WQ0045094_Application (FTSE)_Submittal_5_20240124

Swb r � U S / it-tk tied I/2f/24 Z4
State of North Carolina
R Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEMEXTENSION APPLICATION
Division of Water Resources FTA 10-23& SUPPORTING DOCUMENTATION
Application Number., (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Evolve at Deep River. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ® Other
3. Signature authority's name: Michael P. Winstead. Jr. "per 15A NCAC 02T .0106(b)
Tide: Manager '
4. Applicant's mailing address: 2918-A Martinsville Road
City: GreensbordState: NC ' Zip: 27408-_
5. Applicant's contact information:
Phone number. 3( 36) 485-4658Email Address: mikena evolvecos.com '
II. PROJECT INFORMATION:
1. Project name _Y a
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 adetailed 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 locatedefildmiff
4. Approximate Coordinates (Decimal Degrees): Latitude:36.037688' Longitude:-79.966456`
5. Parcel ID (if applicable): 167961. 170013. 207385(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
Professional Engineer: Charles P. Trubv, Jr.'
Firm: CPT Engineering and Surveying. In%
License Number: 14984
Mailing address: 4400 Tuning Street
City: High Po't State: NC Zip: 27265
Phone number. 3( 30 M-8800 Email Address: ebuckt(a?cptengineering.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside Wastewater Plant Permit Number. NCO024210 '
Owner Name: City of High Point '
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermtNumber(s): WQ_
2. Downstream (Receiving) Sewer Information: 8 inch ' X Gravity ❑Force Main
3. System Wide Collection System PermitNumber(s) (if applicable): WQCS00010 -
Owner Name(s): City of High Point -
FORM: FTA 10-23 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 ®NiA �
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_% Commercial_ % Industrial (See 15A NCAC 071'.0103(20))
If Industrial, is there a Pretreatment Program in effect?❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(tf)? ❑ 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
Multi -Family Apartments (264 Units)
240 gal/1 bedroom
96
23,040 GPD
240 gal/2 bedroom
132
31,680 GPD
360 gal/3 bedroom
36
12,960 GPD
Swimming Pool/Clubhouse
10 gal/person/day
485
4,850 GPD
gal/
GPD
gaL'
GPD
Total
72,530 GPD
a See 15A NCAC 02T .0114(b), (d) (e)(1) and (e)(2) for caveats 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-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: 72530 GPD (per 15A NCAC 02T .01-14 and G.S. 143-215.1)
> Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
[]Pump StationPorce 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 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
8
289
DIP i
8
1,503
SDR-26
Total
1,792
➢ Section H & 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
VM. PUMP STATION DESIGN CRITERIA (If Applicable) — 2T .0305&MDC (Pump Stations/Force Mains):
PROVIDEA SEPARATE COPY OF THIS PAGEFOR 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 pomp 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 beper fitted (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 reliabilityin accordance with 15A NCAC 02T .O305(h)(D:
❑ Standby power source or ❑Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(hxl)(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 facilityand may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per dayl5A 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 applicantand is compatible with thestation.
➢ If the portable power source or pump is dedicated to multiple pomp 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 par 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&15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/alternatives found inl_5A NCAC 02T.0305(f) & fg)? ® 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)
l8inches
2Water 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, W S-I waters of Class 1 or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
""Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB fromnormal
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 (M. see Section XI of this application
"15A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(t) cannot be achieved. Please check "yes"
above if these ahematives are used and provide narrative information to explain.
"Stream classifications can be identified using the Division's NC Surface Water Classifications weboaae
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 ❑NIA
➢ 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: Cane Fear' n 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 2B.0202
i
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.
U.3 RC d - A f-;� , -rD >•"tN - 2—,:3 Z,1W Wi ; 4iiJ^ #2.>23L-73t, - C.,VX. -. c7t r'ln. VJ 4e-oc V i i2
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional petmits/cestifications)? M Vcs❑ No
Per 15A NCAC 02T.0105(c)f6), 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 tine, 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 kCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

X. CERTIFICATIONS:
Does the submitted system comply with I5A NCAC 02T, the hiiuimpm Design Criteria iol uw Pcimiuins of Puny Stations
Force Mains (latest versiont,. and the Gmvity 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
2. Professional Engineer's Certification:
h Charles P Truby, Jr attest chat this application for Evolve at Deep !!fiver
(Profcssim W Fagineer's name from Application hem 111.1 ) (Pro)ect Name from Application item RI )
has been reviewed by me and is accurate, complete and consistent with the informmtian 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 Design Criteria
for Gravity Sewers (latest version), and the Minimum !.Design Criteria for the Fast -Track Permitting of Pun i 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 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application information, including
failure to disclose any design noncompliance with the applicable Rules and design criteria, may subject the North Carolina -licensed
Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: I
��.�01tt1 CA y •7�
I �0. oFES$ja2��7t
o SEAL
9 'Fti�Ep • Q
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, /N)etNte t P. W;nStewd y 'Si. , attest that this application for Evolve at Deep River
(Signatum Authority Name atom Application hem 1.3) (Project Name from Application Item 11,1)
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 pans 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 General Statutes 143-215.and 143-215.6B, any person who knowingly makes any false statement,
representation, or certif ton in a applica' n packs shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $IO,000as civil tt ties up,t�25,00Qtr violation.
Signature:
Date: /l —/5-- 2-3
Page 6 of 5

