WQSV00006_Application_20240213

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division 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 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 15A 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 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® 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.
➢ 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.
➢ If the project is funded by American Rescue Plan Act (ARPA) funds, please include the ARPA project number in the cover
letter and in parentheses under Project Name (Section II.1. of the application).
C. Application Fee (All New and Modification Application Packages):
El Submit a check or money order in the amount of $600.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track Application (Required for All Application Packages, Form FTA 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 SecreLaa 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 Project Name in Item II.1 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.
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Pagel of 3

® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(bl. 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).
E. Flow Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.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.
➢ 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 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.
➢ 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)(1) 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 .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: DEW
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & 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 guality 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
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 Quality 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 Q ual ity Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pender
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Alamance, Alleghany, Ashe, Caswell, Davidson,
Water Quality Section
Suite 300
Davie, Forsyth, Guilford, Rockingham, Randolph,
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

DWR
Division of Water Resources
Application Number:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Paliouras Enterprises, 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: James Paliouras per 15A NCAC 02T .0106fb]
Title: Managing Member
4. Applicant's mailing address: PO Box 715
City: Chapel Hill State: NC Zip: 27514-
5. Applicant's contact information:
Phone number: 919) 942-5356 Email Address: globaltravelnc&ahoo.com
H. PROJECT INFORMATION:
1. Project name: Paliouras FM Relocation
2. Application/Project status: ❑ Proposed (New Permit) ® Existing Permit/Project ❑ ARPA funded
If a modification, provide the existing permit number: WQ0037048 and issued date: March 31,2014,
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: WQ0037048
3. County where project is located: Orange
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.056' Longitude:-79.079'
5. Parcel ID (if applicable): 9873694294 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Jeremy A. Allen License Number: 34361
Firm: Highfill Infrastructure Engineering, P.C.
Mailing address: 2703 Jones Franklin Rd. STE 201
City: Cry State: NC Zip: 27518-
Phone number: [phone] Email Address: jallen ZWepc.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Town of Hillsborough WWTP Permit Number: NCO026433
Owner Name: Town of Hillsborough
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0035536
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): Town of Hillsborough
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 [ ] ORM: DES' i been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA O nerational A eement 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: 0 % Domestic 100 % Commercial 0 % 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 vesprovide a copi of flow reduction a roval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow
No. of Units
Flow
Aldi Grocery Store without food service
100 gal/1,000
19,209
1,921 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
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.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 1,921 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

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC f Gravid Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
456
PVC
➢ 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
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pumn_Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Paliouras PS
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.0560 Longitude:-79.0790
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.144 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): 100 gallons per minute (GPM) at 82 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
3
729
PVC
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.l.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) Grinder
6. Power reliability in accordance with 15A NCAC 02T .0305(h)f 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(t)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(t) & (g)? ❑ Yes [—]No
15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(fl or (a), see Section X.1 of this application
*15A NCAC 02T.0305(aa 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 webnaee
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: Neuse ❑ 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) 16 t, 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 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

DocuSign Envelope ID: 98439D51-D2A5-4E83-922E-A1A18A94AOOA
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T the Minimum Design Criteria for the Permitting of Pun= Stations
and Force Mains f latest version), and the Gravity Sewer Minimum. Design Criteria_flatest 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
concurrentlti with the approval of the permit, and projects requiring a variance approval mar• be subject to longer
review times. For proiects 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:
I, Jeremy A. Allen , attest that this application for Paliouras Force Main Relocation
(Professional Engineer's name from Application Item 111.1.) (Project Name from Application Item II.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,
MinimumDesL,n- Criteria far Gravim Sewers ( latest version,- and the Minimum Desi en Criteria for the Fast Track Permitting
of Pumn Stations and Force N Pains ( latest verdpM. 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)
:............\... N l.t.1/.I... ........
North Carolina Professional Engineer's seal, signature, and date: \\ '( A
O EM
7,y
a r,
y 34361
• F Z �• 1 .' � .
y
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:..........................................................
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, James Paliouras , attest that this application for Paliouras Force Main Relocation
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item H.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: Date: 2/7/2024
FORM: FTA 10-23 Page 5 of 5

