HomeMy WebLinkAboutWQ0044808_Revised_Application (FTSE)_20231017tkpjv_�6j "ir rerr_elveJ leIi7/2�25
DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: Vj" 4y 6$ (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Mt Vista Health Park Inc (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: Scott Morris per 15A NCAC 02T .0106(b)
Title: Member
4. Applicant's mailing address: PO Box 1547
City: Denton State: NC Zip: 27239
5. Applicant's contact information:
Phone number: 336) 250-3039 Email Address: scottmorrisl4(a),icloud.com
❑ Privately -Owned Public Utility
❑ Other
II. PROJECT INFORMATION:
1. Project name: Mt. Vista Health Park
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ 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: W000_
3. County where project is located: Davidson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.62400 Longitude:-80.1189°
5. Parcel ID (if applicable): 6668-04-744326 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
I. Professional Engineer: H. Mack Summev Jr. PE License Number: 26447
Firm: Summey Eneineerine Associates, PLLC
Mailing address: PO Box 968
City: Asheboro State: NC Zip: 27204-1106
Phone number: 336) 328-0902 Email Address: mack(o),summevengineerine.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Denton Wastewater Treatment Facility Permit Number: NCO026689
Owner Name: Town of Denton
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): WQ_
2. Downstream (Receiving) Sewer Information: _ inch ❑ Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS_
Owner Name(s):
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 ❑ N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ® No ❑ N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes [-]No ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic 0 % Commercial 0 % Industrial (See 15A NCAC 02T .0I03(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ®No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow
No. of Units
Flow
Single Family Residential
360 gal/day
38
13,680 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
13,680 GPD
a See 15A NCAC 02T .0114(b). (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 10 440 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21 Page 2 of 5
VII. GRAVITY SEWER DESIGN CRITERIA (if Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
6 1014 SDR 35
➢ 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
VIH. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude:
3. Total number of pumps at the pump station:
3. Design flow of the pump station: _ millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): _ gallons per minute (GPM) at _ feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) _
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(13),.
D Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
D 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.
D 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 separations/alternatives found in 15A NCAC 02T.0305(f) & (e)? ® Yes ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (a). see Section X.1 of this application
* 15A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(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 Classifications webpage
2. Does this project comply with the minimum separation requirements for water mains? ®Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name:_ ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .02001 ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(61(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.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T 0402 "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5
x CEftT1A1CATION3
I. Does tho submllsed system comply with JI&J .AC.4T. the bMOX%mg3 tkninn f dterio for the P.pmiaina of Pumm Steams
mffi v hlaiti-bA1a g i vmiun-, and the Si[4y1 �-M111I®.i® (I4iYY0.C(_Aorly 6si;A ySmimlla uppNabk9
® Yes ❑ No
If no, far pro)" requiring a dngie variance, cormpleta and submit the VoritmoeJAkerostivo Deafgn Request applicatkm
(VADC 10-14) and soppplting doetm morto for revtow to the Central Ounce. Approval of ae niolo t will }£jsmod
2. Ptoieosioml FAgi eves Cemacmdon..
1, H. Mack Summay k , atteat tlwt this application for _ _ _ Mt Vista Subdivision _
ti'mfexAn.I txxatnow'v e�me mom App/eAdM hmo 91.1.) iP. n Ni~ IWm Appi"inn tun+ ll.I i
has been reviewed by ree sad is accurate. empkte cad consistent with the Information supplied im use plans,
spedfkatiums, emtWft' latt aleubdloaa, nod 42 otter soppoMme doermemtmdon to dan brat of my know fsdga 1 funtha
attest that to the beat of my hopwlodge the proposed de -sign has bean prepared in acatda ce with the &Wife" reguldkma,
lvktlttl.Wn �Sttkfut. [c>r (i vi-�ct5l�st ��Jxtnt aml the 11�iljftittitfjksiyn. tntcna r�r t}1C t',iat-.flack IggyiSttny
«J..L'tntrp ?aeon .lwcc faces tlstev . ctyrun 1. AMMO other profmniaWs may have developed contain pa tiem of this
submittal package, inclusion of these materials nmder my siRrhuture and seat signifies that 1 have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In agtardmnee with Gametal Statham 143-215.6A ad 143-21SAIK war pane who kbowiogly maltoa my fnLe
ff1M mat, tepresaatatha, or cordficadm is my appbcOm peeling e distill be gufiry of a Clara 2 misdemaapv, wktrh may
Include a fins not so exceed $10.000, as well a cW pamhies up to $25.000 per violation. Wiwi ra tinaYim ofdw appUadom
itPormatiou. imhdmg imilm todselae may dookl a tuna atmplinace with the avow." & yps,��� criyty tpxy subject
the Nmt1 Carding -licensed Proiamlopat Falsest b refetal d the lioepailrg boetd._(i'i�t *� — 1-1_ n
Nort► Carodnn rwtosionni Emgiseees semi. oci ature. mad dons:
