WQ0043533_Application (FTSE)_20220603

DocuSign Envelope ID: AD907DDF-8490-4350-B5OANC7iB EEnvironmental Quality
DWR
SUN 3 2022
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources Raleigh Regional Office TA 06-21 & SUPPORTING DOCUMENTATION
Application Number: aQ b 4 3 S3 3(to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
I. Applicant's name: Amgen Inc. (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ Slate/County ❑ Municipal ❑ Other
3. Signature authority's name: Robert Kenyon per i5A NCAC 02T..1060)
Title: VP Site Operations
4. Applicant's mailing address: I Amgen Center Dr.
City: Thousand Oaks State: CA Zip: 91320
5. Applicant's contact information: Robert Kenyon
Phone number: [phone] Email Address: rkenyo01rr,amgen.com
11. PROJECT INFORMATION:
1. Project name: Amgen Project FIeX Batch — Private Sanitary Sewer Extension
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Wake
4. Approximate Coordinates (Decimal Degrees): Latitude: 35:40'31.64" Longitude:-78:54'28.86"
5. Parcel ID (if applicable): 0720702658 (or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer: W. Jordan Brewer, P.E.
Firm: Kimley-Horn and Associates, Inc.
Mailing address: 300 S Main Street, Suite 2I2
City: Holly Springs
License Number: 039196
State: NC Zip: 27540--
Phone number: [phone] Email Address: iordan.brcwer.c kimley-horn.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Utley Creek WRF Permit Number: NC0063096
Owner Name: Town of Holly Springs
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
I. Permit Number(s): WQ- *downstream sewer (Friendship Innovation Park) is being permitted concurrently
2. Downstream (Receiving) Sewer Information: 18 inch IRI Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00192
Owner Name(s): Town of Holly Springs
FORM: ETA 06-21
Page I of 5

DocuSign Envelope ID: AD907DDF-8490-4350-B50A-72A7282379BE
VI. GENERAL REQUIREMENTS
I. 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 Develop is Operational Arcemeni LFORM; DEVj been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an UtJA. POA Operational. Agnernent (FORM:1.1OAI and
supplementary documentation as required by I5A NCAC 02T.0115(c) been attached?
❑ Yes ❑No El NIA
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls)
❑ Residential (Leased) ❑ Retail with food preparation/service
❑ School / preschool / day care 0 Medical / dental ? veterinary facilities
❑ Food and drink facilities ❑ Church
Businesses / offices / factories ❑ Nursing I -tome
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
O Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : _% Domestic % Commercial 100 % industrial (See 15A NCAC 02T _010312Qj)
If Industrial, is there a Pretreatment Program in effect? ® Yes❑ No
6. Has a flow reduction been approved under 15A N(tA ' 02T .0114j1'? ❑ Yes ® No
➢ If ves, 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'"e
No. of Units
Flow
gal/
GPD
gal/
GPD
Pharmaceutical Medical Factory
100,000 gal?day
1
100,000 GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
100,000 GPD
a See 1$A NCAC 02T .01 I41b), (d), (e)(1) nod I€ L 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 15 _NC'AC 02T,0I 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 100,000 GPD (per I5A NCAC 021 .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:
O Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21
Page 2 of 5

DocuSign Envelope ID AD907DDF•8490.4350-B50A-72A7282379BE
VI1. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers)!
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
S"
2,171
PVC
➢ Section 1I & 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 scope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) 02T .0305 & MDC (Pump Stations/Force Mainsl:
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN TIIIS PROJECT
I. Pump station number or name: N/A
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Total number of pumps at the pump station:
3. Design flow of the pump station: 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): �_. gallons per minute (GPM) at
5. Summarize the force main to be permitted (for this Pump Station):
feet total dynamic head (TDII)
Size (inches)
Length (feet)
Material
If any portion of the force main is less than 4-inches in diameter, please identify the me hod of solids reduction per
MDCPSFM Section 2.0I C.I .b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) .
6. Power reliability in accordance with 15A NCAC 02T .03050)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(t3)
➢ 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 I5A NCACO2T.0305(h)(I)(C):
❑ 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,
➢ lithe 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.
FORM: FTA 06-21 Page 3 of 5