nA�tg�--1 LIMITED LIABILITY COMPANY ANNUAL REPORT
,v
1012017
NAME OF LIMITED LIABILITY COMPANY: GEMCAP Development, LLC
SECRETARY OF STATE ID NUMBER: 1444920 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 7n71
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Kilpatrick Townsend & Stockton LLP
2. SIGNATURE OF THE NEW REGISTERED AGENT:
E - Filed Annual Report
1444920
CA202105501575
2/24/2021 10:00
Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
1001 West Fourth Street
Winston Salem, NC 27101-1029 Forsyth County
SECTION B: PRINCIPAL OFFICE INFORMATION
1001 West Fourth Street
Winston Salem, NC 27101-1029
1. DESCRIPTION OF NATURE OF BUSINESS: Commercial Development and Construction
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
418 N. Marshall St #201
Winston Salem, NC 27101
5. PRINCIPAL OFFICE MAILING ADDRESS
418 N. Marshall St #201
Winston Salem, NC 27101
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Paul Gray Williams
TITLE: Vice President
ADDRESS
418 N. Marshall St #201
Winston-Salem, NC 27101
NAME: George V Dunn
TITLE: Managing Member
ADDRESS:
418 N. Marshall St #201
Winston-Salem, NC 27101
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
George V Dunn
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
George V Dunn
2/24/2021
Managing Member
DATE
Print or Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525
■

SOSID:1444920
Date Filed: 5/12/2015 9:11:00 AM
Elaine F. Marshall
State of North Carolina North Carolina Secretary of State
Department of the Secretary of State C2015126 01007
Limited Liability Company
ARTICLES OF ORGANIZATION
Pursuant to §57D-2-20 of the General Statutes of North Carolina, the undersigned does hereby submit
these Articles of Organization for the purpose of forming a limited liability company.
1. The name of the limited liability company is: GRMCAP Holdings, LLC
2, The name and address of each person executing these articles of organization is as follows:
Kristan D. Bryant, Organizer
100 N. Cherry Street, Suite 600
Winston-Salem, NC 27101
3. The name of the initial registered agent is: George V. Dunn
4. The street address, mailing address and county of the initial registered office of the limited liability
company is:
Number and Street: 210 W. Fourth Street, Suite 200
City, State, Zip Code: Winston-Salem, NC 27101 County: Forsyth
5. The limited liability company has a principal office. The street address, mailing address and county
of the principal office of the limited liability company is:
Number and Street: 210 W. Fourth Street, Suite 200
City, State, Zip Code: Winston-Salem, NC 27101 County: Forsyth
6. These articles will be effective upon filing.
This is the 4' day of May, 2015.
Knsian D. Bryant, Organizer
CORPORATIONS DIVISION P.O. Box 29622 RALEIGH, NC 27626-0622
(Revised January 2014) 1 (Form L-Ol)
#649868v2

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State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: GEMCAP Development
Project Name for which flow is being requested: Paliouras Force Main Relocation
More than one FTSE may be required for a single project if the owner of the JVJVTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name:
b. WWTP Facility Permit #
Not owner of WWTP
: N/A
A11 flaws are in MGD
c. WWTP facility's permitted flow N/A
d. Estimated obligated flow not yet tributary to the WWTP N/A
e. WWTP facility's actual avg. flow N/A
f. Total flow for this specific request .0050
g. Total actual and obligated flows to the facility N/A
h. Percent of permitted flow used N/A
Il. 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) (S) (C) (D)=(B+C)
(E)=(A-D)
Design
Average Approx. Obligated,
Pump Pump Daily Current Not Yet Total Current
Station Station Firm Flow** Avg. Daily Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pt), Flow, Daily Flow, Obligated
Available
Number) No. MGD MGD MGD MGD Flow
Capacity***
Paliouras
W00037048 .086 .035 .004 .004 .008 _
.027
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Town of Hillsbrou` h
Downstream Pen -nit Number: Unknown
Page I of 6
FTSE 10-18

