WQ0044721_Application (FTSE)_20230907

NC De t State of North Car,_ ... _
p OfEnvirotlrnental Department of Environmental Quality
DWRQa1�ty Division of Water Resources
SEP w FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources 7 203 FTA 05-21 & SUPPORTING DOCUMENTATION
nalelgh Regional Office {to be completed y
Application Numbe . pleled b nwRt
WC?0C>Lfe7V
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Clayton
2. Applicant type: ❑ Individual ❑ Corporation ❑ General
❑ Federal ❑ State.:County ® Munich
3 Signature authority's name: Jonathan K. Jacobs, PE, CFM per 15A NCB
Title: Assistant Engineering Director
4. Applicant's mailing address: PO Box 879
City: Clayton State: NC Zip: 27528
5. Applicant's contact information:
Phone number: [phone] Email Address: iiacobsri-tawnofclaytc
11. PROJECT INFORMATION:
1. Project name: Carolina Overlook Phase 2G & 2H
2. Application/Project status: S Proposed (New Pennit)
if a modification. provide the existing permit number: WQ00 anc
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: WQO{1
3. County where project is locatod, John,tom
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.67 Longitude: -78.45
5. Parcel ID (ifapplicable): 05HO2012G (or Parcel ID to closest downstream sewer)
Ill. CONSULTANT INFORMATION:
I Professional Engineer: Colleen Duryea, PE _ License Number: 049345
Finn: WithersRavenel Inc.
Mailing address: 1 15 MacKenan Drive
city: Car State: NC zip: 27511
Phone number: 919.469.3340 Email Address- [e-mail]
WithersRavenel Inc
115 MacKenan Dr.
Cary, NC 27511
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NC Dept of Environmental State of North Carolina
Quality Department of Environmental Quality
DWR Division of Water Resources
Division of Water Resources SEP 'p� FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
INSTRU S FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
ROOM ice
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 15A NCAC 02T and the Division's
Minimum Design Criteria (Grit%its Sewer & Piiat p Stations?Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300, Division policies, and good engineering- practices.
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 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a pennit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
Y Projects that do not meet any part of the minimum design criteria (MDC) documents,
> Projects that involve more than one variance from the requirements of 15A NCAC 02T,
Y Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps,
Y Simplex 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 all required 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 result in return of the application, Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® 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 LetterINarrative 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 permit numberistatus of any other required sewer permits (downstream/ttpstream)
If necessary for clarity, include attachments to the application form.
C. Application Fee (Ail New and Modification Application Packages):
® Submit a check or money order in the amount of $480.00, dated no more than 40 days prior to application submittal.
Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 05-21):
® Submit the completed and appropriately executed application.
If necessary for clarity or due to space restrictions, attachments to the application maybe made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
f4otth Carolina Secretary of Staw,
❑ If the Applicant Type in Item 1.2 is a partnership or d/b; a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item 11.1 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 Caru�Lna
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the applications shall be signed in accordance with 15A NCAC 02T .0 1061 b . Per
15A NCAC 02T _0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .O106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
Page I of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
p Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
Y Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
1i� The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
* Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215,611 a].
Y Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® 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 location of the project components (gravity sewer, pump stations, & force main)
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. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently 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/modified). The
narrative should also include whether any previously permitted 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 15A NCAC 02T .0305(h)Ll ), submit documentation of power reliability for pumping stations.
Y 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 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 operation of this pump station."
Y 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):
❑ Per 15A. NCAC 02T .0115(a)1 I } provide the Certificate of Public Convenience and Necessity from the North Carolina Utz i xs_
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's. Water and Sewer Division Public Staff stating an application
for a 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 HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A_ NCAC 02T .01 151c), submit the properly executed Operational Agreement (F(2RM: HOA1.
❑ Per 15A NCAC 02T .01 15(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15&NCAC 02T .01 15(b), submit the properly executed Operational Agreement (FORM: DEV),
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of

