WQ0044858_Application (FTSE)_20231025

DWR
Division of Water Resources
State of North Carolina
e(v�� Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: (00,00 (I c� (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Asheboro (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: John N. Ogburn, III per 15A NCAC 02T .0106(b)
Title: Ci . Manager
4. Applicant's mailing address: 146 N. Church Street
City: Asheboro State: NC Zip: 27204-
❑ Privately -Owned Public Utility
❑ Other
5. Applicant's contact information:
Phone number: 336) 626-1201 x2313 Email Address: L bg urn(g),ci.asheboro.nc.us
II. PROJECT INFORMATION: ,
1. Project name: Cone Health MedCenter Asheboro
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: Randolph
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.750260' Longitude:-79.8280'
5. Parcel ID (if applicable): PIN 7752481417 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Michael L. Slusher License Number: 20590
Firm: Davis -Martin -Powell & Associates
Mailing address: 6415 Old Plank Road
City: High Point State: NC Zip: 27265-
Phone number: 336) 886-4821 Email Address: mslusher n,dw-inc.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: City of Asheboro WWTP Permit Number: NCO026123
Owner Name: Jonh N. Ogburn, III
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00025
Owner Name(s): John N. O,gburn, III
FORM: FTA 06-21 Pagel 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: % Domestic 100 % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ 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 a>b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
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.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 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
8" 157 DIP
➢ 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
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Puma Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: RCC Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.750260' Longitude:-79.8280'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.259 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): 180 gallons per minute (GPM) at 119 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6"
2,752
DIP
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. Lb. ❑ 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)(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 separations/alternatives found in 15A NCAC 02T .0305() & N-V ® Yes ❑ No
15A NCAC 02T.0305(fl 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
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I 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-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( or (g), 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 webpaae
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 .0200? ❑ 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)(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.).
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. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum 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 request will be issued
concurrently with the approval of the permit and projects requiring a variance approval may be subject to longer
review times For proiects requiring two or more variances or where the variance is determined by the Division to be a
shmificant portion of the proiect, the full technical review is required.
2. Professional Engineer's Certification:
I, Michael L. Slusher ,attest that this application for Cone Health MedCenter Asheboro
(Professional Engineer's name from Application Item I1I.1.) (Project Name fiom Application Item II.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 Desi2n 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, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, John N. Ogbum, III , attest that this application for Cone Health MedCenter Asheboro
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item 1I.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 143-215.6B, any person who knowingly makes any false
statement, entation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine notNto exceed-$10,000 as we ct it penalties up to $25,000 per violation.
Signature:
FORM: FTA 06-2
Date:
Page 5 of 5

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COPY Fa� RED,Fp6,rC oNe_tir
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: City of Asheboro
Project Name for which flow is being requested: Cone Health Med Center Asheboro
More than one FTSE may be required for a single project if the owner of the J",7P 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: City of Asheboro WWTP
b. WWTP Facility Permit #: NC0026123
All flows are in MGD
c. WWTP facility's permitted flow 9.0
d. Estimated obligated flow not yet tributary to the WWTP 0.743
e. WWTP facility's actual avg. flow 3.741
f. Total flow for this specific request 0.004
g. Total actual and obligated flows to the facility 4.488
h. Percent of permitted flow used 50%
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:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design
Average Approx, Obligated, Total
Pump Pump Daily Current Not Yet Current Flow
Station Station Finn Flow** Avg. Daily Tributary Plus
(Name or Permit Capacity, * (Finn / p fl, Flow, Daily Flow, Obligated Available
Number) No. MGD MGD MGD MGD Flow Capacity***
29 WQCS00025 0.259 0.104 0 0.000 0.004 0.100
* 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 Pen -nit Number: N/A
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I John N Ogbum, III 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 nonnal 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 lias.adequate capacity to transport and treat the proposed new wastewater.
Page ? of 6
FTSlc 10-18

�11+�II':follI
.. ceVe
MY 2 5 3023
Winston-Selem
Regional Office
NCDEQ-Division of Water Resources
Winston-Salem Regional Office
450 W. Hanes Mill Road
Winston-Salem, NC 27105
DAMS • MARTIN • POWELL ENGINEERS & SURVEYORSdrn p
October 24, 2023
Re: City of Asheboro
Cone Health MeclCenter
Asheboro
DIVIP Project 220106
On behalf of the City, we are submitting this application package for sewer system improvements for the
above referenced project. The project consists of a 180 gpm pump station, 2,752 LF of 6" forcemain, and
157 LF of 8" gravity sewer. This pump station will serve a proposed Cone Health Facility, which is being
permitted separately.
Enclosed are the following items for the referenced project for your review and approval:
• One original and one copy of the executed Fast Track sewer system extension application
• Copy of the Cone Health FTSE as submitted by Stimmel
• Check in the amount of $600 for the review fee
We trust this information is complete and will allow you to proceed with your review of these sewer
system improvements. If you have any questions, please do not hesitate to contact our office.
Sincerely,
DAVIS • MARTIN • POWELL & ASSOCIATES, INC.
MicrelL.:ii;u2sher, �PE___­_
MS/dd
cc: John Ogburn, III City Manager
Kelway Howard
File (enc)
P: �2022 �2201 00 Doc � WDEQ-Application Package5ubmittol. docx
T: 336-886-4821 • F: 336-886-4458 • License: F-0245
6415 Old Plank Road, High Point, NC 27265 • www.dmp-inc.com