DocuSign Envelope ID: AD907DDF-8490-4350-B50A-72A7282379BE
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in I5A NCAC 021' .0305111.& (gl?
15A NCAC 02T.0305(f) 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)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water 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 11 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, 1-IQW, 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
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(11 or (at. see Section X.I of this application
*15A NCAC 02T.0.305(R) contains alternatives where separations in 02T,O305(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 Syrface Water Classifications +vebnaac
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?
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's ¢laO 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: Cape Fear
If yes, does the project comply with setbacks found in the river basin rules per I5A LcAC 02B . 00?
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
Yes
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is req
❑ No ❑NIA
❑ No
® Yes ❑ No
❑ Yes ® No
uired.
6. Does project comply with j A NCAC 02L0105(c I6) (additional permits/certifications)? ® Yes ❑ No
Per I5A NCAC 02T_0105#cl(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 1 5A NCAC 021.040 , "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to strcambanks that arc 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.
Page 4 of 5
FORM: FTA 06-21

DocuSign Envelope ID AD907DDF-8490-4350-B50A-72A7282379BE
X. CERTIFICATIONS:
I . Does the submitted system comply with 1 5A NCAC 02T the Minimum Desit.n Criteria for the Permitting of Pump Stations
and Force Mgjgstlatest versions, and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance. complete and submit the Variancc.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 annroval of the permit, and protects rcauirina a variance annroval may be subiect to longer
review times. For nroiects requiring two or more variances or where the variance is determined by the Division to he a
significant portion of the nroiect. the full technical review is required,
2. Professional Engineer's Certification:
I. W, Jordan Brewer attest that this application for Amgen Proicct FIeX Batch— Private Sanitary Sewer Extension.
(Prof . iunal {Engineer's name from Application Item 111 I 1 Outer' Name from Application Item
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 Ile>ign Criteria for Gravity Sewers t 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 I43-215.6B. 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 S 10,000, as well as civil penalties up to S25.000 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)
E `\`otttlFllll/���
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I. Robert Kenyon , attest that this application for _Amen Proicct FIeX Batch- Private Sanitary Sewer Extension
i!V gnatwe Authors!: Name from Application hem 13 ) /Pro ect Name from Application Item III )
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 arc 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 arc not completed and that if all required supporting information and attachments arc not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes l43-215.0A 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 S 10,000 as well as civil penalties up to S25.000 per %iolation.
Signature:
FORM: FT:t 06-21
SEAL x ':
1 039196 ?
-
3/21/2022
Date: 3/ / ri 3 _
Page 5 of 5

DocuSign Envelope ID AD907DDF-8490-4350-950A-72A7282379BE
Dhi Ilion of Water fte .ources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Amgen, Inc.
Project Name for which flow is being requested: Amgen Project FIeX Batch - Private Ext.
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.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Utley Creek Wastewater Treatment Plant
b. WWTP Facility Permit #: NC 0063096
All flows are in MGD
c. WWTP facility's permitted flow 6 MGD
d. Estimated obligated flow not yet tributary to the WWTP 0.721 MGD
e. WWTP facility's actual avg. flow 2.828 MGD
f. Total flow for this specific request 0.1 MGD
g. Total actual and obligated flows to the facility 3.649 MGD
h. Percent of permitted flow used 60.8%
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
Average Approx. Obligated, Total
Pump Pump Daily Current Not Yet Current Flow
Station Station Firm Flow** Avg. Daily Tributary Plus
(Name or Permit Capacity, * (Firm 1 pf), Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
Friendship to be 2.088 0.835 0 0.100 0.100 1.988
* 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 Tess 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 < O.
Downstream Facility Name (Sewer): Friendship PS
Downstream Permit Number: to be permitted concurrently
Page 1 of 6
FTSE 10-18

