WQ0044474_Application_20230612

GocuSign Envelope ID: E66BDC83-9FB9-404F-B40*(OWJEC331197
Pl of �:rrt�rr�rrr)rcr?tat State of North Carolina
Quality Department of Environmental Quality
Division of Water Resources
W, -R
JUN 12 ZL FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources ++ FTA 06-21 & SUPPORTING DOCUMENTATION
C�f1�f rrlt M
�—r Lti fl{�i�a
Applica tion Number: [� (tobeoompleted by DwR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant'sname: Town ofPittsboro(company, municipality, HOA, utility, etc.)
2. Applicanttype: ❑ Individual 1J Corporation General Partnership
11 Federal ❑ State/County X, Municipal
3. Signature authority's name: Kent Jackson per 15A NUAC 02-f .01 D6(b 7
Title: Town Engineer
4. Applicant's mailingaddress:635EastStreet-POBox759
City: Pittro State: NC Zip: 27312-
5. Applicant's contactinfomtation:
Phone number: (9199)542-7190 EmailAddress: kjackson ittsboronc.gov
II. PROJECT INFORMATION:
�i Privately -Owned Public Utility
❑ Other
1. Project name: R-5930A
2. Application/Projectstatus x' Proposed (New Penn it) Existing Perm it/Project
Ifamodification, provide the existingpermitnumber: WQ00 andissueddate: ,
For modifications, alsoattach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existingpermit number: WQ00
3. County where project is located: Chatham
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.723894` Longitude:-79.170498'
5. Parcel ID (if applicable): N/A (or Parcel IDtoclosest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: NateHarvev License Number: 045249
Firm: Kimley-Ham&Associates.Inc.
Mailing address: 300 Morris St. Suite 200
City: Durham State: NQ Zip: 27701-2127
Phone number: (Ngl )§U-48383 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY(WWTF) INFORMATION:
1. FacifityName: Ch�nPark Water Recovery Center Pen -nit Number: NIC0020354
OwnerName: ClearwaterC4 LLC
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Perm itNumber(s): WQ0040741
2. Downstream (Receiving) Sewerinformation: 16 inch ❑ Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00146
OwnerName(s): TownofPittsboro
FORM: FTA06-21 Page 1 of

DocuSign Envelope ID: E66BDC83-9FB9-404F-B46A-OF27EC331197
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 ndl Agreement (FQ9 -V been attached?
Yes No ® NIA
3. If the Applicant is a Home/Property Owners'Association, has an HOk-POAOfrerationalAgrccrrlamt(FORM:HOA)and
supplementary documentation as required by 15A NCAC 02T.0 I I 5(c) been attached?
Yes No ® N/A
4. Origin ofwastewater:(checka11thatapply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retadwith food preparation/sery ice ❑ Hotel and/or Motels
❑ Schoolipreschoolidaycare ❑ Medical dental veterinary facilities ❑ SwimmingPool/Clubhouse
❑ Food a n d drin k fac ilities ❑ Church ❑ Swim m ing Pool/Filter Backwash
❑ Businesses;' offices/ factories ❑ Nursing Home ❑ Other(Explain in Attachment)
5. Nature of wastewater: °oDomestic _ 0111Commercial%Industrial(,$W LIANC'AC'.0).T.0103f201)
If Industrial, is there a Pretreatment Program in effect? Yes No
6. Has a flow reduction been a pproved under 15A NC At' 02T_0I L4 j? L 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(o)
Daily Design Flow. n
No. of Units
Flow
gal/
GPD
ga II
GPD
gall
GPD
ga V
GPD
ga I/
GPD
gal/
GPD
Total
GPD
a See 15ANCACO2T_0114ft(d,1teXI)and(0L?.jfor caveatstowastewaterdesign flowrates(i.e.,minimum, flow per
dwelling; pro posed u nknown non-residential development u ses; public a ccess facilities located near high public use areas;
a nd residential property located south or east of the Atlantic I ntracoastal Waterway to be used as vacation rentals a sdefined
in G.S.42A-4).
b Per 15ANCACO2T.0114(c), design flow ratesfor establishmentsnot identified [in toblet5ASIC'ACO2T.0114]shallbe
deterniinedusin gavailable flow data, water us ingfix tures, occupancy oroperation patterns, and other m ea su red data.
S. Wastewatergenerated byproject: _ GPD (per Il A. NC'AC" 02 T .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 approximatetimeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number:_ issuance Date:
❑ Rehabilitation orreplacernent ofexisting sewers with no new flow expected
❑ Other(Explain):
FORM: FTA 06-21 Page 2 of 5