QWR ': ­
Dlvfsion of Water Resources
State of North Carolina
Depmtnenl of Frwironnental Quality
Division of Water Resources
Flow7lacking for Sewer Extemion Applications
(F'ISE 10-23)
Mdiy Requesting Albcahm HighPofidNC
Project Nane for which flow, Is being mgrsestat Evolve at Deep Riser
hf»r that one FYSE ntay be rrqutredjora shtgle project tjrhe owner ojthe WWI? is nol responsiblefa• all pump sialions along the
rode ojthe pvpased wastewate flow
I. Couplete this section only if you arc the owned oftbe wastewater beaorent plaza.
a. W WIP Facility nano: Faststde W WPP
b. W WIP Facility Penrd P: NC0024210
All mmareinMGD
a W WIP faciWs PemYted flow
26
d. Estimated obligated flownot yet tributary to the W WIP
4.4833
e. VAM facility's achal average flow
14.92�
f Total flow for this specflic request
0.0725,
f4 Total actual and obligated flows to tie facility
19.4758
It Percent ofpevutted lbw used
74.91%
H. Cortplete this section for eachpurp station your ere responsible br abng the rate offt proposed wastewater Bow
List poop station located between tie project connection point and the WWIP.
(A) (B) (C) (DY<B}C) (E)=(A-D)
Pump Purp Design Approx Obligated Total Current
Station Station Firm Average Daily Cment Not Yet Flow Plus Available
(Narnn or Pend Capacity, Flow** Avg. Daily Tributary Obligated Ctpacily **
Number) No. MGD (Finry`pO Flow DaiyFbw, Flow MGD
MGD MGD MGD MGD
Regisuas-Cic WQ0000929 4.2 La O.5629 0.1983 076I2 0.928
Riverdale Wp0008572 300887 11.4842 9,3901 1.5875 92M 1im
* The Finn Capacity of any pump station is defined as the uaxhrou aptun<red DowtMt can be
achieved pith the largest pump taken out of service.
** Design Average Daily Flowis the run' capacity of the pmnp station divided by a peaking factor (pt)
not less than 2.5, pet -Section 2.02(A)(4)(c) of the Mlninann Design Criteria.
*** A Planning Assessment Addenda n sha8 be attached for each pmnp station located between the
project connection point and the W WlR vdere the Available Capacity Fs <0.
DovmstreanFaciiyNann(Sewer): EaslsideWWIT
DDwnskcamPerart Number (Sewer): NC0024210
Page 1 of 8
FTSE 10-23

M. Certification Statement
1, i1r_n kk Boo .e ceatdy to the best ofmy knowledge that the addition of the vvolunr of
wastewater to be perniated in the project has been evaksted along the rode to the receiving wastewater
Imadnent ficitity arch that de flow finmths project is not anticipated to came any capacity related saodary
sewer overflows or overbraden any dov+m treampnp station en mute to the receiving beabreMptard
under nonrel cutanstancM given the nple rolation ofde planned a pmventents identified in the
phnnng assessment what applicable. This am%Is has been perbmed in accordance with local
established polices and procedures using the best available data. Ibis cutAkation applies to those term
listed above in Sections I and II plus all attached phn ning asscssroent addenda ns for which I am de
responsible party. Signahao ofdois form i dicates acceptance ofths wastewater lbw,
mgO�ISigs(me
VzOroey '
Date
kb
Title ofSigoiog Official
AsCA. rP"I.,C �uv,Yer ll,Ye��or
Pago 2 of 0
FTSE 10-23

Yo' =OLFA
P,UA LIO-ZERVICES'
9��--
De'ffick Boone
Public'-Sdtv.iddEI'AEisiiitdiit-Ditect6t
- 0- -.. -, 0-0-j-, I -
J!6##y-,23,,4024
WDENR.
Winston-Salem: Regional Offidd
450 W.; "anes-INIIII Rd,
solo,
Winst6if-gatern,NC. 2716�
D6ar Sir, or Madam:
p.
to
Project Ev6fve at, Deep River
Applicant:: MJCIFT High Pofrit, LLC; MOW High
Point; LLC
Greensbdrbi NC`
Thib-iseto acknoWledge, that the Cify.,'of High,Point.will accept'for treatment - in the.
,Eastslde.Wastewater Treatfie t':Pfiant (it.4rm1f#NC6024210y,.wAstert'erflb w from.the
above referenced projed in the affivuht of 72,5WGPDj,Whi6hwill be discharged tofacilities operated idrid maintained -b the CIty6f High Point,
.If further information. is needed, Oldase1et -rile k.hoW.
Sincerely,
Derrick Q. Boone
.Assistant. Public --Services Director
DOB/tab
211 M 0 1 �.Soutfi Ha-0111. nAt H ghTolnt, No 27290, 330.991.21111 HIghPoIntNC;.g'oV

22oei 2y'
State of North Carolina
Di 1 %� Department of Environmental Quality
w Division of Water Resources
—quommomp'— FAST TRACK SEWER SYSTEMEXTENSION APPLICATION
D( lsion of Water Resources FTA 10-23& SUPPORTING DOCUMENTATION
Application Number. obecomplelcd by DwR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Evolve at Deep River. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ® Other
3. Signature authority's name: Michael P. Winstead. Jr." per 15A NCAC 02T 0106(b)
Title: Manager
4. Applicant's mailing address 2918-A Martinsville Read
City: Greensboro State: NC Zip: 27408-
5. Applicant's contact information:
Phone number. (3- M) 485-4659- Email Address: mikeAevolvecos.cvtti
II. PROJECT INFORMATION:
1. Project name: Evolve at Deep River
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 adetailed 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: Guilford '
4. Approximate Coordinates (Decimal Degrees): Latitude:36.037688° Longitude:-79.966456'
5. Parcel ID (if applicable): 167961, 170013. 207385(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer. Charles P. Trubv, Jr. License Number. 14984
Firm: CPT Engineering and Surveying. Inc.
Mailing address: 4400 Tvninc Street
City: High Point State: NC Zip: 27265
Phone number. 336 812-8800� Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside Wastewater Plant Permit Number. NCO024210
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ_
2. Downstream (Receiving) Sewer Information: $ inch X Gravity ❑Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00010
Owner Name(s): City of High Point
FORM: FTA 10-23 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 ONO O1/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ONO ®N!A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM HOA)and
supplementarydocumentation as required by 15A NCAC 02T.0115(c) been attached?
■ ■ _�
4. Origin of wastewater: (check all that apply):
❑Residential(Individually Owned) ❑Retail (stores, centers, malls) ❑Car Wash
®Residential (Leased) ' ❑Retail with food preparation/servire ❑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)
S. Nature of wastewater: 1001/oDomestic_% Commercial_ % Industrial (See I SA NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect?❑ Yes ❑ No
6. Hasa flow reduction been approved under ILA 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 Flowi6
No. of Units
Flow
Multi -Family Apartments (264 Units)
240 gaUl bedroom
96
23,040 GPD
240 gal/2 bedroom
132
31,680 GPD
360 gal/3 bedroom
36
12,960 GPD
Swimming Pool/Clubhouse
10 gal/person/day
485
4,8M GPD
gah
GPD
gal/
GPD
Total
72,530 GPD
a See 15A NCAC 02T .01141b), (d). (e)(1) and (e)(2) for caveats 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. 42A4).
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: 72530 GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑Pump StatiomTorce 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 10-23 Page 2 of 5

