WQ0044660_Application (FTSE)_20230810

State of North Carolina
Department of Environmental Quality
D, Division of Water Resources
k stR. R
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Divlslon 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 15A NCAC 02T and the Division's
Minimum Design Criteria (Qmvity Sewer & Pump 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 engineerine 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 permit 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):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance frorn the requirements of 15A NCAC 02T;
:- Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ 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 infonnation. 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 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 permit numberistatus of any other required sewer permits (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 than 90 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 may be made.
® If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary. of State.
❑ If the Applicant Type in Item 1.2 is a partnership or ftia, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Itern II.1 shall be consistent with the project narne 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
licensed Professional EagLeer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(N. 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 .0106(b).
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Pagel of3

E. Flow Tracking/Acceptance Form (Form: FTSF. 04-16) (if Applicable):
® Submit the completed and executed FTSE Porn? from the owners of the downstream 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 F`I'SE 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 FTSF indicates that owner has adequate capacity and will not violate G.S. 143-215.67(al_
➢ Intergovernmental agreements or, other contracts will not be accepted in lieu of a project -specific FTSF.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x I 1-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 .0305fh)(1), submit documentation of power reliability far pumping stations.
➢ 'f his 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."
➢ 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)f I) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
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 Pubic 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_01.15.(c), submit the properly executed }�erational Agreement {FORM: HQA)
El Per 15A NCAC 02T .01 15(c), submit a copy of the Articles of Incorporation, Declarations and lay -laws.
❑ Developers of lots to be sold
❑ Per .15A NCAC 02T .0115(b), submit the properly executed Operational Agreement CORM: DEV).
Cor more information, visit the Division's collection systems websile
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 T 943 Washington Square Mall Beaufort, Berne, Camden, Chowan, Craven,
Water Quality Section Washington, North Carolina 27889 Curriluck, Dare, Gates, Greene, Hertford, Hyde,
[phone] Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Re ional 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 Quali, Section Suite 300 Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105 Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
L - I
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 3 of

Sewer Project Narrative
For
Mission Field — Phase One
Mission Field -- Phase One in Rocky Mount is a Park that consists of a playground and
baseball field and will be located on a 33.17 Ac. parcel. The wastewater generated by this
project is being permitted under another permit but was calculated using the daily flow of
250 gal/plumbing fixtures. The flow allocated for 2 bathrooms with 3 fixtures each which
totals a daily flow for the project of 1,500 GPD. It will consist of 100% Domestic flow.
The sewer system for this permit consists of approximately 257 LF of Private 8-inch
PVC gravity sewer line including 2 new mardioles. The wastewater treatment plant
facility that will be handling this flow is the Rocky Mount WWTF (Permit ## NC
0030317). The permitted flow for the WWTF is 21.0 MGD and after the allocation of the
Mission Field — Phase One flow the WWTF will be allocated at 55.45% of its total
capacity.

State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
9DIvIslon of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: VQov-'/VI'4ko (tu be+:ompletedby DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1 Applicant's name: Englewood Baptist Church, Inc.(company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Dr. Chris Aiken per 15A NCAC 02T .01061bf
Title: Pastor_
4. Applicant's mailing address: _135.0 Winstead Avenue NC Dept Of nvjronmer)t
City: Rocky Mount State: NC Lip: 27803- dl Q11al,ty
5. Applicant's contact information: AUG
10 Phone number: �) 937-8254 Email Address: 2�23
11. PROJECT INFORMATION: Raleigh Reg10rlal O.,C,
I. Project name: Mission Field - Phase One
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If 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.
f new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Nash
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.94598" Longitude:-77.84826-`
5. Parcel ID (if applicable): 3840 1701 7286 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: J. Michael Stocks License Number: 19843
Firm: Stocks Engineering
Mailing address: 801 E Washington St.
City: Nashville State: NC Zip: 27856-
Phone number: 252) 459-8196 Email Address: mstocks c stocksengineerin�.cam
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Rocky Mount WWTP Permit Number: NCO030317
Owner Name: Town of Rocky Mount
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ _.._ .
2. Downstream (Receiving) Sewer Information: . inch ❑ Gravity ❑ Force Main
3. System Wide Collection System Pert -nit Number(s) (if applicable): WQCS
Owner Name(s):
FORM: FTA 06-21 Page 1 of 5

V.I. GENERAL_ REQUIREMENTS
1. If the Applicant :s a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached`?
❑ Yes ❑ No ®N A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement( FORM: DEV] been attached?
❑ Yes ❑ No ® NIA
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HDA] and
supplementary documentation as required by 15A NCAC 02T.01 15(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparationlservice ❑ Hotel and/or Motels
❑ School/ preschool / day care ❑ Medical I dental I veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ® Church ❑ Swimming Pool/Filter Backwash
❑ Businesses 1 offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial _ % Industrial (See 15A NCAC 02T .0103(201
If Industrial, is there a Pretreatment Program in effect? El Yes ❑ No
6. I [as a flow reduction been approved under 15A CAC 2T ? ❑ Yes ® No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow 1,b
No. of Units
Flow
GPD
gall
GPD
gall
GPD
gall
GPD
gall
GPD
gall
GPD
Total
;. eKGPD
See 15A NCAC 02T .0114(bL (d). (01.1) and (02] for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .01 14(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114i shall be S
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data. JP r
Ir 8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T.0 114i p I'
y Do not include future flows or previously permitted allocations a+
If permitted flow is zero, please indicate why:
0
❑ Pump Station,'Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line. X
Please provide supplementary information indicating the approximate tinieframe for permitting upstream sewers with flow.
® Flow has already been allocated in Permit Number: New Protect Currently Being Permitted Issuance Date: xG
❑ Rehabilitation or replacement of existing sewer's with no new flow expected
❑ Other (Explain): , U�
N�o
vti �
FORM: FTA 06-21 Page 2 of 5 C1

GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
Lyn"
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet)
Material
8"(Private)
257'
SDR 35 PVC
➢ Section 11 & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
s Section Ill contains information related to minirnum slopes for gravity sewer(s)
r Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC {Pump Stations/Force Mains):
PROVIDE A SL"PARATE COPY OF 1-1-I1S PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Total number of pumps at the pump station:
3. Design flow of the pump station: _..._. millions gallons per day (firm capacity)
This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per purnp(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) I Length (feet) I 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 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15,A N(AC 02T .0305(h)(I ):
❑ 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 purnp connection and telemetry:
D 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 pwnp is dedicated to multiple purnp 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 & l5A NCAC 02T .0305(o):
I . Does the project comply with all separations{alternatives found in I5A NCAC 02T .0305(f) &, ? ® Yes ❑ No
15A NCAC 021.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Storm sewers and other utilities not listed below (vertical)
'Water mains (vertical - water over sewer preferred, including in benched trenches)
'Water mains (horizontal)
Reclaimed water lines (vertical - reclaimed over sewer)
Separation Required
18 inches
18 inches
10 feet
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 11 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, I-IQW, 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
5 feet
Any building foundation (horizontal)
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
i Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
36 inches
Final earth grade (vertical)
➢ If noncompliance with 02T.0305(L) or (a see Section X.I of this application
* 15A NCAC 02T.0305(pl contains alternatives where separations in 02T.0305(f1 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 webpaLe
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N+"A
➢ If no, please refer to 15A NCAC 18C.0906(0 for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N.-:A
➢ Please provide supplementary information identifying the areas of non-conformance.
See the Division's draft separation requirements for situations where separation cannot be met.
No variance is required if the alternative design criteria specified is utilized in design and construction.
4. is the project located in a river basin subject to any State buffer rules? ® Yes Basin name: 'far -Pamlico ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 0213,0200? ® Yes ❑ No
This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwidelindividual permits ❑ Yes ® No
or 401 Water Quality Certifications?
Please provide the perinit number/permitting status in the cover letter if coverage;'authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6 (additional permitslcertifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105 iq , directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interferencelconflict 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

X: CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Prrmittina of Pump Stations
and F rce Mains (latest version, and the Gravity Sewer Minimum Design Criteria (latest versi) 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 request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to Ionp_er
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
sienifjcant portion of the project, the full technical review is required.
2. Professional Engineer's Certification,-
1, J. Michael Stocks attest that this application for Mission Field - Phase One
(Professional Engineer's name from Application ]tern lit 1.) (Project Name from Application Item I I)
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. 1 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 Permitxin�
9LEymp 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 S25,000 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 NCA �t��e�s2i��tr
.... -_... _.. e�++ ........ ....... � `........ .
++ %A CAR •.
North Carolina Professional Engineer's seal, signature, and date:Q;� G� ..•...�Q�/ �i�
i 4 SEAL
19843
CO
g%
G +
's- Applicant's Certification per 15A NCAC 02T .0106(b):
1, C��►� - Lem_, attest that this application for _ � !•�g �btak QV �
(Signature Authority Name from Application Item 1.3.) (Project Name from Application Itei:t II 1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
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 41 3.215*dA and 143-2i15.6B, 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: 7, W/ _ Date: S ! 9 /71S
FORM: FTA 06- 21 Page .) of '?

1
State of North Carolina
4 Department of Environmental Quality
Division of Water Resources
Division of Water Resources Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Englewood Baptist Church, INC
Project Name for which flow is being requested: Mission Field— Phase One
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wasiewater,Jlow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Rocky Mount WWTP
b. WWTP Facility Permit #: NC 0030317
All flows are in MGD
c. WWTP facility's permitted flow 21.000
d. Estimated obligated flow not yet tributary to the WWTP 0.814
e. WWTP facility's actual avg. flow 10.83
f. Total flow for this specific request 0.0015
g. Total actual and obligated flows to the facility 11.6455
h. Percent of permitted flow used 55.45
I1. 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 WW"ITP:
(A) O (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm / po, Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MGD MGD Flow Capacity***
Old Mill Rd 1.786 0.7142 0.6622 0.052 0.7142 0.0
* The Firm Capacity 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.
*** 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): Tar River Regional WWTP
Downstream Permit Number: NC 0030317
Page 1 of 6
FTSE 04-16

III. Certification Statement:
I 3tL4r---J' J r r-1 -- _ 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 indicates accewanee of this wastewater flow.
Signing Official Signature
Date
Page Z of 6
FTSE 04-16

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PLAT WAS APPROVED BY THE CITY PLANNING -
BOARD ON DAY OF 20
DIRECTOR OF DEVELOPMENT SERVICES
CERTIFICATION BY THE CITY ENGINEERING DEPARTMENT THAT THIS CONSTRUCTION PLAT AND
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REQUIRED IMPROVEMENT DRAWINGS MEET THE APPROPRIATE CITY STANDARDS. ��� \� \ �\ _ \� _ __:!� - \\\ "-U�' • ,� O \\
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SCALE: 1 " = 40'
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REVISIONS
2-1-23 TRC COMMENTS
3-23-23 TRC COMMENTS
5-31-23 DEQ COMMENTS
FILE NO. 2019-028
HORZ. SCALE:
1"=40'
VERT. SCALE:
NONE
OUR MISSION IS TO CREATE A CHRIST-CENTERED COMMUNITY OF CARING THAT MINISTERS TO THE SPIRITUAL, PHYSICAL, EDUCATIONAL, EMOTIONAL, OR REHABILITATIVE NEEDS OF INDIVIDUALS AND FAMILIES
CE-02