WQ0044956_Application (FTSE)_20231018

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R $Arm d-7 Cek r6--9 /e /P a 21 State of North Carolina
Depsertment of Environmental Quality
QWDivision of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Dlvlsbn of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: t fL ' f 0 � 7 J L po be completed by owx)
All items roust be completed or the application will be returned
L APPLICANT INFORMATION
First Christian Ch roh of High Point
L Applicant's name: _ tcompany, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: Beth Lille per 15ANCAC 02T.0106(b)
Title: Admin. Assistant
4. Applicant's mailing address: 2066 Deep River Rd
City: High Point State: NC Zip: 27265__
5. Applicant's contact information:
Phone number. 336 454 5292 offtceadmin firstchristianh or9
%) - EmadAddress: _ P
IL PROJECT INFORMATION:
1. Project name: First Christian Church Youth House
❑ Privately -Owned Public Utility
® Other
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: Guitford
36.0148635 -79 973626a
4. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
5. Parcel ID (if applicable): —(or Parcel ID to closest downstream sewer)
QL CONSULTANT INFORMATION:
1. Professional Engineer: Swtt Graham, PE License Number: NC-4 33738
Firm: Graham & Associates, Egineering, PLLC
Mailing address: 163 Wiidhurst Ln
City. Statesvne State: NC
t
7, 04 4588
Phone number. _f -
Zip: 28625
Emad Address: gmhameng, a nng@gmailcom
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMA7
1. Facility Name: Eastside WWTP Permit Number: NCO024210
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ 0008572
2. Downstream (Receiving) Sewer Information: 12 inch Gravity ❑ Force Main
3. System Wine Collection System Permit Number(s) (if applicable): WQCS_
Owner Name(s): City of High Pant
FORM: ETA 10-23 Page 1 of 5

VL 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 15ANCAC 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 Poot/Clubhouse
❑ Food and drink facilities
® Church
❑ Swimming Pool/Fiher Backwash
❑ Businesses / offices / factories
❑ Nursing Home
❑ Other (Explain in Attachment)
5. Nature of wastewater:_%Domestic 100 %Commercial_% Industrial (See 15ANCACO2T.0103(20)1
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Hasa flow reduction been approved under I SANCAC 02T.0114(f)? []Yes ®No
If yes. Provide a cony of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow'p
No. of Units
Flow
Churches no day care or ramps. This is for teenage
Youth gathering twice a week (2 bathrooms)
3 gall Person
20
60 GPD
gal/
GPD
gal/
GPD
gall
GPD
gaU
GPD
gall
GPD
Total
60 GPD
a See 15A NCAC 02T.0114(b). (d). (e)(1) and (e)(2) forcaveats to wastewater design flow rates (i.e. 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-41.
b Perl5ANCAC 02T.01 14(c), design flow rates for establishments not identified [intable.15ANCAC 02T.0114 shallbe
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 60 GPD (per I SA NCAC 02T.0 114 and G.S. 143-215. 1)
➢ 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 timefmme for permitting upstream sewers with flow.
❑ Flow has already been aRoca ted in Permit Number. _ Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 10-23 Page 2 of 5

VIL GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
6 100 PVC
F-F
➢ 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 '
VHI. PUMP STATION DESIGN CRITERIA (if Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGF FOR EACH PUMP STATION INCLUDED INTHiS PROJECT
1. 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 (£ran 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 (fDH)
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.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)(I)(B);
➢ Required for all pump stations with an average daily flow greater than or equal to15,000ga0onsper 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 15ANCACO2T.0305(hxl)(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 iscompatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of allthe 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 10-23 Page 3 of 5

