NC0021849_Application (ATC)_20240201 (9)

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
SECTION 1: INSTRUCTIONS AND INFORMATION
A. The Division of Water Resources will accept this application package for review only if all of the items are provided and the
application is complete. Failure to submit all of the required items will result in the application package being returned as
incomplete per 15A NCAC 02T .0105(1i)..
B. A check or money order must be submitted in the amount of $1000.00 dated within 90 days of application submittal and made
payable to North Carolina Department of Environmental Quality (NCDEQ).
C. Plans and specifications must be prepared in accordance with 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General
Statute 133-3, North Carolina General Statute 143-215.I, andl]ivision of Water Resources Minimum I]esin Criteria for N111DES
Wastewater Treatment Facilities.
D. The plans and specifications submitted must represent a completed final design that is ready to advertise for bid.
E. Any content changes made to this Form ATC 10-23 shall result in the application package being returned.
F. The Applicant shall submit ONE ORIGINAL and ONE DIGITAL COPY (CD) of the application, all supporting documentation
and attachments. All information must be submitted bound or in a 3-ring binder, with a Section tab for each Section, except the
Engineering Plans.
G. Check the boxes below to indicate that the information is provided and the requirements are met.
H. If attachments are necessary for clarity or due to space limitations, such attachments are considered part of the application
package and must be numbered to correspond to the item referenced.
I. For any project that requires review under the State Environmental Policy Act (SEPA), an Authorization to Construct cannot be
issued prior to the completion of a State Clearinghouse advertisement period for a FONSI, EIS, etc. unless the project qualifies for
a Determination of Minor Construction Activity.
J. For more information, visit the Division of Water Resources web site at: http://portal.ncdetir.orl lwcblwglswp/ps/npdcs.
K. In addition to this Authorization to Construct, the Applicant should be aware that other permits may be required from other Sections
of the Division of Water Resources (for example: reclaimed water facilities permits; Class A or B biosolids residuals permit).
SECTION 2: APPLICANT INFORMATION AND PROJECT DESCRIPTION
A. APPLICANT
Applicant's name
Town of Hertford
Signature authority's name per 15A NCAC 02T .0106(b)
Janice McKenzie Cole
Signature authority's title
Town Manager
Complete mailing address
114 W. Grubb Street, Post Office Box 32 , NC 27944
Telephone number
252-426-5311
Email address
[e-mail]
B. PROFESSIONAL ENGINEER
Professional Engineer's name
Carolyn Hawkins
Professional Engineer's title
Assistant Project Manager
North Carolina Professional Engineer's License No.
054923
Firm name
WithersRavenel
Firm License number
F-1479
Complete mailing address
117 MaeKenan Drive, Cary, NC 27511
Telephone number
919-465-3340
Email address
[e-mail]
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 1

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
C. NPDES PERMIT
NPDES Permit number NCO021849
Current Permitted flow (MGD) — include permit
flow phases if applicable 0.7 MGD
D. PROJECT DESCRIPTION
Provide a brief description of the project: Replacement of electrical and mechanical components at the Wastewater Treatment
Plant WWTP headworks including the replacement of the bar screensgrit removals sent. control panels, and updates to the
supervisory control and data acquisition (SCADA). There will be no change to the piant's_capacity_
SECTION 3: APPLICATION ITEMS RE UIRED FOR SUBMITTAL FOR ALL PROJECTS
A. Cover Letter
® The letter must include a request for the Authorization to Construct; the facility NPDES Number; a brief project description
that indicates whether the project is a new facility, facility modification, treatment process modification, or facility
expansion; the construction timeline; and a list of all items and attachments included in the application package.
® If any of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North Carolina
General Statute 143-215.1, and Division of Witter Rcsources Minimum Design Criteria For NPDES Wastewater Treatment
Facilities are not met by the proposed design, the letter must include an itemized list of the requirements that are not met.
B. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $1,000.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
C. NPDES Permit
® Submit Part I of the Final NPDES permit for this facility that includes Part A (Effluent Limitations and Monitoring
Requirements) for the monthly average flow limit that corresponds to the work that is requested for this project.
D. Special Order by Consent
❑ If the facility is subject to any Special Orders by Consent (SOC), submit the applicable SOC.
® Not Applicable.
E. Finding of No Significant Impact or Record of Decision
❑ Submit a copy of the Finding of No Significant Impactor Record of Decision for this project.
❑ Provide a brief description of any of the mitigating factors or activities included in the approved Environmental Document
that impact any aspect of design of this project, if not specified in the Finding of No Significant Impact or Record of
Decision.
® Not Applicable.
F. Engineering Plans
® Per 1 SA NCAC 02T .0504(c )t 1), submit one set of detailed plans that have been signed, sealed and dated by a North Carolina
Licensed Professional Eii' jneer.
® Per 21 NCAC 5h .1 103(a)(6), the name, address and License number of the Licensee's firm shall be included on each sheet
of the engineering drawings.
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 2

