WQ0044454_Application (FTSE)_20230424

!Greenville
�V_� Utilities
April 18, 2023
lu •M4111 ToTel
Assistant Regional Supervisor
North Carolina Division of Water Quality
943 Washington Square Mall
Washington, NC 27889
Subject: Hawthorne Emerald West
Sewer Main Extension
Dear Mr. Tankard:
APR 2 4 2023
water G?ua,fty
Regbnal Operations section
Washington t3e9lonal Otflce
\,(QWgt4q&4
We are submitting herewith one (1) original and one (1) copy of the executed Non -Discharge
Permit Application and Flow Tracking/Acceptance for Sewer Extension Permit Applications
along with a check for $480.00 for the subject project. We request your approval of the sewer
improvements.
We trust that you will find this submittal to be in order and that your approval will be
forthcoming. In the meantime, should you have any questions or require any additional
information, please let us know.
Sincerely,
Clifton H. Cahoon, PE
Construction / Contracts Engineer
Enclosures
c: Mr. David W. Springer, PE, Interim Director of Water Resources
Mr. W. Jordan Brewer, PE, Kimley-Horn
Connected To You Post Office Box 1847 1 Greenville, North Carolina 27835-1847 1 guc.com 1 252-752-7166

Kimley>>> Horn APR $ 4 2023
was' a,alny
January 12, 2023 Wash►ngio moons �
State of North Carolina
NC Department of Environmental Quality
Water Quality Section
943 Washington Square Mall
Washington, North Carolina 27889
RE: Fast Track — Public Sewer Extension
Project Name: Hawthorne Emerald West
Attached, please find the applications and submittal items for review of the proposed sanitary sewer
gravity line. The proposed public sanitary sewer main is for the Emerald West project located in
Greenville, North Carolina, at 0 Allen Road. Emerald West is a multifamily residential project which
includes townhomes, multifamily buildings, parking garages, a clubhouse, and recreational areas.
This project is proposing approxmately 207 LF of 8-inch DIP encased in _16°-inch steel. The public
sewer line will connect to an existing public manhole located at the northwest comer of the site,
across Allen Road. The flow from the site will be approximately 100,200 GPD.
The following are transmitted to you for review:
• $480 Application Fee
• FTA 12-07 ver2 Checklist and Application
• FTSE,10-18 Flow Tracking/Acceptance Form
• Site Maps
• USGS Map
• Aerial Map
Please do not hesitate to contact me at [phone] or lordan.brewerakimlev-hom.com should
you or your staff have any questions for this review.
Sincerely,
W. Jordan Brewer, P.E.
Kimley-Horn and Associates

