WQ0045658_Application (FTSE)_20240729

Robinson
N Design
N Engineers
Sewer Extension at Lakemoor 1 Condominiums
Laurel Park, NC
,Vvater Quality Regional Operations
Project Narrative Asheville Regional Office=
Currently, buildings located in Lakemoor 1 Condominiums are connected to City of
Hendersonville sewer service via a private aerial line that crosses the creek in Laurel
Green Park and connects to a public line that bisects the park. The public line is then
tied into the main at 5th Avenue. Lakemoor 1 condominiums are the only service
connections utilizing the public line bisecting the park with Lakemoor 2 being serviced by
a sewer main running parallel to the creek.
As the aerial crossing represents a risk to public health and water quality, the proposed
work involves abandoning service to it and removing the crossing. The sewer main
servicing Lakemoor 2 will be extended by one additional manhole with 165 linear feet of
8" SDR 35 installed. The existing lateral lines will subsequently be extended into the new
manhole so that the aerial crossing and public line in the park can be abandoned.
No additional service load will be placed on the sanitary sewer system. All connections
to the new manhole are currently in service.
131 V Avenue West, Hendersonville, NC 28792 // robinsondesignengineers.com

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� Department of Environmental Quality
Division of Water Resources
Vatef. duality Regional Upei-ation:
Division of water Resources Asheville Regional Q1tt * Tracking for Sewer Extension Applications
(FTSE 10-23)
Entity Requesting Allocation: City of Hendersonville
Project Name for which flow is being requested: Sewer Main Extension Lakemoor 1
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: City of Hendersonville WWTP
b. WWTP Facility Permit #: NCO025534
All flows are in MGD
c. WWTP facility's permitted flow 4.800
d. Estimated obligated flow not yet tributary to the WWTP 0.40777
e. WWTP facility's actual avg. flow 2.422
f. Total flow for this specific request 0.000
g. Total actual and obligated flows to the facility 2.830
h. Percent of permitted flow used 59.0%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow** Current Tributary Flow Plus
(Name or Permit Capacity, * (Firm / pf), Avg. Daily Daily Flow, Obligated Available
Number) No. MGD MGD Flow, MGD MGD Flow Capacity***
* 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 between the
project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
Page 1 of 6
FTSE 10-23

III. Certification Statement:
I Adam Steurer 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.
a4u, Q Jta!�
Signing Official Signature
Utilities Director
Title of Signing Official
06/28/2024
Date
Page 2 of 6
FTSE 10-23

PLANNING ASSESSMENT ADDENDUM (PAA)
Submit a planning assessment addendum for each pump station listed in Section II where Available Capacity is < 0.
Pump Station (Name or Number):
Given that:
a. The proportion and amount of Obligated, Not Yet Tributary Daily Flow (C) accounts for
% and MGD of the Available Capacity (E) in Pump Station
; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately
MGD per year; and that
c. A funded Capital Project that will provide the required planned capacity, namely
is in design or under construction with
planned completion in ; and/or
d. The following applies:
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow
this flow to be permitted, without a significant likelihood of over -allocating capacity in the system
infrastructure.
I understand that this does not relieve the collection system owner from complying with G.S. 143-
215.67(a) which prohibits the introduction of any waste in excess of the capacity of the waste disposal
system.
Signing Official Signature
Date
Page 3 of 6
FTSE 10-23

