WQ0044024_Application (FTSE)_20221230

State of North Carolina
R Department of Environmental Quality
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Division of Water Resources
�09 FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources 11 FTA 06-21 & SUPPORTING DOCUMENTATION
0 v Application Number: l� (to be completed by D\iR)
�/V All items must be completed or the anolication will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Bermuda Run (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: Andrew Meadwell per 15A NCAC 02T .0106(b)
Title: Town Manager
4. Applicant's mailing address: 120 Kinderton Blvd.
City: Bermuda Run State: NC Zip: 27006 -_
5. Applicant's contact information:
Phone number: ( 336 ) 998-0906 Email Address: Ameadwellntownofbr.com
II. PROJECT INFORMATION:
1. Project name: Atiston Place
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: Davie
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.004°Longitude:-80.434'
5. Parcel ID (if applicable): 5872-53-1543 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: John D. Lipka License Number: 026494
Firm: MLA Design Group, Inc.
Mailing address: 120 Club Oaks Ct. Suite 100
City: Winston-Salem State: NC Zip: 27104-_
Phone number: [phone] Email Address: johgftillerla.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Muddy Creek Wastewater Treatment Facility Permit Number: WOCS00003
Owner Name: Winston-Salem / Forsyth County Utilities
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Nurber(s): W 000 43247
2. Downstream (Receiving) Sewer Information: 8 inch S Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS0043247
Owner Name(s): Town of Bermuda Run
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: DE V) been attached?
[:]Yes [:]No ®N/A
3. If the Applicant is a Home/Property Owners' Association has anHOA/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) ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swirmming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swinmung Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attaclunent)
5. Nature of wastewater: 100 °/u Domestic _°/n Commercial _ % Industrial See 15A NCAC 02T.0103(2041
If Industrial, is there a Pretreatment Program in effect? Yes❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? []Yes ®No
➢ If yes, provide a cony of flow reduction approval letter with this aunlication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,n
No. of Units
Flow
gal/
gal/
GPD
gal/
GPD
gall
GPD
gall
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(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.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 00 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 timefranre 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): See Narrative
FORM: FTA 06-21 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (GravitySewe NJ:
I. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 49 SDR35
➢ Section If & 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 _ feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter, please identif}, the method of solids reduction per
MDCPSFM Section 2.01C. Lb. ❑ 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
➢ 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)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetn,:
➢ 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 tinmeframes, 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) & M? ® Yes ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Stomr sewers and other utilities not listed below (vertical)
18 inches
'-Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
WWater 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 nonnal
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
*15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(fl cannotbe achieved. Please check "yes"
above if these alteratives 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 subnut a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Roue.
3. Does the project comply with separation requirements for wetlands? []Yes []No ®N/A
➢ Please provide supplementary information identifying the areas of nonconformance.
➢ See the Division's draft separation requirements for situations where separation carrot 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 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual pemuts ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the pernut 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 ❑ No
Per 15A NCAC 02T.0105(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, storrnvater 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:
I. 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. Aonroval of the request will be issued
2. Professional Engineer's Certification:
I, John D. Lipka , attest that this application for Aris on Place
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item ILl)
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, signature, and date: �,•`°� G R
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Andrew Meadwell , attest that this application for Ariston Place
(signature Authority Name from Application Item 1.3.) (Project Name from Application Item Il. 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 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.
Signature: dog
Date: /L/Ze-/ZZ
I I
FORM: FTA 06-21 Page 5 of 5

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State of North Carolina December 14, 2022
Department of Environmental Quality
Division of Water Resources N C Department of
Winston-Salem Regional Office Environmental Quality
450 West Hanes Mill Road, Suite 300 Received
Winston-Salem, NC 27105
Ariston Place (Town of Bermuda Run - Public Systems) DEC 3 0 2022
FTA 05-21 & Supporting Documents
Bermuda Run, NC Winston-Salem
Attn: DWR, Regional Office
MLA Design Group is pleased to provide you with the Fast Track Sewer System extension application for the subject
project. Ariston Place is a 5 building — 98 unit (one and two bedroom) Multi -Family Residential Development with
a Club House. The project is located off from NC Hwy 801 in the Town of Bermuda Run, Davie County, NC. The
pre-existing 6.54 acre project parcel supported three single family homes and limited commercial uses. Currently
demolition and bulk grading operations are underway as the project has received proper permits for these activities
through the county and state.
The daily design flow of domestic wastewater generated by the project is calculated at 23,520 GPD and included on
the application. The private gravity sanitary sewer system consists of approximately 710 if of 8" SDR35 PVC pipe
and four precast concrete manholes. The private gravity system runs north to south within the property and will
connect to a new public manhole within the Ivy Circle Road/Utility Easement. The new pubic manhole will gravity
connect with approximately 50 If of 8" SDR35 PVC beneath Ivy Circle Roadway to an existing manhole on the south
side of the Ivy Circle Road/Utility Easement. The new public manhole and 50 if of 8" SDR PVC will be permitted
under a separate Fast Track Application with the Town of Bermuda Run as the Applicant. The existing manhole on
the south side the Ivy Circle Road/Utility Easement is at the upstream side and services the Bermuda Run Country
Club. It is our understanding that the existing Country Club system gravity flows to Town of Bermuda Run W WTP
which is under renovations and the influent is temporarily pumped through a new force main to the Eastern Davie
system while cleaning and removal (Decommissioning) of the W WTP along with upgrading the influent pump station
are made. The Town of Bermuda Run has been granted permit WQ0043247 to upgrade its pump station for this
purpose.
This permit application and supporting documents are submitted for the public section of gravity sewer running
beneath the Ivy Circle Roadway. The proposed Ariston Place wastewater is a tributary to the Town's renovations by
gravity.
It is our understanding, if this application information provided is complete and acceptable, a permit will be issued
with the condition that; No wastewater flow shall be made tributary to the subject sanitary sewer system until the
Downstream Sewer Owner and/or WWTF Owner expansion is constructed, operational, and the eneineer's
certification has been received by the Division. I I5A NCAC 02T.0304(b) & 15A NCAC 02T .00161.
Submitted By: Jo D. Lipka, PE
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Attachments: - One Original FTA "wet ink"
One Copy FTA
Application Fee ($480.00)
FTSE Forms (Copies)
USGS Site Map
Aerial Location Map