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
® Plans must be labeled as follows: FINAL DRAWING —FOR REVIEW PURPOSES ONLY —NOT RELEASED FOR
CONSTRUCTION.
❑ 15A NCAC 02H .0124 requires multiple (dual at a minimum) components such as pumps, chemical feed systems, aeration
equipment and disinfection equipment. Is this requirement met by the design? ❑ Yes or ❑ No. If no, provide an
explanation: Not applicable for this project
Plans shall include:
❑ Plans for all applicable disciplines needed for bidding and construction of the proposed project (check as appropriate):
❑ Civil ® Not Applicable
® Process Mechanical
❑ Not Applicable
❑ Structural
® Not Applicable
® Electrical
❑ Not Applicable
® Instrumentation/Controls
❑ Not Applicable
❑ Architectural
® Not Applicable
❑ Building Mechanical
® Not Applicable
❑ Building Plumbing
® Not Applicable
® Plan and profile views and associated details of all modified treatment units including piping, valves, and equipment (pumps,
blowers, mixers, diffusers, etc.)
❑ Are any modifications proposed that impact the hydraulic profile of the treatment facility? ❑ Yes or ® No. If yes, provide
a hydraulic profile drawing on one sheet that includes all impacted upstream and downstream units. The profile shall include
the top of wall elevations of each impacted treatment unit and the water surface elevations within each impacted treatment
unit for two flow conditions: (1) the NPDES permitted flow with all trains in service and (2) the peak hourly flow with one
treatment train removed from service.
❑ Are any modifications proposed that impact the process flow diagram or process flow schematic of the treatment facility? ❑
Yes or ® No. If yes, provide the process flow diagram or process flow schematic showing all modified flow paths including
aeration, recycle/return, wasting, and chemical feed, with the location of all monitoring and control instruments noted.
G. ® Engineering Specifications
® Per 15A NCAC 02T .0504[6(2], submit one set of specifications that have been signed, sealed and dated by a North Carolina
I.ieen ted Professional Engineer.
® Specifications must be labeled as follows: FINAL SPECIFICATIONS — FOR REVIEW PURPOSES ONLY — NOT
RELEASED FOR CONSTRUCTION.
Specifications shall include:
® Specifications for all applicable
disciplines needed for bidding
and
construction of the proposed
project (check as
appropriate):
❑ Civil
® Not Applicable
®
Instrumentation/Controls
❑ Not Applicable
® Process Mechanical
❑ Not Applicable
❑
Architectural
® Not Applicable
❑ Structural
® Not Applicable
❑
Building Mechanical
® Not Applicable
® Electrical
❑ Not Applicable
❑
Building Plumbing
® Not Applicable
® Detailed specifications for all treatment units and processes including piping, valves, equipment (pumps, blowers, mixers,
diffusers, etc.), and instrumentation.
® Means of ensuring quality and integrity of the finished product including leakage testing requirements for structures and
pipelines, and performance testing requirements for equipment.
® Bid Form for publicly bid projects.
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 3

Division of Water Resources
H. Construction Sequence Plan
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
® Construction Sequence Plan such that construction activities will not result in overflows or bypasses to waters of the State.
The Plan must not imply that the Contractor is responsible for operation of treatment facilities. List the location of the
Construction Sequence Plan as in the Engineering Plans or in the Engineering Specifications or in both: Construction
Sequencing will be shown on the Engineering Plans under General Notes and Legend.
I. Engineering Calculations
® Per 15A NCAC 02T .0504(c)(3), submit one set of engineering calculations that have been signed, sealed and dated by a
North Carolina Licensed Professional Engineer; the seal, signature and date shall be placed on the cover sheet of the
calculations.
For new or expanding facilities and for treatment process modifications that are included in Section 4.C, the calculations
shall include at a minimum:
® Demonstration of how peak hour design flow was determined with a justification of the selected peaking factor.
❑ Influent pollutant loading demonstrating how the design influent characteristics in Section 4.13.2 of this form were
determined.
❑ Pollutant loading for each treatment unit demonstrating how the design effluent concentrations in Section 4.13.2 of this form
were determined.
❑ Hydraulic loading for each treatment unit.
❑ Sizing criteria for each treatment unit and associated equipment (blowers, mixers, pumps, etc.)
❑ Total dynamic head (TDH) calculations and system curve analysis for each pump specified that is included in Section 4.C.6.
❑ Buoyancy calculations for all below grade structures.
❑ Supporting documentation that the specified auxiliary power source is capable of powering all essential treatment units.
J. Permits
® Provide the following information for each permit and/or certification required for this project:
Permit/Certification
Not
Applicable
Date
Submitted
Date
Approved
Permit/
Certification
Number
If Not Issued Provide
Status and Expected
Issuance Date
Dam Safety
N/A
Soil Erosion and Sediment Control
N/A
USCOE / Section 404 Permit
N/A
Water Ouality Certification (401 ]
N/A
USCOE / Section 10
N/A
Stormwater Management Plan
N/A
CAMA
N/A
NCDOT Encroachment Agreement
N/A
Railroad Encroachment Agreement
N/A
Other:
N/A
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 4

