WQ0045113_Application (FTSE)_20240118

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State of orth Carolina
DWR Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number:4//.3 (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicants name: City of Burlington company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Craig Honeycutt per 15A NCAC 02T .0106(b)
Title: City Manager
4. Applicant's mailing address: 425 South Lexington Avenue
City: Burlington"State: NC — Zip: 27215-'
5. Applicant's contact information:
Phone number: C136) 222-5050�' Email Address: engineerinpAbwlingtonnc.gov
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
1. Project name: Smith Warehouse'
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date: _,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000_
i
3. County where project is located: Alamance
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0149. Longitude:-79.4895'
5. Parcel ID (if applicable): 112119 (or Parcel ID to closest downstream sewer)
lII. CONSULTANT INFORMATION:
1. Professional Engineer: Kent E. Bamev ' License Number: 19275
Firm: Landmark Builders Inc
Mailing address: 3520 Triad Court
City: Winston-Salem State: NC Zip: 27107-_
Phone number. 3�36) 784-2000 Email Address: kbamevalandmarkbuilders.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: South Burlington ' Permit Number: NCO023876
Owner Name: City of Burlington
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s):WQjNotavailablel
2. Downstream (Receiving) Sewer Information: 8 inch' ® Gravity ' ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00008'
Owner Name(s): Ctiy of Bwlington 1�
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/A1(
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 / factorieg ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic 100 % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ❑ No
➢ If yes, provide a cony of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow °"
No. of Units
Flow
2 loading bays (proposed building)
100 gallloading bay '
2
200 GPD
General Business (existing building)
25 gal/employee/1 shift'
15�
375 GPD'
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
575 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. 42AA).
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: 575 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 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

VU. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 180 DIP
➢ Section 11 & 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
Vill. 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 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. Lb. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 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 in 15A NCAC 02T .0305(t) & (e)? ® Yes ❑ No
15A NCAC 02T.0305 t contains minimum separations that shall be provdided for sewers stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
"Any private or public water supply source, including any wells, WS-1 waters of Class I or
Class Il impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
"Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (e), see Section X.1 of this application
"15A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(1) 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
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ® Yes Basin name: Cape Fear River ❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
D If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T. the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version). and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will
2. Professional Engineer's Certification:
1, fK+er e • L3wrn t a , P�" , attest that this application for S eh.4h VI/Stre hoYi''
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item 11.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and 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 Pumo Stations and Force Mains I 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 1 have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, 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)
...........................................................
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North Carolina Professional Engineer's seal, signature, and date: �,# CA jp;Yn
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, Litx/mot /7niratNGtJL L , attest that this application foriZj�/eY>TC
(SignaturaAuthority Nanw4om Application Item 1.3.) (Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. i also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — in accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, 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: `--� ti`CL�^t J Date:
FORM: FTA 10-23 Page 5 of 5

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
" ....... Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE 10-23)
Entity Requesting Allocation City of Burlington
Project Name for which flow is being requested: Smith Warehouse
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump stations along
the route of the proposed wastewater flow.
1. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name:
b. WWTP Facility Permit #:
South Burlington WWTP
NCO023876
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated Sows to the facility
h. Percent of permitted flow used
All flows are in MGD
12.00
1.449754
6.330000
0.000575
7.780329 �
64.84% -
II. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
List pump stations located between the project connection point and the WWTP
(A)
(B) (C) (D)=(B+C) (E)=(A-D)
Design
Obligated,
Average Daily
Approx. Not Yet Total Current
Pump Station Firm Flow"
Current Avg. Tributary Flow Plus
(Name or Capacity,(Fimilpf),
Daily Flow, Daily Flow, Obligated Available
Number) GPD GPD
GPD GPD Flow Capacity""'
The Finn Capacity of any pump station is defined as the maximum pumped flow that
can be achieved with the largest pump taken out of service.
" Design Average Daily Flow Is the firm capacity of the pumpstation divided by a
peaking factor (pf) not less than 2.5.
•" A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WVrP where the Available Capacity 5 0.
Downstream Facility Name (Sewer) :
Downstream Permit Number
1 of 6 FTSE 10-18

III. Certification Statement:
I, W. Todd Lambert, P.E. z certify to the best of my knowledge that the addition of the
volume of wastewater to a permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any
capacity related sanitary sewer overflows or overburden any downstream pump station en route to the
receiving treatment plant under normal circumstances, given the implementation of the planned
improvements identified in the planning asssessment where applicable. This analysis has been
performed in accordance with local established policies and procedures using the best available data.
This certification applies to those items listed above in Sections I and 11 plus all attached planning
assessment addendums for which 1 am the responsible party. Signature of this form certifies that the
receiving collection system or treatment works has adequate capacity to transport and treat the proposed new
wastewater.
Signing Official Signature
City Engineer
Title of Signing Official
Date
2 of 6 FTSE 10-18