DocuSign Envelope ID: AD907DDF-8490-4350-B50A-72A7282379BE
III. Certification Statement:
1 Kendra Parrish 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 1 and 11 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.
[dbYoeut
6sCu56ovFi.33.,O
Signing Official Signature
Exec Director of utilities and Infrastructure
Title of Signing Official
Page 2 of 6
6/1/2022
Date
FTSE 10-18

DocuSign Envelope ID: AD907DDF-8490-4350-B50A-72A7282379BE
Kimley )> Horn
March 21, 2022
State of North Carolina
NC Department of Environmental Quality
Water Quality Section
3800 Barrett Drive
Raleigh, North Carolina 27609
NC Dept of Environmental Quality
AIN 3 2022
Raleigh Regional Office
RE: Fast Track — Private Sewer Extension
Project Name: Amgen Project FIeX Batch — Sanitary Sewer
Attached, please find the applications and submittal items for review of the proposed sanitary sewer
gravity line. The proposed private sanitary sewer main is for the Amgen Project FIeX Batch project
located in Holly Springs, North Carolina, at 4130 Friendship Road. Amgen Project FIeX Batch is an
industrial project which includes a manufacturing / warehouse building, manufacturing support
building, and CUB.
This project is proposing approximately 2,171 LF of private 8-inch PVC gravity sewer lines and
associated services to the building. The private sewer line will connect to an existing public manhole
located at the southeast corner of the site, west of the stream. The flow from the site will be
approximately 100,000 GPD.
The following are transmitted to you for review:
• $480 Application Fee
• Documentation of Business Registration
• ETA 06-21 Checklist and Application
• FTSE 04-16 Flow Tracking/Acceptance Form
• Sewer Design Application Certification
• Site Maps
• USGS Map
• Aerial Map
Please do not hesitate to contact me at [phone] ordan.brewer }lcimley-horn.com should
you or your staff have any questions for this review.
Sincerely,
W. Jordan Brewer, P.E.
Kimley-Horn and Associates
kimley-horn.com
421 Fayetteville Street, Suite 600. Raleigh, NC 27601
[phone]

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DocuSign Envelope ID: AD907DDF-8490-4350-B50A-72A7282379BE

DDcuSign Envelope ID: AD907DDF-8490-4350-B50A-72A7282379BE
BUSINESS CORPORATION ANNUAL REPORT
10-zoi9
NAME OF BUSINESS CORPORATION:
Amgen Inc.
■
SECRETARY OF STATE ID NUMBER: 0256564
REPORT FOR THE FISCAL YEAR END: 12/31/2020
SECTION A: REGISTERED AGENT'S INFORMATION
STATE OF FORMATION: DE
1. NAME OF REGISTERED AGENT: Corporation Service Company
2. SIGNATURE OF THE NEW REGISTERED AGENT:
no.-ca+se•ny
E - Filed Annual
Report
0256564
® Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
2626 Glenwood Avenue Suite 550 2626 Glenwood Avenue Suite 550
Raleigh, NC 27608 Wake County Raleigh, NC 27608
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Parent public company. Discovers, develops, manufactures and delivers innovative human therapeutics.
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
One Amgen Center Drive P.O. Box 23926
Thousand Oaks, CA 91320-1799 Tampa, FL 33623-3926
6. Select one of the following if applicable. (Optional see Instructions)
❑ The company is a veteran -owned small business
The company is a service -disabled veteran -owned small business
SECTION C: OFFICERS (Enter additional officers in Section E.)
NAME: Robert A Bradway NAME: Jonathan P Graham NAME: Justin G Claeys
TITLE: President TITLE: Secretary TITLE: Treasurer
ADDRESS:
One Amgen Center Drive
ADDRESS: ADDRESS:
One Amgen Center Drive One Amgen Center Drive
Thousand Oaks, CA 91320-1799 Thousand Oaks, CA 91320-1799 Thousand Oaks, CA 91320-1799
SECTION D: CERTIFICATION OF ANNUAL REPORT, Section D must be completed in its entirety by a person/business
entity.
Jonathan P Graham 4/7/2021
SIGNATURE DATE
Foram must be signed by an officer listed under Section C of this form.
Jonathan P Graham Secretary
Print or Type Name of Officer Print or Type Title of Officer
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh. NC 27828.0525

