WQ0045634_Town_of_Liberty_Kinro_PS_Rebuild_FTSSE_Permit_App_20240719

Docusign Envelope ID: E503BACC-DB99-4360-649B-15D26712CEOA
State of North Carolina
PICCLa/ LfC-/� 211 ��� Department of Environmental Quality
DWRDivision of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: ) _ `fib be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Liberty (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: Scott Kidd per 15A NCAC 02T .0106(b)
Title: Town Manager
4. Applicant's mailing address: 239 S. Fayetteville St. P.O. Box 1006, Liberty, NC, 27298
City: Liberty State: NC Zip: 27298-
5. Applicant's contact information:
Phone number: [phone] Email Address: townmanager(o,townoflibertync.org
11. PROJECT INFORMATION: 5�; J
ta.rry PS
1. Project name: Town of Liberty Collection System Improvements - Contract 1 (VUR-W-ARP-0106: SRF-ASADRA CS370460-04)
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: Randolph
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.8370' Longitude:-79.5669'
5. Parcel ID (if applicable): 78455 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Christopher Huff License Number: 024420
Firm: WithersRavenel
Mailing address: 115 MacKenan Drive
City: Ca r State: NC Zip: 27511-
Phone number: 919) 795-0401 Email Address: chuffna,withersravenel.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Town of Liberty WWTF Permit Number: W00003090
Owner Name: Town of Liberty
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQCS0028
2. Downstream (Receiving) Sewer Information: 12 inch Z Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00280
Owner Name(s): Town of Liberty
FORM: FTA 10-23 Page 1 of 5

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
® School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
® Food and drink facilities ® Church ❑ Swimming Pool/Filter Backwash
® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater : 70 % Domestic 20 % Commercial 10 % Industrial (See 15A NCAC 02T .0103(20)1
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ® No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f) ❑ Yes ® No
➢ If Yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,n
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
0 GPD
a See 15A NCAC 02T .0114(b). (d). (e)(1) and (e)(22) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] 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 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
® Other (Explain): The Kinro Pump station is going: to be rehabilitated with the installation of a rerouted gravity sewer
entering: the wet well and a rerouted force main from the valve vault to the existing force main. No new flow will be allocated
with this project.
FORM: FTA 10-23 Page 2 of 5

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & NIDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
15 46 PVC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Kinro Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.8370' Longitude:-79.5669'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.41 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): 284 gallons per minute (GPM) at 129 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
6
22
DIP
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.l.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(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

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(fl & (g,)? ® 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
ZWater mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
ZWater mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class 11 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(a), see Section X.1 of this application
* 15A NCAC 02T.0305(a) 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 webnage
2. Does this project comply with the minimum separation requirements for water mains? ® Yes [—]No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: Cape Fear ® 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 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
X. CERTiFiC.ATiONS:
1 Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
if no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
Town of Liberty Collection System
Professional Engineer's Certification: Improvements - Contract 1
(VUR-W-ARP-0106; SRF-ASADRA
1, Christopher Huff, PE attest that this application for CS370460-04)
(Professional En.gineer's name from Application hem ITT. I.) (Project Name from Application item IT. I )
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. i further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that i have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — in accordance with General Statutes 143-215.6A and 143-215.613, 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 S 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: ,.�;` C A f�
Z.
3. Applicant's Certification per 15A NCAC 02T
I, Scott Kidd
(Signature Authority Name from Application hem 1.3.)
.A, . I
ti *�_• SEAL
024420
•�9•Z4,t -4
°�
G iNfcEQ'•`X
Town of b�4'%00168 n System
0106(b): improvements - Contract 1
(VUR-W-ARP-0106; SRF-ASADRA
attest that this application for CS370460-04)
(Project Name horn Application Item IT. I )
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. i will make no claim against the Division
of Water Resources should a condition of this permit be violated. i also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
VOTE — 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 tine not to exceed S 10,000 as well as civil penalties up to $25,000 per violation.
Digd by:
1
Signature: -
x4CS6AFuSneDD 1 EE5440...
Date: 7/19/2024
FORM: FTA 10-23 Page 5 of 5

T
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SITE AERIAL MAP
1 0 WithersRavenet
Engineers Planners Surveyors

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COLLECTION SYSTEM IMPROVEMENTS -
KINRO PUMP STATIONjj� SITE TOPO MAP 40 WithersRavene!
,/ Engineers I Planners I Sur:-eron