DocuSign Envelope ID: E66BDC83-9FB9-404F-B46A-0F27EC331197
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) -02T.0305&MDC (CravitySewers�:
1. Summarize gravity sewerto be permitted:
Size (inches) Length (feet) Material
➢ Section II & ITI of the MDC for Perm ittingof Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes forgravitysewer(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&Ir'1DCfl'uinnStations/ urc t4I"ri :
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. Tota I number ofpumps 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 largestpump out ofservice.
4. Operational point(s) perpump(s): gallons perminute (GPM) at feet total dynamic head (TDH)
5. Sum marize the force main to be permitted (forth is Plump Station):
Size (inches)
Length (feet)
Material
12
2,633
DIP
If any portion ofthe force main is less than 4-inches in diameter, please identifythe method of solids reduction per
MDCPSFMSection 2.0IC. 1.b.❑ GrinderPump ❑ Mechanical Bar Screen r j Other (please specify)
6. Power reliability in accordancewith 15ANCACO2T.0305(h)(l1:
L Standby power source or t Standbypump
➢ Must have automatic activation and telemetry -15A NCAC 02T.0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greaterthan or equal to]5,000gallonsperday
➢ Must be permanent to facility and may notbe portable
Or if the pump station has an average daily flow less than 15,000gallons per day 15ANCACO2T.0305(h)(1)(C):
C Portable power source with manual activation, quick -connection receptacle and telemetry -
or
U 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 powersource or pump is dedicated to multiple pump stations, an evaluation ofall the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timcframes, shalIbe provided
as part of this perm it application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

DocuSign Envelope ID: E66BDC83-9FB9-404F-B46A-OF27EC331197
IX. SETBACKS & SEPARATIONS— (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in I A N ' ? U Yes ❑ No
15 A NCAC 02T.0305lfl contains minimum separations that shall be nrov ided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below(vertical)
18 inches
ZWa ter mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
ZWa ter m ains (horizontal)
10 feet
Reclaimed waterlines (vertical - reclaimed over sewer)
18 inches
Reclaimed waterlines (horizontal- reclaimed oversewer)
2 feet
**Any private orpublic watersupply source, includingany wells, WS-I waters of Class I or
Class1I impounded reservoirs used as a sourceof drinkingwater, and associated wetlands.
100 feet
* *Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water(ortide elevation)andwetlands associatedwith thesewaters (see item IX.2)
50 feet
**Any otherstream, lake, impoundment, orgroundwater loweringand surfacedrainage
ditches, as well as wetlands associatedwith these waters orclassified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cutsof2 feet or more vertical height
10 feet
Dra inage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
y It noncompliance with U2-L(J305(IJorWL see Section X.I of this application
*[SANCACO2"[",0305{g)containsaltemativeswhereseparationsin02.'I'.0305{f cannotbeachieved. Please check"yes"
above if these alternatives are used and providenarrative information to explain.
* *Stream classifications can be identified using the Division's NC Sg-rfau Water Class ifcawns webM
2. Does this project comply with them inimumseparation requirements for water mains? ®Yes ❑ No ❑ N/A
➢ If no, please refer to 15ANCAC 18C.0906(f)fordocumentationrequirementsandsubmitaseparatedocument,
signed 'sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements forwetlands? Yes ❑ No [Z MA
➢ Plea se provide supplementary infonnationidentifying the areas ofnon -conformance.
➢ SeetheDivision's dra ft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design andconstruction.
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 ISANCAC'02B.0 0? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per l SA NCAC 2B.0202
S. Does the project require coverage/authorization under a404Nationwidelindividualpennits ❑ Yes ® No
or 40l Water Quality Certifications?
➢ Please provide the permit number'permitting status in the cover letter if coverage authorization is required.
6. Does project comply with15ANCAC OTLOIG5(c)(6)(additional permit..certifications)? X Yes U No
Per 15 A NC A.0 02 T.0 105 (c)[6), directly related environmental perm its or certification applications must be being prepared,
have been applied for, orhave been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, sto rmwater management plans, etc.).
7. Does this project include any sewer collection lines thatare deemed "high -priority?" . Yes X No
Per ,I5Ah ACO2T.M2',"high-priority sewer" means any a erial 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 attachmentwith details for each line, including type (aerial line, size, in a terial, and location).
High priority lines shall be inspected by the permitteeor its representative at least once every six -months and
inspections documented per 15ANCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

