WQ0015930_Application (FTSE)_20230403

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���. v�� State of North Carolina
` Department of Environmental Quality
Division of Water Resources
DWR
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: LEI (to be completed by DWR)
MOP
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Rockingham County Public Utilities (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: Ronnie Tate per 15A NCAC 02T .0106(b)
Title: Director
4. Applicant's mailing address: 371 NC Hwy 65
City: Reidsville State: NC Zip: 27320-
5. Applicant's contact information:
Phone number: [phone] Email Address: rtate&vco.rockingham.nc.us
H. PROJECT INFORMATION:
1. Project name: NCDOT Project: BP7.R021 Rockingham County =(Bridge # 233 Mebane Bridge Rd.)
2. Application/Project status: ❑ Proposed (New Permit) ® Existing Permit/Project
If a modification, provide the existing permit number: WQ00364 and issued date: 11/7/2008,
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: Rockingham
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.47186' Longitude:-79.74546'
5. Parcel ID (if applicable): (or Parcel ID to closest downstream sewer)
Ill. CONSULTANT INFORMATION:
l . Professional Engineer: Corey Bousquet License Number: 023041
Firm: Hinde En ineering
Mailing address: 401 Harrison Oaks Blvd., Suite 220
City: Cary State: NC Zip: 27513-_
Phone number: [phone] Email Address: cbousquettchindeen ing eering com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Mebane Bridge WWTP Permit Number: NCO025071
Owner Name: City of Eden
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ00364
2. Downstream (Receiving) Sewer Information: 10 inch ❑ Gravity ❑x Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Rockingham County
FORM: FTA 06-21 Page 1 of 5

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Vl. GENERAL REQUIREMENTS
l . 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 ®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.01 15(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 ❑ Swimming Pool/Clubhouse
® Food and drink facilities ® Church ❑ Swimming Pool/Filter Backwash
® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 15 % Domestic 85 % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(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(f))
Daily Design Flow'''
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T .0114(b),(d), (c)(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 .01 14(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: _ 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

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VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
l . Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
➢ 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 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
198
PE tubing, SDR 9
10
184
Ductile Iron, PC
350
12
680
HDPE, SDR 9
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
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 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

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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 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
➢ If noncompliance with 02T.0305(f) or (a), see Section X.1 of this application
*I 5A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(fl 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 webpaee
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: Roanoke ❑ 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 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 ❑ No
Per 15A NCAC 02T.0 I 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

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X. CERTIFICATIONS:
1. 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. Aiaroval of the request will be issued
concurrently with the approval of the permit, and projects reguirinLy a variance auuroval may be subject to lonEer
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 nroiect, the full technical review is required.
2. Professional Engineer's Certification:
I, Corey Bous uet , attest that this application for BP7.R021 - Rockingham County
(Professional Engineer's name from Application Item III.1.) (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 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 143-215.613, 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. 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:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
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1, Ronnie Tate , attest that this application for BP7.R021 - Rockingham County_
(Signature Authority Name from Application Item 1.3.) (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 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.
DocuSigned by:
Signature: rbtA it, UG Date: 3/29/2023
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FORM: FTA 06-21 Page 5 of 5

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HINDE
ENGINEERING
401 Harrison Oaks Blvd.
Suite 220
Cary, NC 27513
Phone: [phone]
Fax: [phone]
LETTER OF TRANSMITTAL
To: Winston-Salem Regional Office WQS
450 W. Hanes Mill Road, suite 300
Winston-Salem. NC 27105
Re: BP7.R021 Rockingham County. 10" Force
Main Relocation. NCDOT Project: BP7.R021
Bridge No. 233 on SR 1964 (Mebane Bridge
Road) over the Dan River.
I am sending you the following item(s):
I'!C D C ri,rrnfj�,ijt of
Enwin-, „ .
�' 1; .?pity
E"14 da� C! 3 2023
Winston-Salem
Date: March 29. 2023
Job No.: NCDOT Project:
BP7.R021 Rockingham
County
COPIES
DATE
NO.
DESCRIPTION
1
3-29-2023
1
Original Sewer Permit Application
1
3-29-2023
1
Copy of Sewer Permit Application
1
3-29-2023
1
8.5" x 11.5" Color Copy of USGS Topo Map
1
3-29-2023
1
Project Narrative
1
3-29-2023
1
Check for $480.00
These are transmitted as checked below:
❑ As requested
® For approval
❑ For review and comment
Remarks:
Copy to: File
Ronnie Tate
❑ For your use
❑ For Signatures
DocuSigned by:
Signed:
BE23F928878C49A...
Corey D. Bousquet, PE
Project Manager

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4 HINDE
14 ENGINEERING
401 Harrison Oaks Blvd., Suite 220,
Cary, NC 27513
Office: 919-653-0001
March 29, 2023
Mr. Lon Snider
Winston-Salem Regional Office
Water Quality Regional Operations
NC Division of Water Resources, DEQ
(336)-776-9800
Subject: Sewer Permit Narrative
Rockingham County Public Utilities — Relocation of 10" DI Force Main
NCDOT Project: BP7.R021, Mebane Bridge Road
Rockingham County
Dear Mr. Snider:
The following force mains (2-inch PE Tubing, 10-inch DI RJ and 12-inch HDPE) are being
proposed on the east side of Mebane Bridge Road, Rockingham County. The existing 10-inch DI
force main attached to the bridge and the 2" force main crossing Mebane Bridge Road are being
relocated due to the future demolition of the Bridge over the Dan River. There will be 198 feet of
2-inch PE Tubing, SDR 9, 184 feet of 10-inch DI RJ, PC 350 and 680 feet of 12-inch HDPE,
SDR 9 force mains being proposed on the east side of the Mebane Bridge Road. The portion of
proposed force main outside the limits of Dan River will be (I0-inchDI RJ, PC 350, lined with
Protecto Ceramic Epoxy 401). The portion of proposed force main crossing the Dan River will
be installed by directional bore (I2-inchHDPE Pipe, SDR 9). The existing 2" force main will be
relocated using proposed (2-inch PE Tubing, SDR 9). Concrete blocking will be used to restrain
the tie-in points to the existing 10-inch DI force main. There will be no additional flow generated
with the installation of the new 10" DI and 12" HDPE force main.
The sewer permit submittal also includes the sewer permit application, site map and $480.00
permit fee.
Sincerely,
DocuSigned by:
Hinde Engineering Project Engineer
Cc: Ronnie Tate ([e-mail])
Director
Hinde Engineering
401 Hairison Oaks Blvd., Suite 220,
Cary, NC 27513
Office: 919-653-0001