WQ0043588_Application (FTSE)_20220622

DWR
Division of Water Resources
NC Dept of Environmental Quality
JUN 22 2022
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SERER SYSTEM EXTENSION APPLICATION
Raleigh Regional Office FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: !(4GD y.3c (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Sleepy Hollow Development Co. (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: Ralph C. Hodge per 15A NCAC 02T .0I060)
Title: President
4. Applicant's mailing address: 2101 F Miller Rd. S.
City: Wilson State: NC Zip: 27893-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Sleepy Hollow Development Co.
2. Application/Project status: ® Proposed (New Permit)
❑ Existing Permit/Project
If a modification, provide the existing permit number: WQOON_A and issued date: N_A,
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: WQOON A
3. County where project is located: Wilson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.698` Longitude: -77.924
5. Parcel ID (if applicable): 3721-01-2671 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Robert S. Bartlett, PE License Number: 20106
Fimi: Bartlett Engineering & Surveying, PC
Mailing address: 1906 Nash Street N.
City: Wilson State: NC Zip: 27893-
Phone number: [phone] Email Address: robert@,bartietteng.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Hominy Creek Water Reclamation Facility Permit Number: NC0023906
Owner Name: City of Wilson
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0041572
2. Downstream (Receiving) Sewer Information: 12 inch El Gravity 7 Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 06-21
Page 1 of 5

VI. GENERAL REQUIREMENTS
. 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 Developer's Operational Agreement LFORM: DEV,} been attached?
® Yes ❑ No ❑ NIA
3. If the Applicant is a Home:Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by I5A NCAC 02T.01 15(c) been attached?
❑Yes ❑No 0N.A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually 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
❑ Nursing Home
❑ Car Wash
❑ Hotel and/or Motels
❑ Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : _% Domestic % Commercial 100 % Industrial (See 15A NCAC 02T .0I03{.20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes® No
6. Has a flow reduction been approved under 15A NCAC 02T,0I 14LO? ❑ Yes ® No
D If ves, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(1))
Daily Design Flow a,b
No. of Units
Flow
Existing Commercial/Industrial
Existing Private System, No Addit. Flows
NIA
Exist. GPD
gal/
GPD
gal!
GPD
gall
GPD
gal
GPD
gal
GPD
Total
Exist. GPD
a See 15A NCAC 02T .01 I4(ISI, (d}, {el( 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 facili ies 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 ISA NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T,0I I4] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: Existing GPD (per I5A NCAC 02T .0114)
D 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:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
® Other (Explain): Existing Private Sewer Line.
FORM: FTA 06-21
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
8 538
Unknown
ti
➢ 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 requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) - • 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
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 (TDH)
Size (inches)
Length (feet)
Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305{hl{ 1):
❑ Standby power source or ❑ Standby pump
➢ Must have 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 and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(l)(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.
➢ 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
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations.alternatives found in 15A NCAC 02T .0305(f).& (g)? ® Yes ❑ No
15A NCAC 02T.0305{f} contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, 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 1 or
Class I1 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, HQW, 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{f} or (g}, see Section X.1 of this application
*I 5A NCAC 02T.0305(gl, contains alternatives where separations in 02T0305(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 Surface Water Classifications webpage
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? ® Yes ❑ No ❑ N?A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft 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: ® No
If yes, does the project comply with setbacks found in the river basin rules per ISA NCAC 02B .0200'? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B_0202
5. Does the project require coverage.authorization under a 404 Nationwideiindividual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit numberpermitting status in the cover letter if coverage:authorization is required.
6. Does project comply with 15A NCAC 02T,0105{c)(6) (additional permits.certifications)? ® Yes ❑ No
Per 15A NCAC 02T.01054c)(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 SA NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are 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.
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Perniittin}t of Pump Stations
and Force Mains (latest version), and the ljrayity Sewer Minimum Design Criteria [latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/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 approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, Robert S. Bartlett, PE, attest that this application for Sleepy Hollow Development Co. Private Sewer Extension
(Professional Engineer's name from Application Item III.I.) (Project Name from Application Item II 1)
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 Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Puma 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 1 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 $10,000, as well as civil penalties up to $25,000 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 56.07 0 1)
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North Carolina Professional Engineer's seal, signature, and dat. CAR0 ,
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20106
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Ralph C. Hodge, President, attest that this application for Sleepy Hollow Development Co. Private Sewer Extension
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II. I)
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 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. 1 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 he returned to me as incomplete.
NOTE -. In accordance with General Statutes I43-215.6A 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 $10,000 as well as civil penalties up to $25,000 per violation.
Signature: __/19
12 Date: -21
FORM: ETA 06-21 Page 5 of 5

BARTLETT
ENGINEERING & SURVEYING, PC
1906 Nash Street North Wilson, NC 27893-1726
Phone: [phone] Fax: [phone]
www.bartlett.us.com
June 20, 2022
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Raleigh Regional Office
3800 Barrett Drive
Raleigh, North Carolina 27609
Reference: Fast Track Application for Gravity Sewers
Private Sewer Extension
Sleepy Hollow Development Co.
Wilco Blvd.
Wilson, North Carolina
Bartlett Job No. 22-129
To Whom It May Concern:
NC Dept of Environmental Quality
JUN 2 2 2022
Raleigh Regional Office
This Permit Submittal is for an existing 8" private sewer line (538 L.F.) that currently has an existing
service to the Wilson County Offices located at 2101 Miller Road S., Wilson NC. This entire tract is
owned by Sleepy Hollow Development Co., and at this time they are looking to sell an approx. 2.97
AC Lot to the County, where the County has been leasing property for years. Due to the change of
ownership, and one landowner tying into another Iandowner's private sewer, the City is requesting
this existing private line be permitted. No previous record of permitting for this private line have
been located.
The entire system is and has been existing (for 50+ years?). There are no proposed sewer lines or
services and all flows to remain as existing, with no additional flow to be added.
Enclosed for your review and approval are two (2) copies of the following items related to the
above referenced project:
■ Fast Track Application for Gravity Sewers
• USGS Topographic Map
■ Feature Report
• GIS Aerial Location Map
■ Developer's Operational Agreement
P.. PI Oh=Ct I ILI:S\RHOSIeepy Hollow Lot 1tPerrnits\Private Sewer&22-I29 NCDENR Priv Sew Cove' Lena doc