III. Certification Statement:
I /Y i,G_%Q f t,D. ! c I/ 01jr—S certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Officidl Signature
/ u l 0A N2 l r-\ `') / Qm b Q-r Pc, l t" o L& ey
Title of Signing Official
Date
Page 2 of 6
FTSE 1Q-18

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: GEMCAP Development
Project Name for which flow is being requested: Paliouras Force Main Relocation
More than one FTSE may be required for a singleproject if the owner of the WWTP is not responsible for allpump
stations along the route of the proposed wastewater low
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Town of HillsborouLb WWTP
b. WWTP Facility Permit #: NC0026433
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
Add flows are in MGD
3.0
0.483
1.083
.0050
1.571
52
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Design
Average
Approx.
Obligated,
Pump
Pump
Daily
Current
Not Yet
Total Current
Station
Station
Firm
Flow**
Avg. Daily
Tributary
Flow Plus
(Name or
Permit
Capacity, *
(Firm / pf),
Flow,
Daily Flow,
Obligated
Available
Number)
No.
MGD
MGD
MGD
MGD
Flow
Capacity***
E. Bradv
WQ0035536
1.584
.6336
.340
.1158
.4558
.1778
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): WWTP
Downstream Permit Number: As Above
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I K. Marie Strandwitz. PE certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
3/18/2022
Signing 01jicial Signature Date
Utilities Director
Title of Signing Official
Page 2 of 6
FTSE 10-18

MUM
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
March 31, 2014
Mr. James Paliouras
Paliouras Enterprises LLC c/o East West Partner Management Co.
1450 Environ Way
Chapel Hill, NC 27517
Subject: Permit No. WQ0037048
Paliouras Enterprises LLC
Paliouras Property
Wastewater Collection System Extension
Orange County
Dear Mr. Paliouras:
John E. Skvarla, III
Secretary
In accordance with your application received February 18, 2014, and additional information received on
March 27 and 31, 2014, we are forwarding herewith Permit No. WQ0037048, dated March 31, 2014, to
Paliouras Enterprises LLC for the construction and operation of the subject wastewater collection, system
extension. This permit shall be effective from the date of issuance until rescinded, and shall be subject to
the conditions and limitations as specified therein. This cover letter and supplement shall be considered a
part of this permit and are therefore incorporated therein by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 11.4: Requires that the wastewater collection facilities be properly operated and maintained in
accordance with 15A NCAC 2T .0403 or any individual system -wide collection system
permit issued to the Permittee.
It shall be responsibility of the Paliouras Enterprises LLC to ensure that the as -constructed project meets
the appropriate design criteria and rules. Failure to comply may result in penalties in accordance with
North Carolina General Statute §143-215.6A through §143-215.6C, construction of additional or
replacement wastewater collection facilities, and/or referral of the North Carolina -licensed Professional
Engineer to the licensing board.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This
request must be in the form of a written petition, conforming to Chapter 1508 of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-
6714. Unless such demands are made, this permit shall be final and binding.
1628 Mail Service Center, Ralegh, North Carolina 27699.1628
Location: 3800 Barrett Drive Ralegh, North Carona 27609
Phone: [phone] ; FAX- 919-788-7159
Internet: www.ncwaterouality.ona

i
If you need additional information concerning this matter, please contact Cheng Zhang at [phone] or
via e-mail at [e-mail].
Sincerely,
for Thomas A. Reeder, Director
Division of Water Resources, NCDENR
by S. Daniel Smith, Raleigh Region Water Quality Regional Operations Supervisor
Division of Water Resources, NCDENR
cc: David Lutz, P.E., CES Group Engineers, LLP, Denver, NC 28037
Orange County Health Department
Raleigh Regional Office, Water Quality Regional Operations
Water Resources Central Files
PERCS (electronic copy)