DocuSign Envelope ID: E66BDC83-9FB9-404F-B46A-OF27EC331197
X. CERTIFICATIONS:
1. Does the submitted system comply with ISANIC'ACO2T, the K1inimutnDcsig3iCrittriabribe PcrmittingofP'limcStations
and Forcc Mains Liatest version),andtheGtavityScwcrMinimumDesign('ritifia f I i tve,r.k-mJasapplicable?
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
cnnsprrentty with the asmroval of the raermit, and Ltroiects requirinE a variance approval may be subiect to lorteer
review times. For projects requiringtwo or more variances or where the variance is determined, by the Division to he a
slgnificant-portion of the project. the full technical review is required.
2. Professional Engineer's Certification:
1, Nate Harvey ,attest that this applicationfor R-5930A
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item U.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 applica ble regu lations,
M inimum Desi2ttt C fit eria fol. Gta vitY SOwen. (latest version), and theM it3imLim Dcsi�nr C'ritcria for -rhe Fa sr -Track Fern1 ittn1$
of Pump Stations and Force Mains (latest versionl. 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 theproposed. 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, wh ich may
include a finenotto exceed $10,000, as wellas civilpenaltiesup to $25,000 per viola tion. Misrepresentation ofthe application
information, including failure to disclose any design non-compliance with theapplicable Rulesanddesign criteria, maysubject
the North Carolina -licensed Professional Engineer to referral to the licensingboard. (21 NCAC 56.0701)
`��tlttltttrrr�
North Carolina Professional Engineers seal, signature, and date:
3. ApplieanesCertifjcation per 15ANCAC 02T .0106(b):
1, Kent Jackson __, attest that this application for R-5930A
(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 enfotcement
action thatmay include civil penalties, injunctive relief, and/orcriminal 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 ofth is 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 J_41-M,6A and 1434 15.6k, 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
includea fine notto exceed $10,000 as well as civil penaltiesup to $25,000 perviolation.
DoeuSigned by.
Signature: " " &Sm Date: 6/1/2023
FORM: FTA 06-21 Page 5 of 5