DocuSign Envelope ID: AD9o7DDF-8490-4350-B50A-72A7282379BD
May 16, 2022
Director, Division of Water Resources
Raleigh Regional Office
Water Quality Operation Section
3800 Barrett Drive
Raleigh, NC 27609
bjly e5prings
NC Dept of Environmental Qualit
AUN „ 3 2022
Raleigh Regional Office
Re: Application for Sewer Extension Permit
Project: Amgen Project FIeX Batch -Private Sewer Extension
Dear Sir or Madam:
Please find enclosed the following items in application for a sewer extension permit to the Town
of Holly Springs existing sewer distribution system:
0 One original and one copy cover letter including a project narrative
o A check in the amount of $480.00
0 One original and one copy of the State of North Carolina Fast Track Sewer System
Extension Application (FTA 04-16)
o Two copies of FTSE 04-16 Flow Tracking/Acceptance Form
o Two color copies of a 8.5-inch by 11-inch portion of a 7.5 minute USGS Topographic
Map showing project area
0 Two copies of a street level map showing all relevant project areas
0 One copy of the locally -required Design and Application Certification
Feel free to contact me at 919-577-3150 should you have any questions or need additional
information in order to process this application.
Sincerely,
DotuSigned by:
el,(Jp
Kendrit-D°V lifsh,4 P.E., CFM
Executive Director of Utilities and Infrastructure
KP/tr
cc: Project Consultant Engineer, W. Jordan Brewer, PE
Rachel Ingham, Utility Engineer
Drew Johnson, Development Construction Manager
Theresa Randall, Utility Permitting Specialist
Project file/Correspondence #41996
3002
04 17 2018
Ds
rX
Rachel Ingham
Utility Engineer
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

NC Dept of Environmental Qualit>
Project:
w. Jordan Brewer, PE
Design Engineer:
oocuSign Envelope ID: AD907DDF-8490.4350-B50A-72A7282379BE
3 2022
DO NOT SEWER K/NS UNTIL
CONSTRUCTIONIT DRAWINGS HAVF�. 'Ary•�i 1fl v STAFF!
Sewer Design and Application Certification
Note: This form must be submitted with the Fast Tract Application for extension to the Town of
Holly Springs Sewer System
Amgen Project Flex Batch
Address: 300 S Main st, suite 212, Holly Springs, NC 27540
Phone Number: 919-654- 6654
Email:
[e-mail]
Date Complete Application Package Received by Town:
PP z 6/1/2022 ) (by DJ)
l?i
Date A roved 6/1/2022 (by R (by KDP 2022
As design engineer for this project, I certify the following (please check (x) each applicable box):
O That thc design of the project is in complete conformance with the Town of Holly
Springs Engineering Design and Construction Standards and NC DEQ Sanitary Sewer
Design Regulations;
O That each of the following items are completed and enclosed for submittal to thc State for
a sewer extension permit:
❑ One cover letter that includes a project narrative
o A check in the amount of $480.00 to NC DEQ
o A check in the amount of $200.00 to the Town of Holly Springs
❑ One State of North Carolina form FTA 04-16 Fast Tract Sewer System
Extension Application
o One FTSE 10- 1 8 Flow Tracking for Sewer Extension Applications
❑ One color copy of an 8.5-inch by 11-inch portion of a 7.5-minute
USGS Topographic Map showing project area
❑ One copy of a street level map showing all relevant project areas
o One copy of the locally -required Design and Application Certification
(this form)
Design Engineer's Signature
pgcuSlgned by: -
114111-nlaCr•EllIel.
Date 6/1/2022
Please contact Theresa Randall at [phone] or theresa.randalliholl}spring<snc.gov if you
have anguestions. -
2003 Sewer Design Application Certification
U 1.14.21
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hallyspringsnc.gov