WQ0045516_YMCA_Camp_Weaver_Sewer_Extension_FTSSE_Permit_App_3rd_Submission_20240726

3rd submission received 7/26/24, second submission received 7/20/24 could not be printed, saved, edited, likely corrupted
State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
Division of Water Resources
Application Number:
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: YMCA of Greensboro, Inc. (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: Rhonda Anderson per 15A NCAC 02T .0106(b)
Title: President and CEO
4. Applicant's mailing address: 4924 Tapawin og Trail
City: Greensboro State: NC Zip: 27406-
5. Applicant's contact information:
Phone number: [phone] Email Address: Gareth.clews(ae ymca,greensboro.org
II. PROJECT INFORMATION:
1. Project name: YMCA Sewer Extension
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: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'
5. Parcel ID (if applicable): 116415 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brent Sievers License Number: 27339
Firm: FEI Civil Engineers
Mailing address: 8518 Triad Drive
City: Colfax State: NC Zip: 27235-
Phone number: [phone] Email Address: bsieversAfeiconsulting com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: T.Z. Osborne Permit Number: NCO047384
Owner Name: City of Greensboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0037174
2. Downstream (Receiving) Sewer Information: 8" inch ❑X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 10-23 Page 1 of 5

X. CERTIFICATIONS:
1, Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Puml2 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
concurrent!y with the approval of the permit, and projects reguirine a variance avproval may be subject to longer
review times. For nroiects requiring two or more variances or where the variance is determined by the Division to be a
significant Bortion of the prooect. the full technical review is re uired.
2. Professional Engineer's Certification:
attest that this application for MC.A s Uj. EX s 1611/
(Professional Engineer's name from Application Item III. I.) (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 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 $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: mot* �*k
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, �h?4e JI attest that this application for
(Signature Authority Naive from Al5plication Item I.3.)
.y y•
�1••-
D3
YMCA Sewer Extension
(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 I43-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
l Date:
FORM: FTA 10-23 Page 5 of 5