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 Highway 70
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 Carolina 27609
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, Pender
[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: FTA 05-2 1 & SUPPORTING DOCUMENTATION Page 3 of 3

I of! State of North Cary.. ..
NC De
P Environrnen Quality Department of Environmental Quality
DWR.Division of Water Resources
' S�P FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources 7 2023 FTA 06-21 & SUPPORTING DOCUMENTATION
Kaleigh R IQnal office Application Numb C(; (to be completed by DWRi
C0QC)04q'1 Z[
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name. Town of Clayton
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State.:County ® Municipal ❑ Other
3 Signature authority's name: Jonathan K. Jacobs, PE, CFM per 15A NCA(. 021 0106i b.l
Title: Assistant Engineering Director
4. Applicant's mailing address: PO Box 879
City: Clayton State: NC Zip: 27528
5. Applicant's contact information:
Phone number: [phone] Email Address: iiacobs _,townofclavtonne.org
II. PROJECT INFORMATION:
1. Project name: Carolina Overlook Phase 2G & 2H
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: Johnston
4. Approximate Coordinates (Decimal Degrees): Latitude:.35.67 Longitude: -78.45
5. Parcel ID (if applicable): 05HO2012G (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Colleen Duryea, PE License Number: 049345
Firm: WithersRavenel Inc.
Mailing address: 115 MacKenan Drive
City; Cary State: NC Zip: 27511
Phone number: 919.469.3340 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1, Facility Name: Little Creek Water Reclamation Facility Permit Number: NCO025453
Owner Name: Town of Clayton
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ 0030569
2. Downstream (Receiving) Sewer Information: 16 inch N Gravity Force Main
3. System Wide Collection System Permit Number(s) (if applicable) WQCS001 l0
Owner Name(s): Town of Clayton
FORM: FTA 06-21 Page I 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 0 WA
2. if the Applicant is a Developer of lots to be sold, has a Dcvcloper's OurratiLinal !W cement (FORM. DEV1 been attached?
❑ Yes ❑ No ® NiA
3. If the Applicant is a Home/Property Owners' Association, has an lrl.f lA/PflA { e(atiotia( Agtszmcnt I FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0I 15(c) been attached?
❑ Yes ❑ No ® NIA
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/Clubliouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial % Industrial (See.15A_NCAC 02T .0103(?tl )
If Industrial, is there a Pretreatment Program in effect? ❑ Yes[-] No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(il? ® Yes ❑ No
> if yes, provide a copy of flow reduction approval letter with this ayplication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(1))
Daily Design Flow' a
No. of Units
Flow
Single Family Home
250 gall day
90
22,500 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal;'
GPD
gall
GPD
Total
22,500 GPD
a See ISA NCAC 02T .01 14tbi,fd, t(11 attd (e1t21 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 0?T.01 1 4] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 22,500 GPD (per 15A NCAC 02T. 0 114)
> 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

VI1. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
I. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8-inch 2,478 PVC
➢ Section II & II1 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
Vlll. PUMP STATION DESIGN CRITERIA (If Applicable) -- 02T .0305 & MDC Mums Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
Pump station number or name: NIA
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 pouit(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 identify the method of solids reduction per
MDCPSFM Section 2.01 C.I .b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(11:
❑ 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

