WQ0045632_Application_20240719

Hood Richardson, PA C576
110 West Second Street
Washington, N. C. 27889
252-975-3472
July 1, 2024
NCDEQ/DWR
Water Quality Section
PERCS Unit
1617 Mail Service Center
Raleigh, N. C. 2769-1636
RE: Cover letter
Town of Belhaven Waste Water Treatment Plant
Willie H. Davender, Jr
7336 Terra Ciea Road
Pantego, N. C. 27860
Gentlemen:
RECEIVED
JUL 19 Z924
NCDEQ/DWR/NPDES
This a permit application to add 150 gallons of grinder pump sewage to an existing 6 inch force main.
Items in this permit package (two copies of each):
1. This letter and Check List, Pages 1 thru 4
2. Original and one copy of Form: ASEA 10-2, pages 1 thru 5.
3. Application fee, a check for $600.00.
4 "Flow Tracking Acceptance Form" FTSE 10-18 pages 6 and 7
5. Engineering plans 8.5 by 13 inch size. Pages 8, 9, and 10.
6. Specifications, two pages, legal size, Pages 11 and 12.
7. Manufacturers specifications, 2 pages numbered 13 thru 32.
8. Engineering calculations and down stream analysis. Pages 33 thru 38.
9. USGS site map. Page 39.
10. Aerial photograph and location maps. Pages 40 thru 43.
11. FEMA flood map. Page 44.
12. Closest stream classification. Page 45.
Sincerely yotirs,
rHood L. Richardson, PE

T--d w lv or r3. 2� fv► ✓2
CW1 11 i -e- 0, ����� � R� State of North Carolina
T) Department of Environmental Quality WRDivision of Water Resources
15A NCAC 02T .0300 - ALTERNATIVE SEWER EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORM: ASEA 10-23 & SUPPORTING DOCUMENTATION
Plans, specifications and supporting documents shall be prepared in accordance with, 15A P ►C 02_ T .0100 15A NCAC 02T
.0300, Division Policies and good engineering practice. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application.
For more information, visit the Water Quality Permitting Section's collection systems website
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.
Unless otherwise noted, the Applicant shall submit one original and one copy of the application and supporting documentation.
A. O e Original and One Copy of Application and Supporting Documents
Required unless otherwise noted
B. Cover Letter (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.
➢ 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 11.1. of the application).
C. Application Fee (All New and Major Modification Application Packages):
XSubmit a check or money order in the amount of $600.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ).
D. Alternative Sewer Extension (Form: ASEA 10-23) Application (Required for All Application Packages):
Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
141,. ❑ If the Applicant Type in Item I.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
14 J4 ❑ 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 H.1 shall be consistent with the project name on the plans, specifications, flow acceptance
letters, agreements, etc.
L The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Eneil
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 A 106(b).
E. Section X & XI Attachm ` (If Applicable):
f ❑ If the project includes gravity sewer, pump stations with multiple pumps and force mains, include the Section X & XI
attachment(s).
F. ! .w Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
la Submit the completed and appropriately executed Flow Tracking/Acceptance for Sewer Extension Permit Form from
I the owners of the downstream sewers and treatment facility.
➢ The flow acceptance indicated in form FTSE 10-23must not expire prior to permit issuance and must be dated less than
one year prior to the application date.
INSTRUCTIONS FOR FORM: ASEA 10-23 & SUPPORTING DOCUMENTATION Page 1 of 4

➢ Submittal of this application and form FTSE 10-23indicates that owner has adequate capacity and will not violate G.S.
143-215.6T ... —
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE 10-23.
INSTRUCTIONS FOR FORM: ASEA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 4