VII, .6 f)
vv
I., Sumrnan'zegravity.sewer-igbtpermitted�c
�SiziqnclfqIeugthlffeeq Malerlat
20 "Pip,
1',303 ';SDi46
as
Sectfon-Si&MofiheM-D'C-for-Permiftinglof'Gt . avityr-Sewers contains information relatO,q!*riw
➢ Section.-Iff'contains inf6rmation rclaied-to mrii'-Xn'iiorn-slopi!g for g-r-a­ - ­­ ` -.
m
1:.. Pump staiion-nurriber or?mame:
.Z., :Ap fmale.0 proxi D afl5egre -'Lgotg4, 1446W����
-..S.-.-:Totknuxiibqqrpippsaitfie,p
k
v-
tiftem 'the 6jjt;6f§7ef'.'je
Ope ational poirtm p pwngft —zm-16-n-s piirlbi bld (GPW�K,. ftibttotaLdyMniOfead (TDH)
5.
-foyqre�k4bjfjtym Lcq9roap v;f&-f3X-N—CV�-02—T-. _a pe
12 ;Standby ppwer sourct-,q ❑Standby-PAMDs
15;Oo0••gallons;pe> day`
Cl PortableVowgrsoTree,witit iganuAkdvation, yutck-counectlon kceptikld I and telefnetCy -
or
❑ �o i6 pwppkng uAft.V p.dS fn
.., T4 *W49 " _er&ncFy.piitnj�,
>1
FORNIC-TTA10-23: - P49 3 of 5.

I1C. Sl✓TBr�CKS Bc SEPARATTOIVS.=(028 020Ud'cISA NCA(4 02T 0305(tj�:
d Does.'fhe project.comp_lywfth allsepatapons/illfemahves found 1n19A NCAC 02T, 0303(_6W (OZ, Yes, ❑.No;
15ANCAC 02T:0305ff1 confainsYriin mtim senatatifinF that 'Aaft: heiirmFM,4 fnr cea i;.r tr" ce
11.
93
4.
!SetliackPsrameter*
separahoriReljuifed'
Storm sewemand4other utihhes not listed below.(vertical) •
i.Aches;
a ,
Water matns;(verttcal-water over sewer preferred; including ip benched freaches):_-_
I8 inches
-=Water-ptains.(horizontal); -
" ` ` 10 feet -
Rectaitnedwater-lines (yertical - reclaimed.oversewer)',
1$ inches
lieclaimed.water lines (horizontal:- reclaimed over'sewer)
2
'!Any. private or public water supplysowce, including anywells WS-jWaters of Classj.or
Class II impounded reserv6iis used as a source:of dunking' water and associated wetlands..
100 feet
«'Waters classified WS:(eXcept WS IWeW, ,,5-V),'B, SA, ORW,'HQW, or.S13 ffom normal
,high'water'(or tideelevation) and wetlands associated with thesemaiers (see item,IX.2)
50 feet
-`'Any other, stream,cakei impoundment; or groundwater loweAiii and.surface:dra nag.e
ditches, as wellas.wetlands.'associated with these waters.or.classified as WL.
16zfeet
Anybuilding foundation (Horizontal)
5 feet '
Any basement:(hor zonlal)
10 Tat
- -
Top: algpe of.embankmeiil or cuts 6f2 feet,or-utore pertical,height _
I O;feet
Drainage _sgstems and ihterceptor.drains
5-feet'
Any swimmingpools .
10 "feet
Final earth grade,(vertical) - . _ ,
36 inches,'
"Stream; classifications can'aie identified'usina the Divisions NC Surface Water Glassificat ons'.We6na¢e
❑No ❑ N(A
ate document;;:
Doesthepmjectcomplyvriih.separationiequiremen7tsforweilands7 ®Yes ❑,No ❑,13/A-
t 3 'Please iovfdc.sulipleulentary info nnatfowidentifying the�areasof non-conformance.
See,the:Division's`&i A sepamiion requirements for situations where sepataGon cannot be met?
,A Novarianceis.requiiedif#healtemativedesigncriteriaspecifiedisulili-zed -in'design-andconstructiou:
,5. 'Does the projeci requh-e;coyerage(aufhorization undera,404 NationwidelindiVidual'permits _0 Yes ❑'1461
'or 401, Water Qpality Certifications?
➢,'., Please:provide the pemiit:nuntber/oermitting,statm inithe coverletter if covemgelauilmidiation is required.'
6_DoesprojeetcomplywifhYSANCACO2T'0105(c)(61(addiGonalpermits(certifications)? ®.Yes❑_No
1'er 15A NCAC 02TA105(e)(6), directly related-'enyiironmentai',perrnifs orcertificatfon applications must be being prepared;
have been applied for,,or have been obtained,'lssuance ofihis permit is.contingenton issuance of dependenf.permits (erosion.
and°sedinierifation 6o irol"plahs, stormwatei management plans; eic.).
7- DoesthisprojectinclMd ahyscwer collection lines that are deemed"high-priority7-'t [I Yes ®,No
Per .SA NCACO2T0402,,"hrgh.priorityse-wer."' means any,aerialsewersewer contacting'surfacewaters,
siphon;.or sewers positioned, parallel"to streambanks that are subiect to; erosicn thaf.undemilnes.or: deteriorates the'sewert
Siphons apd?sewers_suspended.througkiiitecferencelcoulUct boxes require a variance;approval.
➢' If yes,inclndean:attach-meat;with• details foneachaine,;including-typeOerialline;size material, and location).
:,at least once'everysix-montfis and
Individual System -Wide. Collection permit.
FORM: FTA 10-23 liage4 of S

