WQ0045500_Application (FTSE)_20240603

Burd, Tina J
From: Burd, Tina J
Sent: Friday, June 7, 2024 2:28 PM
To: Massey, Ronald F; Lanier, Nicholas
Cc: Cocanower, Jordan M; Tharrington, Tom
Subject: WQ0045500 - Blue Claw Lane Sewer
The Wilmington Regional Office of the Division of Water Resources, Water Quality Operations Section received the Fast
Track Sewer System Extension Application (FTA) and $600.00 fee for the subject project on June 3, 2024. The project
has been assigned to Jordan Cocanower, cc'd. Please note that the FTA has been revised and requests the applicant to
identify if this project is ARPA funded. If you omitted this information from the FTA, please contact Bryan Lievre, email
below, so that we can update our records. Otherwise, you will be contacted by the applicable staff member if additional
information is needed.
Staff Reviewer
Counties Served
Contact Information
Tyler Benson
Jordan Cocanower
Brunswick, Columbus, Duplin & Pender
Carteret, New Hanover & Onslow
ylerbnsan.d.er},r�c,gov
jordan.cacanowerdecJ.nc.pov
Bryan Lievre
All - ARPA Projects Only
bry_.lie_vreu de_e{ nc.o�
Tom Tharrington
All — Coordinator, Please Copy on All Emails
tom.tharrin ton de .nc. ov
1. Please provide a copy of the entire application in digital format to your assigned reviewer indicated above. The
application and drawings should be provided as separate files.
2. Please indicate in the subject line of the email the permit number (if available), name of the project, and county
where the project is located.
Please be advised that the construction of the proposed activities may not commence until the sewer permit is issued.
Best Regards,
Tina Burd
Administrative Associate II
Wilmington Regional Office
Division of Environmental Assistance & Customer Service
Phone [phone]
New email: tina.burd de .nc. ov
NCDEQ
Wilmington Regional Office
127 Cardinal Drive Ext.
Wilmington, NC 28405
IE Q
,# - n-)ao' t 5E3£1{iE t;;?#C to arld from this e?C dress is SCIf]yct io the
bjor€h Caro"'I ?a Pub ic Hecw'd's Law and may he cifsdosed to third parties

Burd, Tina J
From: Nicholas Lanier <[e-mail]>
Sent: Friday, June 7, 2024 2:28 PM
To: Burd, Tina J
Subject: [External] Automatic reply: WQ0045500 - Blue Claw Lane Sewer
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I will be away from the office starting 5PM Wednesday June 5, 2024 thru 8AM Monday June 17,
2024. I will not have cell phone or internet access. If you need assistance before I return, please
contact Christy Baysden at [e-mail], 910-938-6527, or Randa Soules at
[e-mail], 910-938-5330.
Thank you,
Nicholas P. W. Lanier, PE
Senior Engieer
City of Jacksonville
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State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Divislon of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: Moo 4 5 6D (to be con)plctcd by DWR)
All items must be completed or the application will be returned
L APPLICANT INFORMATION:
i. Applicant's name: City of Jacksonville (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County N Municipal ❑ Other
3. Signature authority's name: Ronald_F. Massey per 15A NCAC 02T .0106(b)
Title: Deputy City Manaeer
4. Applicant's mailing address: PO Sox 128
City: Jacksonville State: NC Zip: 28541-
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
1. Project name: Blue Claw Lane _S0 "
2. Application/Project status: N Proposed (New Permit) ❑ Existing Permit/Project ❑ ARPA funded
If a modification, provide the existing permit number: WQ00 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: WQ00
3. County where project is located: Onslow
4. Approximate Coordinates (Decimal Degrees): Latitude: 34.740837' Longitude:-77.440241'
5. Parcel ID (if applicable): (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
l . Professional Engineer: Nicholas P. W. Lanier, PE License Number: 55668
Finn: City of Jacksonville
Mailing address: PO Box 128 RECEIVED/NCDE4R/DWR
City: Jacksonville State: NC Zip: 28541-
Phone number: [phone] Email Address: nlanier(a,iacksonvillenc.aov JUN 0 3 2024
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION: wa1e1QuaNtyRegional
Operations section
1. Facility Name: City of Jacksonville Land Treatment Facility Permit Number: W0000 ton Regronal orpce
Owner Name: Ci1y of Jacksonville
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ00009267
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS
Owner Name(s): City of Jacksonville
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 ® NIA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
[-]Yes ❑ No ® NIA
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 : 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(201)
If Industrial, is there a Pretreatment Program in effect? ❑ Yes El No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? [:]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',a
No. of Units
Flory
Residential
880 gal/acre/day
3.65
3212 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gall
GPD
Total
GPD
a See I SA NCAC 02T .01 14(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 pleasured data.
8. Wastewater generated by project: _ 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 tirneframe 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):
RECEIVED/NGDENR/DWR
JUN 0 3 2024
Water Quallty Regional
Operations Soction
Wilmington Regional Office
FORM: FTA 10-23 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. SUnn'narize gravity sewer to be permitted:
Size (inches) Length (feet) Material
S 400 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 street 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. Lb. ❑ Grinder Pump ❑ Mechanical Ear Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(li)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(13);
➢ 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(fl & 6W ® 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-J 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(f) or W, see Section X.I of this application
*I5A NCAC 02T.0305(g) 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 webpaae
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ NIA
➢ If no, please refer to I5A NCAC 18C,0906(o 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: ® 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 pen -nits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit nunrberlpermitting status in the cover letter if coveragelauthorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per I5A 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 pert -nit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stonnwater 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/confliet 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 Desi n 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
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects reguiring two or more variances or where the variance is determined by the Division to be a
sign ific anLRortion of the project, the full technical review is required.
2. Professional Engineer's Certification:
1, Nicholas P. W. Lanier, PE , attest that this application for Blue Claw Lame
(Professional Engineer's name from Application Item Ill. 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,
Minimum Desi n 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:
REGEIVEDINCDENRIDWR
JUN 0 3 2024
Water Qualty Regional
Operations section
Wilmington Regional Office
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, Ronald F. Massey , attest that this application for
(Signature Authority Name from Application Item I.3.)
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Blue Claw Lane
(Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 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: >1T�"�`�` Date:
FORM: FTA 10-23 Page 5 of 5

