WQ0043924_Application (FTSE)_20221019

October 12, 2022
Ref: 33589.25
NCDEQ/DWR
Washington Regional Office
Water Quality Section
943 Washington Square Mall
Washington, North Carolina 27889
RECENEDMCDENRIDV
OCT 19 2022
Water Quality
Regional Operations Section
Washington Regional Office
w qo o
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hb®
Re: Sentara Albemarle Medical Center (SAMC) Phase 1 Medical Office Building (MOB)
Elizabeth City, NC 27907
Mr. Tankard:
Please accept this submission of the 15A NCAC 02T.0300 Fast Track Sewer System Extension Application
FTA 06-21 and Supporting Documentation. Included in the submission are the following attachments:
• Fast Track Sewer System Extension Application FTA 06-21 (One original/one copy)
• Application Fee ($480)
• Transmittal Letter
• Flow Tracking/Acceptance Form FTSE 04-16
• Site Maps
If you have any questions or need additional information, please do not hesitate to 'contact me at
757.490.0132. Thank you for your attention to this project.
Sincerely,
VHB Engineering NC, P.C.
J.D. Hines, PE
Project Manager
jhines©vhb,com
Engineers I Scientists I Planners I Designers
\\vhh. com\9b ,,q\Virglmaeearh\3358925 Sentar.+Albemarle \dors\Imte,s\TI ammrttal
Letteis\2022- 10-12SAIr1CLETTER_NCDE4 DWR Srv; Extensicat Appbolirndocx
Venture I
940 Main Campus Drive, Suite 500
Raleigh, North Carolina 27606
P 919.829.0328
F 919.833.0034

VHB Engineering NC, P.C.
940 Main Campus Drive, Suite 5gCENED/NCDENR/DWR
Raleigh, NC 27606-5217
Telephone [phone]
Fax [phone] OCT CT 19 2022
Water Quality
Regional Operations Section
To: Attention: Mr. Robert: TalpfQhgton Regional Office
NCDEQ Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
We are sending you: ® Attached
TRANSMITTAL
Date: 10/12/2022
VH B
Project No.: 33589.25
Re: Sentara Albemarle Medical Center — Phase 1 MOB
NCDEQ Fast Track Sewer System Extension Application
FTA 06-21 & Supporting Documentation
Under Separate cover via Regular Mail the following
items:
❑ Shop drawings ❑ Prints ❑ Plans ❑ DVDs n Specifications Copy of Letter ❑ ChgOd
Other
Copies
Date
No.
Description
2
10/11/2022
Fast Track Sewer System Extension Application FTA 06-21 (Original/Copy)
1
10/10/2022
Review Fee ($480.00 Check #1233)
1
10/12/2022
Transmittal Letter
1
10/11/2022
Flow Tracking/Acceptance Form FTSE 04-16
1
10/11/2022
Site Maps
These are transmitted as checked below:
® For approval ❑ Approved as submitted ❑ Resubmit Copies for approval
❑ For your use E Approved as noted ❑ Submit Copies for distribution
❑ As requested ❑ Retum for corrections ❑ Return Corrected prints
❑ For review and comment ❑ For bids due
❑ Returned prints on loan to VHB
REMARKS:
VHB agrees to provide materials to the Client stored electronically. The Client recognizes that data, plans, specifications, reports, documents, or other Information recorded on or
transmitted as electronic media, Including, but not limit to, CADD Documents (together, "Electronic Documents-) are subject to undetectable alteration, either intentional or
unintentional, due to, among other causes, transmission, conversion, media degradation, software error, or human alteration. Accordingly, the Electronic Documents are provided
to the Client for informational purposes only and not as an end product. VHB makes no warranties, either express or implied, regarding the fitness or suitability of the Electronic
Documents.
The Electronic Documents are instruments of professional service, and shall not be used, in whole or In part, for arty project other than that for which they were created, without
the express written consent of VHB and without suitable compensation to VHB. Accordingly, the Client agrees to waive any and all claims against VHB resulting In any way from
the unauthorized alternation, misuse or reuse of the Electronic Documents, and to defend, indemnify, and hold VHB harmless for any claims, losses, damages, or costs, including
attomey's fees, arising out of the alteration, misuse or reuse of any Electronic Documents.
Copy to: File
By: Myrina L. Gaglione, PE