State of North.Carolina
Department of Environmental Quality
Division. of Water Resources
P _. ;._ j_ FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
'Division of MraINSTRUCTIONS FOR FORME FTA 06.21 & SUPPORTING DOCUMENTATION
This application is for sewer adciv6ons 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 StationsTorce Mains) and that plans, specifications and supporting deemnents
have been prepared in accordance with 15A NCAC 02T. 15A NCAC 02T .03M Division policies, and good eozineorhat oraetices.
While no upfront engineering design documents am required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit applicatim to the Division. This would inchmde plans, design
calculations, and project specifications reed in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documeats shall be inunediabdy available upon regaest by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.03U3.
Projects not eligible fior review via the fast track procoas (must be submitted for-faIl teclmnital.review):
➢ Projects that do not meat any part of the minimrmi design criteria (MOC) don
➢ Projects that involve more than one variance fronm,the requirements of 15A NCAC 0217;
➢ Pressure sewer; systems utilizing simplex septic tanker pumps (sue) or simplex grinda pumps;
Simplex STEP or simplex grinder pumps connecting to prized systems (e g. force mains);
➢ Vacuum sewer systems,
General — When submitting an application, please use the folbwmg inetiimtians as a checklist in order to ensure all required items are
submitted. Adherence to these instruction and checking the provided boxes will help produce a quicker review time and reduce time
amount of requested additiatud won. Failm to submit aff required It Will necessitate additional procesdag and review
th e, and may result in return of the app6cotion. Unless otherwise noted, the Applicant shall submit one original and one copy of
time applies and supporting docammentation_
A. One Original rid One Copy (second copy nay be digital) of Application and Sapporting Documents
® Required unless otherwise noted. Sim on original must be `tenet ink" or secure digital signatures.
Please do not submit engineering design Plana with time application unless specifically requested.
& Cover Letter/Narrative Description (Required lfbr All Appheation Packages):
® List all A ms included in the application package as well as a brief description of the requested permitting action.
➢ Be specific as to the systems type number of homes served, flow allocution required, eta
➢ Include the pe mit-mmmber/stnius-of my other required sewer permits (downstream/apkream)
➢ If necessary for clarity, include attachments to the application fomm.
C. Application Fee (All New and Modification Application. Packages):
® Submit a check or money order in the amount of $480.00, dated no mac than 90 days pricy to application submittal
➢ Payable to North Carolina Departrnent o€Envkonmental Quality (NCDEQ)
D. Fast Track.Apptieation (Required for AN Applicatim Packnes, Form FTA 05-21):
® Submit the cammpleted and appropriately executed applies
➢ If necessary far clarity or due tD space restrictions, attachments to the application may be made.
0 If the Applicant Type in item L2 is a corporation or company, provide documentation it is regWmvd for business with the
North Carolina Secretaro of State.
❑ If the Applicant Type in Item L2 is a partnership or d/bla, enclose a copy of tho- certificate filed with the Register of Deeds in
the county of business.
® 'lima Project Name in Item IL I shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Prokesional Engincu's.Certification on Page 5 of the application shall be signed, sealed and dam by a North Carolina
licensed Professional F.tlaineer_
® The Applicant's C rdfication on page 5 of time application shall be signed in accordance with 15A NCAC 02,17.0106(b). Per
15A NCAC 02T .0106(6� an alternate person may be designated w the signing official if a delegation letter is provided from
it person who meets the criteria in 15A NCAC 02T .OI OW
INSTRUCTIONS FOR FORM: FFA 06-21 & SUPPORTING DOCUMENTATION Page 1 of 3.

1
I
E. Flow Try Acce ng/ pierce Form (Form; FTSE 04-16) (If Applicable):
® Submit the completed and executed FTSE form fi-orn the owners of the downstream sewers and treatment facility.
D hfultTle R ms maybe required where the downstream sewer owner and wastewater fteatment facility are diffient.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated lass than one year
prior to the application data.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
D" Intergovernmental agreements or other contracts will not be accepted in lieu ofa project -specific FTSE.
F. Site Maps (All Application Paclrsgesr
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of suffcient scale to identify the entire project area,
including the closest surface waters.
D Gencral location of the project components (gravity scorer, pump stations, & ford main)
I ➢ 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. Emoting Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and dear narrative idwfting the pmvionly permitted items to remain in the penW*, 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 peamittod items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers. to be listed in
the lira! permit
H. Power Reliability Plan (Required if portable reliability option utilized for Pamp Station):
❑ Per 15A NCAC 02T .0305(b)(l), submit documentation ofpower 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 confracted by the applicant and is compatible with
the ststion. 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 appui pecances
and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to maniple pump stations, an evalwation of an the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel thnetrames, shall
be provided L the case of a makiple station power outage. (Required at tone of certification)
L Certificate of Public Convenience and Natty (All Application Packages for Privatel343wned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility fianciiiso fix the area to be sewed by the sewer
extension, or
13 Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a fremchise has been received andthat the service area is contiguous to an existing fianclused area or that fimmchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers ibr lots to be sold):
❑ Hom0roparty Owners' Associations
❑ Per 15A NCAC OZT .0115(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.
❑ Dk—mlopm of lots to be sold
❑ Per 15A NCAC 02T .0115(b).. submit the properly wwcutad Q tM9 Agreement (FORM: DLIV )
For more h#bnnado)% visit the Dlvislon's collectjon systimrs websfte
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION
I Jb I
Papa 2 of 3