1- Does The sa(rti»tted sysle
M yes ONb:
2; �Pco(essional:Engineer's:Certfcaton;
I; darles P Tnitiv. it - A"!g hatthls apphcafltin;far __ "_ Evolve aiDeep 13ivar:. .
(Pturesvionol$oglneers.m=fm6APptlr"a6onTt6n:OLl:), (Pn%icCt >imefmmilpp6eeuonTtem ltwz
NOTE Inaccordance with Genial S&tutes .143415`6A-and-143=215.69, anyperson.wN6 knowingly'mikes-any.falssee statement,,
represeatatton or certficahon in any application package shall be-guiliyof a:'d ass.2 misdemeanor; whicTi may rncludea fine not;to
ezceKSIG000• as ;well as c AL.-venaltie's.ua;to 525.000d'oer violation: Mistenresentition cif the annlicannn inrnnnntinn inrh, fine
NatNh Caiollaa Pro[e�_ tonal Engliteer's sealei'gaaftt►+e,anti dale �; •ra'•�.���CgRp
FEssio ��'L
_ b
q ,.A SEAL
3: Applicant's Certification pet 15A'NCAC 02T .0106(ti)
f `
/11�ir►ac + �..W,tisfcti:C��'�1 --,.attest.diatthis applicatio_nfor GvolveatDeeoRverr
iStiyrmNte:Aut6orityNnrnefmm Applieanon hem!L7.� (Pio1al Haim km AgrlicaUon_It=11,1).
attest_ffiat this,'appRcadon has. been reviewed by�We and ps accurate!aad, complete to the;+Wt C piy',I&—
I understendit}iai ifall requited parts of [his application, am not c6mpleted and, tfial ifall required Stipp"bran&"documental
attachments are'not included; this applii atioa package is.sub(ect to being returned$s incomplete I,undetstand thatany disc)
mastewate'r'fmm ihis:non-dis;6harge•system to surface -waters or the land will resµlt jn as tmmedtat6,, enfbrcetaent action ti
include civil penalties, injunc6vexeltef; and/or cnininal pr-m-cuttan' I will ma&e.po claim 8geinst fie DivWwFkof WaLOW
a .condittomot this, permit'be violated: T also; understand' if all requued-parts of,this AV cation package are ripi
ordance -General Statutes 143-215.6A and .143-215 6B'-,any person- ivW.kn-0waugly-titakes any false statement,
or certif ton inn 'appikati npacka shall be gu ltyof,a Class'2 misdeineanot, wttich.may'jttclade;a firionotTu
as clvd tip has up' - 25 vtoletion7
••�1 - Page 6 of 5.
If
u;

DWR
Division of Water Resources
//ZZ/Za2e.�
( State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEMEXTENSION APPLICATION
FTA 10.23& SUPPORTING DOCUMENTATION
Application Number: 1164rd'77 � (to be completed by DwR) ..
All items must be completed or the implication wW be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Evolve at Deep River, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State(County ❑ Municipal ® Other
3. Signature authority's name: Michael P. Winstead, Jr. per 15A NCAC 02T .0106(b)
Title: Manager
4. Applicant's mailing"'
City: Greensboro Sta
S. Applicant's contact it
Phone number: 3(_ 6J
IT. PROJECT INFORMATI
1. Project name: Evolve s
2. Applicatiotv'Project sta
If a modification, provi
For modiIIeatlons; _ _—...nu in tte0 G of the checklist.
If new construction, but vw r or a master plan, provide the existing permit number. W Q00_
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude:36.03768V-Longitude:-79.966456 J
5. Parcel ID (if applicable): 167961, 170013, 207385(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Charles P. Truby, Jr. = License Number; 14984
Firm: CPT Engineering and Surveying,. Inc
Mailing address: 4400 Tvrting Street
City: High Point State: NC Zip: 27265
Phone number: (33 J 812-8800'� Email Address: chuckt(M-atengineering com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside Wastewater Plant Permit Number: NCO024210 r
Owner Name: City of High Point'
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ_
2. Downstream (Receiving) Sewer Information: 8 inch - X Gravity ❑Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00010
Owner Name(s): City of High Point
FORM: FTA 10-23 Page 1 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/AZ
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.01 I5(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 (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(flv []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''b
No. of Units
Flow
Multi -Family Apartment.-, (264 Units)
240 gaVl bedroom
96
23,040 GPD
240 gal/2 bedroom
132
31,680 GPD
360 gal/3 bedroom
36
12,960 GPD
gall
GPD
gav
GPD
Bay
GPD
Total
67,680 GPD
a See 15A NCAC 02T .0114(b). (d), (eH 1) and (e)(2) for caveats 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. 42A4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table I SA 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: 67 680 GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
A 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):
t�
FORM: FTA 10-23 Page 2 of 5

Vii_: GRAVIWSEWER-DESIr4lfCRITERIA(If;AppLcabley:=02T,0305&MDG(GiavitgSesversl:
Q :Suilmanta;giavltgse�ieztoitepeimitfeil:,
u
Size (m*t9j! Lengtti!(fgetj Material
8 280 DIP'
5503 3DR 26.=
:Total 1;792.
Sewefi _c6hidios'itiformationxelated fo: design criteria
l Puing stahonpumber oi'-ziatjte;?_
2.� - . afe_ o- c.
,t'pprox�.mC4ordiiiates"(Aecimal;Regrees)i7atitudedu .--..- - y ongdba
-
3. Design:flow-ofthbpuinpstation:_millionsgallonsperday(fum,capacitr7
Tliisshould reilec(the-total GPM for the.pump s'tafionwitli�ihe largestpump: out ofsery ce:
4. Operational point(s) per;pump(s);. _ gallons per minute CGPW at _ feet to tat dyna_nuc head {TDH)_
5. Summarizethe'force main to be;permitted (for 'ihis`Pump Staiiou):
5.(i¢�hee) ? ?I engtli.(fcet) lVIaterlal:
1 -
i�
i
Ifwiy sitidhofthe`f6fceinain'is]esisthin 4-fnchesindiameterpleaselderitifxthe:methodo$solids.reduction per-
:kIACPSFtY &6tion2O1C;Ib,EI'CmnderPump Ef MeclianicalBarScreea Other(pfeasespecify)-
6:;P,aWeireliafiilitynaccordancewidi.lSA'NCAC�2TF',03aS(81?Il'
Standby power. source or QStandby pump.
�3*, ;lvlust liave'automatic act�vat�pn.and;telemetry;-;1"SA:I�TCAC 02T;0�05(li)(I)(8)', -
Requifed'foiaU pum¢stahons with an average daily flow greater flianorequalto.15,000;gallonsper day
Q' :Mus-(be - — 6en4to fee7ityknd:may.no46e portable
Orfthep.:imp'station
has_atraverageilaily tTow:7ess tTian';15,060 gallons;perday,]SANGACb2T:0305(h)(1)(G�;:
�.. ;Portable powerso.urce wiih manual aetivation;.quick-connection recepiacle:and-ttelemetry
of
Q '; .' rfable pumping;univwith plugged:emergencypump connection and ielemeiry:
,Include documenfafion that the poriable source i'& ownedor conimcied�by t$e appheantand'!VoompaUbie vv th it
A if the: poitable:power-source or pump -is dedicaied'io multiplwpump stations; an evaluation ofall thepuml
�s(orage.capacities and the.rotation.scheduleofflie,portable.power source nr-pump, including travel tuneftdnie:
provided aspart of ttiis.pecmif application inihe case ofa muliiple:stationpower outage:
FORM:1 A W-23, P.age3 of5