DWR
Division of Water Resources
RECENEDINCDENR/DWR
�QC q3q �f 1 State of North Carolina
Department of Environmental Quality
OCT 19 2022 Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
RegloitittiFOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
Washington RAgInnal Office
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300, Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPs) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please
submitted. Adherence to these instructions and c'
amount of requested additional information. Fail
time, and may result in return of the applica'
the application and supporting documentation.
A. One Original and One Copy (second c'
® Required unless otherwise noted. S
Please do not submit engineering c.__
"'wing instructions as a checklist in order to ensure all required items are
-a boxes will help produce a quicker review time and reduce the
--Ins will necessitate additional processing and review
B. Cover Letter/Narrative Description (Required for A..
jlicant shall submit one original and one copy of
nd Supporting Documents
" or secure digital signatures.
,s specifically requested.
Kages):
® List all items included in the application package, as well as . escription of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 05-21):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
El If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of $tate.
El If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
❑ The Project Name in Item 11.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of thc application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .01 06(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
> Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
> The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
> Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
> General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
• Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be. added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
> This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump 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 in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .01 15(a)(I) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .01 15(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .01 15(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

1'H1N COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE, REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 28778-8211
[phone]
[phone] Fax
Avery, Buncombe, Burke, Caldwell, Cherokee,
Clay, Graham, Haywood, Henderson, Jackson,
Macon, Madison, McDowell, Mitchell, Polk,
Rutherford, Swain, Transylvania, Yancey
Water Quality Section
Fayetteville Regional Office .
225 Green Street Suite 714
Fayetteville, North Carolina 28301-5095
[phone]
[phone] Fax
Anson, Bladen, Cumberland, Hamett, Hoke,
Montgomery, Moore, Robeson, Richmond,
Sampson, Scotland
Water Quality Section
Mooresville Regional Office
610 E. Center Avenue
Mooresville, North Carolina 28115
[phone]
[phone] Fax
Alexander, Cabarrus, Catawba, Cleveland,
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
Stanly, Union
Water Quality Section
Raleigh Regional Office
3800 Barrett Drive
Raleigh, North Carolina 27609
[phone]
[phone] Fax
Chatham, Durham, Edgecombe, Franklin,
Granville, Halifax, Johnston, Lee, Nash,
Northampton, Orange, Person, Vance, Wake,
Warren, Wilson
Water Quality Section
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
Water Quality Section
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
[phone]
[phone] Fax
Brunswick, Carteret, Columbus, Duplin, New
Hanover, Onslow, Pender
Water Quality Section
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, North Carolina 27105
[phone]
[phone] Fax
Alamance, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Stokes, Surry, Watauga, Wilkes, Yadkin
Water Quality Section
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Elizabeth City (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: Montique McClary per 15A NCAC 02T .0106(b)
Title: Interim City Manager
4. Applicant's mailing address: 306 E. Colonial Ave, PO Box 347
City: Elizabeth City State: NC Zip: 27907-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Sentara Albemarle Medical Center (SAMC) Phase 1 — Medical Office Building
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: Pasquotank
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.295556° Longitude: -76.296944°
5. Parcel ID (if applicable): 8903 481702 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: J,D. Hines License Number: 046684
Firm: VI-IB Engineering NC, P.C.
Mailing address: 940 Main Campus Drive, Suite 500
City: Raleigh State: NC Zip: 27606-
Phone number: [phone] Email Address: jhines(a vhb.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Rogerson WWTF Permit Number: NC0025011
Owner Name: City of Elizabeth City
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0032683
2. Downstream (Receiving) Sewer Information: 12 inch ❑ Gravity ® Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00082
Owner Name(s): City of Elizabeth City
FORM: FTA 06-21
Page 1 of 5