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separationslaltematives found in i5A N 'A 0 - 305 ? K 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-1 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-1 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 021.015(0 ur , see Section X.I of this application
* I SA N 21'.0305fid contains alternatives where separations in 02T.03051 f) 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 C'lassilicaxTiiFns wrbi�;ac
2. Does this project comply with the minimum separation requirements for water mains? ❑■ Yes ❑ No ❑ WA
> If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/scaled by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑■ Yes ❑ No ❑ WA
> Please provide supplementary information identifying the areas of non-conformance.
> See the Division's draft sQaration r2QUirements 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: NBUSI? Riy ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .02U0"l Yes ❑ No
> This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nat ionwide;'individual permits ❑ Yes N 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)t6) (additional permitsicertifications)? 0 Yes ❑ No
Per . NCAC 02T.010*10), 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 N 'F 40, "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 MiniMininjilm DesiQU 'rit eri a for the Permiaftgf Pump Stations
an .Ferree Mains ;latest Vzrsicnt}, and the Gravuy Sewer Minimum Desi n riteria-(IAwst version as applicable?
0 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 recluest will be issued
concurrently with the avoroval of the permit, and uroiects reguiring a variance approval may be subject to longer
review times. For ro'ects reguiring two or more variances or where the variance is determined by the Division to be a
si¢nificant portion of the proiect, the full technical review is required.
2. Professional Engineer's Certification:
Colleen Duryea PE
Carolina Overlook Phase 2G & 2H
I
attest that this application for
(Professional Engineer's name from Application Item I11.1.) (Project Name From Application Item I1.1)
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 Destcn Criteria for Gtavivy.Sewers.tlatest.vetsioni, and the Minimum Design Criteria for -the Fast -Track Permitting
of Pu; f 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:
CA R0 go,
Y � eoeeoa00Y0 a .�O
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g 049345 o q
130au91ynea 11.: o IN e° e
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, Jonathan K. Jacobs PE CFM , attest that this application for
(Signature Authority Name from Application Item 13 ) (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-'_ 15-613, 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.
Signature: Date:
FORM- FTA 06-) I Paue 5 of 5

NC Dcpf of nvllp4mvnfsr Quality
State of North Carolina
Di-lwk
Department of Environmental Quality
SEP 7 2023 Division of Water Resources
Divlslon or Water Itesourc- Flow Tracking for Sewer Extension Applications
i ■ �J-��]N���Q`y}{+JRr■.��IIJ� (FTSE 10-18)
I I1�1 - i��5 wwr� w
Entity Requesting Allocation: Town of Clayton
Project Name for which flow is being requested: Carolina Overlook Phase 2G & 2H
Mare than one FTSE may be required for a single project if fire owner of the WWTP is trot responsible for all prunrp
stations along the route of the proposed wastewaterJlow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Little Creels Water Reclamation Facility
b. WWTP Facility Permit #: NC 0025453
All flows are in MGD
c. WWTP facility's permitted flow LCWRF 2.5 + JoCO 1.4 +
Raleigh 1.75 = 5.65 MGD
d. Estimated obligated flow not yet tributary to the WWTP 0.966
e. WWTP facility's actual avg. flow 3.248
f. Total flow for this specific request 00225
g. Total actual and obligated flows to the facility 4.2365
h, Percent of permitted flow used 74.9%
1I. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)—(A-D)
Design Obligated,
Pump Pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
Clayton to Raleigh -NIA 2.52 1.008 0.388 0.4382 0.8215 0.1865
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is <: 0.
Downstream Facility Name (Sewer): Clayton to Raleigh PS
Downstream Permit Number: NIA
Page 1 of 6
I-TS1 10-18

111. Certification Statement:
Jonathan K. Jacobs, PE, CFM certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has a(lequate opacity to transport and treat the proposed new wastewater.
ng
Director
Title of Signing Official
`.7
Page 2 of 6
i;TSE 1 D-18

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section 11 where Available Capacity is <
0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Of Signature
Date
Page 3 of 6
FTS11. 10 18

Instructions for Flow Tracking form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit #- Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow_
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not _yet tributary to the WWTP, MOD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through interlocal
agreements or other contracts not yet contributing flow to the collection system are also included. For POTWs
that implement a pretreatment program, include flows allocated to industrial users who may not be using all of
their flow allocation. Please contact your Pretreatment Coordinator for information on industrial flow tributary
to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years and
reconciled their flow records, to the best of their ability, so it is known how much flow has been obligated and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entity.
e. WWTP facility's actual av . flow, MGD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + f]
h. Percent of permitted flow used: Equals [(g 1 c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there is 0.5
MOD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.015 MGD.
The first Fortn FTSE submitted after January 15, 2008 may have numbers like this:
c. = 6.0 MGD
d. — 0.5 MGD
e. 2.7 MGD
f. = 0.015 MGD
g. — 3.215 MGD
h. -- 53.6 %
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d. — 0,515 MGD
c. — 2.73 MGD
f. — 0.102 MGD
g. = 3.349 MGD
h. — 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
I:TSI- 10-18

