WQ0037797_Application (FTSE)_20150513

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A. APPLICATION
NFORMATION
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USE THE TAB KEY TO MOVE FROM FIELD TO FIELD
1. Owner/Permittee:
la. City of Goldsboro
1 b.
Full Legal Name (company, municipality, HOA, utility, etc.)
Mr. Scott Stevens, City Manager
Application Number: Y V• DO ?R (`1
(to be completed by DWR) VVVV VVVV "I
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials)
lc. The legal entity who will own this system is:
El Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify):
1d. PO DrawerA le. Goldsboro
Mailing Address City
1 f. NC 1 g. 27533
State
1 h. 919-580-4330 1 i. 919-580-4344 1j.
Telephone Facsimile
2. Proiect (Facility) Information:
2a. Norwood Ave Sewer Extension
Brief Project Name (permit will refer to this name)
3. Contact Person:
3a. Bryan K Jones, PE
3b.
Zip Code
E-mail
2b. Wayne
County Where Project is Located
Name and Affiliation of Someone Who Can Answer Questions About this Application
919-221-5222
Phone Number
3c. [e-mail]
E-mail
1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.:
2. Owner is ® Public (skip to Item B(3))
2a. If private, applicant will be:
❑ 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))
3. City of Goldsboro
❑ Private (go to Item 2(a))
2b. If sold, facilities owned by a (must choose one)
❑ Public Utility (Instruction D)
❑ Homeowner Assoc./Developer (Instruction E)
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
4a. Goldsboro WWTP
Name of WWTF
5a. City of Goldsboro
Owner of Downstream Sewer
5b. 8 ® Gravity
Receiving Sewer Size El Force Main
6. The origin of this wastewater is (check all that apply):
❑ Residential Subdivision
® Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
4b. NC 0023949
WWTF Permit No.
5c. WQ0035817
Permit # of Downstream Sewer (Instruction F)
❑ Retail (Stores, shopping centers)
❑ Institution
El Hospital
❑ Church
❑ Nursing Home
❑ Other (specify):
100 % Domestic/Commercial
% Industrial
(Attach Description)
% Other
(Attach Description)
7. Volume of wastewater to be allocated or permitted for this particular project: 10,080 gallons per day
*Do not include future flows or previously permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit No. RECEID/NCDENR/DWR
❑ Rehabilitation or replacement of existing sewer with no new flow expected
(see 15A NCAC 02T .0303 to determine if a permit is required)
MAY 13 2U'5
FTA 10-14 APPLICATION
Page 4 of 6 limy AegK)nal
ons Section
Regional Office

B. PERMIT INFORMATION (CONTINUED)
9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for
the value in Item B(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in
Item B(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use
data in accordance with 15A NCAC 2T .0114 (f).
84 bedrooms @ 120 gpd = 10,080 gpd
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet) New Gravity or Additional
Force Main
8" 530 Gravity
11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary)
Pump Station Location ID: (self chosen - as shown on plans/map for reference)
Longitude: Latitude:
Design Flow Operational Point Power Reliability Option
(MGD) 1 GPM @TDH - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
Pump Station Location ID: (self chosen - as shown on plans/map for reference)
Longitude: Latitude:
Design Flow Operational Point Power Reliability Option
(MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
❑ Yes ® No If Yes, permit number of 2nd treatment facility :
(RO — if "yes" to B,12 please contact the Central Office PERCS Unit)
13. Does the sewer system comply with the Minimum Design Criteria for the Permitting of Pump Stations and Force Mains
(latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request (VADC 10-14) application and supporting
documents for review. Approval of the request is required prior to submittal of the Fast Track Application and
supporting documents.
FTA 10-14 APPLICATION
Page 5 of 6

14. Have the following permits/certifications been submitted for approval for the system or project to be served?
Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A
Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A
Trout Buffer Waiver? ❑ Yes ❑ No ® N/A
Stormwater? ® Yes ❑ No ❑ N/A
15. Does this project include any high priority lines (15A NCAC 02T .0402 (2)) involve aerial lines, siphons, or interference
manholes)? These lines will be considered high priority and must be checked once every six months
Check if Yes: ❑ and provide details:
C. CERTIFICATIONS
1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name)
1, Scott A Stevens attest that this application for Norwood Ave Sewer Ext. has been
reviewed by me and is accurate and complete to the best of my knowledge. l 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 143-215.6E 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 t. $25,000 per violation.
1 a.
Sign}rfg Official Signature
Z3- IC
Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY
TO OTHER UTILITIES, DESIGN CALCULATIONS, ETC. REFER TO 15A NCAC 02T .0305
2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
1, Bryan K Jones, PE ,attest that this application for Cypress Court Apartments has been
reviewed by me and is accurate, 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, 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 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 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.
2a. Bryan K Jones, PE
Professional Engineer Name
2b. Bryan K Jones Consulting Engineers, PA
Engineering Firm
2c. PO Box 10882
Mailing Address
2d. Goldsboro
City
2e. NC 2f. 27532
State Zip
2g. 919.221.5222 2h. 2i. [e-mail]
Telephone
Facsimile
E-mail
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SEA
0302
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"IN K JO?�
NC PE Seal, Signature & Date
FTA 10-14 APPLICATION
Page 6 of 6

OF WA7- 9 State of North Carolina
^4�G Department of Environment and Natural Resources
r Division of Water Quality
-c Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE —10/07)
Project Applicant Name: City of Goldsboro
Project Name for which flow is being requested: Lochstone Apt. ( Norwood Ave Sewer Ext.)
More than one FTSE-10/07 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: City of Goldsboro Water Reclamation Facility
b. WWTP Facility Permit #: NC 0023949
All flows are in MGD
c. WWTP facility's permitted flow 14.2
d. Estimated obligated flow not yet tributary to the WWTP 1.585595
e. WWTP facility's actual avg. flow 9.67
f. Total flow for this specific request 0.01008
g. Total actual and obligated flows to the facility 11.265675
h. Percent of permitted flow used 79.34 %
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
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Firm/Design) Daily Flow, MGD
Westbrook Pump Station
18 mgd/firm 9.12 MGD
III. Certification Statement:
I, Scott A. Stevens , certify that, to the best of my knowledge, 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. 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 for which I am the responsible party. Signature of this form indicates
acceptance of this wastewate iw.
q-Z3 /5
Signing/Ocial Signature City Manager Date

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