WQ0045301_Application (FTSE)_20240418

DWR
Division of Water Resources
A ECEIVEDINCDEN R/D W R
State of North Carolina
APR _ii JOHment of Environmental Quality
Division of Water Resources
FAST T�2AC �&P EXTENSION APPLICATION
INSTRUCTIONS FOR Fr'SW'P§20S1Yti §gd'ORTING 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 forth.
➢ 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 11.1. of the application).
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $600.00, dated no more than 90 days prior to application submittal.
➢ Payable 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 1.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item 11.1 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: ETA 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(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).
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)
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/Propertv Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b). submit the properly executed Operational Agreement (FORM: DEV ).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 3

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water 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 Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources VIA 10-23 & SUPPORTING DOCUMENTATION
Application Number: Mop 3 O 1 (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Cvoress Glen Retirement Community (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 time: Laurie Stallings per 15A NCAC 02T .0106(b)
Title: Executive Director
4. Applicant's mailing address: 100 Hickory St
City: Greenville State: NC Zip: 27858-,
5. Applicant's contact information:
Phone number: [phone] Email Address: Istallings(@,umrh.org
II. PROJECT INFORMATION:
1. Project name: Cypress Glen Retirement Community Expansion
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project ❑ ARPA funded
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
3. County where project is located: Pitt
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.610776' Longitude:-77.347289'
5. Parcel ID (if applicable): 057242 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Michelle Clements License Number: 029422
Firth: The East Group
Mailing address: 324 Evans St
City: Greenville State: NC Zip: 27858-_
Phone number: (2) 758-3746 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: GUC WWTP Permit Number: NCO023931
Owner Name: Greenville Utilities Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): W00010804
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System PermitNumber(s)(if applicable):WQCS.. S='-000I%
Owner Name(s): Greenville Utilities Commission
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/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Asreement (FORM: DEVI been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Aereement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply)
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ® Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial _ % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes[] No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(t)? ❑ Yes ® No
➢ If yes, provide a cony of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow •,b
No. of Units
Flow
Convalescent, nursing, rest homes with
laundryfacilities
120 gal/bed
180
12,960 GPD
gal/
GPD
gal/ /
GPD
gal/
GPD
gal/ i
GPD
gal/
GPD
pk11 a-
Total
12,960 GPD
♦l .
a See 15A NCAC 02T .0114(bl. W. (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: 12960 GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted now 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

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 inch 1,164 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 (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.l.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(H:
❑ 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(f) & (a)? ® Yes ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter"
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'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 021'.0305(f) or (a), see Section XI of this application
*15A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpaee
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
➢ 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: Tar -Pamlico ❑ 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 coveragetauthorization 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.
➢ 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 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:
I, mtey�Ale n .6kroft ,S , attest that this application for dm mr m 0en 1{4MC1MliPf [OLAMA4AM�4
(Professional Engineer's name from Application Item 111.1.) ct Name from Application Item It.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 version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
0 EEssi�
SEAL 9r''
029422L Mfg
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Laurie H. Stallings. Executive Director , attest that this application for Cy -press Glen Retirement Community
(Signature Authority Name from Application Item 1.3.) (Project Name from Application Item 11.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance 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.
FORM: FTA 10-23 Page 5 of 5