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
K. Residuals Management Plan
❑ For all new facilities, expanding facilities, or modifications that result in a change to sludge production and/or sludge
processes, provide a Residuals Management Plan meeting the requirements of 1 SA NCAC 02T .0304(i] and .0508; the Plan
must include:
❑ A detailed explanation as to how the generated residuals (including trash, sediment and grit) will be collected, handled,
processed, stored, treated, and disposed.
❑ An evaluation of the treatment facility's residuals storage requirements based upon the maximum anticipated residuals
production rate and ability to remove residuals.
❑ A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department approved
residuals disposal/utilization program that has adequate permitted capacity to accept the residuals or has submitted a
residuals/utilization program application.
❑ If oil, grease, grit or screenings removal and collection is a designated unit process, a detailed explanation as to how the
oil/grease will be collected, handled, processed, stored and disposed.
® Not Applicable.
SECTION 4: PROJECT INFORMATION
A. WASTEWATER TREATMENT PLANT FLOW INFORMATION — COMPLETE FOR NEW OR
EXPANDING FACILITIES
1. Provide the following flow information:
Plant Flows
Existing Plant Design
MGD
Current NPDES Permit Limit
MGD
Current Annual Average
(past 12 months)
MGD
For Past 12 Months:
Start Date: month/yr
End Date: month/yr
For Past 24 Months:
Start Date: month/yr
End Date: month/yr
Maximum Month
MGD
MGD
Maximum Day
MGD
MGD
Peak Hour
MGD
MGD
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 5

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Divlslon of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
B. WASTEWATER TREATMENT FACILITY DESIGN INFORMATION — COMPLETE FOR NEW OR
EXPANDING FACILITIES AND FOR TREATMENT PROCESS MODIFICATIONS
1. Have all of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North
Carolina General Statute 143-215.11 and Division of Water Resources Minimum Design Criteria f6r NPDES Wastewater
Treatment Facilities been met by the proposed design and specifications? ❑ Yes or ❑ No. If no, provide justification as to
why the requirements are not met, consistent with 15A NCAC 02T .0105(n):
2. Provide the design influent and effluent characteristics that are used as the basis for the project design, and the NPDES
permit limits for the following parameters:
Project Basis of Design
Influent
Design Influent
Design Influent
Concentration
Concentration
Load
- Current
(Must be
(Must be
Annual
supported by
supported by
Design Effluent
Average (past
Engineering
Engineering
Concentration and/or
NPDES Permit Limits
12 months) if
Calculations
Calculations
(monthly average)
Parameter
Available
Section 3.H
Section 3.111)Load
Ammonia Nitrogen
mg/L Summer
mg/L Summer
(NH3 N)
mg/L
mg/L
lb/day
mg/L Winter
mg/L Winter
Biochemical
mg/L Summer
mg/L Summer
Oxygen Demand
mg/L
mg/L
lb/day
(BOD5)
mg/L Winter
mg/L Winter
Fecal Coliform
per 100 mL
per 100 mL
Nitrate + Nitrite
Nitrogen (NO3-N +
mg/L
mg/L
NOz-N
Total Kjeldahl
mg/L
Nitrogen
mg/L
mg/L
Total Nitrogen
lb/year
lb/year
mg/L
mg/L
Total Phosphorus
mg/L
mg/L
lb/day
lb/year
lb/year
Total Suspended
mg/L
mg/L
lb/day
mg/L
mg/L
Solids (TSS)
3. Based on the "Project Basis of Design" parameters listed above, will the proposed design allow the treatment facility to meet
the NPDES Permit Limits listed above? ❑ Yes or ❑ No. If no, describe how and why the Permit Limits will not be met: -
4. Per 15A NCAC 02T .0505(jl, by-pass and overflow lines are prohibited. Is this condition met by the design? ❑ Yes or ❑
No If no, describe the treatment units bypassed, why this is necessary, and where the bypass discharges:
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 6