IX. SETBACKS & SEPARATIONS — (02B .0200&15A NCAC 02T.0305(f));
1. Does the project comply with all separations/alternatives found inl5A NCAC 02T .0305(t) & (g)?
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
® Yes ❑ No
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18inches
Wf•ater mains (vertical -water over sewer preferred, including inbenched trenches)
18 inches
�N' ater mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water litres (horizontal - reclaimed over sewer)
2 feet
""Any private or public water supply source, including any wells, WS-1 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 DC2)
50 feet
"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlandsassociated 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. I t
"Stream classifications can be identified using the Division's NC Surface Water Classifications webpgeg t
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A c
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signedlsealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® Yes ❑ No ❑ NIA
➢ 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.
c
4. Is the project located in a river basin subject to any State buffer rules? ® Yes Basin name: Cane Fear n Nod
If yes, does the project comply with setbacks found in the river basin rules per f SA NCAC 02B :0200? ® Yeso No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
w
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits No
or 401 Water Quality Certifications?
➢�r� Please !p)rovide the permit number/permitting status in the cover letter if coveragefauthorization is required.
/' ` V,ev: �9 sr. G., eY 5w.�:ti;ffi,/:
F us.9G'v� .�c�• 1iJ s�+!- z� - a"c"f J
6. Does project comply with I SA NCAC 02T.0105(c)(6) (additional' permitslcertificatioa)? ® Yes❑ No DW X4i`-
Per 15A NCAC 02T 0105(c)(6), directly related environmental permits or certification applications must be Ding prepared, 2e zJo 7T-W
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.).
F
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0.4 , "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/confiict 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 shag 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. CERTiPICATIONS:
1. Does the submitted system comply with i5A NCAC 02T, the iMe mimum Design Liiteria I'or the kr�rnajLn of jump S_ tatitLy 4-nj
Force Mains (latest version)., and the Gravity Sever Minimum Design Criteria (latest version as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the VariancelAlternative Design Request application (VADC 10-
14) and supporting documents for review to the Central Office. Agoroval of the request will be issued concurrently with the
2. Professional Engineer's Certification:
I Charles P Truby. Jr . attest that this application for Evolve at Deep River
(Pmtesgional F,ngineer's noire From Application Item in. I.) (Project Name from Application Item ILI)
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 Design Criteria
for Gravity Sewer's (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 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation. 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. (2) NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
L A' 44,ka i P. W'ns`tew0 t I'fattest that this application for Evolve at Deep River
(Siparme Authority Name from Apptici timt hem 13.) (Project Name firm Application Item i1.1)
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 General Statutes 143-215.6A and 143-215.68, any person who knowingly makes any false statement.
representation, or certif,pfion in apytapplicatjpn pack agq shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as w s civil n ties up 25, r violation.
Signature:
Date: (>t ! 2-3
Page 6 of 5

ate of
rth
DWR K BCC 11/e,.0 i1A.12oR Stnviron mental Quality
Department of Environmental Quali
Division of Water Resources
FAST TRACK SEWER SYSTEMEXTENSION APPLICATION
Division of Water Resources FTA 10-23& SUPPORTING DOCUMENTATION
Application Number:
(to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
I. Applicant's name: MPW High Point
LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual
❑ Corporation ❑ General Partnership
❑ Federal
❑ Sta[dCounty ❑ Municipal
3. Signature authority's name: Michael
P. Winstead. Jr per 15A NCAC 02T .0106(b)
Title: Manager
4. Applicant's mailing address: 2918-A Martinsville Road
City: Greensboro State: NC
Zip: 27408-_
5. Applicant's contact information:
Phone number: 3( 36) 485- 4658 Email Address: mike(a evolvecos.com
IT. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
® Other
1. Project name: Evolve at Deep River
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 adetailed 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: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude:36.037688° Longitude: -79.96 56'
5. Parcel ID (if applicable): 167961. 170013, 207385(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer. Charles P. Truby. Jr. License Number. 14984
Firm: CPT Engineering and Surveying. Inc.
Mailing address: 4400 Tuning Street
City: High Point State: NC Zip: 27265-_
Phone number: (726) §J2-8800 Email Address: chuckUZcptengineering com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside Wastewater Plant Permit Number. NCO024210
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): WQ_
2. Downstream (Receiving) Sewer Information: $ inch X Gravity ❑Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00010&�-
Owner Name(s): City of High Point
FORM: FTA 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 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 (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect?[] Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T 01 14(t)? ❑ Yes ® No
➢ If yes, Provide a copy of flow redaction approval letter with this Implication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow kb
No. of Units
Flow
Multi -Family Apartments (264 Units)
240 gal/1 bedroom
96
23,040 GPD
240 gal/2 bedroom
132
31,680 GPD
360 gal/3 bedroom
36
12,960 GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
67,680 GPD
a See 15A NCAC 02T .01 14(b). (d). (e)(1) and (e)(2) for caveats 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. 42A4).
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: 67 680680 GPD (per 15A NCAC 02T .0114 and G S 143-215.1)
➢ Do not include fume 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 10-23 Page 2 of 5

VH. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305&MDC (Gravity Sewersl:
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
289
DIP
8
1,503
SDR-26
Total
1,792
➢ 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):
PROVIDEA SEPARATE COPY OF THIS PAGEFOR EACH PUMP STATION INCLUDED IN THIS PRO CT
I. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude:
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational points) 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 2.01 C.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) _
6. Power reliabilityin accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or ❑Standby pump
➢ Must have automatic activation and telemetry - ISA 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 facilityand may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per dayl5A 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 applicantand is compatible with thestation.
➢ 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 10-23 Page 3 of 5

DC. SETBACKS & SEPARATIONS — (02B .0200&15A NCAC 02T .0305(t)):
1. Does the project comply with all separations/alternatives found inl5A NCAC 02T .0305(f) & (e)? ® Yes ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be Drovided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18inches
'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 - rechumed over sewer)
2 feet
"Any private or public water supply source, including any wells, WS-1 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 fat
Drainage systems and interceptor drains
5 fat
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or f e). sec Section X.1 of this application
*15A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(fl 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 weboaee
2. Does this project comply with the minimum separation requirements for water mains? ®Yes ❑ No ❑ N/A
D 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 nonconformance.
➢ Seethe Division's draft separation reouirements 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: Cage Fear I -I 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 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ® Yes ❑ No
or 401 Water Quality Certifications?
D Please provide the permit number/permitting status in the cover letter if coveragelauthorization is required.
U.S.A.C,0.E Ae 109 10, SA4-240-01018i➢%19*Z613670- CEFT9F#CAT104110.W46006142
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional pernits/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.04021 "high -priority sewer' means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interferencelconflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the 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 10-23 Page 4 of 5

