WQ0043539_Application_20220616

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number jAlQ CO'4353q (to be completed by DWR)
RECEIVEDINUUtQ/DW
JUN 16 ZO2Z
All items must be completed or the application will be returned
WOROS
I. APPLICANT INFORMATION: MOORESVILLE REGIONAL OFFIC
1. Applicant's name: City of Statesville (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: A. Scott Harrell, P.E. per 15A NCAC 02T .0106(b)
Title: Assistant City Manager
4. Applicant's mailing address: P. O. Box 1111
City: Statesville State: NC Zip: 28687-1111
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Davis Street Sanitary Sewer Extension & Improvements
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Iredell
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.784849° Longitude: -80.878888°
5. Parcel ID (if applicable): 4744-256-812 & -888, 4744-257-829
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Matthew I. Grant License Number: 33292
Firm: Jordan Grant & Associates, PLLC
Mailing address: 2351 Simonton Road
City: Statesville State: NC Zip: 28625-8246
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Permit Number:
Owner Name: City of Statesville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 04-16 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 DNo ZN/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
O Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
® Residential Owned
❑ Residential Leased
❑ School / preschool / day care
❑ Food and drink facilities
❑ Businesses / offices / factories
❑ Retail (stores, centers, malls)
❑ Retail with food preparation/service
❑ Medical / dental / veterinary facilities
❑ Church
0 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 % Commercial
% Industrial (See 15A NCAC 02T .0103(20))
�Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? 0 Yes ® No
➢ If ves, provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
3 bedroom dwelling
120 gal/bedroom
3
1,080 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
1,080 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 1,080 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
0 Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16
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
246
PVC
> Section II & III of the MDC for Permitting 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 requirement is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: . Longitude: -
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at
5. Summarize the force main to be permitted (for this Pump Station):
feet total dynamic head (TDH)
Size (inches)
Length (feet)
Material
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or pump with 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
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
> It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
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
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g)
➢ 15A NCAC 02T.0305(fl contains minimum separations that shall be provided for sewer systems:
® Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
24 inches
Water mains (vertical -water over sewer 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
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 (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
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
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(f) cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(f) or (g),. see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ® Yes ❑ No ❑ N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No ❑ N/A
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
❑ Yes ® No
5. 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 are 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.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ®No ❑ N/A
➢ 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 permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

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?
®Yes El No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and supporting documents.
2. Professional Engineer's Certification:
I,
(Professional Engineer's name from Application Item III.1.)
attest that this application for
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, Gravity Sewer
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. ,0,S6°"i'j'v,a3a�,�
•Nr"•
"
North Carolina Professional Engineer's seal, signature,and date: r ••"ti•,S1 °'"
t 33292
47:::1
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aaaee
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I,
C?%
- c,T met-Av ,etz
Signature Authority's name & titll from Application Item I.3.)
attest that this application for
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 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: 9/WM
FORM: FTA 04-16
Page 5 of 5

Jordan Grant & Associates, PLLC
JORDAN
GRANT
June 13, 2022
Mr. Corey Basinger, Environmental Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
Department of Environmental Quality
610 East Center Avenue, Suite 301
Mooresville, North Carolina 28115
Re: Sewer System Extension to serve
Davis Street
City of Statesville
Iredell County, NC
Dear Mr. Basinger:
RECEIVED/NCDEO/DWR
JUN 16 2022
WOROS
MOORESVILLE REGIONAL OFFICE
Please find enclosed one paper copy of the Fast Track Sewer System Extension Application
(FTA 04-16), Flow Tracking Sewer Extension Application (FTSE 10-18), plans, application fee
(our check for $480.00), a street level vicinity map, and a USGS topography map for the above
referenced project for your review in the permitting process.
The proposed project will require the installation of 246 linear feet of 8" PVC sewer main, 1
doghouse manhole in Salisbury Road and 1 manhole in the right of way of Davis Street. The
sewer project will also require the installation of 3 sewer service laterals.
Please contact me with questions, comments and/or approval.
If you have any questions or need additional information, please contact me.
Sincerely,
Matthew I. Grant, PE, PLS, Owner
P.O. Box 151
Statesville, NC 28687 [phone]
jordan-grant.com

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: City of Statesville
Project Name for which flow is being requested: Davis Street Sanitary Sewer Extension
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: 4th Creek WWTP
b. WWTP Facility Permit #: NC003183
All flows are in MGD
c. WWTP facility's permitted flow 6.0
d. Estimated obligated flow not yet tributary to the WWTP 0.5063
e. WWTP facility's actual avg. flow 2.66
f. Total flow for this specific request 0.0011
g. Total actual and obligated flows to the facility 3.1674
h. Percent of permitted flow used 52.79%
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):
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

22 Max al. Tev-twl= f -
GRAPHIC SCALE
1 inch = 100 ft.
100 200
SITE AERIAL MAP EXHIBIT
DAVIS STREET SANITARY SEWER
EXTENSION & IMPROVEMENTS
DRAWN BY: BY
CHECKED BY: MIG
SCALE: 1" = 100'
PIN NO: 4744-256-812 & -888, 4744-257-829
DEED REF:
DATE OF MAP: 5/17/22
REVISION:
SURVEY DATE: 4/8/22
DRAWING FILE: EXH-SITE MAP
0 DAVIS STREET, STATESVILLE, NORTH CAROLINA 28677
• ATESVILLE TVVNSHIP I IREDELL COUNTY I NORTH CAROLINA

NAD83 - 2011
GRAPHIC SCALE
1 inch = 200 ft.
200 400
PROPOSED r
CONN
EXISTING 8
)
600
Ciminmel
USGS TOPO MAP EXHIBIT
DAVIS STREET SANITARY SEWER
EXTENSION & IMPROVEMENTS
DRAWN BY: BY
CHECKED BY: MIG
SCALE: 1" = 200'
PIN NO: 4744-256-812 & -888, 4744-257-829
DEED REF:
DATE OF MAP: 5/17/22
SURVEY DATE: 4/8/22
REVISION:
DRAWING FILE: EXH-USGS MAP
0 DAVIS STREET, STATESVILLE, NORTH CAROLINA 28677
STATESVILLE TWNSHIP I IREDELL COUNTY I NORTH CAROLINA