G. Epineering Plans (Required for Ali Application Packages):
Per 15A NCAC 02T .0305 b 1), submit two sets of detailed plan sets that have been signed, sealed and dated by a
North Carolina licensed Professional . and shall include at a minimum:
➢ Table of contents with each sheet numbered.
➢ A general location map with at least two geographic references and a vicinity map.
➢ Plan and profile views of the sewer extension as well as the proximity of the sewer extension to other utilities and
natural features
➢ Detail drawings of all items pertinent to the sewer extension (including clean -out locations) and pump stations.
➢ The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 100 feet of the project.
➢ Minimum separations required per 15A NCAC 02T.0305(f), and where separations cannot be maintained, alternative
criteria per 15A NCAC 02T.0305(g).
➢ Minimum cover for sewer extensions required per 15A NCAC 02T.0305(f) must also be shown clearly on the plans.
➢ Nodes/Zones listed in calculations and computer models must be accurately reflected on the plans.
➢ Plans must include lot numbers, zones, approximate pump and top of wet well elevations, and pump model number and
capacity in a table format.
Jj Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY,
(� NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final plans. However, the plans may be
labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
H. Specifications (Required for All Application Packages):
or
Per 15A NCAC 02T .0305 b 3 , submit specifications that have been signed, sealed and dated by a North Carolina
Licensed Professional Enizineer, and shall include at a minimum:
➢ Table of contents with each section/page numbered.
➢ Detailed specifications for pump stations (i.e. packaged grinder pump requirements, valves, controls, etc.)
➢ Site Work (i.e., earthwork, clearing, grubbing, excavation, trenching, backfilling, compacting, fencing, seeding, etc.)
➢ Materials (i.e., low pressure mains and laterals, force main, gravity, concrete, method of construction, etc.)
➢ Electrical (i.e., control panels, transfer switches, automatically activated standby power source, etc.)
➢ Means for ensuring quality and integrity of the finished product in accordance with the Minimum Design Criteria,
including leakage and pressure testing for the sewer extension.
Specifications shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW
ONLY, NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However,
the specifications may be labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
Specifications for standard equipment may only be omitted for municipalities with approved standard specifications,
` but the use of the standard specifications must be noted on each sheet of the plans.
I. Engineering Calculations (All Application Packages):
Per 15A NCAC 02T .0305 b 2 and ISA NCAC 02T .0305 ' 1,, submit engineering calculations that have been
signed, sealed and dated by a North Carolina licensed Professional Ene,` , and shall include at a minimum:
➢ Friction/Total Dynamic Head calculations and system curve analysis (with one pump Winning, two pumps running, etc.)
➢ Pump selection information including pump curves, manufacturer's information, and recommended installation
guidelines.
➢ Pump station cycle times and pump run times.
➢ Minimum velocities in the sewer extension in accordance with the Minimum Design Criteria
➢ Flotation calculations for all units constructed partially or entirely below grade (i.e. pump stations)
HIA ❑ If computer models are provided to document system design, the model and corresponding node/zone nomenclature
must clearly and accurately reflect the plans and specifications.
Note that upon completion of the review process and prior to permit issuance, a request for the final plans and
specifications will be requested on digital media (CD, DVD, Jump Drive, etc.) for our records. You will be notified when
this information is requested, as the review may necessitate changes
INSTRUCTIONS FOR FORM: ASEA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 4