Smith Warehouse Public Sewer Extension
USGS
U.S. DEPARTMENT OF THE INTERIOR WRLINGTON QUADRANGLE
./ Ju J NORTH CAROLINA • AlMU1KE CWNTY
` U.S. GEOLOGICAL SURVEY ?.$-MINUTE SERIES
science /w a changing world

Smith Warehouse Public Sanitary Extension
Existing public sanitary line

T A ATT1A X A "TT
. H I V L1V1f1Ri1
We Build Confidence.
Letter of transmittal
Date: 1/12/2024
To: NCDEQ
450 West Hanes Mill Road
Winston-Salem, NC 27105
Attn: Jenny Graznak, Asst. Regional
Supervisor, Water Resources
Re: Smith Warehouse
NC Department of
Environmental Quality
Received
JAN 18 2024
Winston-Salem
Regional Office
Job No.: AH-22176
From: Kent E. Barney, PE
3520 Triad Court
Winston-Salem, NC 27107
We are sending you (x)Attached ( )Under separate cover via
( )Shop Drawings ( )Prints (x)Plans ( )Samples
( )Copy of Letter ( )Change Order(s)
the following items:
( )Specifications
Copies
Date
Description
1
Fast Track Sewer Extension FTA 06-21 package
1
Fast Track Sewer Extension FTA 06-21 package co
1
Check for $480 payable to NCDEQ
These are transmitted as checked below:
For approval
)Approved as submitted
Resubmit )copies for approval
For our use
)Approved as noted
Submit copies for distribution
As requested
Returned for corrections
Return corrected prints
For review and comment
Remarks:
Jenny,
Please call me at 336-784-2000 with any questions.
Thanks,
Kent E. Barney, PE
Copy to:
Signed:"
Landmark Builders 1 3520 Triad Court I Winston-Salem, NC 27107
p.336.784.2000 I www.landmarkbuilders.com

— TLfA�1V L1V1A 'n I;
We Build Confidence. Environn"if'" '
ReccNeO
JAN 18 2024
January 12, 2024
Winston-5--'
Regional C
Public 8" sanitary sewer for Smith Warehouse
Enclosed please find the executed, executed FTSE 10-23, color USGS map and aerial
location map for the referenced Smith Warehouse Project. The proposed 180 If of 8" gravity sewer line
will serve a new 2 loading bay warehouse and an existing general business facility with approximately
25 employees. The total anticipated sewer flow is 575 GPD. The new line will be located in a 60' public
right of way for Troxler Road (SR 1151).
Landmark Builders 1 3520 Triad Court I Winston-Salem, NC 27107
p.336.784.2000 I www.landmarkbuilders.com

T A A T711% N A 11 TT
I,HIVLlVIHI[n
We Build Confidence.
Letter of transmittal
Date: 1 /29/2024
To: NCDEQ
450 West Hanes Mill Road
Winston-Salem, NC 27105
Attn: Ronald C. Boone,.
Environmental Program Consultant
Re: Smith Warehouse
NC Department of
Environmental Quality
Received
FEB 01 2024
Winston-Salem
Regional Office
Job No.: AH-22176
From: Kent E. Barney, PE
3520 Triad Court
Winston-Salem, NC 27107
We are sending you (x)Attached ( )Under separate cover via
( )Shop Drawings ( )Prints (x)Plans ( )Samples
( )Copy of Letter ( )Change Order(s)
the following items:
( )Specifications
Copies
Date
Description
1
Fast Track Sewer Extension FTA 10-23 application
1
Fast Track Sewer Extension FTA 10-23 application co
1
Check for $600 payable to NCDEQ
These are transmitted as checked below:
For approval
)Approved as submitted
Resubmit )copies for approval
For our use
)Approved as noted
Submit copies for distribution
As requested
Returned for corrections
Return corrected prints
For review and comment
Remarks:
Ron,
Please call me at 336-784-2000 with any questions.
Thanks,
Kent E. Barney, PE
Copy to:
Landmark Builders 1 3520 Triad Court I Winston-Salem, NC 27107
p.336.784.2000 ( www.landmarkbuilders.com