4
3. Applicam'o Cetti6catam per ISA NCAC O T .Olofifb):
I. �._,oui9 . attest that this applications for Mt Vian Ffealth Park 1nt`.
Isisowe Anshan Nam: rem npplwRm Inca, 1.J.1 Il40rca Naar Sum A npuea,an is i m.1)
attest that this application Aims berm reviewed by at sad is Sorurmte and complex to the beat of nay knowledge -
I un crstand that if all required pans of this application in not completed and [hot if all required uuppnning documentation
and attachments ate mot lock", tmis sppltcati in ps¢kagm is sub}oa to being mi umad n incomplete. 1 understmc. that any
dncharge of wasttwster from this non -discharge system so surface waters or the land will result in an imm'diale enforcement
action that may include civil penalties, injunctive relief, andlor criminal prosecution. I will make no claim apint the Division
of Wald Resources should a CmAithge of this permit be vbWed. 1 also urukeshnd the if all required parts of this s irpl'tmtian
package me not completed and that if all required supporting information and atachrmema are not included, this application
package will be returned to me as mconpkrte.
NOTE — In scoedinace with Gentvml $taWlm 143-215AA mad 143-215.60 any perm who knowingly makes any Woe
etatema it. representation, or certification In my applkittits package shall be guilty of a Chem 2 mandwasnor, which may
kncl le a fine not a e cead Sio,000 u well as civil pamdtin up to f;2SA00 per violation. /J
FORM: PTA 06.21 Pogo 5 Of s
Date: October 4th, 2023
To:
Summey Engineering Associates, PLLC
Engineering • Land Planning • Consr
epartmerr of
PO Box 968 — Asheboro, NC 272011invironmer_
pnc .
(336) 328-0902 / Fax: (336) 328-0922 / Mack@sumr�eyengineering.com
Orr
TRANSMITTAL
Jenny Graznak
NCDEQ-DWR
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
region.:. .
Mt Vista Health Park
Davidson County, NC
Sanitary Sewer Extension
Sea Job No. E-7778
We are sending you attached the following items:
❑ Shop Drawings ❑ Samples ❑ Copy of Letter
❑ Prints ❑ Specifications ❑ Other
® Plans ❑ Disk
# Co ies
Drawing #
Description
Disposition
1
$480.00 Application Fee
1
Cover Letter
2
Fast Track Sewer Application
2
Flow Tracking Acceptance Form
1
USGS Topo Map
1
Aerial Photo
1
Construction Documents
Remarks
Jenny,
Please see the enclosed the information for your review. Please let us know if you have
any questions, concerns or need any additional information from us.
Thank you,
e n(aBlake
devin�summevengineering.com
336-328-0902
Project Narrative
For
6" Sewer Line Extension
For the
Mt Vista Health Park
The purpose of this sewer line extension is to provide service to 38 proposed single
family residential units. The new development is located on 106 Mt. Vista Health Park
Rd. in Denton NC.
There will be one 6" private sewer main connected to an existing 8" Sanitary Sewer main
owned by the Town of Denton located to the north of the property. There will be a total
of 1,014 LF of 6" private sewer main extension with this project. Denton Wastewater
Treatment Facility has the capacity to serve this new development and many other
services. There is no practical alternative to provide sewer services for this development.
Prepared By: H. Mack Summey Jr., P.E.
