WQ0043970_Application (FTSE)_20221104

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41BF7C588
DWR
Division of Water Resources
NC Dept of Environmental Quality
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
NOV 4 2622 FTA 06-21 & SUPPORTING DOCUMENTATION
ApptialedgiNgaritEmal OfficeW dtd 4' 39 I70RI
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Holly Springs (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ['Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Kendra Parrish per 15A NCAC 02T _0I060)
Title: Executive Director of Utilities and Infrastructure
4. Applicant's mailing address: 128 S Main Street P.O. Box 8
City: Holly Springs State: NC Zip: 27540-
5. Applicant's contact information:
Phone number: [phone] Email Address: kendra.parrish(r hollyspringsne.gov
II. PROJECT INFORMATION:
1. Project name: Carolina Springs Sewer Outfall
2. Application/Project status: ® Proposed (Ncw Permit)
❑ Other
❑ 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: Wake
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.68761 Longitude:-78.87003`
5. Parcel ID (if applicable): 0730834534 (or Parcel ID to closest downstrcam sewer)
Ill. CONSULTANT INFORMATION:
1. Professional Engineer: Anthony E. Mills License Number: 039280
Firm: Shenandoah Homes, LLC
Mailing address: 3724 National Dr. Suite 215
City: Raleigh State: NC Zip: 27612-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Utley Creek WRF Permit Number: NC0063096
Owner Name: Town of Holly Springs
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0042565
2. Downstream (Receiving) Sewer Information: 16 inch IX. Gravity i_) Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00192
Owner Name(s): Town of Holly Springs
FORM: FTA 06-21
Page I of 5

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DSA41BF7C588
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 ® NIA
2. If the Applicant is a Developer of Tots to be sold, has a Developer's Operational Agreement (FORM: DEN!) been attached?
❑ Yes ❑ No ®N.
3. if the Applicant is a Home/Property Owners' Association, has an HOA, POA Operational Agreement {FORM:. HOAj and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® NIA
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/Fitter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater : 50 % Domestic 50 % Commercial % Industrial (See 15A NCAC 02T .0103(201)
If Industrial, is there a Pretreatment Program in effect? ❑ Yes No
6. Has a flow reduction been approved under 15A NCAC 02T .0114( f)? ❑ Yes ® No
). If ves, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow',b
No. of Units
Flow
Hotel
120 gal/room
225
27,000 GPD
Apartment — I or 2 bedroom units
240 gal/Unit
622
149,280 GPD
Apartment — 3 bedroom units
360 gal/Unit
118
42,480 GPD
Retail
0.115 ga1SF
182,590
20,998 GPD
1 Office
0.111 gal/SF
444,000
49,284 GPD
IcePlex
Provided by Calvert Ice Sports
25,030 GPD
Total
314,072 GPD
a See I5A'1CAC 02T _01.140b1, {d), lc](and {e1t2) 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 I5A NCAC 02T .01 I4(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 314,072 GPD (per 1.5A 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
El Other (Explain):
FORM: FTA 06-21
Page 2 of 5

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41BF7C588
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"
3345.49
PVC
8"
1602.95
DIP
12"
2059.89
PVC
12"
444.70
DIP
16"
413.91
PVC
➢ 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 thc 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 me hod of solids reduction per
MDCPSFM Section 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 1156, irAC 02T .03051h11 R):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - l 5A NCAC 02T.0305(h)( I )(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 thc portable power source or pump, including travel timcframes, shall be provided
as part of this permit application in thc casc of a multiple station power outagc.
FORM: FTA 06-21 Page 3 of 5

DocuSign Envelope ID: EE5148D2-0127-4068-96C2-DBA41BF7C588
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(0):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305th & 10? ® Yes ❑ No
l5A NCAC 02T.0305(fl contains minimum separations that shall be rovidcd 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
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-1 waters of Class 1 or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-1 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
*l5A NCAC 02T.0305(v) contains alternatives where separations in 2.0305(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 webnage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ NIA
➢ 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?
➢ 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: Cape Fear
If yes, does the project comply with setbacks found in the river basin rules per I5A NCAC 02B .0200?
➢ This includes Trout Buffered Streams per 1 5ANCAC 2l3.020
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits
or 401 Water Quality Certifications?
➢ Please provide the permit number..permitting status in the cover letter if coverage.authorization is requi
® Yes ❑ No ❑ NIA
❑ No
® Yes ❑ No
❑ Yes ® No
red.
6. Does project comply with 15A NCAC 02T.0105(elf 6) (additional permitsrcertifications)? ® Yes ❑ No
Per 15A NCAC 02T.01051ci 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 (east 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