NODE iR
STATE OF NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
Paliouras Enterprises LLC
Orange County
for the construction and operation of approximately 270 linear feet of 8-inch gravity sewer, a 60—gallon per
minute pump station, as well as approximately 540 linear feet of 3-inch force main to serve a convenience
store, a pharmacy, a car wash, and a carry out only restaurant as part of the Paliouras Property y project, and
the discharge of 8,100 gallons per day of collected domestic wastewater into the City of Hillsborough's
existing sewerage system, pursuant to the application received February 18, 2014, and additional
information received on March 27 and 31, 2014, and in conformity with 15A NCAC 2T; the Division's Gravity
Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design
Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable;
and other supporting data subsequently filed and approved by the Department of Environment and Natural
Resources and considered a part of this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
Permit issued this the 31s day f-March, ZG14.
✓ /
for Thomas A. Reeder, Director
Division of Water Resources, NCDENR
By Authority of The Environmental Management Commission
Permit Number: WQ0037048

SUPPLEMENT TO PERMIT COVER SHEET
Paliouras Enterprises LLC is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the Hillsborough Wastewater
Treatment Facility (NC0026433) prior to being discharged into the receiving stream.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted .tune 1, 2000 as applicable, unless specifically mentioned herein. Division approval is
based on acceptance of the certification provided by a North Carolina -licensed Professional Engineer in the
application. It shall be the Permittee's responsibility to ensure that the as -constructed project meets the
appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
1. SPECIAL CONDITIONS
I. The Operational Agreement between the Permittee and the Environmental Management Commission is
incorporated herein by reference and shall be a condition of this permit. Noncompliance with the terms of the
Operational Agreement shall subject the Permittee to all sanctions provided by North Carolina General Statutes
§143-215.6A to §143-215.6C for violation of or failure to act in accordance with the terms and conditions of this
permit.
II. STANDARD CONDITIONS
1. This permit shall not be transferable. In the event there is a desire for the wastewater collection facilities to
change ownership, or there is a name change of the Permittee, a formal permit request shall be submitted to the
Division accompanied by documentation from the parties involved, and other supporting materials as may be
appropriate. The approval of this request shall be considered on its merits and may or may not be approved.
2. This permit shall become voidable unless the wastewater collection facilities are constructed in accordance with
the conditions of this permit; 15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted
February 12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump
Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting materials unless specifically
mentioned herein.
3. This permit shall be effective only with respect to the nature and volume of wastes described in the application
and other supporting data.
4. The wastewater collection facilities shall be properly maintained and operated at all times. The Permittee shall
maintain compliance with an individual system -wide collection system permit for the operation and maintenance
of these facilities as required by 15A NCAC 2T .0403. If an individual permit is not required, the following
performance criteria shall be met as provided in 15A NCAC 2T .0403:
a. The sewer system shall be effectively maintained and operated at all times to prevent discharge to land or
surface waters, and to prevent any contravention of groundwater standards or surface water standards.