X. CERTIFICATIONS:
I. Does the submitted system comply with 15A NCAC 02T, the Minimum Desirn Criteria tot Iht: Pcrmittine cd Puc[ q_Stations and
Force Mains (laws't version) and the Gravity Sewcr 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
2. Professional Engineer's Certification:
I, Charles P Truby. Jr attest that this application for Evolve at [Jeep River
(Professional Engineer's name from Application item III. I .) (Pm*t Name Bum Application Item IL I )
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plaits, 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 Design 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 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation. 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 Caivgna Professional Engineer's seal, signature and date: •.•a�HESS
CARO •�O
••
Q 9; Y
SEAL
149i34
S
3. Applicant's Certification per 15A NCAC 02T .0106(b): it
I, Al-riKe l P. ilthws-fe►s0 r 'Sf. , attest that this application for Evolve at Deco River
(Sivwnue Authority Name fiem Apptietlian hem 1.3.) (Project Name fmm Application Item 11.1)
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 requited 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 w General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certif ton in s9Mijapplicatty,Qn packa$$Qq shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as civil v0pities uDJ6/$25,0004tEr violation.
Signature: V ✓fir Date: U-15' 2,3
'(/ Page 6 of 5

DIv1simi of Water ikCSOUrty
State of North Camlbw
Department of Environmental Quality
Division of Water Resinous
How Trucking far Sewer Extension Applications
(FFSE 10-23)
Erlity, Requesting Allocation: Hig),PomtNC
Project Nano for which flows being requested: Ewlte at Deep River
More than one ME ma), be required for a single project if the owner of the W1ITP is not responsible for all pump stations along the
thine of the proposed ivastervater flow
1. Complete this section only iflou are de owwr oflhe wastewater ueaurert plant.
a. WWIP Faciltynane: Easiside VAVIP
b. W WIP Facility Pemit tl: NC0024210
Alf flons are in AIGD
c. W WIP facility's Pemitted flow
26
d. Isti rated obligated flow not let tributary to the W WIP
4.4833
c. WWI? fackys actual average lbw
14.92 /
f Total flow for this speck request
0.0677 /
g Total acnml and obligated lbws to the facuLt' y
19.471
It Percat ofpemtited flow used
74.89r/r
H. Conplete the section for each pump station your are responsible for along the route of this proposed wastewater flow
List punp station located between the project connection poirt and de W WTP
(A) (o) (C)
(D)- (13+C) (E)(A-D)
Pump Pump Design Apprnx Obligated
TotalCurent
Station Station Firm Average Daily Current Not Yet
Flow Pis Available
(Nan>r or pen it Capacity,Fbw" Avg Daily Tributary
Obligated Capacity***
Neriner) No. MGD (Finr'pt) Flow Daily Flow
Flow MGD
MGD MGD MGD
MGD
Registers -Creek WO0000929 12 is 0.5629 0,1983
Riverdale WO0008572 30,0887 11,4842 8.3901 1,5875
D IIII O 9I88
9,9776 1,5066
* 11he Hrru Capacity of any punp station is defined as the maxinumpmnped flow that can he
achieved with the largest punp taken out of service.
** Design Average Daily Flow is the firm capacity of the punp station divided
by a peaking factor (p9
not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall he attached for each punp station located between the
proect connection point and the WWPP vs ere the Available Capacity is <_ 0.
IbwssueamFacrTayNane(Sewer): EastsideM'VVIP
Do%v sueanr Pemit Ntumber (Sewer): NC0024210
Page 1 of 8
FTSE 10-23

III. Certification Statenrtt
I, Penick Boole, ccaify to the best of ny knowledge that Or addition of the whir of
wastewater to be pemitted it Bis project las been etakated along the rouse to de recehilT uastcuater
heahrent facility and that the Bow finny this projects not anticipated to cause any capacity related sanitary
server oxcdlows or oNenburden any downlstreann pump station en route to Or neceiv* fieali erd plant
order n anal circumstances, given the i nplenrntation of the planed inprownents identified in Or
planning assessnent where applicable. This analysis has been perfomrd in accordance with local
established policies and procedures ushug the best available data. This certification applies to those deny
listed above in Sections I and II plus all attached planning assessnent addendu r s for wltich I an) Or
responsible patty. Signtune of Buis form indicates acceptance ofthis vvaslewater flow.
lslh
Tile of Siguirg Official
, sS4, P W" a,V zAoe-
/2 Z?1Z 3
Date
Page 2 of 8
FTSE 10-23

REF: USGS QUAD MAPS PROPOSED SANITARY 5ENR
GUILFORD COUNTY, N.C. EXI5TIN6 5ANITARY 5EY ER
2022
ENGINEERING AND SURVEYING, INC.
LAND DEVELOPMENT CONSULTING
wr WBa5 FIRM L6Er5E NO. C-015
4400 TYNING STREET
HI PONT, NORTH CAROUNA 27265
PHONE: [phone] - FAX: [phone]
EVOLVE AT DEEP RIVER
GS QUAD MAP
HIGH POINT, NC
5GALE: 1'=200' 1)

ENGINEERING AND SURVEYING, INC. ELEVATE HAW RIMER
LAND DEVELOPMENT CONSULTING
'ree-s ter' LICENSE W. o-l3,s STREET MAP
4400 STREET GRAHAM, NC
HIGH POINT, NORTHORTH CAROIINA 27265
PHONE: [phone] - FAX: [phone] SGALE: 1'=1000'

y YJ4
4lk
1
f J� -
'
_ r
> ` i
1
1
w �
w iS
�►7 •• • K9 , ,,., •
F'P0 05W SANITARY 5EPER.
EXI5TIN5 SANITARY 5EHER
ENGINEERING AND SURVEYING, INC. EVOLVE AT DEEP RIVER
LAND DEVELOPMENT CONSULTING
W-BELSNO. 4°15 AERIAL MAP
4400 T STREET HIGH POINT, NC
HIGH POINT, NORTH
CAROLJNA 27265
PHONE: [phone] - FAX [phone]GALE'1'=2OO'