J. Downstream Sewer Evaluations (All Application Packages)
Per 15A NCAC 02T .0305hL22 and ..5A NCAC 02T .0304 h 1 , submit engineering calculations that have been
signed, sealed and dated by a 4orth Carolina licensed Professional Engineerfor receiving collection systems:
❑ For connection to a gravity sewer, submit:
An evaluation of the gravity sewer based on peak flow from the proposed project and peak flows already tributary to
the existing gravity sewer. Provide calculations and detail how existing peak flows were determined.
❑ For connection to a pump station, submit:
An evaluation of the existing pump station to pump peak flow from the proposed project and peak flows already
tributary to the existing pump station. Provide calculations and detail how existing peak flows were determined.
For connection to a force main/low pressures sewer, submit:
An evaluation of the existing system based on peak flows from the proposed project and peak flows already tributary to
the existing system. In addition, evaluate the ability of each pump station tributary to the existing system to pump
against additional head created by greater flows through the system. Evaluation may include alternative designs such
as telemetry to coordinate pumping between pump stations (provided sufficient storage is available). Also include an
evaluation of the discharge point of the existing force main/pressure sewer.
K. Si 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
Si
and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
)� Include a street level map showing general project area.
L. Existing Permit (All Modification Packages):
8 Jll��,t [ISubmit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
M. Power Reliability Plan (All Application Packages): 2 `f Wa-r— fl-V rL /v -0—
#/% ❑ Per i 5A NCAC 021- .0305(h)L[ L ; . submit documentation of power reliability for simplex/vacuum units.
ml 1- ❑ Per 15A NCAC 02T .0305(hX 1 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)
N. Final Environmental Document (If Applicable):
❑ Per 15A AC 02T .0105f c If 4 a, submit one copy of the environmental assessment and one copy of the final
W1 r environmental document (i.e., Finding of No Significant Impact or Record of Decision).
/�` ❑ Include information on any mitigating factors from the Environmental Assessment that impact the design and/or
construction of the subject sewer.
O. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
k ❑ Per 15A NCAC 02T .0115fa1[ 1 ' provide the Certificate of Public Convenience and Necessity from the - . -h Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
/t/ f �❑ Provide a letter from the " rolina Utilities Commission's Water and Sewer Division Public Staff stating an
I �d 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.
INSTRUCTIONS FOR FORM: ASEA 10-23 & SUPPORTING DOCUMENTATION Page 4 of 4

P. Operational Agreements (Applicat►-as from HOA/POA and Developers for lots Lo be sold):
❑ HO PrOPPM Owners' Associations
IA.
❑ Per 15A NCAC 02T.0115(c]submit the properly executed - perational Agreement (FOR. ❑ Per 15A NCAC 02T .0 1 15(cl submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
//, ❑ Per . jA NCAC 02T .0115(bl, submit the properly executed Operational Agreement (FORM: i
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NCDEQ/DWR
WATER QUALITY SECTION
PERCS UNIT
By U.i. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY ST. SUITE 925
RALEIGH, NORTH CAROLINA 27604
INSTRUCTIONS FOR FORM: ASEA 10-23 & SUPPORTING DOCUMENTATION Page 5 of 4

T.� State of North Carolina
DWR.Department of Environmental Quality
Division of Water Resources
Dk4ston of Water Resources 15A NCAC 02T .0300 - ALTERNATIVE SEWER EXTENSION APPLICATION
ASEA 10-23 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by DWR)
I. APPLICANT INFORMA
rol✓✓r7' 6 P �Ct 4A,/'��G i61�clf �`� . ,6)/w-r��,� f (QGL / JTA fi 1�e
1. Applicant's name: (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ state Municipal ❑ County
3. Signature authority's name: per . AC 02T .0.
Title: 141Afre- WYf 7-e-A 3Cr)o-e2 vtfd A
4. Applicant's mailing address: 3 %� � rr Al /f t'./
City. / 44-V State: AJC Zip: 2_79/ D
5. Applicant's contact information;
Phone number: — Email Address:
H. PROJECT INFORMATIO,11: Z -P f . /�, d f Pq Y r-e�d� c
L Project name:
2. Application/Project status: *<OpOsed (New Permit) ❑ Existing Permit/Project ❑ ARPA funded
If a modification, provide the existing permit number: WQ00 -Al " wand issued date: /VL-4+
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: 6" 4,4=0 A r- 0
0 5Y6`%9 2 -7 C> �7� Z U Z Z 4. Approximate Coordinates (Decimal Degrees): Latitude: Longitude...".
III. CONSULTANT INFO�TION-
1. Professional En ' eer: F�` `1 rtLLic nste Nuumbedicy � 7
Firm: f7ov /4 l ,Dk Ascr�yc/ PA
Mailing address: %J0 Alt r 1 ACV
V I S77-4"LZ,7-
r
1,r4skiq qq /Y L 27 ri�9
statb:�
City: Zi : - 1. CV-7"V\ ,
Phone number: ( j_ 7 �` 3 E d
mail Address: ��'�
k
1V. WASTEWATER TREATMENT �C� �.(eWINFORMA TION:
1. Facility Name: - Permit N�oWTF) umbe : 11 r /
017GygZ
Owner Name:'toy nj op- �- & eU / V'Z
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): 1 � G v 2- b ' 7 2-
System Wide Collection System Permit Numbe s):
Owner Name(s): _rat ,� a-/` /f-e-/ `t-,tv. ? y
t
FORM: ASEA 10-23 Pagel of 5