1 � .
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative maintenance
schedule, spare parts inventory and overflow response has been developed and implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365 days per
year). Pump stations that are connected to a telemetry system shall be inspected at least once per week.
e. High -priority sewer lines shall be inspected at least once per every six -months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance with 15A
NCAC 28 .0506(a), and public notice shall be provided as required by North Carolina General Statute §143-
215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least biannual
distribution of educational materials for both commercial and residential users and the legal means to
require grease interceptors at existing establishments. The plan shall also include legal means for
inspections of the grease interceptors, enforcement for violators and the legal means to control grease
entering the system from other public and private satellite sewer systems.,
2. For privately owned collection systems, the Grease Control Program shall include at least bi-annual
distribution of grease education materials to users of the collection system by the permittee or its
representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2) of this
Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
i. Right-of-ways and easements shall be maintained in the full easement width for personnel and equipment
accessibility.
j. Documentation shall be kept for Subparagraphs (a) through (1) of this Rule for a minimum of three years with
exception of the map, which shall be maintained for the life of the system.
S. Noncomoliance Notification:
The Permittee shall report by telephone to a water resources staff member at the Raleigh Regional Office,
telephone number 919-791-4200, as soon as possible, but in no case more than 24 hours or on the next working
day, following the occurrence or first knowledge of the occurrence of either of the following:
a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable of
adequate wastewater transport, such as mechanical or electrical failures of pumps, line blockage or
breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Voice mail messages or faxed information is permissible, but this shall not be considered as the initial verbal
report. Overflows and spills occurring outside normal business hours may also be reported to the Division of
Emergency Management at telephone number [phone] or [phone]. Persons reporting any of the
above occurrences shall file a spill report by completing and submitting Part I of Form CS-SSO (or the most current

e
Division approved form) within five days following first knowledge of the occurrence. This report must outline the
actions taken or proposed to be taken to ensure that the problem does not recur. Part 11 of Form CS-SSO (or the
most current Division approved form) can also be completed to show that the SSO was beyond control.
6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to interrupt
service by the existing utilities nor result in an overflow or bypass discharge of wastewater to the surface waters
of the State.
7. Per 15A NCAC 2T.0116, upon completion of construction and prior to operation of these permitted facilities, the
completed Engineering Certification form attached to this permit shall be submitted with the required supporting
documents to the address provided on the form. A complete certification is one where the form is fully executed
and the supporting documents are provided as applicable. Any wastewater flow made tributary to the
wastewater collection system extension prior to completion of this Engineer's Certification shall be considered a
violation of the permit and shall subject the Permittee to appropriate enforcement actions.
If the permit is issued to a private entity with an Operational Agreement, then a copy of the Articles of
Incorporation, Declarations/Covenants/Restrictions, and Bylaws that have been appropriately filed with the
applicable County's Register of Deeds office shall be submitted with the certification.
A complete certification is one where the form is fully executed and the supporting documents are provided as
applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings (plan & profile views of sewer lines & force mains) of
the wastewater collection system extension. Final record drawings should be clear on the plans or on digital
media (CD or DVD disk) and are defined as the design drawings that are marked up or annotated with after
construction information and show required buffers, separation distances, material changes, etc.
b. One copy of the supporting pump station design calculations (selected pumps, system curve, operating point,
buoyancy calculations, available storage if portable generator(s) or storage greater than longest past three
year outage reliability option selected) for any pump stations permitted as part of this project.
c. Changes to the project that do not result in non-compliance with this permit, regulations, or the Minimum
Design Criteria should be clearly identified on the record drawings, on the certification In the space provided,
or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting in non-
compliance with this permit (including pipe length increases of 10% or greater, increased flow, pump station
design capacity design increases of 5% or greater, and increases in the number/type of connections), regulations,
or the Minimum Design Criteria. Requested modifications or variances to the Minimum Design Criteria will be
reviewed on a case -by -case basis and each on its own merit. Please note that variances to the Minimum Design
Criteria should be requested and approved during the permitting process prior to construction. After -
construction requests are discouraged by the Division and may not be approved, thus requiring replacement or
repair prior to certification & activation.
8. A copy of the construction record drawings shall be maintained on file by the Permittee for the life of the
wastewater collection facilities.
9. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2T; the Division's Gravity
Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for the
Fast -Track Permitting of Pump Station and Force Mains adopted June 1, 2000 as applicable; and other supporting
materials may subject the Permittee to an enforcement action by the Division, in accordance with North Carolina
General Statutes §143-215.6A through §143-215.6C, construction of additional or replacement wastewater
collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to the licensing board.