Address: P.O. Box 968 Asheboro, NC 27204
Phone: (336)-328-0902
Project: Mt. Vista Health Park
State of North Carolina
DPDepartment of Environmental Quality W RDivision of Water Resources
' Division of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Denton
Project Name for which flow is being requested: Mt. Vista Health Park
More than one FTSE nuty be required for a single project if the owner of the 1ViVTP is not responsible for all pump
stations along the route of Cite proposed wastewaterJlon:
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Denton Wastewater Treatment Facility
b. WWTP Facility Permit It: NC0026689
A//Jlotvs are in MGD
c. WWTP facility's permitted flow 0.8
d. Estimated obligated (low not yet tributary to the WWTP 0.0
e. WWTP facility's actual avg. flow GA05
f. Total flow for this specific request 0.00216
g. Total actual and obligated flows to the facility 0.405
h. Percent of permitted flow used 51
11. 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) (P)--(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, MOD MGD Flow Capacity*
• The Firm Capacity (design flow) or 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): N/A
Downstream Permit Number: N/A
Page 1 of
FTSE 10-18
III. Certification Statement:
I Angel Jenkins 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 11 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 adequate capacity to transport and treat the proposed new wastewater.
Signing Official
Page 2 of 6
FTSE 10-18
(! i
I Rif
�
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|
f
R
u,� m�■■m
ROY COOPER
ELIZABETH S. BISER
Secaetary
RICHARD E. ROGERS jR.
DurcYw
Summey Engineering Associates, PLLC
Attn: H. Mack Summey Jr., PE
P.O. Box 968
Asheboro, NC 27204-1106
NORTH CAROUNA
Enhranm ral Quality
October 5, 2023
NC D. ,(tment of
Environmental Quality
Received
OCT 12 2023
Winston-Salem
Regional Office
SUBJECT: INCORRECT FAST TRACK SEWER SYSTEM EXTENSION APPLICATION PERMIT FEE
Project: Mt. Vista Health Park
Davidson County
Dear Mr. Summey:
The Winston-Salem Regional Office has received your Fast Track Sewer System Extension
Application for the subject project. However, North Carolina's 2023 Appropriations Act Session
Law 2023-134 (effective July 1, 2023) included an increase for fast track sewer extension permit
fees from $480 to $600.
We are returning your check for $480 for the subject project but withholding the application
documents. Please resubmit payment of the new permit fee of $600 for this project as soon as
possible so we may complete processing of your permit application.
Please contact me by phone at 336.776.9695 or by email at jenny.graznak@deq.nc.gov if you
have any questions.
Sincerely,
aecasl, a by:
ON ]C ' d56
Jenmer .tiraznak, Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
�� North Carolina Department of Envaomnemal Q�ulity Division o(Water ftesoures
Wcu[an-Salem Regional Office 1 450 W. Hanes Mill Rd. Sww 300 I W wamn-Salem, Noah Camhna 27105
336 776.9900
Division of Water Resources
Entity Requesting Allocation: Town of Denton
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Project Name for which flow is being requested: Mt. Vista Health Park
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 wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Denton Wastewater Treatment Facili
b. WWTP Facility Permit #: NC0026689
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
0.8
0.0
0.419
0.01368
0.419
52
Il. 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:
Pump
Pump
Station
Station Firm
(Name or
Permit Capacity,
Number)
No. MGD
(A)
(B)
Design
Average
Approx.
Daily
Current
Flow**
Avg. Daily
(Firm / pf),
Flow,
MGD
MGD
(C)
(D)=(B+C) (E)=(A-D)
Obligated,
Total
Not Yet
Current
Tributary
Flow Plus
Daily Flow,
Obligated Available
MGD
Flow Capacity***
* 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): N/A
Downstream Permit Number: N/A
Page 1 of 6
PTQF 1 0-1 R
III. Certification Statement:
I Angel Jenkins certify to the best of my knmvledge that the addition of
the volume of wastewater to be permitted in this project has bcen 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, givens 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 Iisted 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 adequate capacity to transport and treat the proposed new wastewater.
Signing
Title of Signing Official
Date
Page 2 of 6
FTS E 10-18