WQ0045531_Application (FTSE)_20240618

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Burd, Tina J
From: Burd, Tina J
Sent: Wednesday, June 19, 2024 9:36 AM
To: [e-mail]; Howard Resnik
Cc: Cocanower, Jordan M;Tharrington,Tom
Subject: WQ0045531 -Wrightsboro Commons Public 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 18, 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 Brunswick, Columbus, Duplin & Pender tyle.r.bensorlc�ag nc Qv
Jordan Cocanower Carteret, New Hanover&Onslow [e-mail]
Bryan Lievre All-ARPA Projects Only k�ryn_lie_v_re�.de_q_nc:gov
Tom Tharrington All—Coordinator, Please Copy on All Emails [e-mail]
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: [e-mail]
NCDEQ
Wilmington Regional Office
127 Cardinal Drive Ext.
Wilmington, NC 28405
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t�;'o0h :c;t"C1i!li0 Public r~S'€e con:6 �..a' and,1J a y'b <dl>CiC)56i�i<>OfirC; oaritc S
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CSD� � vo �553 �
ENGINEERING
June 18, 2024
Jordan Cocanower
Received
North Carolina Department of
Environmental Quality JUN 18 2024
Division of Water Resources
127 Cardinal Drive Extension
Wilmington, North Carolina 28405 NCDEO
Wilmington Regional Office
Re: Wrightsboro Commons, Phase 1
Public Sewer System Extension
New Hanover County
CSD Project No. 23-0653
Dear Mr. Cocanower:
The enclosed public Fast Track sewer permit applica,,.,,, N. ,, o. " C-900 gravity sewer main to serve
Wrightsboro Commons, a proposed 226-unit mixed-use development located off Castle Hayne Road in New Hanover
County.This will be a mix of 1, 2, and 3-bedroom units.The new 8" gravity main will connect to an existing CFPUA
manhole located in the northern right-of-way of Riverside Drive. The main will be installed by the developer and owned
and maintained by Cape Fear Public Utility Authority. A private sewer permit application is being submitted
concurrently for the onsite collection system, and that permit will have the flow allocation. Enclosed for your review
and approval please find:
- One (1) original and one (1) copy of Fast Track Sewer Application (FTA 10-23)
- $600.00 application fee, check#11980
- Street View Map
- USGS Quad Map
If you have any questions or comments, please contact us at(910) 791-4441 or by email at [e-mail].
Thank you for your assistance.
Sincerely,
��76 /�< "�
Mike Broyhill
Engineering Technician
Encl.: As noted above
Cc: BRC Wrightsboro Commons, LLC; Wrightsboro Commons Partners, LLC
3805 Cherry Avenue-Wilmington, NC 28403-910 7914441-www.csd-engineering.com—License#C-2710 ENGINEERING

State of North Carolina
DWK
Department of Environmental Quality
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 I�,\ NCAC 02T and the Division's
Minimum Design Criteria(Gray its Se�\er& 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 enE!ineerinr.!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 I ,\ N(',NC 0'1 .0105 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.0 303.
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. RECEIVEDM CD
ENR/DW,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 sigt rel 8 2D24
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description(Required for All Application Packages): Water oua&y Re91onaioperations Section
® List all items included in the application package,as well as a brief description of the requested petton q fgil Ci n.
➢ 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):
® 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 Secretar\ o1 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 I1.1 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
licewwd Prole„ional l:n,incer.
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 I�A I .()I(iollb). 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 6.ti. 1.1,3-_'_15.67t„J.
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
® 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):
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❑ Per,I_ 1,,_\C:\C 021 ,03�L5 h c I ), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day I
➢ 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)
1. Certificate of Public Convenience and Necessity(All Application Packages for Privately-Owned Public Utilities):
❑ Per II�A tic:;\(_0_1 .0 I E._( i_)r I)provide the Certificate of Public Convenience and Necessity from the North Carolina_(_!t lit.i,�s
Ck)im1ni"ior demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
for a franchise has been received and that the(service area is'contigu us o a existing
g f i franchised
sed area
tit;r t stating h application
Provide a letter from the North C orulil
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):
❑ }dome/PropertvOwners' Associations
❑ Per I i1 \'C 1C__o'f o If._Li 0, submit the properly executed itikiiwl1�rv�mcii _(l(;)I:�1_ !]c),\.i.
El Per 15A NCAC 02T.01 15(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per I 1_NC 1 _0_1 .cal_1_��h,). submit the properly executed clp,rauiuiwl \Lt%cc entt1OKm_: I)I \ t.
For more information, visit the Division's collection systems ,r,{'..v.iw
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 AI'I'R01'ItIA_1'I:
REGIONAL OFFICE ADDRESS COUNTIES SERVED
Asheville Regional Office 2090 US Highway 70 Avery, Buncombe, Burke, Caldwell, Cherokee,
Water_Qt,ality 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
Washinctton 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, j
[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
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INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23&SUPPORTING DOCUMENTATION
Application Number: W 00q 553 I ((o be completed by DWR)
All items must be completed or the aaplication will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Cape Fear Public Utility Authority (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: Jeff Theberae. PE per I i,\ \CAC u'1 .0106(b)
Title: En ink Manager
4. Applicant's mailing address:235 Government Center Drive
City: Wilmington State:NC Zip:28403-
5. Applicant's contact information: RECEIVED/NCDENR/DWR
Phone number: [phone] Email Address:jeff.theberge2cfpua.or-- JUN 18 2024
II. PROJECT INFORMATION:
p ( Water Qualty Regional
1. Project name:Wriphtsboro Commons 1 IA JI•K/�\ operations Section
Wilmington Regional Office
2. Application/Project status: ® 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:New Hanover
4. Approximate Coordinates(Decimal Degrees): Latitude: 34.287224' Longitude:-77.923269'
5. Parcel ID(if applicable): (or Parcel ID to closest downstream sewer)
Ill. CONSULTANT INFORMATION:
I. Professional Engineer: Howard Resnik, PE License Number: 025483
Firm: CSD En ine�ering
Mailing address: PO Box 4041
City: Wilmington State:NC Zip:28406-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY(WWTF)INFORMATION:
1. Facility Name: Permit Number:
Owner Name:Cape Fear Public Utility Authority
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream(Receiving)Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s)(if applicable): WQCS
Owner Name(s):Cape Fear Public Utility Authority
FORM: FTA 10-23 Page I of 5