Vinson, Scott
From: Michelle Clements <[e-mail]>
Sent: Wednesday, April 17, 2024 5:12 PM
To: Vinson, Scott
Subject: RE: [External] RE: Cypress Glen Retirement Community Fast Track Sewer Application
Attachments: Page 5 Cypress Glen Sewer Application.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Scott,
Thanks for the feedback and the questions. I reached out to the Architect to verify and found out that we have 51— 2
bedroom units and 6 1- bedroom units so a total of 108 beds @ 120 GPD = 12,960. So the total number was correct, just
the number of beds got transposed.
I've updated page 5 and it is attached.
RECENEDINODENt
Thanks for your help,
Michelle Clements, PE
APR 1 a ?024
Senior Civil Engineer i Land Planning and Infrastructure Team Leader
Oust" fiction
THE EAST GROUP
w ope Ofll�
324 Evans Street i Greenville, NC 27858
wasshi�9tonPegtonal
Cell: [phone] i Office: [phone]
[e-mail] i www.eastgroup.com
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From: Vinson, Scott <[e-mail]>
Sent: Tuesday, April 16, 2024 4:53 PM
To: Michelle Clements<[e-mail]>
Subject: RE: [External] RE: Cypress Glen Retirement Community Fast Track Sewer Application
Michelle,
With Cypress Glen proposing 159 beds at 120 gaVbed, does that mean they are now proposing 19,080 GPD of
Flow instead of 12,960 GPD?
If so, please revise the narrative as well as Page 2 of 5 of the application and email a copy to replace those in the
application file.
Thanks,
Scott
Scott Vinson
Environmental Engineer
Washington Regional Office
Water Quality Regional Operations Section
NCDEQ — Division of Water Resources
943 Washington Square Mall

Washington, NC 27889
[phone] office
[phone] direct line
Email: Scott.Vinson(a)deg.nc.gov
�EQ�
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
From: Michelle Clements <[e-mail]>
Sent: Tuesday, April 16, 2024 1:00 PM
To: Vinson, Scott <[e-mail]>
Subject: [External] RE: Cypress Glen Retirement Community Fast Track Sewer Application
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Scott,
Hope you are doing well.
Thanks for catching that. We do have 57 units and they are a combination of 1, 2 and 3 bedroom units. The 180 beds
was an estimate but in reviewing the Arch plans it looks like we will actually have 159 beds.
Let me know if we need to revise anything.
Thanks,
Michelle Clements, PE
Senior Civil Engineer I Land Planning and Infrastructure Team Leader
THE EAST GROUP
324 Evans Street [ Greenville, NC 27858
Cell: [phone] [ Office: [phone]
michelle.clements(deastgroup.com [ www.eastgroup.com
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From: Vinson, Scott <[e-mail]>
Sent: Tuesday, April 16, 2024 12:36 PM
To: Michelle Clements <[e-mail]>
Subject: Cypress Glen Retirement Community Fast Track Sewer Application
Michelle,
We are processingyour application for the Cypress Glen Sewer Extension project and have a question about the
proposed Flow calculation. The narrative speaks of 57 new living units and page 2 of 5 on the Application gives 180
Units at 12Ogal/bed (Convalescent, nursing, rest homes w/ laundry facilities rate) for a total new Flow of 12,960
GPD.
Could you please clarify the new of Units and/or number of beds per Unit to help quantify the total new Flow of
12,960 GPD?

Everything else looks fine and I am drafting up the permit for review once this information can be submitted.
Thanks,
Scott
Scott Vinson
Environmental Engineer
Washington Regional Office
Water Quality Regional Operations Section
NCDEQ — Division of Water Resources
943 Washington Square Mall
Washington, NC 27889
[phone] office
[phone] direct line
Email: Scott.Vinson0deo.nc.00v
D_EQ�
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized
stale official.

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/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Aereement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned)
❑ Retail (stores, centers, malls)
❑ Car Wash
® Residential (Leased)
❑ Retail with food preparation/service
❑ Hotel and/or Motels
❑ School / preschool / day care
❑ Medical / dental / veterinary facilities
❑ Swimming Pool/Clubhouse
❑ Food and drink facilities
❑ Church
❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories
® Nursing Home
❑ Other (Explain in Attachment)
5. Nature of wastewater: !K% Domestic _% Commercial _ % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ® No
➢ if ves, provide a cony of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Tvpe (see 02T.0114(f))
Daily Design Flow ••b
No. of Units
Flow
Convalescent, nursing, rest homes with
laundry facilities
120 gallbed
108
12,960 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gaV
GPD
Total
12,960 GPD
a See ISA NCAC 02T .0114(b). (d). (e)(I) and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 12960 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): aoy;01euo16ay utioultlsem
RECEIVED/NCDENR/DWR uogoeS suolle.adQ leuoifiau
l4l�enp reteryt
FORM: FTA 10-23
APR 18 2024
`Nalor Quality
}i Regional Gpwations Section
Washington Regional offio9
VZU 81 add
8MG/dN3G0N/03Al3031J
Page 2 of 5