10. In the event that the wastewater collection facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action, including those as may be required by
this Division, such as the construction of additional or replacement facilities.
11. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes, rules,
regulations, or ordinances that may be imposed by other government agencies (local, state and federal) which
have jurisdiction, including but not limited to applicable river buffer rules in 15A NCAC 28 .0200, erosion and
sedimentation control requirements in 15A NCAC Ch. 4 and under the Division's Genera( Permit NCG010000, and
any requirements pertaining to wetlands under 15A NCAC 28.0200 and 15A NCAC 2H .0500.

Fast Track EMinee
Ang Certification
M
Permittee: Paliouras Enterprises LLC
Project: Paliouras Property
Complete and submit this form to the permit issuing regional office with the following:
Permit No: WQ0037048
Issue Date: 31/03/14
• One copy of the project record drawings (plan & profile views arld detail drawings of sewer lines) of the wastewater
collection system extension. Final record drawings should be clear on the plaits or on digital media (CD or DVD disk) in pdf
format. Record drawings should indicate the design and the marked up changes during construction.
• Supporting design calculations (selected pumps, system curve, operating point, available storage if portable generator(s) or
storage greater than longest past three year outage reliability option selected) for any pump stations permitted as part of
this project
• Changes to the project should be clearly identified on the record drawings or in written summary form. Permit
modifications are required for any changes resulting In non-compliance with this Permit, regulations or minimum design
criterla. Modifications should be submitted Prior to certification.
This project shall not be considered complete nor allowed to operate until the Division has received this Engineer's Certification
and all required supporting documentation. Therefore it is highly recommended that this certification be sent In a manner
that ravides raaf of recei t b the Division.
PERMnTEE'S CERTIFICATION
1, , the undersigned agent for the Permittee, hereby state that this project has been
constructed pursuant to the applicable standards & requirements, the Professional Engineer below has provided
applicable design/construction information to the Permittee, and the Permittee is prepared to operate & maintain the
wastewater collection system permitted herein or portions thereof.
Printed Name, Title
Signature
Date
ENGINEER'S CERTIFICATION
❑ Partial 0 Final
1, as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observe (❑ periodically, ❑ weekly, ❑ full time) the construction of the subject project for the
Permittee hereby state that, to the best of my abilities, due care and diligence was used in the observation of the
construction such that the construction was observed to be built within substantial compliance of this permit; iSA NCAC
02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as
applicable; and other supporting materials.
North Carolina Professional Engineer's
Seal, signature, and date:
SEND THIS FORM & SUPPORTING DOCUMENTATION
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS
SURFACE WATER PROTECTION SUPERVISOR
Raleigh REGIONAL OFFICE
3800 Barrett Drive
Raleigh, NC 27609
The Permittee is responsible for tracking all partial certifications up until a final certification is received. Any wastewater
flow made tributary to the wastewater collection system extension prior to completion of this Engineer's Certification
shall be considered a violation of the permit and shall subject the Permittee to appropriate enforcement actions.
DWR Use Only
Flow from this project is tributary to:

STATE OF NORTH CAROLINA
COUNTY OF Permit No.
DEVELOPER'S OPERATIONAL AGREEMENT
This AGREEMENT made pursuant to G.S. 143-215.1 (d 1) and entered into this day of
_ 2/1veiny d O 1 � , by and between the North Carolina Environmental Management
Commission, an agency of the State of North Carolina, hereinafter known as the COMMISSION; and
pe?.L2 vw-- ' rn r�crf`"es, _ , a corporation/general partnership registered/licensed to do
business in the State of North Carolina, hereinafter known as the DEVELOPER.
WITNESSETH:
1. The DEVELOPER is the owner of the certain lands lying ind County, upon
which it is erecting and will erect dwelling units and other improvements, said development to be known
as ,pro posed .sCrvAC -51� '0�_ ^� i% 5&nd (hereinafter the Development).
2. The DEVELOPER desires, to construct a wastewater collection system with pumps, wastewater treatment
works, and/or disposal facilities (hereinafter Disposal System) to provide sanitary sewage disposal to serve
the Development on said lands.
3. The DEVELOPER has applied to the COMMISSION for the issuance of a permit pursuant to G.S. 143-
215.1 to construct, maintain, and operate the Disposal System.
4. The DEVELOPER has created or shall create unit ownership in said dwellings units, other improvements
and lands through fling of a Declaration of Unit Ownership (hereinafter Declaration), pursuant to Chapter
47C or 47F of the North Carolina General Statutes.
5. The DEVELOPER has caused to be formed or will cause to be formed at the time of filing of the
Declaration, the (Unit Owners' Association) _ _ (hereinafter
Association), a non-profit corporation organized and existing under and by the virtue of the laws of the
State of North Carolina, for the purpose, among others, of handling the property, affairs and business of
the Development; of operating, maintaining, re -constructing and repairing the common elements of the
lands and improvements subject to unit ownership, including the Disposal System; and of collecting dues
and assessments to provide funds for such operation, maintenance, re -construction and repair.
6. The COMMISSION desires to assure that the Disposal System of the Development is properly
constructed, maintained and operated in accordance with law and permit provisions in order to protect the
quality of the waters of the State and the public interest therein.
NOW, THEREFORE, in consideration of the promises and the benefits to be derived by each of the parties
hereto, the COMMISSION and DEVELOPER do hereby mutually agree as follows:
I. The DEVELOPER shall construct the Disposal System in accordance with the permit and plans and
specifications hereafter issued and approved by the COMMISSION, and shall thereafter properly operate
and maintain such systems and facilities in accordance with applicable permit provisions and law.
2. The DEVELOPER shall not transfer ownership and/or control of the Disposal System to the Association
until construction has been completed in accordance with the permit and approved plans, and the staff of
the Division of Water Resources has inspected and approved of the facilities. In order to change the name
of the permit holder, the DEVELOPER must request that the permit be reissued to the Association. The
request must include a copy of the Association Bylaws and Declaration.
3. The DEVELOPER shall not transfer, convey, assign or otherwise relinquish or release its responsibility
for the operation and maintenance of its Disposal System until a permit has been reissued to the
DEVELOPER's successor.
FORM: DEV OS-13 Page I oft

4. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System and F
appurtenances thereto are part of the common elements and shall thereafter be properly maintained and
operated in conformity with law and the provisions of the permit for construction, operation, repair, and
maintenance of the system and facilities. The Declaration and Bylaws shall identify the entire wastewater
treatment, collection and disposal system as a common element which will receive the highest priority for
expenditures by the Association except for Federal, State, and local taxes and insurance.
5. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System will
be maintained out of the common expenses. in order to assure that there shall be funds readily available to
repair, maintain or construct the Disposal System, beyond the routine operation and maintenance
expenses, the Declaration and Association Bylaws shall provide that a fund be created out of the common
expenses. Such fund shall be separate from the routine maintenance funds allocated for the facility and
shall be part of the yearly budget.
6. In the event the common expense allocation and separate fund are not adequate for the construction,
repair, and maintenance of the Disposal System, the Declaration and Association Bylaws shall provide for
special assessments to cover such necessary costs. There shall be no limit on the amount of such
assessments, and the Declaration and Bylaws shall provide that such special assessments can be made as
necessary at any time.
7. If a wastewater collection system and wastewater treatment and/or disposal facility provided by any city,
town, village, county, water and sewer authorities, or other unit of government shall hereinafter become
available to serve the Development, the DEVELOPER shall take such action as is necessary to cause the
existing and future wastewater of the Development to be accepted and discharged into said governmental
system, and shall convey or transfer as much of the Disposal System and such necessary easements as the
governmental unit may require as condition of accepting the Development's wastewater.
8. Recognizing that it would be contrary to the public interest and to the public health, safety and welfare for
the Association to enter into voluntary dissolution without having made adequate provision for the
continued proper maintenance, repair and operation of its Disposal System, the DEVELOPER shall
provide in the Association Bylaws that the Association shall not enter into voluntary dissolution without
first having transferred its said system and facilities to some person, corporation or other entity acceptable
to and approved by the COMMISSION by the issuance of a permit.
9. The agreements set forth in numbered paragraphs 1, 2, 3, 4, 5, 6, 7, and 8 above shall be conditions of any
permit issued by the COMMISSION to the DEVELOPER for the construction, maintenance, repair and
operation of the Disposal System.
10. A copy of this agreement shall be filed at the Register of Deeds in the County(ies) where the Declaration is
filed and in the offices of the Secretary of State of North Carolina with the Articles of Incorporation of the
Association.
IN WITNESS WHEREOF, this agreement was executed in duplicate originals by the duly authorized
representative of the parties hereto on the day and year written as indicated by each of the parties named below:
FOR THE ENVIRONMENTAL
MANAGEMENT COMMISSION
Thomas A. Reeder, Director
Division of Water Resources
(Date)
Name of DEVELOPER
Bv.()r7 Am" (4rz7 (��Y!!x�
(Sipp6ture)
Print Name and Title
eby
(Date)
FORM: DEV 08-13 Page 2 of 2