docuSign Envelope ID: EE5148132-0127-406B-96C2-DBA41BF7C588
X. CERTIFICATIONS:
1. Does the submitted system comply with I 5A 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 project, the full technical review is required.
2. Professional Engineer's Certification:
I, Anthony E Mills, attest that this application for Carolina Springs Sewer Outfall
(Professional Engineer's name from Application Item 111.1.) (Project Name from. Application hem 11.1)
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. 1 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 Pennittinj
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, signature, and date:
Doe uSlpni
DocuSlgned by-
T
Q1nlLot f
EE84B53.9ri 64AE.
11/1/2022
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, Kendra Parrish, attest that this application for Carolina Springs Sewer Outfall
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item 11.1)
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 arc 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. 1 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.
Signature:
DocuSianed by
_Eve,
Date:
10/31/2022
FORM: FTA 06-21 Page 5 of 5

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41 BF7C588
NC Dept of Environmental Quality
Division of Water Resources
NOV 4
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Raleigh Regional Office (FTSE
Tracking for Sewer Extension Applications
(FTSE 1 0- 1 8)
Entity Requesting Allocation: Town of Holly Springs
Project Name for which flow is being requested: Carolina Springs Sewer Outfall
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: Utley Creek Wastewater Treatment Plant
b. WWTP Facility Permit 11: NC0063096
All flows are in MGD
c. WWTP facility's permitted flow 6.000
d. Estimated obligated flow not yet tributary to the WWTP 1.573
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
2.829
0.314
4.716
78.6
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 Pump
Station Station
(Name or Permit
Number) No.
Carolina WQ0042364
C...r..,.,�
Finn
Capacity, *
MGD
(A)
Design
Average
Daily
Flow**
(Firm 1 Pt),
MGD
1.967 0.787
(B) (C)
Approx. Obligated,
Current Not Yet
Avg. Daily Tributary
Flow, Daily Flow,
MGD MGD
0 .432
(D)=(B+C) (E)=(A-D)
Total Current
Flow Plus
Obligated
Flow
Available
Capacity***
0.432 0.355
* The Firm Capacity (design flow) 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, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** 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 < 0.
Downstream Facility Name (Sewer): Carolina Springs Pump Station #1
Downstream Permit Number: WQ0042364
Page 1 of 6
FTSE 10-18

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA418F7C588
I1I. Certification Statement:
I Kendra D- Parrish, PE _ 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 certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
rw
Oo�ned6y:
B`6i/4•0
Signing Official Signature
Exec Director of utilities and infrastructure
Title of Signing Official
Page 2 of 6
10/31/2022
Date
FTSE 10-18

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41BF7C588
Carolina Springs Sewer Outfall (PRCDC202200'�ept of Environmental Qu
Utility Permit Application (PRUP202202330)
Submittal Date: October 21st, 2022 NOV 4 20
Raleigh Regional Office
v
SHENANDOAH
Shenandoah Homes, LLC
Residential Developer / Land Development
NCBELS Firm License #D-0428
Submittal Items
Designed By:
Andy Mills, PE
Michael Jeska, El
Cover Letter
Sewer Design and Application Certification Form 2003
Carolina Springs Sewer Outfall Signature Set
Carolina Springs Sewer Outfall Calculations
$480.00 Check to NC DEQ
$200.00 Check to Town of Holly Springs
FTA 06-21 f"TA 04-1G Fast Tract Sewer System Extension Application
FTSE 10-18 Flow Tracking for Sewer Extension Applications
USGS Topographic Map
Project Site Aerial
Project Narrative
The proposed Sanitary Sewer Outfall is designed to serve the Shenandoah Homes portion of the
Carolina Springs project. The 137.37 acre Mixed Use property is located at 3708 Old Holly Springs Apex
Rd. Apex, NC 27539. The sewer outfall will tie into an existing manhole and downstream pump station
designed by WithersRavenel, Inc.
Wastewater flow rates were calculated using the NCAC 02T values for a hotel (120 gal/room x 225
rooms), 1 or 2 bedroom apartments (240 gallunit x 622 units), 3 bedroom apartments (360 gal/unit x 118
units), and retail (.115 gal/SF x 182,590 Sq Ft). The site will produce a total average daily flow of 314,072
GPD and total peak flow of 835,240 GPD (1.292 CFS). The maximum flow depth (1/2 pipe diameter) and
minimum velocity (2 fps) has been met for every pipe in the outfall. The sanitary sewer system is comprised
of 34 manhole structures and 7,867 LF of pipe. Ductile Iron Pipe has been specified at stream and road
crossings. Manhole and pipe quantities are listed below, and full calculations can be found in the Carolina
Springs Sewer Outfall Calculations packet:
8" PVC = 3345.49 LF
8" DIP = 1602.95 LF
12" PVC = 2059.89 LF
12" DIP = 444.70 LF
16" PVC = 413.91 LF
Total Pipe Length = 7866.94 LF
4' Diameter Manholes = 30
5' Diameter Manholes = 4
Total Manholes = 34

