WQ0029331_Application (FTSE)_20050916

EAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 1
nal
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
FAST -TRACK APPLICATION
DWQ-WANAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
ECEIVED
SEP 1 6 2005
INSTRUCTIONS: Indicate that you have included the following list of required application, package items by checking the
space provided next, to each Item. Failure to submit all required items will lead to your application being returned as
incomplete or additional processing and review time. This form may be photocopied for use as an original.
❑ I. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. Any changes to this form will result in the application being returned. The Division of Water Quality
(Division) will only accept application packages that have been fully completed with all applicable Items
addressed. You do not need to submit detailed plans and soect lcations unless you respond NO to Item B(12).
❑ II. Application Fee - Submit a check in the amount of $400 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR).
❑ III. Certificates of Public Convenience and Necessity - If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility Is authorized to hold the utility franchise for the area to be served by the
sewer extension. if a CPCN. has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The protect name in the
CPCN or letter must match that provided In Item A(2a) of thls application.
❑ IV. Operational Agreements — Submit oneoriginal and two copies of a properly executed operational agreement tf
the sewer extension Is permitted by a private applicant and will be serving residential or commercial lots (e.g.,
houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If the applicant is a
homeowners' association, use Form HOA 02/03. If the applicant is a developer, use Form DEV 02/03_ EVEN IF
THE PROJECT WILL BE TURNED OVER TO A MUNICIPALITY, FORM DEV 02/03 IS REQUIRED.
❑ V. Flow Acceptance Letters. —'If the owner of the downstream sewers and/or WWTF is different from the applicant,
submit two copies of a flow acceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and project name, amount of
flow accepted, and nameand permit number of the receiving sewers/WWTF. The flow acceptance must not
expire prior to permit Issuance and must be dated less than a year prior to the application date.
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific flow acceptance
letter.
❑ VI. Map— 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 Identify the entire protect area location as well as the closest downslope surface
waters as clearly as possible. Each map portion must be labeled with the map name and number, the Identified
location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project
involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties,
basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within
100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the
location In Section C of the permit application.
❑ VII. Stream Classifications — Section C
• if any portion of the project is within 100 feet of any down slope surface water, Section C must be completed
for the pertinent sections.
• If the entire projectareais_a minimum of 100 feet away -from any down slope surface waters BUT there is a
pump station involved where a history of power outage is to be used to provide adequate design storage
Instead of dual feed or permanent or portable generator, Section C must be completed to demonstrate that
the closest down slope surface water is Class C (see 15A NCAC 2H .0219(h)(3)(D)).
• Use the guidance document entitled, "Determining Watershed Classifications for Form FTA 02/03 (Fast -Track
Sewer Systems)" available from http://h2o.enr.state.nc.us/ndpu or by contacting the appropriate regional
office.
FT 110 - PPV ndrna

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
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❑ V111. Environmental Assessments — ff this protect Is subject to an Environmental Assessment (EA) [15A NCAC
01C .0500], this application can not be used. Send the protect application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617. Applications can not be
processed until a Finding of No Significant impact (FONSI) or Environmental Impact Statement (EIS) has been
issued. A copy is to be submitted with that permit application.
❑ IX. Certifications — Section D
The application must be certified by both the applicant and a North Carolina Registered Professional Engineer
(PE). The applicant signature must match the signing official listed in Item A(1 b). The PE should NOT certify the
application if he/she is unfamiliar with 15A NCAC 2H .0200, the Gravity Sewer Minimum Design Criteria (most
recent version) and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains
(most recent version), as applicable to the project. Certification by a PE who is unfamiliar with these documents
is subject to NC Board referral.
THE COMPLETED FTA 02f03 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $400
FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 28778
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell,
Cherokee, Clay, Graham, Haywood,
Henderson, Jackson, Macon,
Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania,
Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Fayetteville, North Carolina 28301
(910) 48
[phone] Fax
Anson, Bladen, Cumberland, Harnett,
Hoke, Montgomery, Moore, Robeson,
Richmond, Sampson, Scotland
Mooresville Regional Office
•
919 N Main Street
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba,
Cleveland, Gaston, Iredell, Lincoln,
Mecklenburg, Rowan, Stanly, Union
Raleigh Regional .Office
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
[phone]
[phone] Fax
Chatham, Durham, Edgecombe,
Franklin, Granville, Halifax, Johnston,
Lee, Nash, Northampton, Orange,
Person, Vance, Wake, Warren,
Wilson
Washington Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
[phone]
[phone] Fax
Beaufort, Bertie, Camden, Chowan,
Craven, Currituck, Dare, Gates,
Greene, Hertford, Hyde, Jones,
Lenoir, Martin, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrrell, Washington,
Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus,
Duplin, New Hanover, Onsiow,
Pender
Winston-Salem Regional Office
.
585 Waughtown Street
Winston-Salem, North Carolina 27107
[phone]
[phone] Fax
Alamance, Alieghany, Ashe, Caswell,
Davidson, Davie, Forsyth, Guilford,
Rockingham, Randolph, Stokes,
Surry, Watauga, Wilkes, Yadkin
For more information, visit our web site at: ht4pi/h2o.enr.state.nc.us/ndpu/
PTA mini - T?ev')rind