1a onvi!lQ y� UVNNN 0 0
0
_Ya
May 8, 2024
NCDEQ-DWR
Wilmington Regional Office
127 Cardinal Drive
Wilmington, NC 28405
RE: Fast Track Sewer System Extension Application
Blue Claw Lane
Greetings,
City of Jacksonville
Public Services, Engineering Division
PO Box 128 • Jacksonville NC 28541-0128.910 938-5233
Please accept this cover letter and package as our submittal for the above referenced project.
Submittal contains the following.
1. Cover Letter & Narrative
2. Application Fee - $600.00
3. FTA 10-23
4. FTSE 10-23
5. USGS Site Map
6. Construction Drawings
This application package is for adding approximately 400ft of new 8" gravity sewer main to an
existing system within the City of Jacksonville. System is located at the end of Allison Hatchel
Ave, on the south side. Exact location of extension will be on a new road that will be
constructed as a part of this project.
Project Narrative
The Blue Claw Lane project will include the construction of a new gravel road with 8" water
main and 8" gravity sewer main extension. Approximately 400ft of new gravity sewer main will
be installed, along with one new manhole. Piping will be PVC and will have a grade of .45%.
New line is designed to receive 17,181 gpd, which is a half -full flow design for this size and
slope of line. At 240gpd, this new line can receive up to 71 new homes. Project will not require
NCDEQ erosion control permit or NCDEQ stormwater permit. Project is not within a wetland or
flood zone.
Because the project is being built to serve only a few parcels, we have used 880 gal/acre/day as
our rate as shown on the application. We do not have future development, beyond this project,
planned at this time.
Should you have any questions or if I can be of further assistance, plea%88 0Ea/qgI p%pe a
call.
City Hall, 815 New Bridge Street - 910 938-52001 JacksonvilleNC.gov JUN 0 3 2024
Water Quality Regional
Operations Section
Wilmington Regional office

Page 2
Thank you,
Nicholas P. W. Lanier, PE
Senior Engineer
cc: file

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources Flow Tracking for Sewer Extension Applications
(FTSE 10-23)
Entity Requesting Allocation: City of Jacksonville
Project Name for which flow is being requested: Blue Claw Lane
More than one FTSE may be required for a single project if the owner of the WWTP is not responsiblefor all pulp
stations along the route of the proposed wastetvater,flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: City of Jacksonville Land Treatment Facilit
b. WWTP Facility Permit #: WQ0009267
AlI f1'ows are in MGD
c. WWTP facility's permitted flow 9.0
d. Estimated obligated flow not yet tributary to the WWTP 0.523
e. WWTP facility's actual avg. flow 5.446
f. Total flow for this specific request 0.017
g. Total actual and obligated flows to the facility 5.613
h. Percent of permitted flow used 62.3
11. 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
Approx.
Obligated, Total
Pump Pump
Average
Current
Not Yet Current Flow
Station Station Firm
Daily Flow**
Avg. Daily
Tributary Plus
(Name or Permit Capacity, *
(Firm / po,
Flow,
Daily Flow, Obligated
Available
Number) No. MGD
MGD
MGD
MGD Flow
Capacity***
Brinson0-11
WQ0005268 1.584
0.6336
0.1578
0.017 .1748
.4588
* 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
project connection point and the WWTP where the Available Capacity is ¢ 0.
Downstream Facility Name (Sewer): COJ Land Treatment Facility
Downstream Permit Number: WQ00009267
Page 1 of 6
between lt NCnEN�DW
R>rC�
FTSE 10-23
JUN 0 3 Z0Z4
Water ouaAty Regw 1
opesations Section
Wilmington Re91e11at otllce

III. Certification Statement:
I Ronald F. Massey 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 Official Signature
Deputy City Manager
Title of Signing Official
S
Date
Page 2 of b
FTSE 10-23

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State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Olvlslon 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, S� & 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 e�neering practices.
While no upfront engineering design documents are required for submittal, in accordance with l5A 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) finds, 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� 6 i �b�n tall.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
JUN 0 3 2024
D. Fast Track Application (Required for All Application Packages, Form FTA 10-23):
® Submit the completed and appropriately executed application. water Quality Regional
Oer➢ Section
If necessary for clarity or due to space restrictions, attachments to the application may be made. Wiington R y m one office
❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretaa 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 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: FTA 10-23 & SUPPORTING DOCUMENTATION Page 1 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 I 1-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
® Inchide 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, andlor 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(li)(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 .0l I5(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 .01 15(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 Mail
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, 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

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