4
Section II
List the pump station name or number and approximate pump station firm capacity, approximate design average
daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow through the
pump station (C) for each pump station that will be impacted by the proposed sewer extension project. Calculate
the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D). Include the proposed flow
for this project with other obligated flows that have been approved for the pump station but are not yet tributary
(C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as per the
Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not less than
2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump station
if the system has future specific plans related to capacity that should be considered in the permitting process.
(A)
(B)
(C)
(D)=(B{C)
(E)=(A-D)
Obligated,
Design
Approx.
Not Yet
Total Current
Firm
Average
Current Avg.
Tributary
Flow Plus
Pump Station
Capacity
Daily Flow
Daily Flow,
Daily Flow,
Obligated
Available
(Name or Number)
MGD
(Firmi pf)
MGD
MGD
Flow
Capacity*
Kaw Creek PS
0.800
0.320
0.252
0.080
0.332
-0.012
Valley Road PS
1.895
0.758
0.472
0.135
0.607
0.151
Page 5 of 6
l:TSF 10-I9

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section lI where available capacity is_ 0.
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated flows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary overflows and must take all steps necessary to complete the project or control
the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned project in
the future not yet funded but in a formal plan adopted by the system. The system should carefully weigh the
certainty of successful timely project completion for any expansion, flow management diversion or infiltration and
inflow elimination projects that are the foundation of a planned solution to capacity tracking and acceptance
compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080 MGD of the
committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that will provide the required planned capacity, namely
_ is in design or under construction with planned
completion in _ _ ; and/or
d. The following applies:
The master nlan and ten vear capital plan contain recommended scone and fundine for a capital project entitled
Kaw Creek Pump Station upgrade with funding_ planned in .lulu 2014. This project is planned to add 0.100 MOD
to the firm capacity of the pump station by October 2015. Inclusion of this proposed capital project as a condition
of this Flow Trackin Acceptance for Sewer Extension Permit Application elevates this project's priority for
funding and construction to be im lemented ahead of the activation of obligated, not yet tributary flows in amounts
that exceed the firm pump station capacities identified in Section 11 above.
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow this flow
to be permitted, without a significant likelihood of over -allocating capacity in the system infrastructure.
Page 6 of 6
FTS F 10-18

w

;:WithersRavenel
Our People. Your Success.
NC Dept of Environmenral
Quality
July 3, 2023
SEP - 7 2023
PROJECT ENGINEER'S REPO081edghRe
giMW
Project Name: Carolina Overlook Phases 2G & 2H (aka Phase 3)
Location: Clayton, Johnston County, NC
Parcel ID: 05HO2012G
Owner/ Developer: Pulte Home Company, LLC
1225 Crescent Green Ste. 250
Cary, NC 27518
Consultant: WithersRavenel
Sol Rios -Moore, Senior Project Manager, Residential
[e-mail]
Ph. 919.469.3340 1 Direct. 919.238.0497
PROJECT DESCRIPTION AND NARRATIVE
The proposed development is located at 1162 Covered Bridge Road, inside the Town of Clayton
jurisdictional limits. The project proposes the construction of 90 Single -Family units. The project
is anticipated to generate the following wastewater flows:
90 UNITS AT 250 GPD = 22,500 GPD
TOTAL = 22,500 GPD
The proposed gravity sanitary sewer system will consist of approximately 2,478 LF of 8" PVC
total (2,051 LF of SDR35 and 427 LF of C900).
The new gravity sanitary sewer system will be owned, operated, and maintained by the Town of
Clayton, NC.
115 MacKenan Drive I Cary, NC 27511
t: 919.469.3340 I f: 919.467.6008 1 www.withersravenel.com I License No. 1=-1479
Asheville I Cary I Charlotte I Greensboro I Pittsboro I Raleigh I Southern Pines I Wilmington