Instructions for Flow Tracking form (FTSE) and Planning Assessment Addendum (PAA)
Section I
a. WWTP Facility Name: Enter the name of the WWTP that will receive the wastewater flow.
b. WWTP Facility Permit M Enter the NPDES or Non -Discharge number for the WWTP receiving the
wastewater flow.
c. WWTP facility's permitted flow, MGD: From WWTP owner's NPDES or Non -Discharge permit.
d. Estimated obligated flow not yet tributary to the WWTP, MGD: This includes flows allocated to other
construction projects not yet contributing flow to the collection system. Flows allocated through interlocal
agreements or other contracts not yet contributing flow to the collection system are also included. For POTWs
that implement a pretreatment program, include flows allocated to industrial users who may not be using all of
their flow allocation. Please contact your Pretreatment Coordinator for information on industrial flow tributary
to your WWTP.
As of January 15, 2008 the POTW should have reviewed flow allocations made over the last two years and
reconciled their flow records, to the best of their ability, so it is known how much flow has been obligated and
is not yet been made tributary to the WWTP, in accordance with local policies and procedures employed by the
reporting entity.
e. WWTP facility's actual avg. flow, MGD: Previous 12 month average.
f. Total flow for this specific request, MGD: Enter the requested flow volume.
g. Total actual and obligated flows to the facility, MGD Equals [d + e + fJ
h. Percent of permitted flow used: Equals [(g / c)* 100]
For example:
On January 15 a POTW with a permitted flow of 6.0 MGD, reported to the Regional Office that there is 0.5
MGD of flow that is obligated but not yet tributary. The annual average flow for 2007 is 2.7 MGD. There is a
proposed flow expansion of 0.015 MGD.
The first Form FTSE submitted after January 15, 2008 may have numbers like this:
c.
= 6.0 MGD
d.
= 0.5 MGD
e.
= 2.7 MGD
£
= 0.015 MGD
g.
= 3.215 MGD
h.
= 53.6 %
The next Form FTSE may be updated like this with a proposed flow expansion of 0.102 MGD:
c. = 6.0 MGD
d. = 0.515 MGD
e. = 2.73 MGD
£ = 0.102 MGD
g. = 3.349 MGD
h. = 55.8 %
Each subsequent FTSE form will be updated in the same manner.
Page 4 of 6
FTSE 10-23

Section II
List the pump station name or number and approximate pump station firm capacity, approximate design average
daily flow (A) approximate current average daily flow (B), and the obligated, not yet tributary flow through the
pump station (C) for each pump station that will be impacted by the proposed sewer extension project. Calculate
the total current flow plus obligated flow (D=B+C) and the available capacity (E=A-D). Include the proposed flow
for this project with other obligated flows that have been approved for the pump station but are not yet tributary
(C).
Firm capacity is the maximum pumped flow that can be achieved with the largest pump out of service as per the
Minimum Design Criteria.
Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) of not less than
2.5.
If the available capacity (E) for any pump station is < 0, then prepare a planning assessment for that pump station
if the system has future specific plans related to capacity that should be considered in the permitting process.
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Design
Approx.
Not Yet
Total Current
Firm
Average
Current Avg.
Tributary
Flow Plus
Pump Station
Capacity
Daily Flow
Daily Flow,
Daily Flow,
Obligated
Available
(Name or Number)
MGD
(Firm / pf)
MGD
MGD
Flow
Capacity*
Kaw Creek PS
0.800
0.320
0.252
0.080
0.332
-0.012
Valley Road PS
1.895
0.758
0.472
0.135
0.607
0.151
Page 5 of 6
FTSE 10-23

Planning Assessment Addendum Instructions
Submit a planning assessment addendum for each pump station listed in Section II where available capacity is < 0
A planning assessment for Kaw Creek PS (see example data above) may be performed to evaluate whether there is
significant likelihood that needed improvements or reductions in obligated flows will be in place prior to activating
the flows from the proposed sewer extension project.
If the system decides to accept the flow based on a planning assessment addendum, it is responsible to manage the
flow without capacity related sanitary overflows and must take all steps necessary to complete the project or control
the rate of flow to prevent sanitary sewer overflows.
The planning assessment may identify a funded project currently in design or construction, or a planned project in
the future not yet funded but in a formal plan adopted by the system. The system should carefully weigh the
certainty of successful timely project completion for any expansion, flow management diversion or infiltration and
inflow elimination projects that are the foundation of a planned solution to capacity tracking and acceptance
compliance.
For example:
Given that:
a. The proportion and amount of obligated, not yet tributary flow accounts for 24 % and 0.080 MGD of the
committed flow in Pump Station Kaw Creek; and that
b. The rate of activation of this obligated, not yet tributary capacity is currently approximately 0.01 MGD
per year; and that
c. A funded capital project that will provide the required planned capacity, namely
is in design or under construction with planned
completion in ; and/or
d. The following applies:
The master plan and ten year capital plan contain recommended scope and funding for a capital project entitled
Kaw Creek Pump Station upgrade with funding planned in July 2014 This project is planned to add 0.100 MGD
to the firm capacity of the pump station by October 2015 Inclusion of this proposed capital project as a condition
of this Flow Tracking/Acceptance for Sewer Extension Permit Application elevates this project's priority for
funding and construction to be implemented ahead of the activation of obligated not yet tributary flows in amounts
that exceed the firm pump station capacities identified in Section II above
Therefore:
Given reasonably expected conditions and planning information, there is sufficient justification to allow this flow
to be permitted, without a significant likelihood of over -allocating capacity in the system infrastructure.
Page 6 of 6
FTSE 10-23