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!Abe
Apo. pllcaHon NumbeW �2-9 33
completed by r. bWQ) 1
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1
1. Owner:
a. City of Goldsboro
Full Legal Name (company, municipality, HOA, utility, etc.)
•, :;;,1b.
Joseph R. Huffman, City Manager
Signing Official Name and Title (Please review 15A NCAC 2H .0206(b) for authorized signing officials!)
lc. The legal en who will own this system is:
El Individual Federal 10 Municipality ■ State/County Q Private Partnership Q Corporation El Other (specify):
1 d. P.O. Drawer A
1 e. Goldsboro
City
Street Address
1 f. NC -
l g. 27533
Zip Code
State
1 h. [phone]
11. [phone]
1 j.
E-mail
Telephone
Facsimile
; s .
2. Protect (Facility) Information:
0,a.
a. ''
u
Ashebrooke pPNR.TI. T.S YtEWE132b.
Wayne .
Brief Protect Name (permit will refer to this name)
County Where Project is Located
:
-3. Contact Person:'
-
. Jeffrey L. Komegay, PE, PLS - Protect Engineer .
Name and Affiliation of Someone Who Can Answer Questions About
this Application-
' _
b. [phone]
3c. komsep©bellsouth. net
Phone Number
E-mail
1: Project is
0
New
II
Modification (of an existing permit)
if Modification, Permit No.:
'
For modifications, attach a separate sheet dearly explaining the
reason for the modification (i.e. adding another
Information In this permit application - do not -
been Included In the original permit.
Owner is
►Zc
Public (slip to Item B(3))
■
Private (go
to Item 2(a)) -
x :=
I:!:iT,:,,:.: _•:
5 _
a. If private, applicant will be:
2b. if sold, facilities owned by a (must choose one)
■
•
•
Retaining Ownership (I.e. store, church, single office, etc.) or
Leasing units (lots, townhomes, etc. - slip to Item B(3))
Selling units (lots, townhomes; etc. - go to Item B(2b))
•
•
Public Utility (Instruction 111)
Homeowner Assoc./Developer (Instruction IV)
4.
A �+l .i
K. City of Goldsboro
. Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
•,:
•?aa -
:. City of Goldsboro
4b. 23949-
Name of WWTF
WWTF Permit No.
..:X.`r:,..:.
,.,,,;.;' a
N/A
5b.
5c.
Owner of Downstream Sewer
_ Receiving Sewer Size
Permit • Number of Downstream Sewer (if known) -
A :
6. The origin of this wastewater is (check all that apply):
• •
'O
.:: `
'
■
Restaurant
•
Nursing Home
% Other (specify):
•
Office
ID Other (specify):
7.
Volume
of wastewater to be Dermitted in this project 17.750 gallons per day
=i
_ •
8.
if the
•
•
permitted flow is zero, indicate why:
interceptor Line - Flow will be permitted Is subsequent permits that connect to this line
Flow has already been allocated In Permit No.
•
Rehabilitationorreplacement of existing sewer with no new flow expected
F'A 111in1 - PPV 9 (11/f14.