4, WithersRavenel
424 Gathmore Dairy Road, Suite C
Greensboro, NC 27409
t: 919.469.3340 1 f: 336.605.3009
TO: NIf-MCn - C­+7. 1, Do...;i ;-- C--, T, AA/7-- C-.I,...... D....,. --1%
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina, 27105
WE ARE SENDING YOU ❑x Attached
THE FOLLOWING ITEMS X Application
❑ Copy of Letter
Letter of Transmittal
i07/19/24 • : • 06200805.00
Fast Track Permitting Section (FTA)
Town of Liberty Collection System Improvements
Contract I - Kinro PS
NC De
Environmental Quality
❑ Under Separate Cover via Received
❑ Prints ❑ Plans ❑ Samples J11M �eJAMIns
❑ Change Order ❑ Diskette 0 Other WiWIk#atsSalem
Regional ce
COPIES•
1
07/19/24
•
Cover Letter
1
07/19/24
Application Fee - Check
1
07/19/24
Fast Track Application
1
07/19/24
Entire Project Area Site Map (USGS)
1
07/19/24
General Project Area Site Map (Aerial)
1
07/19/24
USB With Project Information Above
i=SE A,Rc
TRANSMITTED
as checked helno.,
❑x For approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑x For review and comment ❑ Other
❑ FOR BIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS: Attached is the FTA application for the Kinro Pump Station Improvements in the Town of Liberty.
Thank you,
Jack M. Fitzgerald
[phone]
[e-mail]
COPS( TO; NCDEQ - FastTrack Permitting Section SIGNED:
?f enclosures at-e not as noted, kindly not;fy us at once.

®/
ithersRa���ene
N/
Our People. Your Success,
July 18, 2024
Department of Environmental Quality
Winston-Salem Regional Office - Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
Attn: Jenny Graznak
RE: Town of Liberty Collection System Improvements (ASADRA Project CS370460-04)
Dear Ms. Graznak:
On behalf of the Town of Liberty, WithersRavenel is submitting the attached Fast Track Sewer
Extension Permit application for the upgrade of the Kinro Pump Station as part of the Town of
Liberty Collection System Improvements Contract 1 project. There will be no flow requested with
this application.
The project consists of the refitting of the Kinro Pump Station, including but not limited to, removal
of existing above ground pump station, electrical and emergency equipment. The rehabilitation of
existing square precast wet well, and the installation of new submersible pumping equipment, a
valve vault and control piping, wet well mounted comminutor, electrical gear, structure for
electrical gear, emergency generator, bypass pump connection, and a connection to the existing
6-inch force main. Area fencing will also be replaced as part of this project.
The project also includes the following components requiring sewer extension permitting:
• A 284-gpm pump station with duplex pump, on -site audible and visual high-water alarms,
telemetry, and permanent generator with automatic transfer switch.
• 46-LF of 15" PVC Gravity Sewer Main.
• 22-LF of 6" DIP Force Main.
• Two new 5-ft manholes.
This Fast Track Application Package includes the following items:
• Fast Track Application (Form FTA 10-23)
• Check for the $600 application fee
• One (1) 8.5x11 site maps showing the location of project (Aerial)
• One (1) 8.5x11 site map showing the overall project location (USGS)
113�IacKeran Dr-', Cary. NC 27511
t: '7!Y 46:` 3.i- y 1j.46/.6008 i
A_' _ P;tt3noro �,1 pa!eigh 7a._ _ j7" ,i 'n 1 ,

Please do not hesitate to contact me at 336-486-1640 or [e-mail] should
you have any questions or concerns.
Sincerely,
W ii C e S Rav e n e
C:: -
Jack Fitzgerald, PE
Senior Project Manager
Cc: Ken Pohlig, PE, WithersRavenel, [e-mail]
Monica Chevalier, Funding Administrator, WithersRavenel, [e-mail]
Scott Kidd, Town Manager, Town of Liberty, town [e-mail]
rage 2 O1 2

® WithersRavenel
WNOur People. Your Success.
Date Requested
Requested By
Approved By
CHECK INSTRUCTIONS
Check Request
7/16/2024 Date Needed
Santiago Garcia -Rico Jr
Jack M. Fitzgerald
7/16/2024
Amount $600
Payee Name NCDEQ - Fast Track Plan Review
Payee Address 450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina, 27105
ATTN
Delivery ❑ Mail check to vendor 0 Give check to Santiago Garcia Rico
PROJECT INFORMATION
Project Number 06200805.00 Task/Subtask Number 0007A
Project Name Town of Liberty Collection System Improvements - Contract 1
Explanation/Purpose
Contract 1 Submittal Fee - Kinro Pump Station
CODING (Accounting Use Only)
Account
Amount
Check Request
Rev. 09/2015 Page 1 of 1

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
State of North Carolina
Department of Environmental Quality
DWR 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 15A NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stations/Force Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 02T, 15A NCAC 02T .0300. Division policies, and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General — When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures on original must be "wet ink" or secure digital signatures.
Please do not submit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (downstream/upstream)
➢ If necessary for clarity, include attachments to the application 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 I.2 is a corporation or company, provide documentation it is registered for business with the
North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
the county of business.
® The Project Name in Item II.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 Pagel of 3

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
E. Flow Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
❑ Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
G. Existing Permit (Application Packages for Modifications to an Existing Permit):
❑ Submit a copy of the most recently issued existing permit.
❑ Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
❑ The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station. The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall
be provided in the case of a multiple station power outage. (Required at time of certification)
I. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b). submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems website
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 3

Docusign Envelope ID: E503BACC-DB99-4360-B49B-15D26712CEOA
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, 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