T I
j
V� (100 q Ll 4 (5-q State of North Carolina
Dirhloa of 111"Ar 16,-n&rP
. . , Application Number.
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
. . FrA 06-21 & SUPPORTING DOCUMENTATION
(to be camplekd by DWR)
AH Umm must be onravieted or the avollestl[on w3l be retwraed
L APPLICANT INFORMATION:.
1. Applicant's name: Grway ifle UWjfig Cgmgj*on.(company, municipality, HOA, utility, eta)
2— Applicant type: El Individual El C=pmdion El General Partnership ❑ Privately -Owned Public Utility
E] Federal El State/County 0 Municipal El other
3. Signature authority's name: Clifton FL Cahoon, PE per 15ANCAC 02T,0106(b)
Tit1w. CmAnwtionCm4=ts FA&M.
4. Applicant's mailing address: PO Box 1847
City: Uremville, State: North Carolina Zip: 27835--1847
5. Applicant's contact informatitom-
Phone number Cam) 551-3386 Email Address:cWwonchQeuccom
JEL PROJECT INFORMATION-
1. Project name: -Hawthorne Emerald Went -P �,l,fo 1 � � l h n.Q..
2 Application/Project status: Proposed (New Permit) El Emsting PermWPrject
If a modification, provide the existing permit number- WQOO and issued date:
For modkficsfioas�, abo attach a detAed marrafive descrip0on as described In Item G of the cbecklist.
If now copshuctim but part of a -muster plan, provide the existing permit number WQ00-
3. County where p4ect is located: Pig
4. Appr
oximate Coordinates (Decimal Degmesx Latitude- &W Longitude: - 4
5. Parcel ID (if applicable): 01200 (or Parcel ID.tD closest downstream sewer)
M. CONSULTANT INFORMATION'
1. Professional EngineerW. Jordan Brewer. EL License Nmber. 039196 V
Firm: KkfttRom ad Assn .
Mailing address: 300 S. Main St. Sub@ 212
City: Fjoily Spring St ate: North Carolina Zip: .2LS40-4201
Phone number (919 653,-§§:54 Email Address: iordauLbrewanUkbnlev-horn cam
IV. WASTEWATER TREATMENT FACILITY (WWM INFORMATION:
1. Facility Name: Grxnyt7le Utilities CSaaw1won Permit Number NC=931
Owner Name: Greenville Utilities C%miMon
V. RECEIVING DOMR031REAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream (Receivi* Sewer Infumation: 8 inch 0 (3ravity 13 Force Main
3. System Wide Collection Sygem Permit Number(s) (if applic;able): WQCS
Owner Name(s): Greenville Utilities Commissim
FORM: FrA 06-21
Page 1 of 5