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
•
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9. Provide the wastewater flow calculations used in determining the permitted flow In accordance with 15A NCAC 2H
.0219(1) for Item B(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than
that In 15A NCAC 2H .0219(IX1-2) must be approved prior to submittal of this application. Submit a separate request to
the Division of Water Quality Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 in
accordance with 15A NCAC 2H .0219(IX3).
1 bedroom units: 8 bedrooms x 240 gpd = 1,920 gpd
2 bedroom units: 22 bedrooms x 240 gpd = 5,280 gpd
3 bedroom units: 25 bedrooms x 360 gpd = 9,000 gpd
3 washing machines x 500 gpd/machine = 1,500 gpd (in community building)
2 persons per shift in community building office x 1 shift x 25 gpd = 50 gpd
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (Inches)
Length (feet)
Gravity or Force Main
(use the pull down menu)
8
726
Gravity
11
,r
m
z
4
u
ENTER TOTAL LINE LENGTH IN MILES
0.137
11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary)
Location ID .
(self chosen - as shown on
plans for cross-reference)
Design Flow
(MGD)
• Operational Point
GPM © TDH
Power Reliability Option
(1- dual line feed; 2- permanent generator w/ATS; 3-
portable generator wttelemetry; 4-wet well storage)
N/A
. u;
{
Fx
-
" #
12. Does the sewer system comply
Mains (latest version), the
with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force
Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
reference the pertinent minimum design criteria or regulation and Indicate why a
Is requested:
SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
►ii Yes A No if no, please
variance
SUBMIT TWO COPIES OF PLANS,
4
z
z
`•" `
4
x' -
13. Have the following permits/certifications been submitted for approval?
Wetland/Stream Crossings - General Permit or 401 Certification?
Sedimentation and Erosion Control Plan?
Stormwater?
• Yes • No ►i1 N/A
@ Yes • No • N/A
@ Yes • No • N/A
FrA rnm1 - RPv ) f14-/(1i

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 5
1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02/03
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classfflcation data below (attach additional sheets as
necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality
regional office (see Instructions for addresses) QJ3 Indicate the following:
III
A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope
waterbody; AN.Q.,
►Z4 A Stream Classification Is not needed. because the design does not depend on wet well storage as a power reliability
option for any pump station near a Class C down slope waterbody.
x
far;.
Cl)'''-.
'
Location ID on Map
(self chosen - as shown on
map for cross-reference)
Name of
Waterbody
County
River Basin
Waterbody Stream
index
Waterbody
Ciasstflcatlon
<*
A
tributary to Billy
Branch
Wayne
Neuse
27-62-3
C;NSW
th
Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI
regardless of whether a classification is provided!
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1. Applicant's Certification:
1, Joseph R. Huffman, City Manaeer attest that this application for Ashebrooke Houslnci Associates. LLC 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. Note: In accordance with North Carolina General
Statutes 143-215.6A and 143-215.68, 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 nalties up to $25,000 per violation.
1a. /Y-
Si Official SignatuDate
f . fessional Engineer's Certification:
I attest that this application for Ashebrooke Housing Assoclates,LLC has been reviewed by me and is accurate,
complete and consistent with the information in the engineering plans, calculations, and all other supporting documentation
P n9� ngPP h9
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 adopted February
12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June
1, 2000 and the watershed classification In accordance with Division guidance. Although certain portions of this submittal
package may have been developed by other professionals, inclusion of these materials under my signature and seal
signifies that 1 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 143-215.68, 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.
Jeffrey L. Komegay
CAI�rr,rffii
Professional Engineer Name
�ti����,t
Ns- PAN ,-/A, -,
+b. B.R. Komegay, Inc.
��•:p'��/C ?.•�
Engineering Firm
rc. P.O. Drawer 1435
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Address
;.
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-
d. Goldsboro
2e. NC
2f. 27533
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,�,�. •GIN�.•• c''',�`
sty
State
Zip
�,,' 9Fy....... \k ,�`
^2g.
[phone]
2h. (919).580-9053
21. komsep(ci2bellsouth.net
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1 /// r i i i i 11 %
Telephone
Facsimile -
E-mail
Seal, Signature & Date
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