WQ0044955_Application (FTSE)_20231013

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�� zqState of North Carolina
�0� C�ia.c� r� " / Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: 145*5 (to be completed byDWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
I. Applicant's name: Legacy at Haw River LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ Slate/County ❑ Municipal ❑ Other
3. Signature authority's name: Jason DeBoer per
Title: Member / Manager
4. Applicant's trailing address: PO Box 767
City: Burlington State: NC Zip: 27216-_
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
I. Project name: Legacy at Haw River Apartments
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: Alamance
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.090175' Longitude:-79.382372
5. Parcel ID (if applicable): 149386 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Jesse Wilson License Number: NCO18197
Firm: Wilson En ing eering Group
Mailing address: 1001 Chestnut Drive
City: Smithfield State: NC Zip: 27577-_
Phone number. 3(_36) 736-9267 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: East Burlington Wastewater Treatment Plant Permit Number: NCO023868
Owner Name: City of Burlington
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQUnknown
2. Downstream (Receiving) Sewer Information: 8 inch and 6 inch X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00347
Owner Name(s): Town of Haw River
FORM: FTA 06-21 Page 1 of 5

VI. GENERAL REQUIREMENTS
I. 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 been attached?
❑ Yes [:]No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an 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 % Commercial _ % Industrial ( )
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Has a flow reduction been approved under _ . - - ? ❑ Yes ® No
➢ If ves. 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
Residential - 1 Bedroom
240 gal/day
18
4,320 GPD
Residential - 2 Bedroom
240 gal/day
126
30,240 GPD
Residential - 3 Bedroom
360 gaVday
36
12,960 GPD
Office
25 gal/day
1
25 GPD
Gym (640 sf)
325 gal/day
1
325 GPD
gaV
Total
47,870 GPD
a See . - 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 ).
b Per I5A NCAC 02T .0114(c), design flow rates for establishments not identified (in table I shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 47 870 GPD (per -
➢ 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) - &
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
363
PVC SDR 35
8
30
DIP
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section HI 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) — & _ __ __ _ _ __ _ _
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
Pump station number or name: N/A
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
N/A
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.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) —
6. Power reliability in accordance with __—_ _ _ _ __
❑ 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
- ` - ® Yes ❑ No
15A NCAC 02T.0305(f) 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
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 _ , -__ _ see Section X. I of this application
contains alternatives where separations in - - - -- - 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
2. Does this project comply with the minimum separation requirements for water mains? ® Yes [:]No ❑ N/A
➢ If no, please refer to 15A NCAC I8C.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 - — 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: Cape Fear ❑ No
If yes, does the project comply with setbacks found in the river basin rules per ® Yes ❑ No
➢ This includes Trout Buffered Streams per
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 ) (additional permits/certifications)? ® Yes ❑ No
Per _ , 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 , "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 permtttee 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

I:tlt910113 M 1711YA I [IM&P
1. Does the submitted system comply with , the
and the 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
2. Professional Engineer's Certification:
1, Jesse W. Wilson , attest that this application for Legacy at Haw River Apartments
(Professional Engineers name from Application Item III.1.) (Pmiecl Name fmm Application Item IL 11
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,
, and the
Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that 1 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 snakes 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 noncompliance 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):
1, Jason Definer , attest that this application for Legacy @ Haw River Apartments
(Signature Authority Name fmm Application Item 1.3.) (Rroiect Name from Application Item It 1 )
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 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. 1 will make no claim against the
Division of Water Resources should a condition of this permit be violated. 1 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 he returned to me as incomplete.
NOTE — In accordance with General Statutes and , 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 exs5%:10,000 as well a, bi aloes up to $25.000 per violation.
Signature: e Date:
FORM: FTA 06-21 Page 5 of 5

State of North Carolina
01.`�,I�A�
Dlvlslon of Water Resources
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Town of Haw River
Project Name for which flow is being requested:
Legacy @ Haw River Apartment
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: Allocation to East Burlington WWTP
b. WWTP Facility Permit #: NC0023868
All flows are in MGD
c.
WWTP facility's permitted flow
1.0 (Haw River Allocation)
d.
Estimated obligated flow not yet tributary to the WWTP
0.0072
e.
WWTP facility's actual avg. flow
0.2210
f.
Total flow for this specific request
0.0479
g.
Total actual and obligated flows to the facility
0.2761
It.
Percent of permitted flow used
28%
II. 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
Station Station
Firm Flow**
Avg. Daily
Tributary Flow Plus
(Name or Permit
Capacity, * (Firm / pt),
Flow,
Daily Flow, Obligated
Available
Number) No.
MGD MGD
MGD
MGD Flow
Capacity***
Lang St
0.576 0.2304
0.0721
0.000 0.1200
0.1104
* 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
(pi) not lesstthan 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): Lang Street Pump Station
Downstream Permit Number:
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Sean Tencer 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 adequate capacity to transport and treat the proposed new
wastewater.
Signing Official Signature.
Tow.. )& G "I'
Title of Signing Official
211
Date
Page 2 of 6
FTSE 10-18

State of North Carolina
1"n1�j�(�T n1 Department of Environment and Natural Resources
1� j ��J) / , ��v( Division of Water Resources
Division of Water Resources Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE 10-18)
Enity Requesting Allocation City of Burlington
Project Name for which flow is being requested: Legacy @ Haw River Apartments
More than one FTSE may be requiredfor 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: East Burlington WWTP
b. WWTP Facility Permit #: NC 0023868
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 flaws are in MGD
12.00
1.724225
(0.0479) Haw River Allocation
II. 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 : None
(A)
(B)
(C)
(D)=(B+C)
Obligated,
Total
Design
Approx.
Not Yet
Current Flow
Firm Average Daily
Current Avg.
Tributary
Plus
Pump Station Capacity, * Flow**
Daily Flow,
Daily Flow,
Obligated
Name GPD (Firm/pf), GPD
GPD
GPD
Flow
3.8360
5.560225
46.3%
(E)=(A-D)
Available
Capacity***
* 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 pumpstation 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 Capacity5 0.
Downstream Facility Name (Sewer)
Downstream Permit Number:
Page 1 of 2 FTSE 10-18

Certification Statement:
I, W. Todd Lambert, P.E. 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 asssessment 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 adequate capacity to transport and treat the proposed new
wastewater.
Signing Official Signature Date
City Engineer
Title of Signing Official
Page 2 of 2 FTSE 10-18

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Received
Tuesday, October 9, 2023 OCT 13 2023
Legacy at Haw River Apartment Complex Winston-S=! ,m
Haw River, NC RegiIIn=_f �_ , e
Cover Letter for Fast Track Sewer System Extension Application
The project is located on a 11.13 Acre tract of land located on the south side bf 1S Highway 70
Bypass, on the east side of the Advanced Auto Parts Store in Haw River, NC.
Fast Track Sewer System Awfication 1- Public Sewer Section Relocation: Approximately 290
linear feet (LF) of existing 6" vitrified clay (VC) sewer will be removed, relocated and replaced
with 354 (+/-) LF of 8" PVC Sewer Line. This relocated section of the project sewer system is
deemed "Public," and will be owned and maintained by the Town of Haw River. The existing 6"
VC "Public" sewer line through the Legacy property has recently been flushed and video
inspected. The Town of Haw River has determined the existing 6" PVC "Public" sewer to be
clean, linear, and with sufficient capacity for existing and proposed flows. Fast Track Sewer
System Application 1 is being submitted as a sewer relocation application to certify that the
designed portions of the relocated sewer comply with the minimum sewer design standards of
the NCDEQ's Division of Water Resources.
Application Package 1- "Public" includes:
• Application Fee ($480.00)
• Form FTA 06-21
• 8.5 x 11 Color USGS Map
• Vicinity Map
Fast Track Sewer Svstem Application 2 — Private Sewer Svstem Expansion: The "Private"
Sewer Expansion Project will serve:
• Six (6) Apartment Buildings, each housing 30 apartment units (180 Total units)
0 36 One Bedroom Units
0 126 Two Bedroom Units
0 18 Three Bedroom Units
• One (1) Office / Amenity Area
The "Private" sewer system application package includes a summary of average daily flows
generated from the proposed apartment buildings and amenity center (page 2 of 5), as well as the
design certification for approximately 393 LF of 8" sewer, slated to serve the project.
The Current Permits applied for on this project include:
• Sedimentation and Erosion Control Permit — Complete and Approved
Storm Water Permit— Permanent Stormwater Detention and Water Quality Treatment measures
to remove BOD, COD, TSS and nutrients are not required due to Pre- 2006 Existing Impervious
Area.
1001 Chestnut Drive
Smithfield, North Carolina 17577
Phone [phone]

-jc�-
zv
Application Package 2- "Private" includes:
• Application Fee ($480.00)
• Form FTA 06-21
• Forms FTSE 10-18 from the Town of Haw River (Receiving Collection System) and the
City of Burlington (Receiving Treatment System)
• 8.5 x 11 Color USGS Map
• Vicinity Map

State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water RCSOnrCeS 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 and the Division's
Minimum Design Criteria ( & ) and that plans, specifications and supporting documents
have been prepared in accordance with Division policies, and
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 _ 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
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 from 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 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
E 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):
E 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 number/status 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):
E 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):
E Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
E If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with the
❑ 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.
E The Project Name in Item 11.1 shall be consistent with the project name on the Flow acceptance letters, agreements, etc.
E The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with . 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 Page I of 3

E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
N Submit the completed and executed FTSE form 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 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
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
N Submit an 8.5-inch x 11-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
N 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 _ _ — , submit documentation of power reliability for pumping stations.
➢ 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."
➢ 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)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per _ _ _ .. _ provide the Certificate of Public Convenience and Necessity from the _ _
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 _ _ 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.
I Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
N Home/Property Owners' Associations
N Per , submit the properly executed
N 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 _ submit the properly executed
For snore information, visit the Division's collection systernc
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
3800 Barrels Drive
Chatham, Durham, Edgecombe, Franklin,
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Janes, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Wilmington, North Carolina 28405
Hanover, Onslow, Fender
[phone]
[phone] Fax
450 W. Hanes Mill Road
Alamance, Allegheny, Ashe, Caswell, Davidson,
Suite 300
Davis, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION Page 3 of 3