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
Per 15A NCAC 02T .0505(k), multiple pumps shall be provided wherever pumps are used. Is this condition met by the
design? ❑ Yes or ❑ No. If no, provide an explanation:
6. Per 15A NCAC 02T .0505(l), power reliability shall be provided consisting of automatically activated standby power supply
onsite capable of powering all essential treatment units under design conditions, or dual power supply shall be provided per
15A NCAC 02H, 0 124(2)(al. Is this condition met by the design? ❑ Yes or ❑ No. If no, provide (as an attachment to
this Application) written approval from the Director that the facility:
)0- Has a private water supply that automatically shuts off during power failures and does not contain elevated water storage
tanks, and
➢ Has sufficient storage capacity that no potential for overflow exists, and
➢ Can tolerate septic wastewater due to prolonged detention.
7. Per 1 SA NCAC 02T .0505(o), a minimum of 30 days of residual storage shall be provided. Is this condition met by the
design? ❑ Yes or ❑ No. If no, explain the alternative design criteria proposed for this project in accordance 15A NCAC
02T .105(n):
8. Per 15A NCAC 02T .0505(n), the public shall be prohibited from access to the wastewater treatment facilities. Explain how
the design complies with this requirement:
9. Is the treatment facility located within the 100-year flood plain? ❑ Yes or ❑ No. If yes, describe how the facility is
protected from the 100-year flood:
C. WASTEWATER TREATMENT UNIT AND MECHANICAL EQUIPMENT INFORMATION — COMPLETE
FOR NEW OR EXPANDING FACILITIES AND FOR MODIFIED TREATMENT UNITS
PRELIMINARY AND PRIMARY TREATMENT (i.e., physical removal operations and flow equalization);
No. of
Plan Sheet
Specification
Calculation
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided?
es or No
Manual Bar Screen
2
Bar Rack
2.2 MGD at peak hourly flow
M1.01
05 5000
Yes
Mechanical Bar
2
Step
2.2 MGD at peak hourly flow
M1.01
46 21 26
Yes
Screen
Grit Removal
1
Vortex
2.2 MGD at peak hourly flow
M1.01 &
46 23 23
Yes
M1.02
Flow Equalization
gallons
Primary Clarifier
Circular
ft diameter; ft side
water depth
Primary Clarifier
Rectangular
square feet; ft side
water depth
Other
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 7

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
2. SECONDARY TREATMENT (BIOLOGICAL REACTORS AND CLARIFIERS) (i.e., biological and chemical
❑rocesses to remove organics and nutrients)
No. of
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided.
es or No)
Aerobic Zones/
gallons
Tanks
Anoxic Zones/
gallons
Tanks
Anaerobic
gallons
Zones/Tanks
Sequencing Batch
-
gallons
Reactor SBR
Membrane
gallons
Bioreactor MBR
Secondary Clarifier
Circular
ft diameter; ft side
water depth
Secondary Clarifier
Rectangular
square feet; ft side
water depth
Other
TERTIARY TREATMENT
No. of
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided.
Yes or No
Tertiary Clarifier
Circular
ft diameter; ft side
water depth
Tertiary Clarifier
Rectangular
square feet; ft side
water depth
Tertiary Filter
square feet
Tertiary Membrane
square feet
Filtration
Post -Treatment
-
gallons
Flow Equalization
Post -Aeration
gallons
Other
DISINFECTION
No. of
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided.
es or No
gal/day per bank at peak
Ultraviolet Light
(Parallel; in
hourly flow; number of
series)
banks; number of
lamps/bank
Chlorination
(Gas;
gallons of contact
tablet; liquid)
tank/unit
Dechlorination
(Gas;
gallons of contact
tablet; liquid)
tank/unit
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 8

L I P
01"Iij
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
5. RESIDUALS TREATMENT
No. of
Plan Sheet
Specification
Calculations
Treatment Unit
Units
Type
Size per Unit
Reference
Reference
Provided.
es or No)
Gravity Thickening
square feet; ft side
Tank
water depth
Mechanical
Thickening/
dry lb/hour
Dewaterin
Aerobic Digestion
gallons
Anaerobic
gallons
Di estion
Composting
dry lb/hour
Drying
dry lb/hour
Other
6. PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain pumps)
Location
No. of
Pumps
Purpose
Type
Capacity
of each
ump
Plan Sheet
Reference
Specification
Reference
GPM
TDH
7. MIXERS
Location
No. of
Mixers
Purpose
Type
Power of
each Mixer
Plan Sheet
Reference
Specification
Reference
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 9