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%■ WithersRavenet Letter of `transmittal
■ Our People, Your Success. NC Dept of Environmental Quality
115 MacKenan Drive
Cary, NC 27511 SEP — 7 2023
t: 919,469,3340 1 f: 919.467.6008
Raleigh R 09/O6 /2023 MUZ1631W 02211543.00
TO: NCDEQ DWR Raleigh Regional Office
38DO Barrett Drive
Raleigh, NC 27609
WE ARE SENDING YOU THE FOLLOWING ITEMS;
® Attached ❑ Under Separate Cover Via
❑ Shop Drawings ❑ Prints ❑ Plans
❑ Copy of Letter ❑ Change Order ❑ Disk
1 1 $480 Check Application Fee
1 Fast -Track Sewer System Extension Application
1 Project Narrative
1 Vicinity Map
1 USGS Map
2 USB Containing Digital Files
1 FTSE
THESE ARE TRANSMITTED as checked below:
® For approval ❑ Approved as submitted
❑ For your use ❑ Approved as noted
❑ As requested ❑ Returned for corrections
❑ For review and comment
❑ For bids due
Carolina Overlook Phase 2G & 2H (aka Phase 3)
1n NCDEQ Submittal - Sewer FTA
❑ Samples ❑ Specifications
❑ Other
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ Other
❑ Prints returned after loan to us
REMARKS: Please let us know if you have any questions or require additional information.
Kristy Penland, Project Coordinator Sol Rios -Moore, Senior Project Manager
COPY TO: kpenland withersravenel.corn SIGNEC sriosmoore-Awithersravenel.com
Curt Blazier, PE
Director of Small Scale Residential Development
QA/QC: cblaz'err�-Lwithersravenel.corn
RECEIVED:

of
NC oe State of North Car _.
Pt Of Envtrortrrlental Quality Department of Environmental Quality
DWRDivision of Water Resources
SEP , FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources 7 202.3 FTA 06-21 & SUPPORTING DOCUMENTATION
xcalelgl Regiana] offiCO Application Numbe Ito be completed by DWRi
All items must be comaleted or the aualication will be returned
1. APPLICANT INFORMATION:
Applicant's name: Town of Clayton
2 Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State. -County ® Municipal
3. Signature authority's name: Jonathan K. Jacobs, PE. CFM per 15A NC:AC 02 1'.0106Ib1
Title: Assistant Enaineerine Director
4. Applicant's mailing address: PO Box 879
City: Clayton State. NC Zip: 27528
5, Applicant's contact information:
Phone number: (9t9) 553-1554 Email Address: iiacobs(,townofclavtonnc.ora
❑ Privately -Owned Public Utility
❑ Other
Ill. PROJECT INFORMATION:
1. Project name: Carolina Overlook Phase 2G & 2H
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: Johnston
4. Approximate Coordinates (Decimal Degrees): Latitude
5. Parcel ID (if applicable): 05HO2012G
III. CONSULTANT INFORMATION:
35.57 Longitude: '78.45
(or Parcel ID to closest downstream sewer)
I. Professional Engineer: Colleen Duryea, PE License Number: 049345
Finn: Withers Ravenel Anc.
Mailing address: 115 MacKenan Drive
city: Cary State: NC zip: 27511
Phone number: 919.469.3340 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Little Creek Water Reclamation Facility Permit Number: NCO025453
Owner Name: Town of Clayton
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ 0030569
2. Downstream (Receiving) Sewer Information: 16 inch B Gravity L; Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS001 10
Owner Name(s): Town of Clayton
FORM: FTA 06-21 Page I of 5