F
I
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATIONAND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Ashavillo B29XW Office
2090 US Highway 70
Avery, Buncombe, Burke, CaldwWl, Cherokee,
Water Quality Sbetion
Slwamanca, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
(828) 29&4500
Macon, Madison, McDowell, Mltchall, Polk,
[phone] Fax
Rutherford, Swain, T►ansyivarda, Yancey
Fevetkndit PiN lorw Off a
225 Green Street Sidle 714
Anson, Bladen, C rnberland, Harriett, Hoke,
war gwft$*AM
Fayetteville, North Carolina2830t-5095
Montgomery, Moore, Robeson, Richmond,
(910) 433'33M
Samilmn Scotland
(910) 4WW07 Fax
Nk oresvt@e Reolonpt Office
610 E Cenlier Avenue
Alexander. Cabarnm Catawba, C leiveland,
Wster Qustity Section
Mooresville, North Carolina 28115
Gaston, bWell, Lincoln, MecklenbLM Rowan,
[phone]
Starry, Unlon
(704) 683ZM Fax
Off
3800 Barrett Drive
Chatham, Durtxm, Edgecornbe, FraNcBn,
Water Qua ty Section
Raleigh, North Carolina 278M
Granville, Halifax, J&mton, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Wauren, Wilson
Wa8bn!2fl gagdo" office
943 Washington Square Mail
Beaufort, Bartle, Camden, Chowan, Craven,
1Afaler QuatitwSection
IMwhfrugk n, North Carolina 27889
Currituck Da % Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Parlico, PasWotenk,
(252) 9754716 Fax
Per'quirnam Pitt, Tyrrell, Washington, Wayne
Wiilrrillnsrton Reolonall Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplirn, New
Water Qua9ty $ecdon
VAlm ngton, North Carolina 28405
Hanover, Onslow, Pander
[phone]
(910) 3502004 Fax
iMnsbn-Satam Redbam Of""
450 W. Hanes Milt Road
Alarnance, Atieghany, Ashe, CarAml, Davk1son,
Wour.Qual tvS CI&M
Sidle 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, W Dw% Yadkin
Me) 776-98W
(338) T76-9797 Fax
Page 3 of 3

VL GFNF.RAL REQUIItEMENTS
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 AQaeement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners, Association, has an HOA/POA Oaerational 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 ❑ Swimming Pool/Chibbouse
❑ Food and drink facilities ❑ Church ❑ Swimming PooWdter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 1QVA Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes El No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114M ❑ Yes ®No
➢ If Vm provide a copy of Sow redaction approval letter with this application
7. '-.Shmma ize wastewater generated by project:
Establishment Tape (we.92T.0114(t))
Daily Design Flow ''6
No. of U '
Multi Family - 1 Bed ��
240 gal/Day
114
27,360 GPD
Multi Family - 2 Bed
240 gal/Dayi�
168
40,320 GPD
Multi Family - 3 Bed
/360��1/Day
54
19,440 GPD
Townhouse - 2 Bed
,�� 240 gallDay\
32
7,680 GPD
Townhouse - 3 Bed f %
360 gal/Day
15
5,400 GPD
gall
GPD
���
Total
100,
a� �
lv
See 15A NCAC 02T .0114(b (d�(e�l) and (e)(2) for caveats to wastewater design flow rates (Le., minimum flo
dwelling; proposed unknDwn non-residential development uses; public access facilities located new 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) r�
Per 15A NCAC 02T .0114(c), design flow rates fior establishments not identified [m table 15A NCAC 02T.0114j shallbe l{,�
determined using available flow data, water using fxturas, occupancy or operation patterns, and other measured data. i
8. Wastewater generated by project 100200 GPD (per 15A NCAC 02T .0114)
➢ Do not include f m flows or previously permitted allocations
If permitted flow is zero, please indleate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line. i
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

VIL GRAVITY SEWER DESIGN (MIMRIA (ifAppnqbje) -o2T mm & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size ( nches)
Length (tiet)
Material
8"
207
DIP with Steal
Encasement
➢ Section 11 & III of the NW for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Overshdng lines to meet mieimnm slope requirements is not aflowed and a violation of the MDC
VU PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump StationsMorce Maier):
PROVIDE A SEPARATE COPY OF THUS PAGE FOR EACH PUMP STATION 114CLUDED IN THLS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degreesx Latitude: Longitude:
3. Total number of pumps at the pump station:
3. Resign flow ofthe pump station: millions gallons per day (fine capacity)
➢ This should reflect the total GPM fbr the pump station with the largest pump out of service.
4.. Operational points) per pump(s): gallons per minute (GPM) at feet total dynamic head (TDI-1)
5. Summarize the forks main to be permitted (for this Pump Station)r
Sin (inches) Length (het) Material
If any portion of the force main is less than 44nche s in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.l.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 1?uP
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(hx1)(BX
➢ 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(hXlXC):
❑ 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 time portable source is owned or contacted by the applicant and is compatible with the station.
➢ If time portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation s6edule of time 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