NC Dept o1' I.:Ilvirottntcnlal Quality
DocuSign Envelope ID: E66BDC83-9FB9-404F-B46A-CF27EC331197
JUN 12 2023 State of North Carolina
Department of Environmental Quality
DWR ce Division of Water Resources
Raleigh FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
This application is for sewer extensions 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 ILA NCAC 02T and the Division's
Minimum Design Criteria (Giayity Sewer & Pump Statinn brce Mainq) and that plans, specifications and supporting documents
have been prepared in accordance with 15.E NC'AC 02T..15A N A .. 02 Division policies, and gtoodg*neering,pia, ctitxs
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15 .AC 02T -01Clv and the applicable minimum design criteria. These
documents shall be immediately available upon requestby the Division.
Projects thata redeemed permitted (do not require a permit from the Division) are explained in 15ANCA(902TT.03Q3,
Projects not eligible for review via the fast track process (m ust be submitted for full technical review):
➢ Projects thatdo not meetany part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tan k-effluent pumps (STEPs) or sim plex grinder pumps;
➢ Sim plex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General When submitting an application, please use the following instructions as a checklist in order to ensure allrequired items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time,and may resultin returnof the application. I Inless otherwise noted,the Applicant shallsubmit one original andone copyof
the application and supporting documentation.
A. One Original and One Copy (second copy maybe digital) of Application and Supporting Documents
'x Required unless otherwise noted. Signatures on original must be "wet ink"or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
'List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ include the pen -nit numberistatusof any odierrequircdsewcrpcn-nits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Modification Application Packages):
Submit a check or money order in the amount of $480.00,dated no more than90 days priorto application submittal.
➢ Payable to North Carolina Departmentof Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 05-21):
�J Submit the completed and appropriately executed application.
➢ If necessary for clarity ordue to space restrictions, atlachments to theapplication may bemade.
El If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
h[UrrhCarnlinaSecretai-yofState.
?-7 If the Applicant Type in Item I.2 is a partnership or dlbia, enclose a copy of the certificate filed with the Register of Deeds in
the county ofbusiness.
* The Project Name initemli.l shall be consistent with the project name on the flow acceptance letters, agreements, etc.
* The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
kensed Pru fessional Enl4inecr.
The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15ANCACO2T.0106ib]. Per
15ANCAC 02T .0106(c), an aIternatepersonmaybe designated as the signing official if a delegation letter is provided from
a person who meets thecriteria in I SANCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page I of 3

DocuSign Envelope ID: E66BDC83-9F89-404F B46A OF27EC331197
E. Flow Tracking/Acceptance Form (Form; FTSE 04-16) (If Applicable):
Submit the completed and executed FTSE form from the owners of thedownstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
priorto the application date.
➢ Submittalofthis application and form FTSE indicates thatownerhas adequate capacity and will not violate Ci.S-143-2I5.67Ia1
➢ Intergovernmental agreements or other contracts will notbeacoepted in heuof a project-specificFTSE.
F. Site Maps (All Application Packages):
'Z Submit an 8.5-inch x I I -inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General locationof the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
.k Include an actial location map showing general project area (such as street names or la titude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
U Submit a copy of them ostrecently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added'modifiedl The
na rra five should a Iso include whether any previously p ermitted items have been certified.
The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
Per.l 5 A WAC 02T .03.05.(1tI(1.1, submit documentation ofpowerrehability for pumping stations.
➢ This alternative is only available foraveragedaily flows less than l5,000gallonsperday
➢ It shall be demonstrated to theDivision that the portable source is owned or contracted by the applicant and is compatible with
the station. 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 appurtenances
and personnel are available for distribution and o peration of this pump 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 in the case of a multiple station power outage. (Required at time of certification)
1. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
r, Per ISANCAC`Q2T.0II5ia1(1)provide the Certificate ofPublicConvenience and Necessity from the ltiorthCarol�iaUtilitip
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
Provide a lettcrfrom the North Carolina CltiliticsCommissi{1n's WaIcr a n€l Sc%vcr Division Public Sta fFstatinganapplication
fora franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected
J. Operational Agreements (Applications from HOAIPOA and Developers for lots to be sold):
H o m e/Property Owners' Associations
t=: Per I5AN'CACO2T.01 I5tc), submit the properly executed QperationalA=cmcnriFC7€ M:H0 1.
G Per 15ANCACO2T.0115(c), submit acopy ofthe Articles ofIncorporation,Declarations and By-laws.
O Developers of lots to be Sold
Per.15ANCAC07Tr01I5(tsubmit the properly executed (finer-srignalemeiltlFORM:DEV1-
For more information, visit theDrvision %rollf-tionsystems w bait
INSTRUCTIONS FOR FORM: FFA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: E66BDC83-9FB9-404F-B46A-OF27EC331197
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway70
Avery, Buncombe, Burke, Caldwell, Cherokee.
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander,Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan,Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
_Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Fender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: RfA 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3