VL GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been submitted?
❑ Yes []No r�N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's ui2v,,aL1v11a1 t,,,, ccincn[ FvtCM: Ut; V been submitted?
❑ Yes []No �I/A
3. If the Applicant is a Home/Property Owners' Association, has an �cerational Agreement ( FORM: HOA J been submitted?
El Yes ❑No /PIN/A
4. 1
of wastewater: (check all that apply):
Residential 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
El Businesses /offices /factories ❑Swimming Pool/Filter Backwash
❑ Nursing Home ❑ Other (Explain in Attachment)
5. Is/was an Environmental Assessment required under 15A NCAC 01 C? ❑ Yes kNo
If yes, submit the appropriate final environmental document (FONSjI, ROD, etc.)
6. Nature of wastewater: 1r�0 % Domestic/Co cial//o Other waste — specify:
P fy:
Industrial See 15A NCAC 02T .0 10320
7. Wastewater generated by project: /o " GPD (per 15A NCAC 02T .0114 and G.S. 143-215 1)
Hasa flow reduction been approved under 15A NCAC 02T .0114( f ? ❑ Yes pNo
If yes, provide a copy of approval
8. Summarize wastewater generated by project:
Establishment Type Daily Design Flow' No. of Units Flow
odm ►^ E S ( nl L gal/ d 4" _ �Aov 2- J� GPD
J GPD
gal/ GPD
gal/ GPD
gal/ GPD
gal/ GPD
Total GPD
a See 15A NCAC 02T .0114(b). (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; 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 below shall be determined using
available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
CA
FORM: ASEA 10-23 Page 2 of 5

VH. PRESSURE SEWER DESIGN CRITERIA-15A NCAC 02T .0305:
1. Number of simplex pump stations (STEP tanks/effluent pumps, v uum pits, etc.) provided:
2. What is the nearest 100-year flood elevation to the facility? feet mean sea level.
Is any of the proposed project located within the 100-year flood plain? ❑ Yes No
3. If Yes, are the following items provided per 15A NCAC 02T .0305(e is
Water -tight seals on all station hatches and manholes; and
Control panels vents extend two feet above the 100-year flood plain elevation? ❑ Yes ❑ No XNIA
If No, what measures are being taken to protect them against flooding?
4. Volume of storage in wet well above pump on elevation: 237Gallons include calculations)
5. How wer reliability will be provided in accordance with'. - .- - - - ^ 02T .0305 h 41. Z 3 r j 14, �1 �r y
Wet well storage provides 24 hours worth of wastewater storage; or
❑ Wet well storage provides wastewater storage based on power reliability and response times
See "Policy for Meeting Reliability ice�uirements']
➢ Provide 3 years of power history date in the area.
➢ Provide response time to replace a failed pump. This would include travel time, time to replace pump, etc.
➢ Wet well storage would be based on whichever is greater.
All other pump stations meet the reliability requirements of 15A NCAC 02T .0305(6 )1 ' .: ❑ Yes ❑ No 1--AN/A
6. Summarize simplex pump station design elements:
Design Element
Plan Sheet
Reference
Specification
Reference
Emergency Contact Placard or Sticker
g'
3� 3
Screened Wet Well Vent
Restricted Access Details
Control Panel
High Water Alarms (Audible & Visual)
Valves (Check, Gate, etc)
Z�
Air Relief Valves
M/A
32
7. Summarize the pipe length by diameter to be permitted. Lines from a building to the septic or pump tank should be excluded.
(provide attachments if necessary)
Zone I From Node I To Node I Diameter (in) I Length (feet) # Pumps in Zone
8. Air release valve station locations per 15A NCAC 02T .0305!_) (provide attachments if necessary)
Air Release Valve # i Station
Plan Sheet Reference
Pump Model
Specified_ for Zone
3
FORM: ASEA 10-23
Page 3 of 5