V1. 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 D \Jop r';01r�:rmuoiw l__1 �� _z1_�t( i_1 0161 )IX)been attached?
❑ Yes ❑ No ®N/A
3. If the Applicant is a Home/Property Owners'Association,has an 11O,\_110.\Opci ittiolial A_)-enwnt �l OR\1_:_11O,\i 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(tics_1�;A NCAC 0-1-l' .0103{20))
If Industrial, is there a Pretreatment Program in effect?❑Yes❑No
6. Has a flow reduction been approved under I _:�_V'AC 02 I, U 1 141 D? ❑ Yes ® No
➢ If yes,iwovide acopy of now reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type(see 02T.0114(o) Daily Design Flow a•n No.of Units Flow
gal/ GPD
gal/ GPD
gall GPD
gall GPD
gal/ GAD
gal/ GPD
Total GPD
a See 1�A \(';1 C'_02 1__U 1 14(6). (d 1, (c it_I' and t�1(�i 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 C:�,S. _I 2 A-4).
b Per 15A NCAC 02T.0114(c),design flow rates for establishments not identified [in table I S;\_\CAC 02 I'.01 I_I] shall be
determined using available flow data,water using fixtures,occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD(per I_>A `C..\(' 0-1 l'1)I l_} jin�.l c;,ti.__I:1;-11;_I)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
® Other(Explain): Flow to be allocated in private permit submitted concurrently.
FORM: FTA 10-23 Page 2 of 5