Kimley»>Horn
Transmittal
NC Dent of Pnvironmental Quality
MA, 2 2 2023
t:.aleigh Regional Office
300 Moms St
Suite 200
Durham, North Carolina 27701
TEL [phone]
FAX [phone]
Date: 5/18/23 Job Number: 011036532
Project Name: R-5930A Utility Betterments
To: Raleigh Regional Office— Water Quality Section
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone No. 919-791-4200
We are sending these by
U.S. Mail Fed Ex ❑ Hand Delivery
❑ Other
We are sending you
® Attached ❑ Underseparate covervia the foitowin gitems.
❑ Shop drawings ® Prints/Plans ❑ Samples I® Specifications ❑ Change Orders
® Other Engineering Report, Permit Application Fee, PDFcopies on CD
CnniRs nam Aln rlacrrintinn
1
5/18/23
1
Cover Letter
2
5/16/23
2
Form FTA 04-16 Fast Track Application
2
5/15/23
3
Sewer USGS Ma
2
5/15/23
4
Sewer Vicinity Ma
1
519I23
5
Permit Review Fee $480
1
519123
6
USB Drives with PDF permit package
These are transmitted as checked below.
® Foryouruse ❑ Approved as submitted
❑ As requested ❑ Approved as noted
❑ For review and comment ❑ Returned forcorrections
Copy to:
❑ Resubmit ❑ Copies for approval
❑ Submit ❑ Copies ford istnbu lion
❑ Return ❑ Corrected prints
Signed:
Nate H ey
(919) 6784083 1 nate.harvey kimley-hom.con

Kimley»> Horn
May 18, 2023
Raleigh Regional Office
Water Quality Section
1628 Mail Service Center
Raleigh, NC 27699-1628
RE: NCDOT Project R 5930A Utility Betterments
Sewer System Extension Application
Dear WQS:
NC Dept of Environmental Quality
MAY 2 2w3
Raleigh Regjoljal Office
NCDOT has retained the services of Kimley-Horn to design and permit a force main sanitary sewer
extension forwith Town of Pittsboro as part of the R-5930 project, which extends North Chatham
Park Way northward. The force main extension totals approximately 2,633LF including one air
release valve at its single high point.
The force main will serve a future pump station to be designed by McKim and Creed to the northeast
of this project. A subsequent NCDOT project, R-5963D Suttles Road Realignment, will extend this
force main southeast to an existing gravity sanitary sewer manhole. These extensions and pump
station will be permitted by modification of this permit at a later date.
No flow will be added to the system at this time. The pipeline will be constructed and hydrostatically
pressure tested in accordancewith Town of Pittsboro standards, then capped and left full of water
until such time as the R-5963D project extends the force main to its discharge on the south end and
until construction of the force main and pump stating being designed by McKim and Creed at the
north end. The shown on the attached map.
Enclosed are the following for your review:
• 15A NCAC 02T O300 — Fast Track Sewer System Extension Form (2 copies)
• Aerial Image showing proposed relocations (2 copies)
• USGS Topographic Map (2 copies)
• Application fee of $480
• 2 USB drives with all permit requirements
It is our understanding that neither the Certificate of Public Convenience and Necessity nor Flow
Tracking 1 Acceptance Form are necessary due to the nature of the work and zero additional flow.
Please contact me with any q uestions or issues concerning the application at [phone] or
NaJ2-HgrvgyQkimIey-hom.com.
Best Regards,
KIMLEY-HORN AND ASSOCIATES, INC.
/A
Nate Harvey
Utilities Design Engineer

m
I
. N%Mxff. L

N
J
AO
FnHpMdLE Legend
Chatham County
Sewer Corridor
R-6930A North Chatham Park Way 0 500 1,000
Kimley)))Horn Pittsboro, NC I I I
Project USGS Map Feet