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41BF7C588
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science for a changing world
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NC Dept of Environmental Quality
U.S. DEPARTMENT OF THE INTERIOR
U.S. GEOLOGICAL SURVEY
NOV 4 2022
88
Raleigh Regional Office
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DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41BF7C588
NC Dept
fEnvironmenral Qual
NOV 4 2022
Raleigh Regional Office

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41 BF7C588
THE TOWN OF
October 27, 2022
Director, Division of Water Resources
Raleigh Regional Office
Water Quality Operation Section
3800 Barrett Drive
Raleigh, NC 27609
NC Dept of Environmental Qu.
�lly jrjn.as Nov 4 ZazZ
Raleigh Regional Office
Re: Application for Sewer Extension Permit
Project: Carolina Springs Sewer Outfall
Dear Sir or Madam:
Please find enclosed the following items in application for a sewer extension permit to the Town
of Holly Springs existing sewer distribution system:
o One original and one copy cover letter including a project narrative
o A check in the amount of $480.00
o One original and one copy of the State of North Carolina Fast Track Sewer System
Extension Application (FTA 04- 1 6)
o Two copies of FTSE 04-16 Flow Tracking/Acceptance Form
o Two color copies of a 8.5-inch by 1 1-inch portion of a 7.5 minute USGS Topographic
Map showing project area
O Two copies of a street level map showing all relevant project areas
O One copy of the locally -required Design and Application Certification
Feel free to contact me at 919-577-3150 should you have any questions or need additional
information in order to process this application.
Sincerely,
OocuSIgned by
Kendra D. `l3ai Ti, P.E., CFM
Executive Director of Utilities and Infrastructure
KP/tr
cc: Project Consultant Engineer, Andy Mills, PE
Rachel Ingham, Engineering Manager
Drew Johnson, Development Construction Manager
Emily Koncz, Utility Permitting Specialist
Project file/Correspondence #42029
3002
04.17.2018
os
ri2M
Rachel Ingham
utility Engineer
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnc.gov

DocuSign Envelope ID: EE5148D2-0127-406B-96C2-DBA41 BF7C588
Project: Carolina Springs Sewer Outfal'
Design Engineer: Andy Mills. PE
Address: 3724 National Drive, Suite 215, Raleigh, NC 27612
Phone Number: 916.233.8581 Email: [e-mail]
Date Complete Application Package Received by Town: 10121/2022
Date Approved: (by RI)
ri<uP
DO NOT SUBMIT SEWER EXTENSION APPLICATIONS UNTIL
CONSTRUCTION DRAWINGS HAVE BEEN APPROVED BY1CIatEa f Fair(
Sewer Design and Application Certification
nmental Qua
Note: This form must be submitted with the Fast Tract Application for extension to the Toii of J?
Holly Springs Sewer System
Raleigh Regional Office
(by KDP) E5Vi (by DJ)
As design engineer for this project, I certify the following (please check (x) each applicable box)
El That the design of the project is in complete conformance with the Town of Hotly
Springs Engineering Design and Construction Standards and NC DEQ Sanitary Sewer
Design Regulations;
❑ That each of the following items are completed and enclosed for submittal to the State for
a sewer extension permit:
❑ One cover letter that includes a project narrative
o A check in the amount of $480.00 to NC DEQ
❑ A check in the amount of $200.00 to the Town of Holly Springs
❑ One State of North Carolina form FTA 04-16 Fast Tract Sewer System
Extension Application
o One FTSE 10-18 Flow Tracking for Sewer Extension Applications
o One color copy of an 8.5-inch by 11-inch portion of a 7.5-minute
USGS Topographic Map showing project area
One copy of a street level map showing all relevant project areas
One copy of the locally -required Design and Application Certification
(this form)
Design Engineer's Signature a-•-, Date
Please contact Theresa Randall at [phone] or theresasandall@holk. springsnc_gov if you
have any questions.
2003 Sewer Design Application Certification
01.1421
Utilities and Infrastructure Services
P.O. Box 8 • 128 S. Main Street • Holly Springs, NC 27540 • www.hollyspringsnagov