requiremenjs:
AlarmAudtble a- Alarm Visible Cd" Dosing Vol. 3JF, - 2G 5 Draw Down is in.
Thor. Chain or. GPM a qpm TDH ---
Supply Line: •! '
Sae a in.:34 i ft. PVC Unions ®"PVC Bail or Gate Valve fd Valves Accessible ld'Chedc Valve a Anti -siphon Hole 0 Vent Hole V
Electical Equipment: / eJ
O NEMA 4X Box "Box 12 in. above Grade 19' Box Adj. to Pump Tank "-Piggyback Plug IB�Weatherproof Sealant Dii/ump Manually Operable [A'a
or Equivalent -
ft. Trench Depth It..= 4" in. Trench Width 34"'
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