Engineering & Surveying, Inc.
Novgmber29,11023 0/-ON -z y - NC Department of
al
North Carolina Department of Environment and Natural Resources ErIVlfO ReceivedQUality
Water Quality Section
NCDENR Winston-Salem Branch Office JAN 0 5 2024
e Winston-Salem
Re: Fast -Track Application (FTA 04-16) Regional Office
For EVOLVE at DEEP RIVER
High Point, NC 27265
On behalf of MCFT HIGH POINT. LLC , we are submitting herewith for your approval the following documents
relative to the above referenced project:
- (1) Original Fast -Tract Application
- (1) Copy of Fas - et Application (Completed by City of High Point)
- (1) Check fo 480 ( CFT HIGH POINT, LLC)
Specifications for this project will be per the City of High Point standards and specifications. We respectfully request
your approval of these items. If you have any questions or need any additional information, please give me a call.
Thank you for your assistance with this matter.
Sincerely,
CPT Engineering and Surveying, Inc
7,P&T�?
Todd D. Murphy, P.M.
Enclosures
4sdd.nGcFtan9:oeerin9 • co"
4400 Tyning Street • High Point, NC 27265 Phone: [phone] • Fax: [phone]
www.epteneincering.com

NARRATIVE
IQ10 R
Evolve at Deep River
GUILFORD COUNTY
HIGH POINT, NORTH CAROLINA
November 14, 2023
OWNER
MCFT High Point, LLC & MPW High Point, LLC
(Tenants -In -Common)
336.544.6215
DEVELOPER
Evolve Construction, LLC
[phone]
ENGINEER:
CPT Engineering and Surveying, Inc.
4400 Tyning Street High Point, NC 27265
Phone [phone] Fax [phone]

PROJECT DESCRIPTION
The project is located on an approximately 18.02 acre tract in Guilford County, High
Point, NC. The purpose of the project is to construct 11 apartment buildings (264 units)
and clubhouse with associated paved drives and parking including private water and
sewer service.
The site consists of 18.02 acres more or less and is currently field/wooded and vacant.
ADJACENT PROPERTY
Land use in the vicinity is Office Commercial, General Business & Light Industrial
Districts. The site will access the public street network by new driveway entrances on
Penny Road which is located 1,134 LF N of NC HWY 68 S. The second access point is
located 1,448 LF from same intersection.
SOILS INFORMATION
The soil in the project area is mapped as
MhB2, Mecklenburg sandy clay loam, 2 to 6 percent slopes, moderatley eroded
ChA, Chewacla loam, 0 to 2 percent slopes, frequently flooded
WkE, Wilkes-Poindexter-Wynott complex, 15 to 45 percent slopes
HYDROLOGIC SOIL GROUP: ChA, Rating: B / D
MhB2, Rating: C
WkE, Rating: D
per USDA Natural Resources Conservation Service Web Soil Survey.
MCFT High Point, LLC & MPW High Point, LLC plans to retain ownership of the
subject property with NO plans to sell subject property upon completion.

State of North Carolina
DWR
Department Environmental Quality
Division
ion of Water Resources
FAST TRACK SEWER SYSTEMEXTENSION APPLICATIO14
Oledslon of Water Resources INSTRUCTIONS FOR FORM:FTA 10-23& SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has baetr
certified by a professional engineer and the applicant that the project meets the requirements of I5A NCAC 02T and the Divisimils
Minimum Design Criteria (Gravity Sewer&Pump Stations/FOice Mains) and that plans, specifications and supporting documents
have been prepared in accordance withl5A NCAC 02T. 15A NCAC 02T .0300.Division policies, and good engineering
practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in I5A NCAC 02T.0303
Projects not eligible for review via the fast track process (must be submitted for full technical review):
D 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
ID 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/Narradve Description (Required for AU Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit 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):
® Submit a check or money order in the amount of$600.00,dated no more than 90 days prior to application submittal.
➢ Payable toNorth Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 10-23):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ if the Applicant Type in Item I.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.
® The ProjectName in Item 11.1shall be consistent with the project name on theflow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
INSTRUCTIONS FOR FORM: FTA 10-23& SUPPORTING DOCUMENTATION Page 1 of 3

® The Applicant's Certification on Page 5 of the application shall be signed in accordance with I5A NCAC 02T 0106(b). 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).
ii
�I NSTRUCTIONS FOR FORM: FTA 10-23& SUPPORTING DOCUMENTATION Page 2 of 3

E. Flow Tracking/Acceptance Form (Form:FTSE 10-23) (If Applicable):
® Submit the completed and executed FTSE form from theowners of the downstream sewers and treatment facility.
D Multiple fortes 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 pennit issuance and must be dated less than one year
prior to the application date.
D Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-
215.67(a).
D Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® 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
® 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 narradveidentifying 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.
A. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability forpumping 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 15A NCAC 02T .0115(a)(U provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the
sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise
approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Prooerty Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T 0115(b). submit the properly executed Operational Agreement (FORM DEV)
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23& SUPPORTING DOCUMENTATION Page 3 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Reaional Office
225 Green Street Suite 714
Anson, Biaden, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
Grenville, Haltfax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Reaional Office
943 Washington Square Mall
Beaufort, Berta, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Cunituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilminaton Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23& SUPPORTING DOCUMENTATION Page 4 of 3