VIM SETBACKS & SEPARATIONb — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305 &
➢ 15A NCAC 02T,0305(f) contains minimum separations that shall be provided for sewer
Setback Parameter*
Storm sewers and other utilities not listed below (vertical)
Water mains ( vertical -water over sewer including in benched
Water mains {horizontal)
Reclaimed water lines (vertical - reclaimed over se
Reclaimed water lines (horizontal - reclaimed over
**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 drinkin water
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or ride elevation) and wetlands (see item IX.2)
**Any other stream, lake, impoundment, or ground water lowering and surf
ditches ace drainage
foundation
basement
of embankment or cuts of 2 feet or more vertical heicf a
ystems and interceptor drains
I Final earth erade (vertical)
Yes ❑ No
ration R uired
24 inches
18 inches
10 feet
18 inches
2 feet
100 feet
50 feet
10 feet
5 feet
10 feet
10 feet
5 feet
10 feet
36 inches
➢ 15A NCAC 02T.030 ; contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's _-iC Surface Water Classifications webaaue
➢ If noncompliance with ?T.0305(f) or (€ see Section IX of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) [Yes ElNo ❑ N/A
➢ See the Division's drab separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? Yes ❑ No ❑ NIA
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes No
individual permits or 401 Water Quality Certifications? ( ,
➢ Information can be obtained from the 401 & Buffer Permitting.Branch
5. Does project comply with ii-, AA : u2T.0105.(c(66) (additional permits/certifications)? Yes ❑ No
Per 15A NCAC 02T.0105 c 6 , directly related environmental permits or certification applicatio are 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_).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.04�—, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ❑
➢ If yes, include an attachment with details for each line, includin 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 permitee's individual System -Wide Collection permit.
FORM: ASEA 10-23 Page 4 of 5

IX. CERTIFICATIONS:
Does the submitted system comply with l SA NCAC 02T, the MiWmm DesigLQd erla fortha BMRimtr f
and Force Mains (latest ton! and the Sew ink Pt ,�S—Puma t�iong
"Lehr' _ i� Griteris,(latesr vg�sior�] as applicable
Yes ❑ No
If No, complete and submit the Variance! Os Design Request application (VADC 10-14) and supporting documents
for review. Approval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Enghmfs Cer ificaticm:
I, J L+ A1id` ' �"�fG _ _ attest that this application for
(Professional Engineer's name from Application Item III.1.)
v VLty d F &tk4V
? 3 3 Z— 'f�/zn-� C,' �� (Facility name from Application Item II. -1.)
iZu �4.6� J�ilc.�rT-efdj n C .,Z7rl�D
has been reviewed by me and is accurate, complete and consistent wrth the information supplied in the plans, specifications,
engineering calcWations, and all other strppordng docnmamtation to the best of my knowledge. I fm ther attest that to the best
of my knowledge the proposed design has ben prepared in accordance with this application package and its instructions, as
well as all applicable regulations and statutes. Although other profissionals 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 '43-215,&', and 143-215.60, any person who Imowingly 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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per ISA NCAC 02T_O106fb1:
(Signature Authority's name &
-C'*V Vt "' 'oA attest that this application for
rom Application Item I3.)
(Facility name from Application Item II.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge of
wastewater fiom this non-diwbarge system to surface waters or the land will result in an immediate enforcement action that
may include civil penalties, injunctive relief, and/or criminal pion. 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 a mpieted and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete. Al the nermittee for the nressare gower system, I understand I will be
rewired to own, malutain< and onerate all individual pump stations.
NOTE — In accordance with General Statutes - 43 213AA and 143 Z1SAB. any person who knowingly makes any false
statement, representation, or certftation in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $ 10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date: f o20
FORM: ASEA 10-23 Page 5 of 5