ILL. SETBACKS & SEPARATIONS - (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives fo4md in 15ANCAC 02T .0305(t) & (g ® Yes ❑ No
t c A carer n7T (11M I rvr,tainc minim,rm ws%gmtinna that ahaT1 he rrovided fur sewer systems:
--- - Setback Para*
Separation Reqwhvd
Storm sewers and otber utilities not listed below (vertices
18 inches
2Water mains (vertical - water over sewer preferred, including in beached 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, in� any wells, WS-1 waters of Class I or
Class II impounded reservoirs used as a sauna 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 DC2)
..0 fed
**Any other stream, lain, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as Wl,.
I feet
Any building foundation (
5 fed
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical kAeight
10 field
Drainage system and interceptor drains
5 fad
Any swimming pools
10 fed
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or(" we Section )L1 of this application
'15A NCAC 02T.030560 contains atteanatives where separations in 02T.0305(f1 cannot. be achieved. Please check `des"
above if these alternatives are used and provide narrative information to explain.
**Stream dons can be identified using the Division's.NC Surface Water Classificatims vvebaaue
2. Does this project comply with the minimum separation requirements far 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 fur wetlands? ❑ Yes ❑ No ® N/A
Please provide supplementary mfiermation identifying the areas of non-conformance.
➢ See the Division's. draft separation requires for situations where separation cannot be met.
D 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 anbjed to any State buffer rules? ® Yes Basin name: 71ir ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .02001 0 Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require cov+eragdautharization under a 404 Natiaawide/mdividual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authodzation is requite.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/Certifications)? 0 Yes ❑ No
Per 15A NCAC 02T.0105(c)(61 directly related environmental permits or certification applications mast be being prepared,
have been applied for, or have been obtained. Insurance of this permit is contingent an issuance of dependent permits (erosion
a and sedimentWon control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are defined "high-prlorrVr I ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer c4ntactmg surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended tbroz& interforencekouffict boxes ruin a variance approvaL
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and loc tion�
Higk priority lines sbal be bnpedW by the perolttee or ks representative at least once every six- goers and
hmpections documented per 15A NCAC 02T.0403(a)(5) or the per 's indivMhmd Syskm-Wide Collection permit.
F0 M: FTA 06-21 Page 4 of 5

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 Qmyt Sewer Minimum Design Criteria f latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and sabm d the Variance/Akwxdive Design Request application
(VADC 10-14) and supporting documents for review to the Cwtral Office. Anaroval of the request wM be lssoed
2. Professional Fr's Certification:
I, W. Jordan Drawer. F.E. , attest that this application for Hawthorne Emerald West
(Prafn—aal Ensmaces mine from Applicawn Item IIL I.) (Project Name from Applicrajon Item II.1)
hiss been reviewed by me and is auvrate, compkte and consistent with the information supplied In the pbms,
specifications, engineering calculations, and all other supporting documentation to the best of my kuowk dge. I fintber
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 Perham Criteria for the Fast -Trade Permitting
of Pump Stations and Force Maims (latest version] Alter 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 act with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
Ott, representation, or certification m 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. Mmrepresentatim of the application
information, inchuding failure to disclose any design non-compliance with the applicable Rules and design criteria, may mk jed
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina lProfessiomd'Engineer's seal, signature, atsd date:
-
a—
= 039196
UIAN{ 'i612023
3. Applicant' ficapKpex SA NCAC 02T .0106(b):
EibMi�NIO�i/'' .attest that this application four C �
�(S��N.rom An Item Ik) (Project Name $om ApphcaiOa Item H.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 mcomplebe. I understand stand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result m an immediate went
action that may include civil penalties, mjtmctive relief, and/or criminal prosecution. I will make no clams 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 art not completed and that if all regwred supporting infiormadon. and attachments ale not mcluided, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 14�, 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:
&-Z7 *ENE=
Date: 1 3
FORM: FTA 06-21 Page 5 of 5

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