Page 1 of 1 RECENEDiNCDENR/DWR
THE
SO EAST
ff
APR _ 3 2024
Water Ouality
Corporate Office
NCDEQ Regional Operations Section
Washington Regional Office
324 Evau St
Division of Water Quality
GreerMile
NC 27858
Washington Regional Office
Tel 252,758.3746
943 Washington Square Mall
Fax [phone]U
Washington, NC 27889
Raleigh Office
Re: Fast Track Sewer System Extension Application
4326 Lake Bowe Trail
Cypress Glen Retirement Community
Sui
Ralei h11
Greenville, NC
NC 27607
Tel 919,784.9330
Please find included a complete application package for the referenced project.
Fax [phone]
This project is the expansion of an existing Senior Living Community that will add 57 vnrxsasg oup.can
new living units to the campus. The sewer extension being proposed for this project will
be private and connect to an existing public sewer main owned by Greenville Utilities
Commission. The total anticipated additional flow from this project is 12,960 GPD. A
letter from Greenville Utilities Commission accepting the additional flow and confirming
available capacity of the system is included with this package.
This project is privately funded.
Enclosed please find the following:
A. Original and one copy of the application and supporting documents
B. Cover Letter
C. Application Fee
U. F' 1 A Application slgnea Cy VWner an0 M, Him.
E. Flow Tracking Form Signed by Greenville Utilities Commission
F. USGS Topographic Map
Please let me know if you have any questions or comments about the information
provided within.
Thank you,
Michelle S. Clements, PE
The East Group
[e-mail]
252-758-3746
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Greenville
Utilities
April 2, 2024
Ms. Laurie Stallings, Executive Director
Cypress Glen Retirement Community
100 Hickory Street
Greenville, NC 27858
Re: Private Sanitary Sewer Main Extension
Cypress Glen Retirement Community Expansion Project
Greenville, NC
Wastewater Flow Acceptance
Dear Ms. Stallings:
This letter is to confirm that Greenville Utilities Commission has adequate capacity
for and will accept the wastewater discharge from the above referenced project in
the design amount of 12,960 GPD. The receiving facility will be Greenville Utilities
Commission Wastewater Treatment Plant (NC0023931).
If you should have any questions or require any additional information concerning
this matter, please contact me at 252-551-1551.
Sincerely,
Clifton H. Cahoon, P.E.
Water Resources Construction/Contracts Engineer
Greenville Utilities Commission
cc: Mr. Anthony C. Cannon, General Manager/CEO
Mr. David W. Springer, P.E., Director of Water Resources
Mr. J. Scott Farmer, PE, Assistant Director of Water Resources
Ms. Michelle Clements, PE, The East Group
Connected To You Post Office Box 1847 1 Greenville, North Carolina 27835-1847 1 guc.com 1 252-752-7166

State of North Carolina
Department of Environmental Quality
Division of Water Resources
of water Resources Flow Track ing/Acceptancc for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: Cypress Glen Retirement Community
Project Name for which flow is being requested: Cypress Glen Expansion
More than one F'TSE may be requiredfor a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewaterflow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Greenville Utilities Commission
b. WWTP Facility Permit #: NCO023931
AlI lows are in MGD
c. WWTP facility's permitted flow 17.5
d. Estimated obligated flow not yet tributary to the WWTP 2.926
e. WWTP facility's actual avg. flow 10.426
f. Total flow for this specific request .013
g. Total actual and obligated flows to the facility 13.365
It. Percent of permitted flow used 76.369
I1. 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,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, • (Firm / pf), Daily Flow, Daily Flow, Obligated Available
Number) MOD MOD MOD MOD Flow Capacity***
Southside 30.259 12.104 5.791 1.487 7.278 4.826
* The Firm 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 pump station 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 WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Cypress Glen Villas
Downstream Permit Number: W00010804
Page 1 of 6

III. Certification Statement:
I Clifton H. Cahoon, 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 indicates acceptance of this wastewater flow.
Page 2 of 6

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