V11. GRAVITY SEWER DESIGN CRITERIA(if Applicable)-!I. I_.0305 )C Grin iiN Steers
l. Summarize gravity sewer to be permitted:
Size(inches) Length (feet) Material
8 52 C-900
➢ Section 11 & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA(If Applicable)— )2'f .0305& MD_C(Puntp Stations/Force iN111iits):
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.1.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other(please specify)
6. Power reliability in accordance with 1.;1,\'t_1C'_c�' I__.0_05110 I_:
❑ 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 j
➢ 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 pen-nit 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 1�__\ \C';1C(.i'_ l .Ei _c1�[it&- 1 }" ® 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
2Water mains(horizontal) 10 feet
Reclaimed water lines(vertical-reclaimed over sewer) 18 inches
Reclaimed water lines(horizontal -reclaimed over sewer) 2 feet
**Any private or public water supply source, including any wells, WS-1 waters of Class I or
Class 11 impounded reservoirs used as a source of drinking water, and associated wetlands. 100 feet
**Waters classified WS(except WS-1 or WS-V), B, SA, ORW, HQW,or SB from normal
high water(or tide elevation)and wetlands associated with these waters(see item IX.2) 50 feet i
**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 1
Final earth grade(vertical) 36 inches
➢ If noncompliance with 0 2 1",Q,,,O5{I')or.(_),see Section X.I of this application
*I�A \Cµ1C 02 1.0 05(Lo contains alternatives where separations in 02 I'.0,i0ffl 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 Surilic \\al�2r Classil=ications
I
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(0 for documentation requirements and submit a separate document,
signed/scaled 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 clr itt_s .rtratiuil_r�'uuir�mctit� 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 I�A C,\C_(l'B_0_200'' ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A \C,-\C__1.13.01202
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 II ;\ \CCV.' 02 I m 1.0,,(cJLO)(additional permits/certifications)? ® Yes ❑No
Per I1�;1 \C' \C_Ul I.fi I O�Ic.fo1,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_I _N(__\(' 02 f 0102,"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:
L Does the submitted system comply with M.
Al, the
and the'i:^.�'�/^��� \1�ni!x\!Y!�� / �i'�`s'! ���c�—as applicable?
-'
Z Yes No
{[ nu for projects requiring uxing|e variance, complete and submit (lie Vuduncc0Jo:ruu6vm Design Request application
(`vADC )O }4) and supporting documents for iew to the Central Office.
quest will be -issued
concurrently with the approval of the Dermit. and PEglects reguiring a variance approval may be sub*ect to longer
review times.For Proiects requirine two or more variances or where the variance is determined by the Division to be a
significant portion of the pronect,the full technical review is required.
2. Erob:sxioou\ Engineer's Certification:
, "^"-°4-" attest that this application for \/V
(Professional Engineer's name from Application Item 111,1.) (Project Name from Application Item 11.1)
has been reviewed by me and is accurate, complete and consistent with the imyvrmmut/wo supplied in the plans,
specifications,engineering calculations,and all other supporting documentation to the best of my knowledge. lb/rthcr
attest that to the best ofmy knowledge the proposed design has been prepared in uuoorduocc with the applicable n:8u\udonx.
> U�`/��'�/��/,�'('/! /i/:.��l-�c��l.�iiiic,� `e,y.y). and the \i MiluY/n, o [u!�,ii'! 1'oi-(hi_� F;u&]\ui,.,k{'t:n uuln\"
LSl;,u�/!����uuc ��m��!��1-!���g". A|though other profess ionoJsmuy have developed unrtain portions nydhio
muhn6md puokuzu, inclusion of these materials undo my signature and seal signifies that l have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE - In accordance with Oonwm| Statutes 143'215.6A and 143'215.68' any person who knowingly makes any false
utuwumcnt, vcpn:xontuhon, or certification in any application package x6uU be guilty of C|uoo 2 miudemeunor, which may
include a fine not to exceed$10,000,as well as civil penalties up to$25,000 per violation.Misrepresentation of the application
information,including failure to disclose any design non-compliance with the applicable Rules and design criteria,may subject
the North Cum|inu'licensed 9ro[oxoioou| Engineer to referral»othe licensing board. (21 NCAC56.D701)
.
North Carolina Professional Engineer's seal,signature,and date:
9L SEAL
025483
3. Applicant's Certification per \SANCA.0O2T.O1O6(k):
�. . attest that this upp|icuhvo for
(Signature Awhority Name from Application Item 1.3.) (Project Name from Application Item I[.I)
attest that this application has been reviewed by me and is uoomcute and complete to the best of my kn*wKcdge
l understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not indudxd, this application package is subject /o being returned as incomplete. [ understand that any
discharge ofwastewater from this non-discharge system to surface waters or the land will ncouh in an immediate enforcement
action that may include civil penalties, injunctive relief,and/or criminal prosecution. l will make no claim against the Division
o[Water Resources should u condition oy this permit heviolated. l also understand that iy all required parts o[this application
package are not completed and that if all required supporting information and attachments are not inc|udod, this application
package will be returned |omrusincomplete.
NOTE - In accordance with Gmxm| Statutes and '� !� '�'` �/\ any person who knowingly makes any b'|xn
statement. repom:uuuion, or certification in any application puoku8c shall he guilty of C|cao 2 mixdomeunor, which may
include u fine not tn exceed$iO.O00ua well uo civil penalties upto$25.000 per violation.
Signature: Jeff 7heberge Date: Mav30,2024
F0RM: P7A 10'23
pu�e 5uf9 |

Signature:
Email: [e-mail]

Final Audit Report 2024-05-30
Created: 2024-05-30
By: David Dailey([e-mail])
Status: Signed
Transaction ID: CBJCHSCAABAAEgMUBbOLDFiwHluX2lh6TLbBrE79FSDr
TTA 10-23-1_public_PH1 " History
Document created by David Dailey ([e-mail])
2024-05-30-6:05:42 PM GMT
Document emailed to Jeff Theberge ([e-mail]) for signature
2024-05-30-6:06:55 PM GMT
i
Email viewed by Jeff Theberge ([e-mail])
2024-05-30-6:39:55 PM GMT
i
Document e-signed by Jeff Theberge ([e-mail])
Signature Date:2024-05-30-6:40:41 PM GMT-Time Source:server
Agreement completed.
2024-05-30-6:40:41 PM GMT '
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