Also enclosed is the $480.00 sewer permit application fee. Should you have any questions or
require further information during your review, please let us know.
Respectfull
Steve Oliverio
Project Manager
Enclosures
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Wilson County
June 16, 2022
Surrounding Counties
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Tax Parcels
Buckhorn Reservior
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NC Dept of Environmental Quality
Wilson County Parcel Report
JUN 22 2022
PIN:
Parcel Number:
Current Owner ID:
Owner & Address:
Date Sold:
Deed Reference:
Deed Year:
Plat Reference:
Deed Acres:
Actual Year Built:
Effective Year Built:
Main Improvement
Finished Area:
Tax Year:
Assessed Current
Land Value:
Assessed Current
Improvement Value:
Total Assessed
Current Value:
Current Land Use
Yes or No:
Current Land Use Value:
Current Land
Fair Market Value:
Current Improvement
Fair Market Value:
Current Total
Fair Market Value:
Grantor:
Previous ParcelNumber:
Previous Deed Reference:
Plat Book/Page:
Legal Description:
Sales Amount:
Sales Instrument:
Sales Instrument Description:
Sales Disqualifaclion Code:
Sales Disqualifaclion Code Description:
Date Sold:
Vacant Improved Code:
Land Current Usage Code:
Land Rale:
Fair Market Value
Land Rate Code:
Parcel Description Code 1:
Parcel Description Code 2:
Multiple Land Segments:
GIS Calculated Acres
of Selected Polygon:
Quantity:
Road Frontage:
3721 01-2671Raleigh Regime O
ee
3721012671.000
69924435
SLEEPY HOLLOW DEVELOPMENT CO
PO BOX 1179
2216 - 329
2006
36.5
1982
1985
139695
2022
$1,095,000
$5,514,973
$6,609,973
N
$1,095,000
$1,095,000
$5,514,973
$6,609,973
2201 MILLER RD S
36.50AC
$0
AC - ACRES
0600
17 - OFFICE
04 - BUSINESS
36.78
36.5

Current Use Code Main Improvement:
Main Improvement Decription Code: 4006 - 602
Main Improvement Description: BUSINESS - INDUSTRIAL -LIGHT
Construction Quality Grade Decription Code: C - C GRADE
Depreciation Table: C40
Number of Bedrooms:
Number of Full Bathrooms:
Number of Half Bathrooms:
HVAC:
Fireplace Yes or No:
Basement Yes or No:
Attached Garage Yes or No:
Percent of Construction Complete:
Number of Improvements:
Neighborhood Code:
City:
Tax District:
Township:
Area:
Vicinity Map
Orthophotography Map
- SF
N-
N-
N-
100%
015
8344 - US 301-WARD 1-1
WLSN - WILSON
31 - C/CIWI-WILSON
1 - WILSON TOWNSHIP
32 - MKT ZONE-WILSON CITY S

CA202210212712
BUSINESS CORPORATION ANNUAL REPOR'
11612021
NAME OF BUSINESS CORPORATION -
Sleepy Hollow Development Company
SECRETARY OF STATE ID NUMBER. 00.37374
SOSID: 0037374
Date Filed: 4/12.r2022
Elaine F. Marshall
North Carolina Secretary of State
CA2022 102 12712
STATE OF FORMATION' NC r
REPORT FOR THE FISCAL YEAR END:.
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: C. Ralph Hodge
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPO'NTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4_ REGISTERED AGENT OFFICE MAILING ADDRESS
2101 F Miller Rd S
PO Box 1179
Wilson, NC 27893 Wilson Wilson, NC 27894 Wilson
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Land Development
2. PRINCIPAL.OFF.ICEi•PHbNE•NUMBER: [phone] 3. PRINCIPAL OFFICE EMAI�
4. PRINCIPAL OFFICE STREET:ADDRESS
2101 F Miller Rd 5. _• , . -
Wilson, NC 27893 Wilson
Privacy Redaction
" .5. PRINCIPAL OFFICE MAILING ADDRESS
FO Box 1179
Wilson, NC 27894 Wilson
6. Select one of the following if applicable. (Optional see instructions)
The company is a veteran -owned small business
111 The company is a service -disabled veteran -owned small business
SECTION C: OFFICERS (Enter additional officers :n Section E-)
NAME: C Ralph Hodge
NAME Brendle H Walser
NAME -
TITLE: President TITLE: Vice President TITLE
ADDRESS:
3335 Beulahtown Road
Kenly, NC 27542 Johnston
ADDRESS:
671 Zel mai ' Road
Kenly, NC 27542 Johnston
ADDRESS:
SECTION D: CERTIFICATION OF ANN AL REPO - T. Sec n D must be completed in its entirety by a person/business
entity.
(.
330•Z`1
SIfaNATUFTE DATE
Form must be signed by an officer listed under Section C of this for'.
)64,0)7`/7i
Print or Type Name of Officer
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FE
MAIL TO: Secretary of State, Bus ness Rep stration DP Edon. Post Office Box 29525. Raleig
riot or Type Title of Officer