WQSV00006_Application_20240213 (3)

State of North Carolina
DW'R
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02T .0105 — VARIANCE/ALTERNATIVE DESIGN REQUEST
Division of Water Resources INSTRUCTIONS FOR FORM: VADC 10-23 & SUPPORTING DOCUMENTATION
Plans, specifications and supporting documents shall be prepared in accordance with, 15A NCAC 02T .01009 15A NCAC 02T
.0300, Division Policies and good engineering ractices. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the request.
For more information, visit the Wastewater Branch's website at:
htrr: //portal. ncdenr. org/web/wq/swp/ps/cs/ext
General — When submitting a request, 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. Unless otherwise noted, submit one original and one copy of the request and
supporting documentation.
A. Cover Letter (Required for All Request Packages):
® List all items included in the request package and a brief description of the requested permitting action.
® Submit a detailed description of specific criteria that a variance request is submitted for.
15A NCAC 02T, Minimum Design Criteria (MDC) for the permitting of Gravity Sewers, &
Minimum Design Criteria (MDC) for the Permitting of Pum Stations and Force Mains
® Submit a detailed description why the project cannot comply with 15A NCAC 02T or adopted design criteria.
® Submit a detailed description of how the alternative design will meet the requirements of _15A NCAC 02T .0105(n)
B. Application Fee:
® Submit a check or money order in the amount of $600.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ).
C. Request Form (VADC 10-23) (Required for All Request Packages):
® Submit the completed and appropriately executed VADC 10-23 request form.
® The Applicant's certification of the request shall be signed in accordance with 15A NCAC 02T.106(b). Per 15A
NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided
from a person who meets the criteria in 15A NCAC 02T.0106(b).
® The Professional Engineer's Certification of the request shall be signed, sealed and dated by a North Carolina licensed
Professional Engineer.
D. Engineering Plans (Required for All Request Packages):
® Submit one set of detailed plans that have been signed, sealed and dated by a North Carolina licensed Professional
Engineer, pertinent to the variance request. Individual plan sheets related to the request may be submitted instead of
complete plan sets.
® Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY,
NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final plans. However, the plans may be
labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
E. Specifications (Required for All Request Packages): -
® Per 15A NCAC 02T .0304(2)(2), submit specifications that have been signed, sealed and dated by a North Carolina
licensed Professional Engineer, pertinent to the variance request.
® Specifications shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW
ONLY, NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However,
the specifications may be labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
F. Engineering Calculations (All Request Packages):
® Per 15A NCAC 02T .0305(b)(3), submit engineering calculations that have been signed, sealed and dated by a North
Carolina licensed Professional Engineer, pertinent to the variance request.
INSTRUCTIONS FOR FORM: VADC 10-23 & SUPPORTING DOCUMENTATION Pagel of 2

G. Applicable Sewer Extension Application and Supporting Documentation
(Required if submitted in conjunction with a variance request)
® Submit the completed and appropriately executed application if provided in conjunction with the request.
➢ This is exclusive to projects requiring a full technical review (ASEA 10-23 & SSEA 10-23).
➢ Submission of FTA 10-23 and supporting documents to the regional office is only allowed once the variance has
been auvroved by the Central Office. Submission prior will result in the application beine returned.
15A NCAC 02T.0105 — Select Code Related to Variance / Alternative Design Criteria
(b)... The applicant shall provide adequate documentation to the Division to ensure that the proposed system will meet all
design and performance criteria as required under this Subchapter and other applicable rules, be operated as a non -discharge
system, and protect surface water and groundwater standards. Variances to this Subchapter or adopted design criteria must
be specifically requested in the application and, if approved pursuant to Paragraph (n) of this Rule, incorporated into
the permit. The Division may accept certification from a licensed or certified professional (e.g. Professional Engineers,
Licensed Soil Scientist, Licensed Geologist, Technical Specialist) that the design meets or exceeds minimum design criteria
applicable to the project. Division acceptance of certifications by the applicant or by licensed or certified professionals
preparing reports for the application shall not constitute approval of a variance to this Subchapter or applicable minimum design
and performance criteria unless specifically requested in the application and approved in the permit.
(n) The Director shall approve alternative Design Criteria in cases where the applicant can demonstrate that the alternative
design criteria will provide the following:
(1) equal or better treatment of the waste;
(2) equal or better protection of the waters of the state; and
(3) no increased potential for nuisance conditions from noise, odor or vermin.
THE COMPLETED REQUEST AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
ATTENTION: PERCS UNIT SUPERVISOR
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY ST. SUITE 925
RALEIGH, NORTH CAROLINA 27604
INSTRUCTIONS FOR FORM: VADC 10-23 & SUPPORTING DOCUMENTATION Page 2 of 2