' Permittee; Paliouras Enterprises LLC Fast Track En ineerin Certification
Project: Paliouras Property
Complete and submit tUi form to the permit Issuing regional office with the following:
Permit No: WQ0037048
Issue Date: 31/03/14
One copy of the project record drawings (plan & profile views and detail drawings of sewer lines) of the wastewater
collection system extension. Final record drawings should be clear on the plans or on digital media (CD or DVD disk) in pdf
format. Record drawings should indicate the design and the marked up changes during construction.
Supporting design calculations (selected pumps, system curve, operating point, available storage if portable generator(s) or
storage greater than longest past three year outage reliability option selected) for any pump stations permitted as part of
this project
+ Changes to the project should be clearly identified on the record drawings or in written summary form. Permit
modifications are required for anv than es resultin In non-com 311ance with this en rmit, regulations or mini -mum design
criteria. Modifications should be submitted prior to certification.
This project shall not be considered complete nor allowed to operate until the Division has received this Engineer's Certification
and all required supporting documentation. Therefore it is highly recommended that this certification be sent in a manner
that provides aroof of r_ eceit bLthe Division.
PERMITTEE'S CERTIFICATION I
the undersigned agent for the Permittee, hereby state that this project has been
constructed pursuant to the applicable standards & requirements, the Professional Engineer below has provided
applicable design/construction information to the Permittee, and the Permittee Is prepared to operate & maintain the
wastewater collection system permitted herein or portions thereof.
VAv D Lrr 2 z T,�t /L a
b 9I rk
Printed Name, Title Signature Date
ENGINEER'S CERTIFICATION
❑ Partial a ,FInaI
04 t' �.T� : as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observeeriodically, ❑ weekly, ❑ full time) the construction of the subject project for the
Permittee hereby state that, to the best of my abilities, due care and diligence was used in the observation of the
construction such that the construction was observed to be built within substantial compliance of this permit; 15A NCAq,
02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Divislon'
Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 a
applicable; and other supporting materials.
North Carolina Professional Engineer's
Seal, signature, and date:
SEND THIS FORM & SUPPORTING DOCUIViENTA
WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADD
SURFACE WATER PROTECTION SUPERVISOR(
Raleigh REGIONAL OFFICE
3800 Barrett Drive
Raleigh, NC 27609
The Permittee is responsible for tracking all partial certifications up until a final certification is received. Any wastewater
flow made tributary to the wastewater collection system extension prior to completion of this Engineer's Certification
shall be considered a violation of the permit and shall subject the Permittee to appropriate enforcement actions.
DWR Use Only - - -- —
Flow from this project is tributary to: