WQ0043108_Application (FTSE)_20230105 (2)

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Nlinirr>um Desiu r Criteria fir the Permitting of Purnp Ssa1__iijns
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
®Yes No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents
for review. Approval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Profession. Engine 's Certification:
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attest that this application for
(Professional Engineer's name from Application item 111.1.)
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, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track
Pennitting 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 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 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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC ,/
02T..0106(b): T
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(Signature Authority's name & title from Application item 13.)
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attest that this application for
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 arc not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. 1 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.f,A 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 S10,000 as well as civil penalties up to $25,000 per violation.
Signature:
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Date: 11
FORM: FTA 04-16 Page 5 of 5