DWR
Division of Water Resources
Application Number:
I. APPLICANT INFORMATION:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02T .0105 — VARIANCE/ALTERNATIVE DESIGN REQUEST
VADC 10-23 & SUPPORTING DOCUMENTATION
(if applicable, to be completed by DWR)
1. Applicant's name: Paliouras Enterprises, I1C
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership
❑ Federal ❑ State ❑ Municipal
3. Signature authority's name: James Paliouras per 15A NCAC 02T .0106(b).
4. Applicant's mailing address: PO Box 715
City: Chapel Hill State: NC Zip: 27514-
5. Applicant's contact information:
Phone number: [phone] Email Address: Jobaltraveln ahoo.com
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ County
1. Project name: Paliouras FM Relocation
2. Project status: ❑ Proposed ® Existing (if existing, Permit Number: W0003704_8. )
1. Professional Engineer: Jerem,, A. Allen License Number: 34361
Firm: Highfill Infrastructure Eneineerin_,_ P.C.
Mailing address: 2703 Jones Franklin Rd.
City: Cary State: NC Zip: 27518-
Phone number: [phone] Email Address: [e-mail]
IV. VARIANCE REQUEST:
Title: Managing Member
1. Provide a detailed list of specific criteria that a variance request is submitted for:
(e.g., NCAC 02T.0305(f) - Separation, MDC for Pump Stations / Force Mains 3.04(A)(1)(b) — Discharge Piping Velocity, etc)
MDC for Pum:) Stations / Force Mains 4.02.A.1
FORM: VADC 10-23 Pagel of 2

DocuSign Envelope ID: 98439D51-D2A5-4E83-922E-A1A18A94AOOA
Applicant's Certification per 15A NCAC 02T .0106(b1:
James Paliouras
(Signature Authority's name & title from Request Item 1.3.)
Paliouras Force Main Relocation
(Project name from Request Item 11.1.)
attest that this request for
has been reviewed by me and is accurate and complete to the best of my knowledge. I also understand that if all required parts of
this request package are not completed and that if all required supporting information and attachments are not included, this
request package will be returned to me as incomplete. I understand that by certifying this variance request, 1 shall adhere to the
requirements of the variance approval should it be approved and all permit conditions should the permit be approved.
NOTE — In accordance with General Statutes 143-215.6A and 1 , any person who knowingly makes any false statement,
representation, or certification in any request 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.
��s 2/7/2024
Signature: I
Date:
Professional Engineer's Certification:
1, Jeremy A. Allen attest that this request for
(Professional Engineer's name from Request Item III.1.)
Paliouras Force Main Relocation
(Project name from Request Item I1.1.)
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, in accordance with i5A NCA —, .010S( I will provide, equal or better treatment of the
waste; egual or better protection of the waters of the state, and no increased potential for nuisance conditions from noise. odor.
or vermin. I further attest as been prepared in accordance with this request package and its instructions, as well as all applicable
regulations and statutes. 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_ 21� any person who knowingly makes any false statement,
representation, or certification in any request package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
FORM: VADC 10-23 Page 2 of 2