WQ0029333_Application (FTSE)_20070117

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OAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS,. AND FORCE MAINS PAGE 1
FIEGU'J `n State of North Carolina
Department of Environment and Natural Resources
SEP 1 6 2005 Division of Water Quality
FAST -TRACK APPLICATION,
DWQ-WARQtyrry SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure sewers systems are not to be included as part of this application package)
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 thls 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 specifications 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 utlifty'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 this application.
❑ IV. Operational Agreements — Submtt one original and two copies of a properly executed operational agreement if
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 flowacceptance letter from the owner of the downstream sewers and WWTF, if different.
Flow acceptance letters must contain the following minimum information: applicant and protect name, amount of
flow accepted, and name and 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,Ileu 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 project 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 waterbodles (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 project area Is 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)(3XD)).
• 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.
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FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
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PAGE 2 off:
❑ VIII. Environmental Assessments — If this protect Is subject to an Environmental Assessment (EA) [15A NCAC
01C .0500], this application can not be used. Send the project application on Form PSFMGSA 10/99 to the
Non -Discharge Permitting Unit, 1617 Mail Service Center, Raleigh, NC 2769.9-1617. 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 02/03 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
[phone]
[phone] Fax
Anson, Blades, Cumberland, Harnett,
Hoke, Montgomery, Moore, Robeson,
Richmond, Sampson, Scotland
Mooresville Regional Office
919 N Main Street '
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabam.is, Catawba,
Cleveland, Gaston, iredell, Lincoln,
Mecklenburg, Rowan, Stanly, Union
Raleigh Regional Office
.
1628 Mall 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, Bertle, 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, Onslow,
Pender
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, North Carolina 27107
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell,
Davidson, Davie, Forsyth, Guilford,
Rockingham, Randolph, Stokes,
Surry, Watauga, Wilkes, Yadkin
For more Information, visit our web s/te.at• httpi/h2o.enr.state.nc.us/ndpu/
PTA (Y)mg - RPV '7 mind

• FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 3
USE THE TAB KEY TO MOVE FROM FIELD TO FIELD!
Application Number. �Q 0029 333
(to be completed by DWQ)
1. Owner:
+HOUING ASSoC- AZ_—S 1_1_C..
a.CoLDS,oRO i
Full Legal Name (company, municipality, HOA, utility, etc.)
lb. Lyle D. Gardner, Managing Member
Signing Official Name and Title (Please review 15A NCAC 2H .0206 for authorized signing officials1)
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• .
c. The I system is:
1 legal enti who will own this
Ei Individual 0 Federal [] Municipality 0 State/County
■Private
Partnership 0 Corporation 0 Other (specify): LLC
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Id. 7706 Six Forks Road, Suite 200
le. Raleigh
Street Address
City
•
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'E
1f. NC
19• 27615
State
Zip Code
_
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•: `
1 h. [phone]
l i. [phone]
1 j.
Telephone
Facsimile
E-mail
2. Project (Facility) Information:
�+a. Ashebrooke TMENTS R2b..
Wayne
Brief Protect Name (permit will refer to this name)
County Where Project is Located
3. Contact Person:
a. Jeffrey L. Komegay, PE, PLS - Project Engineer
Name and Affiliation of Someone Who Can Answer Questions About
this Application
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b: [phone] "
3c. kornsep@bellsouth. net
E-mail
Phone Number
1. Protect is
0
New
■
Modification (of an existing permit)
If Modification, Permit No.:
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For modifications, attach a separate sheet clearly explaining the
phase, changing Ilne size/length, etc.). Only Include the modified
duplicate protect Information In B(7) and B(10-11}that has already
reason for the modification (i.e. adding another
Information In this permit application - do not
been Included In the original permit.
"` : I:
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Owner Is
•
Public (skip to Item B(3)) ® Private (go
to Item 2(a))
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f:
a. If private, applicant will be:.
2b. If sold, facilities owned by a (must choose one)
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Retaining Ownership (i.e. store, church, single office, etc,) or
Leasing units (lots, townhomes, etc. - skip to Item B(3))
Selling units (lots, townhomes, etc. - go to Item B(2b))
•
•
Public Utility (Instruction III)
Homeowner AssocJDeveloper (Instruction IV).
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c . Ckr of Goldsboro
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Protect
•'
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:;
:. City of Goldsboro
4b. 23949
Name of WWTF
WWTF Permit No.
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;
• :. City of Goldsboro
5b. 8 Inch
5c. not yet known
Owner of Downstream Sewer
Receiving Sewer Size
Permit Number of Downstream Sewer (If known).
f :�•y•
.. The origin of this wastewater Is (check all that apply):
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<
,&4Apartments/Condominiums
•
■
•School
Residential Subdivision
Mobile Home Park
Si
■Institution
■
•
Car Wash
Hospital
Church
100 % Domestic/Commercial
% Industrial
■
Restaurant
•
Nursing Home
% Other (specify):
•
Office
■
Other (specify):
7.
Volume
of wastewater to be permitted in thls project Q gallons per day
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�Y
.
8.
If the
0Interceptor
•
permitted flow Is zero, Indicate why.
Line - Flow will be permitted Is subsequent permits that connect to thls line
Flow has already been allocated In Permit No.
■
Rehabilitation or replacement of existing sewer with no new flow expected
PTA mmI _ PPV fld/rid

FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
PAGE 4
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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 13(7) or the design flow for Ilne 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 Mall Service Center, Raleigh, NC 27699-1617 In
accordance with 15A NCAC 2H .0219(I)(3).
Wastewater flow amount is included in the downstream public lines connecting to this line.
„, f
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
:`
(Inches)(use
Length (feet)Size
Gravity or Force Main
the pull down menu)
71i'y': is
st
8
172
Gravity
6
1516
Gravity
X.'.
j,",... ) }:ram;
.'. ie
: I
n#'
```�`''•'' ENTER TOTAL UNE LENGTH IN MILE
0.320
3''si••Crif N:jl
,.., i11. Summaryof PumpStations to be Permitted(attach additional sheets as necessary)
��r�
,. Location ID
:::•ti': : (self chosen - as shown on
: ' • Inns for cross-reference
Design Flow
MGD '
Operational Point
GPM , TDH
Power Reliability Option
(1- dual line feed; 2- permanent generatorw/ATS; 3-
• ortabie • = nerator whole - • 4-wet well store
N/A
a
12.
=<
:
SUBMIT
Does
Mains
0
the sewer comply with the Minimum Design
system ply g Criteria for the Fast Trade Permitting of Pump Stations and Force
(latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC 2H .0200 as applicable?
Yes • No If no, please reference the pertinent minimum design criteria or regulation and Indicate why a
variance Is requested:
TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION
4-41.,`' :13.
r 1`.Wetland/Stream
k.!. -"-y
ii
i-"`.'' _•Stomiwater?
Have the following permits/certifications been submitted for approval?
Crossings - General Permit or 401 Certification?
Sedimentation and Erosion Control Plan?
■
0Yes
0Yes
Yes
■
•
■
No
No
No
►mil
•
■
N/A
N/A
WA
PTA mm1 - RPV 9 na/na

$1 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 02103
(FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification 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) Oa Indicate the following:
,:.
•
A Stream Classification Is not needed because all parts of the project are at least 100 feet away from any down slope
waterbody, A Q, .
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@
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. •
r..
. . Location ID on Map
:. (self chosen - as shown on
map for cross-reference)
Name of
Waterbody
County
River Basin
gy
Waterbody $m
• Index
h
Why
Classification
A
tributary to Billy
Branch
Wayne
Neuse
27-62-3
C;NSW
`'-
Submit the 8.5" x 11" COLOR topographic map as required In Instruction Vi
. regardless of whether a classification Is provided!
1. Applicants Certification:
1, Lvle D. Gardner. Manasrina Member, attest that this application for Ashebrooke Housing Associates. LLG has
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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 am not Included,
this application package is subject to being returned as incomplete. Note: In accordance with North Carolina General
Statutes 143-215.64 and 143-215.68, any person who knowingly makes any false statement, representation, or -
c 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 dull pe Ides up to $25, 000 per violation. .
/9Af."----
Signing Signature . •Date
}:�
. Professional Engineer's Certification:
•
I attest that this application* ' for Ashebrooke Houslrisi Associates. LLC has been reviewed by me and Is accurate,
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complete and consistent with the information In the engineering plans, 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 adopted February
12, 1998, 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 appllkotlYon shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed $10,000 as well as chill penalties up to $25,000 per violation.
Jeffrey L. Komegay
,`" GARO /I`ir
.�OQ� , SI ,. '',
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Seal, Signature & Date
*
Professional Engineer Name
`.••• .•
b. B.R. Komegay, Inc.
Engineering Firm
c. P.O. Drawer 1435
•
Address
d. Goldsboro
ge. NC
27533
City
stets
zip
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g. [phone]
Rh. [phone]
+ I: komsepabeflsouth.net
Telephone
,
Facsimile -
E-mail
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NORTHEAST GOLDSBORO, NC
1' a 2000' -