VI. GENERAL REQUIREMENTS
1. 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 (FORM: DEV) been attached?
❑ Yes ❑ No Z N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/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 100 % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .01 14(f)? ❑ Yes ® No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(t))
Daily Design Flow `b
No. of Units
Flow
Medical Office Building
250 gal/1 practitioner/shift
82
30,750 GPD
Hospital
300 gal/1 bed
110
33,000 GPD
gal/
GPD
gal/
GPD
gall
GPD
gall
GPD
Total
63,750 GPD
a See 15A NCAC 02T .01 I4(b), (d), (e)(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 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 15A NCAC 02T.01 14] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 63,750 GPD (per 15A NCAC 02T .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:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
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
N/A
N/A
N/A
➢ 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: SAMC
2. Approximate Coordinates (Decimal Degrees): Latitude: 36,29986944° Longitude: -76.26829722°
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.864 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): 135 gallons per minute (GPM) at 85 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
4
820
DI
4
200
HDPE DR11
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(h)(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
➢ Mutt 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)(1)(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)?
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 II 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
D. If noncompliance with 02T.0305(f) or (g), see Section X.1 of this application
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(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 15A 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 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting 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 E No
Per 15A NCAC 02T.0 1 05(c)(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 15A 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:
Does the submitted system comply with 15A NCAC 02T, the Minimum Design criteria for the Permitting of Pump Stations
and Force Mains (latest version), 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 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 projects the full technical review is required.
2. Professional Engineer's Certification:
I, J.D. Hines, P.E., attest that this application for Sentara Albemarle Medical Center (SAMC) Phase 1 — Medical Office
Building 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 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 143-215.6B, 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 56.0701)
North Carolina Professional Engineer's seal n : ' re, and date:
10/N /tctt
Applicant's Certification per 15A NCAC 02T .0106(b):
, attest that this application f
ority Name from Item I.3.)
r
046684
044/
ND. H�``%��.
(Project Name from Application Item
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. I 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 be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, 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.
Date: !O - !1.2°A)
FORM: FTA 06-21
Page 5 of 5

RECEIVEDNCDENRIDWR
Division of Water Resources
OCT 19 2022
Water Quality
BROW
Washington
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Oil
Idire , : eptance for Sewer Extension Applications
.eg (FUSE 04-16)
Entity Requesting Allocation: The City of Elizabeth City
Project Name for which flow is being requested: Sentara Albermarle Medical Center
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.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a.;WWTP.Facility Name: Rogerson Wastewater Treatment Fagilitx
b. WWTP Facility Permit #: NC0025011
All flows are in MGD'
c. WWTP facility's permitted flow 4.5.
d. Estimated obligated flow not yet tributary to the WWTP 0.940
e. WWTP facility's actual avg. flow 3.36
f. Total flow for this specific request 0.0638
g. Total actual and obligated flows to the facility 3.4238
h. Percent of permitted flow used 76.08%
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)+C) (E)=(A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm / pf), Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
Sentara 0.864 0.3456 0 0.0638 0.0638 0.2818
Knobbs
6.48 2.5920 0.8497 0 .8497 1.7423
* The Firm Capacity 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 less than 2.5.
*** 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): Knobbs Creek Drive Pump. Station
Downstream Permit Number: WQ0032683
Page 1 of 6
FTSE 04-16

III. Certification Statement:
I Montique McClary 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 I and II plus all
attached planning assessment addendums for which I am the responsible party. Signature of this
form indicates acceptance of this wastewater flow.
Page 2 of 6
FTSE 04-16

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available
Capacity is < 0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year, and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to
allow this flow to be permitted, without a significant likelihood of over -allocating capacity in the
system infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste
disposal system.
Signing Official Signature Date
Page 3 of 6
FTSE 04-16

Instructions for Flow Tracking/Acceptance form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #: Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not yet tributary to the WWTP, MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through
interlocal agreements or other contracts not yet contributing flow to the collection system are also
included. For POTWs that implement a pretreatment program, include flows allocated to industrial
users who may not be using all of their flow allocation. Please contact your Pretreatment Coordinator
for information on industrial flow tributary to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years
and reconciled their flow records, to the best of their ability, so it is known how much flow has been
obligated and is not yet been made tributary to the WWTP, in accordance with local policies and
procedures employed by the reporting entity.
e. WWTP facility's actual avg. flow, MGD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + f]
h. Percent of permitted flow used: Equals [(g / c)*100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there
is 0.5 MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7
MGD. There is a proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. 0.5 MGD
e. = 2.7 MGD
f. = 0.015 MGD
g. = 3.215 MGD
h.=53.6%
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
f. = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner
Page4of6
FTSE 04-16