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
8. BLOWERS
Location
No. of
Blowers
Purpose
Type
Capacity of
each Blloower
Plan Sheet
Reference
Specification
Reference
ODOR CONTROL
Location
No. of
Units
Purpose
Type
Plan Sheet
Reference
Specification
Reference
D. SETBACKS — COMPLETE FOR NEW WASTEWATER TREATMENT STRUCTURES
1. The minimum distance for each setback parameter to the wastewater treatment/storage units per 15A N.CAC 02T .0506(b are
as follows:
Minimum Distance
Is Minimum Distance
(Required from Neares
Requirement met by the
Setback Parameter
Treatment/Storage
Design. If "No", identify
Unit
Setback Waivers in Item D.2
Below
Any habitable residence or place of assembly under separate
100 ft
❑ Yes
❑ No
ownership or not to be maintained as part of the project site
Any private or public water supply source
100 ft
❑ Yes
❑ No
Surface waters (streams — intermittent and perennial, perennial
50 ft
❑ Yes
❑ No
waterbodies, and wetlands
Any well with exception of monitoring wells
100 ft
❑ Yes
❑ No
Any property line
50 ft
❑ Yes
❑ No
2. Have any setback waivers been obtained per 15A NCAC 02T .050fi(d)? ❑ Yes or ❑ No. If yes, have these waivers been
written, notarized and signed by all parties involved and recorded with the County Register of Deeds? ❑ Yes or ❑ No. If
no, provide an explanation:
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 10

DocuSign Envelope ID: 9EB8D2FD-C49E-4B80-AF99-9C81 EE5744D3
State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
SECTION 5: APPLICATION CERTIFICATION BY PROFESSIONAL ENGINEER
Professional Engineer's Certification per 15A NCAC 02T .0105:
I, Carolyn Hawkins , attest that this application package for an Authorization to Construct
(Typed Name of Professional Engineer)
for the Hertford Waste Water Treatment Plant and Hertford Collection System Rehab WWTP Improvements
(Facility and Project Name)
was prepared under my direct supervisory control and to the best of my knowledge is accurate, complete and consistent
with the information supplied in the engineering plans, specifications, calculations, and all other supporting
documentation for this project. I further attest that to the best of my knowledge the proposed design has been prepared in
accordance with all applicable regulations and statutes, 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General
Statute 133-3, North Carolina General Statute 143-215.11 and Division of Water Resources Minimum Design Criteria for
NPDES Wastewater Treatment Facilities, and this Authorization to Construct Permit Application, except as provided for
and explained in Section 4.13.1 of this Application. I understand that the Division of Water Resources' issuance of the
Authorization to Construct Permit may be based solely upon this Certification and that the Division may waive the
technical review of the plans, specifications, calculations and other supporting documentation provided in this application
package. I further understand that the application package may be subject to a future audit by the Division. Although
certain portions of this submittal package may have been prepared, signed and sealed by other professionals licensed in
North Carolina, inclusion of these materials under my signature and seal signifies that I have reviewed the materials and
have determined that the materials are consistent with the project design.
I understand that 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.
North Carolina Professional Engineer's seal with written signature placed over or adjacent to the seal and dated:
1 1 I11
NDr9 0
° t�.�fa ��iv�itis
a
`'4"GfME��Z1Z�
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 11

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
SECTION 6: APPLICATION CERTIFICATION BY APPLICANT
Applicant's Certification per 15A NCAC 02T .0I06[b):
I, Janice Mckenzie Cole Town Manager , attest that this application package for an Authorization to Construct
(Typed Name of Signature Authority and Title)
for the Hertford Waste Water Treatment Plant and Hertford Collection System Rehab WWTP Improvements
(Facility and Project Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. 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. I further certify that in accordance with 15A
NCAC 02T.0120 (b), the Applicant or any affiliate has not been convicted of environmental crimes, has not abandoned a
wastewater facility without proper closure, does not have an outstanding civil penalty where all appeals have been
abandoned or exhausted, are compliant with any active compliance schedule, and does not have any overdue annual fees.
I understand that the Division of Water Resources' issuance of the Authorization to Construct Permit may be based solely
upon acceptance of the Licensed Professional Engineer's Certification contained in Section 5, and that the Division may
waive the technical review of the plans, specifications, calculations and other supporting documentation provided in this
application package. I further understand that the application package may be subject to a future audit.
I understand that 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: Date:
THE COMPLETED APPLICATION AND SUPPORTING INFORMATION SHALL BE SUBMITTED
TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCESAPDES
By U.S. Postal Service By Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N. SALISBURY STREET, 9TH FLOOR
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 12