IX. SETBACKS &SEPARATIONS—(02B.0200 & 15ANCAC 02T.0305(f)):
1. Does theproject comply with all separations/akematives found in 15ANCAC 02T.0305(f) & (e)? ❑ Yes ❑ No
15ANCAC 02T.0305(f) contains minimum separations that shall he nmvided for sewer systems•
Setback Parameter*
Separation Required
Storm sewers and otherutilities not listed below (vertical)
18 inches
'Watermains (vertical -wateroversewer preferred, including in benched trenches)
18 inches
zWatermams(horizontal)
10 feet
Reclaimed water Imes. (vertical -reclaimed over sewer)
18 inches
Reclaimed waterlines (horizontal - reclaimed over sewer)
2 feet
"Any private orpublic watersupply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinkingwater, and associated wetlands.
100 feet
*"Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, orSB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
*"Any other stream, lake, impoundment, orground waterlowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any budding foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet ormore vertical height
10 feet
Drainage systems and interceptordrains
5feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f l or (R). see Section X.1 of this application
*) 5A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(l) 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 weboase
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/scaled by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ®N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ Seethe 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 riverbasin subject to any State buffermles? ❑ Yes Basin name: _ ® No
If yes, does the project comply with setbacks found in the riverbasm rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 211.0202
5. Does the project require coverage/authorization under 404 Nationwide/individua I permits ❑ Yes ® No
or401 Water Quality Certifications?
➢ Please provide the permit number/permitting stars in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (addkionalpemiits/certifications)? ® Yes ❑ No
Per 15ANCAC 0270105(c)(6), directly related environmental permits or certification applications must be bemgprepared,
have been applied for, orhavebeen obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation controlplans, stomtwatermanagement plans, etc.).
7. Does this project include any sewercollection Imes that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402."high-priority sewer" means any aerialsewer, sewercontacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines ordeteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details foreach.line, including type (aerial Ime, 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 10-23 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system complywith 15A NCAC 02T. the Minimum Design Criteria fnrthe Permitting of Pump Stations
and Force Mn ins fk,test version), and the Gravity SewerMinimum Decien Criteria an test version) as applicable?
® Yes ❑ No
Von, for projects requiring a single variance, complete and submit the VariancelAhereative Design
(VADC 10-14) and supporting documents for review to the Centel Office. Approval of the ret
2. PmfessionalEngineees Certification:
I,_ Scott Graham, PE attest that this application for First Christian Church Youth House
(Professional Engineer's name from Application Item 111.1.) (I mire Name from Application Item 11.1)
has been reviewed by me and is accurate, complete and consistent with the Information supplied in the plans,
specifications, engineering calculations, and o➢other supporting documentation to the hest of my knowledge. I further
attest that to the best of my knowledge the proposed design hasbeen prepared in accordancewith the applicable mgulalions,
Minimum Dcsian Criteria forGnvity Sewers(latest version), and the Mb»mum Desiw Criteria fnrthe Fast -Track Pcrmifling
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials undermy signature and seal signifies that ) 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 143-215.611, any person %vho knot v gly 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 S 10,000, aswell as civil penalties up toS25,000perviolation. Misrepresentation oftheapplicatien
information, including failure to disclose any design non-compliancowith the applicableRuics and design criteria, maysubjeet
the North Carolina-Iiceased Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
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LP� •:FNGIN:•
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3. Applicant's Certification per I5ANCAC 02T.0106(b):
1A.1�1-t') L: I).ot. attest that thisapplication for Tir5f Ckrl b+" CU.vrk �Z)
(Sivature Authority N from Application Item 1.3.) (Project Namefmm Applieatioaltrmil.l)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge; RRR
I understand that if all required parts of this application are not completed and that if all required supporting documcatathn
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge ofwastewarcrfrom this non -discharge system to surfacewvaters or the land will result in an immediate enforcement
action that may include civil penalties,injunetive relief, andfarcrimmal prosecution. I will make no claim against the Divisiou
of WarerResources should a condition of this permit be violated. I also understandthat ifa➢ 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 tome as incomplete.
NOTE —In accordancewith General Statutes 143-215.6A and 143-215.613any 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 fare not to exceed S10,000 as we➢as civil penalties up to S25,000 perviolation.
Signature: Date:
FORM: FTA 10-23 Page 5 of 5

State of North Carolina RECENED
Department of Environmental Quality
Division ofWitter Resources OCT 1 2023
w.
Flow Tracking for Sevier Extemion Applications WRINpDES
Division of Water Resources (ME10-18) NCDEQID
Fnuty Requesting Allocation: HigltPoiYNC
Project Name for which flow is being requested: Fist Christian Church Youth House
Afore than one ME may be rrgnired for a single project iJthe owner of the 1EWFP is not respauible for all pump stations along the
route ofthepropmed wastewater flow
I. Complete this section only ifyou are the owner ofthe wastewater treaty w plant
a. W WIP Facility rant: Eastside W WFP
b. W WIP Facility Permit M NCO024210
A11 flans are in MGD
c. W WIP faci"htys Pemreted Bow
26
d. Estimated obligated flow not yet tributary to the W VIP
2.6221
e. W WIP facilityrs actual amage flow
14.92
f Total flow for this specdtc request
0
g Total actual and obligated flows to the facility
17.5421
It. Petcertofpen iced flow
67A7%
II. Corrplete this section for each pump station your are responsible for along the route of Otis proposed wastewater flow
Ut pump station located between the project connection point and the W M.
(A) (B) (C) (DhB{C) (Ej=(AD)
>' Design Approx Obligated Total Current
Station StationPUMP Firm A%eregoDaily Current Not Yet F1owPlus Available
NPermit CCapacity,' " Fbw** Avg. Daily Tnbutary Obligated Capacity***
(orm or arreor No. MOD (Firmpf) Flow DailyFlow Flow MGD
MGD MGD MGD MGD
Riverd MOOD8572 30,0887 11,4842 8,3101 1.1212 9.4313 2.0529
* 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 firmcapacity of the pump station divided by a pealing factor (pt)
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 W WfP itihere the Available Capacity is < 0.
DownstearnFackyName(Sewer): Eastside WW1P
DowrsuramPemit Nunber (Sewer): NCO024210
NC Depart:mentof
Environmental Quality
Received
OCT 18 2023
Winston-Salem
Regional Office
Page 1 of 6
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Page 2 of 6
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