Flow Tracking for Sewer Extension Permii
Application
Final Audit Report
Created: 2024-06-27
By: Deborah Sholl ([e-mail])
Status: Signed
Transaction ID: CBJCHBCAABAAYQyQpJpt6nwoQA5fZyswcZwTZ3V_go-2
2024-06-28
"Flow Tracking for Sewer Extension Permit Application" History
`,' Document created by Deborah Sholl ([e-mail])
2024-06-27 - 7:55:05 PM GMT
Document emailed to Adam Steurer ([e-mail]) for signature
2024-06-27 - 7:55:11 PM GMT
",, I L Email viewed by Adam Steurer ([e-mail])
2024-06-28 - 12:35:11 PM GMT
Document e-signed by Adam Steurer ([e-mail])
Signature Date: 2024-06-28 - 12:44:44 PM GMT - Time Source: server
Agreement completed.
2024-06-28 - 12:44:44 PM GMT
a Adobe Acrobat Sign
lip,
JUL 29 202-4,
�``°' flo' Ouality Regional Operatiori&-
A` Neville Reqional Office

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1.
2.
3.
4.
Applicant's name: City of Hendersonville (company, municipality, HOA, utility, etc.)
Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State/County ® Municipal
Signature authority's name: Adam Steurer per 15A NCAC 02T .0106(b)
Title: Utilities Director ^� ' � 1 `ti 1
Applicants mailing address: 305 Williams St
City: Hendersonville State: NC Zip: 28792-.
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
Water' (duality Regional Operations
Asheville Regional Office
1. Project name: Sewer Main Extension Lakemoor 1 Condominiums
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
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: Henderson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.313985' Longitude:-82.483191 °
5. Parcel ID (if applicable): 9568173228 (or Parcel ID to closest downstream sewer)
M. CONSULTANT INFORMATION:
1. Professional Engineer: Philip Ellis
Firm: Robinson Design En ig'neers
Mailing address: 131 3`d Ave W
City: Hendersonvilel
Phone number: [phone]
License Number: 39870
State: NC Zip: 28792-
Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Hendersonville Wastewater Treatment Facility Permit Number: NCO0255343
Owner Name: City of Hendersonville
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): City of Hendersonville
FORM: FTA 10-23 Pagel of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational 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: 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ 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,b
No. of Units
Flow
gal/
GPD
gal/
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. 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.01141 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):
FORM: FTA 10-23 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 168 SDR 35
► 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
VHI. 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 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)(B): _
► Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
► Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
► Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
► If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(fl & (g)? ® Yes ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
► If noncompliance with 02T.0305( or (g), see Section X.1 of this application
*I 5A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(fl 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 webpage
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: No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
► This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
► Please provide the permit number/permitting status in the cover letter if 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

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
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
2. Professional Engineer's Certification:
Sewer Main Extension
1 Philip Ellis , attest that this application for Lakemoor 1 Condominiums
(Professional Engineer's name from Application Item III.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 Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permittins?
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 $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: �����gtlllllllllui�iii
P
w No. 39870
June 20, 2024
n;
////;// 1p111 IIE0k \Gj\`\\\
3 Applicant's Certification per 15A NCAC 02T .0106(b):
Adam St
Sewer Main Extension
I eurer
attest that this application for Lakemoor 1 Condominiums
(Signature Authority Name from Application Item 1.3.) (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.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
FORM: FTA 06-21 Page 5 of 5

Signature: (04- a. JIM:fs
Date:
07/01 /2024
FORM: FTA 06-21 Page 6 of 5

22382.FTA
Final Audit Report
10-23.231006 v2
Created: 2024-07-01
By: Deborah Sholl ([e-mail])
Status: Signed
Transaction ID: CBJCHBCAABAAJGrJ_Po3dyMlznz45h1QKE9aUyaH-6H8
"22382.FTA 10-23.231006 v2" History
Document created by Deborah Sholl ([e-mail])
2024-07-01 - 12:41:05 PM GMT
L'4 Document emailed to Adam Steurer ([e-mail]) for signature
2024-07-01 - 12:41:12 PM GMT
15 Email viewed by Adam Steurer ([e-mail])
2024-07-01 - 1:31:34 PM GMT
d© Document e-signed by Adam Steurer ([e-mail])
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