/ State of North Carolina
Dc n ' `p �/� y( Zd Department of Environmental Quality
W ¢w zr v ens doted Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: )2 (to he completed b. nwRt
All items must be completed or the application Hill be returned
1. APPLICANT INFORMATION:
1. Applicant's name: City of Burlington (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
3. Signature authority's name: Craig Honeycutt per 15A NCAC 02T A106(b1
Title: Citv Manger'
4. Applicant's mailing address: 425 South Lexington Avenue-,-
5. City: Burlington's State: NC ✓
Applicant's contact information:
Phone number: 336-222-5050` Email Address: eneineeringra)burlin tg onnc.gov—'
It. PROJECT INFORMATION:
I. Project name: Smith Warehouse s
❑ Privately -Owned Public Utility
❑ Other
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification. provide the existing permit number: and issued date:
For modifications, also attach a detailed narrative description as described is Item G or the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Alamance
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0149 Longitude:-79.4895
5. Parcel ID (if applicable): 112119 (or Parcel Win closest downstream sewer)
111. CONSULTANT INFORMATION:
I. Professional Engineer: Kent E. Bamey✓ License Number: 19275
Firm: Landmark Builders Inc
Mailing address: 3520 Triad Court
City: Winston-Salem State: NC Zip: 27107
Phone number: [phone]Email Address: kbamey(iriandmarkbuilderscom
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: South Burlington-' Permit Number: NCO023876
Owner Name: City of BurlingtorY
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
Permit Number(s): WQ (not available)
Zip: 27215
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity❑ Force Main
3. System Wide Collection System Permit Numbers) (if applicable): WQCS 0008�Owner Name(s): City of Burlington
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: DEVI been attached?
❑ Yes ❑ No ® N/A �
3. If the Applicant is a Home/Property Owners' Association, has an HOArPOA Operational Agreement (FORM: HOAI 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 PooFFilter Backwash
® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic 100 % Commercial _ % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Has a flow reduction been approved under I5_a NCAC 02T .01 14 I ? ❑ Yes ® No
L 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 •.e
No. of Units
Flow
2 loading bays (proposed building)
100 gal/loading bay
2
200 GPD
General Business (existing building)
25 gaVemployee
15
375 GPD
gall
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
575 GPD
7 l 9I,.P
a See I5A NCAC 021 .0114(b). (d). fell 1) and (eN21 for caveats to wastewater design flow rates (i.e.. minimum flow per
dwelling: proposed unknown non-residential development uses: public access facilities located near high public use areas:
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S.. 42A-4).
b Per 15A NCAC 02T .01 14(c), design flow rates for establishments not identified [in table 15A NCAC 021' 01 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 575 GPD (per I5A NCAC 02T .0114)
Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain): flow is currently being reauested via permit modification to permit W00040248 issued date 8 24 2018
FORM: FTA 06-21
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
8 180 DIP
i Section H & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
i 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
Vill. 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)
i This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): _ gallons per minute (GPM) at _ feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter. please identify the method of solids reduction per
MDCPSFM Section 2.01C. Lb. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with I5A NCAC 021 .0305(hl(1):
❑ Standby power source or ❑ Standby pump
Must have automatic activation and telemetry - 15A NCAC 02T.0305(hx I XB)*.
i Required for all pump stations with an average daily flow greater than or equal to 15.000 gallons per day
i 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(hx 1 XQ:
❑ Portable power source with manual activation. quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
i Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
i If the portable power source or pump is dedicated to multiple pump stations. an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump. including travel timeframes. shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B.0200 & 15A NCAC 02T.0305(f)):
I. Does the project comply with all separations/altematives found in 1'A NCAC 021 .0305(t) & (e)?
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)
18 inches
=Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
"Any private or public water supply source, including any wells. WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
"Waters classified WS (except WS-1 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 02 LV 5tt1 or (el. see Section X.I of this application
• I SA NCAC 021.0305te) contains alternatives where separations in 02T.0305(tl 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 N ater Classifications webpaee
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document.
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N'A
e 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: Cape Fear River �❑ No /
If yes, does the project comply with setbacks found in the river basin rules per I SA `'CAC 02B .O100" ® Yes ❑ No
This includes Trout Buffered Streams per I5A NCAC 213.020_2
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
i Please provide the permit number/permitting status in the cover letter if coveragelauthorization is required.
6. Does project comply with 15A_NCAC 021.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15,E `CAC 021.0105(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 02 r.0402. "high -priority sewer' means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
If yes. include an attachment with details for each line, including type (aerial line. size. material, and location).
High priority lines shall he inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
I. Does the submitted system comply with I5A NCAC 021. the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains I 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
2. Professional Engineer's Certification:
1. Kent E. Barney. PE, attest that this application for Smith Warehouse
114nfe5sional Engineer's name front Application Item 111.1.) (Project Name from Application Item 11.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and 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 mersion ). 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 S 10,000, as well as civil penalties up to $25.000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per I SA NCAC 02T.0 I 06(b):
110 VA CA
SEAL -
19275
ZZ
= k<< GiNSe-'* A
77' /. attest that this application for _�zxl
(Signature Auttroriw Name fmm 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.
1 understand that if all required pans 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. 1 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 143-215.6fi, 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: / a j
FORM: FTA 06-21 Page 5 of 5