X. CERTIFICATIONS:
I Does the submitted system comply with 15A NCAC 02T, the lvltn►mum Design Criteria for the Permitting of Pump Stations
and Force Mattes latest ,,erston and the Gravity Sewer klininium 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. Approval of the reguest will be issued
concurrently with the anproval of the permit, and proiects requiring a variance approval may be subject to longer
review times. For projects requirine two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
1 Colleen Duryea, PE , attest that this application for Carolina Overlook Phase 2G & 2H
(Professional Engineer's name from Application Item Ill. I.) (Project Name from Application Item 11. l )
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. l 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 $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
. ........... .... .... ...............
North Carolina Professional Engineer's seal, signatu%.Agd date:
Docu$ipned
cares�ruir.
Applicant's Certification per 15A NCAC 02T .0I06(b):
C A R 0 °OOOo
S° ` popOeoeaepa �� °
=0 a.-��ESS/p�`e 9
SEAL e
049345 0
'G I N"1.
FEDtv0O°e
pa_ _'• E
1, Jonathan K. Jacobs, PE. CFM , attest that this application for
(Signature Authority Name from Application Item 1.3.)
(Project Name from Application Item II ► )
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 understated 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: Date: Z)J fE GVL.,J
FnR M• FTA 06-7 1 Pave 5 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(1) & (g)? N Yes ❑ No
15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
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
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-1 waters of Class I or
Class It 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(t) or (g), see Section X.1 of this application
* 15A NCAC 02`r.0305(g) contains alternatives where separations in 02T.0305 t 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 webpaae
2. Does this project comply with the minimum separation requirements for water mains? X Yes ❑ No ❑ NIA
If no, please refer to 15A NCAC 18C,0906(t) 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 ❑ NIA
> Please provide supplementary information identifying the areas of non-conformance,
> Seethe Division's draft separation requirements for situations where separation cannot be met.
r 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? 0 Yes Basin name: Neuse Rly ❑ No
If yes, does the project comply with setbacks found in the river basin rules per I5A NCAC 02 B .0200? W Yes ❑ No
This includes Trout Buffered Streams per I5A NCAC 2B.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.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, stormwater management plans, etc.).
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 interferencelconflict boxes require a variance approval.
If yes, include an attachment with details for each line, including type (aerial hric, 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 021 .0305 & IIDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted.
Size (inches) Length (feet) Material
8-inch 2,478 PVC
➢ 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
Vlll. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & NIDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
Pump station number or name- NIA
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 ofthe 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)f 1 1:
❑ Standby power source or ❑ Standby pump
Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(I )(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 punip 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

1'L GENERAL REQUIREMENTS
1. lfthe Applicant is a Privately -Owned Public utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® NiA
2. ll'the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement FORM: DFV been attached?
❑ Yes ❑ No ®NiA
3. If the Applicant is a Home.Troperty Owners' Association, has an HOrVPQA Operational Agreement (FORM: I IOA) and
supplementary documentation as required by 15A NCAC 02T.01 15(c) been attached?
[:]Yes [—]No ® NIA
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 1 preschool r day care ❑ Medical r dental I veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming PoollFilter Backwash
❑ Businesses f offices ;factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater : t°a °}a Domestic % Commercial % Industrial (See 15A NCAC 02T .01U3(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes[:] No
6. Has a flow reduction been approved under 15A NCAC'..0?T_ 01.11 tl? ® 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.01 14(f))
Daily Design Flow"
No. of Units
Flow
Single Family Home
250 gal;` day
90
22,500 GPD
gal?
GPD
gal`
GPD
gal/
GPD
gall
GPD
gall
GPD
Total
22,500 GPD
a See I5A NCAC 02T .0I 14(b), (d), (e)(1) and te)(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 .0I 14(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
Wastewater generated by project: 22,500 GPD (per 15A NCAC: 02T .01 14)
;e Do not include hihue 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