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design
average daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow
through the pump station (C) for each pump station that will be impacted by the proposed sewer extension
project. Calculate the total cutieut flow plus obligated flow (D=B+C) and the available capacity (E=A-D).
Include the proposed flow for this project with other obligated flows that have been approved for the pump
station but are not yet tributary (C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as
per the Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not
less than 2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump
station if the system has future specific plans related to capacity that should be considered in the permitting
process.
Design
Firm Average
Pump Station Capacity Daily Flow
(Name or Number) MGD (Firm / pf)
Kaw Creek PS 0.800 0320
Approx.
Cutient Avg.
Daily Flow,
MGD
(C) (D) +C) (E)=(A-D)
Obligated,
Not Yet Total Current
Tributary Flow Plus
Daily Flow, Obligated Available
MGD Flow Capacity*
0.252 0.080 0.332 -0.012
Valley Road PS 1.895 0.758 0.472 0.135 0.607 0.151
Page 5 of 6
FTSE 04-16

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity
is<0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether
there is significant likelihood that needed improvements or reductions in obligated flows will be in place
prior to activating the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to
manage the flow without capacity related sanitary overflows and must take all steps necessary to complete
the project or control the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned
project in the future not yet funded but in a formal plan adopted by the system. The system should carefully
weigh the certainty of successful timely project completion for any expansion, flow management diversion
or infiltration and inflow elimination projects that are the foundation of a planned solution to capacity
tracking and acceptance compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080
MGD of the committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01
MGD per year, and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project
entitled Kaw Creek Pump Station upgrade with funding planned in July 2014. This project is planned to
add 0.100 MGD to the firm capacity of the pump station by October 2015. Inclusion of this proposed
capital project as a condition of this Flow Tracking/Acceptance for Sewer Extension Permit Application
elevates this project's priority for funding and construction to be implemented ahead of the activation of
obligated, not yet tributary flows in amounts that exceed the firm pump station capacities identified in
Section II above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
Page 6 of 6
FTSE 04-16

Engineerslsa.MkW Ptann«sI Deslgnun
VHB Engineering NC, P.C.
940 Main Campus Drive, Suite 500
Raleigh, NC 27606
ph:.919.829.0328
Print Date: 8/18/2022
Pump Station Calculations - phased and 2 flows- Low
Head•Condition
Project ISAMC
Locatlon:'Halstead Road
ElizabethCity,NC
Proj. No.:33580.25;
Date: 11/17/20
Rev. Date:, 6/17/2022,
Computed by: ` JDH:
Checked by.]^_ MLG
1. Average flows for North Carolina are based North Carolina Administrative Code Titel 15A (15A NCAC 02T .0014 Wastewater Design Flow Rates)
Flow Basis
Development Use Quantity Unit Unit Average Hours Adjusted Peaking Peak
Flow Flows Operating Avg. Flow Factor Flow
(GAL) (GPD) (hours) (GPD) (GPD)
Entire_ Development
Totals
MOB #1 82 practitioners 250 20500 16 30750
Hospital 110 beds 300 33000 24
Contributing Flow To Pump Station(gpm)
MOB#1 - 41 practitioners for two shifts per day Is 82 total practitioners
Hospital - 80 beds current/110 beds maximum
Flle:
33000
3.0
3.0
63750
3.0
44.3
gpm
3.0
92250
99000
191250
132.8
\\vhb.com\gbl\proJWlrginteBaach\3358925 Sentara Albemerk\tedh\Utilities Wnitary Sewer\Pump Station\[2022-06-17 SAMC SSPS Caks - HOMA 30 - Phland2 - Low Head Condds]Pump
Station Flows - Ph2

0 Study Intersection
0 Proposed Access Point
Proposed Development
Figure 1:
Vicinity Map
Sentara Albemarle Medical Center
Elizabeth City, NC
Pasquotank County

\\vhb.com\gbl\proj\VirginiaBeach\33589.25 Sentara Albemarle\cad\Id\Planmisc\3358925 FM EXHIBIT.dwg
March 29, 2022
0 1000 2000 400ffeet
1
3

Average Yearly Flow for: Facility name, Permit # Elizabeth City (NC0025011)
Jan.2021
Feb.2021
Mar.2021
Apr.2021
May2021
Jun2021
Ju12021
Aug2021
Sept2021
Oct2021
Nov2021
Dec2021
Permitted Flow:
4.6354839
6.33
3.4390323
2.9663333
2.2822581
3.8703333
2.7267742
4.5587097
2.8946667
2.3506452
2.165
2.1848387
3.367006283 Avg. Flow
2021 % of Permitted Flow:
4.5
74.82236185
(< 80% / 90% OK)