�e CW State of North Carolina
DWR Department of Environmental Quality
C— �1 Division of Water Resources
J FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06.21 & SUPPORTING DOCUMENTATION
Application Number:
I. APPLICANT INFORMATION: 0,,
I. Applicant's name: " H"r"MWUZ �"a F� =J(company, m
(to be completed by DWR)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Munjcipal ® Other
3. Signature authority's name:. Joseph A. M&Wey. Jr, Michael R winstead. Jr. per 15A NCAC 02T A 106(b )
Title: Manager's / /
4. Applicant's trailing address: 2918-A Martinsville Rd f
City: Greensboro State: NC_ Zip: 27408-./,�
5. Applicant's contact information:
Phone number: ( 336) 485- 4658 Email Address: [e-mail] and [e-mail]�
II. PROJECT INFORMATION: /
1. Project name: Evolve at Deep Rivef
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 pan of a master plan, provide the existing permit number: W000_
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36°02'15.678" Longitude:-79057'59.241"
5. Parcel ID (if applicable): 167961: 170013; 207385 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Charles P Trubv. Jr / License Number: 14984�
Firm: CPT Engineering and Surveving.lnc-�
Mailing address: 4400 Tuning Street
City: High Point State: NC Zip: 27265
Phone number: [phone]Email Address: chuckt@cpten ing eering comma
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Eastside Wastewater Plant Permit Number: NCO024210'/
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): WQ_
2. Downstream (Receiving) Sewer Information: 8 inch X 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
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 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)
® Residential (Leased) / ❑ Retail with food preparation/service
❑ School / preschool / day care
❑ Food and drink facilities
❑ Businesses / offices / factories
❑ Medical / dental / veterinary facilities
❑ Church
❑ Nursing Home
❑ Car Wash
❑ Hotel and/or Motels
® Swimming Pool/Clubhouse
❑ Swimming Pool/Filter Backwash
❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic _% 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(f)? [-]Yes ®No
v If Yes, provide a copy of flow reduction approval letter with this avolication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow °'"
No. of Units
Flow
Multi -Family Apartments (264 Units)
240 gall bedroom
96
23,040 GPD
240 gal/2 bedroom
132
31,680 GPD
360 gal/3 bedroom
36
12,960 GPD
gall
GPD
gal/
GPD
gal/
GPD
Total
67,680 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
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: by GPD (per 15A NCAC 02T .01 14)
Y 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
FORM: FTA 06-21 Page 2 of 5

❑ Other (Explain):
VII.
VEIL
GRAVITY SEWER DESIGN CRITERIA (I(Applicable) - 02T .0305 & MDC (Gravi(y Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8"
289,
DIP
8"
1,503'
SDR-26
ek ✓
Total
1,792'
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
D Section DI 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
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 he 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.I.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) _
6. Power reliability in accordance with 15A NCAC 02T.0305(h)(I):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)i
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:
D Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
FORM: FTA 06-21 Page 3 of 5

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 pan of this permit
application in the case of a multiple station power outage.
IX. SETBACKS & SEPARATIONS — (02B .0200 & ISA NCAC 02T.0305(f)):
I. Does the project comply with all separations/alternatives found in 15A NCAC 02T.0305(f) & (g)? ® 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
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-1 waters of Class 1 or
Class If 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
i if noncompliance with 02T.0305(f) or M. see Section X.1 of this application
*15A NCAC 02T.0305(g) 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 webpaee
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
D 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.
D 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 15A NCAC 02B .02001 ® Yes ❑ No
D This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ® Yes []No
or401 Water Quality Certifications?
D Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
U.S.A.C.O.E Action Id. SAW-2023-01078; DWR q 20230733 - Certification No. WQC006142
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 cenification 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 0210402, "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 interferencelconflicl boxes require a variance approval.
If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
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 protects
requiring two or more variances or where the variance is determined by the Division to be a significant portion of the
project, the full technical review is required.
2. Professional Engineer's Certification:
1, Charles P Truby. Jr , attest that this application for Evolve at Deep River
(Pmfe%sional Engineer's name from Application Item [If.1.) (Project Name from Application Item I1.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plaits, 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 Design 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 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation. 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: pO''�1N CARO�i•'�
y
SEAL
14984
L.... _.... �ibirC:N'Ty'dt.. J-_.-._..__J
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I Ae%we P. Vhns- eti,8 t 'Sf. attest that this application for Evolve at Deep River
(Signamte Authority Name from Application Item 1.3.) (Project Name from Application Item 11.1)
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 wyA General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certiVXion in a applicat' n packs shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as w s civil p nnpdties up i 25.00(yg r violation.
Signature:
Date: II ' IS' 2-3 /
FORM: FTA 06-21
Page 6 of 5

X. CERTIFICATIONS:
I. 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 subiect to longer review times. For projects
requiring two or more variances or where the variance is determined by the Division to be a significant portion of the
orojec4 the full technical review is required.
2. Professional Engineer's Certification:
1, Charles P Truby, Jr . attest that this application for Evolve at Deco River
(Professional Engineer'+ name from Application Item 111.1.) (Pmject Name from Application Item 11.11
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, Minimum Design 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 I43-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation. 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: ''��.O�yJ%A CA/�O`A4
.• 2 0..
2'
i Q. 1� �
SFAL
n t 14984 l
IiZ
3. Applicant's Certification per 15A NCAC 02T .0106(b): II Ir" 11-1
attest that this application for Evolve at Deep River
(SignaNte utfiority Name fmm ApPlic Lion Item 1.3.) (Project Name fmm Application Item 11.1)
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 (his 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,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: "v / Date: IS — Z
FORM: FTA 06-21 Page 6 of 5

State of North Carolina
DW Department Environmental Quality
Division of Water Resources
mom
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: FTA 06-21 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared In accordance with ISA NCAC 02T, ISA NCAC 02T .0300, Division policies, and good engineering
practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be Immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
D Projects that do not meet any part of the minimum design criteria (MDC) documents;
D Projects that involve more than one variance from the requirements of I SA NCAC 02T;
D 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
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
® list all items included in the application package, as well as a brief description of the requested permitting action.
D Be specific as to the system type, number of homes served, Flow allocation required, etc.
D 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):
® Submit a check or money order in the amount of $480.00, dated no more than 90 days prior to application submittal.
i Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 05.21):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item H.I shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may he 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) (H Applicable):
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
io Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
D 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.
D Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate
C.S. 143-215.67(a).
Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® 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.
D General location of the project components (gravity sewer, pump stations, & force main)
% Downstream connection points and permit number (if known) for the receiving sewer
® Include an aerial location map showing general project area (such as street names or latitudeflongitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to
be added, and/or items to be modified (the application form itself should include only include items to be added/modified).
The narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
i 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 I5A NCAC 02T .0106(b)) or proposed contractor, stating that
"the portable power generation unit or portable, independently -powered pumping units, associated appurtenances and
personnel are available for distribution and operation of this pump station"
If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump
stations' storage capacities and the rotation schedule of the portable power source or pump, including travel
timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
1. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(I) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the
sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise
approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold)-
® Home/Property Owners' Associations
® Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
® 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 15A NCAC 02T .0115(b). submit the properly executed Operational Agreement (FORM: DEV).
For mare information, visit the Division's collection .sysrems webrite
INSTRUCTIONS FOR FORM: FTA 05-21 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water QualitV Section
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water QualitV Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water QualitV Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: F1'A 05-21 & SUPPORTING DOCUMENTATION Page 3 of 3