WQ0045753_Penn_Burlington_FTSSE_Application_Final_Submission_20240826

NC Depcm'Uro ,i of
Environiriental QU,31ity
AUG 7 6 2024
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 1.,% i11.1':c)n-S, iF'm FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
;, :1 i: ; .1=j C , FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: P (Zf-,b+J 7.3- 3 (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Qit\-_ of Burlington (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ElState/County ® Municipal ❑ Other
3. Signature authority's name: CraJign cult per ISA NCAC 02T .0106tb)
Title: City Manager
4. Applicant's mailing address: 425 S. Lexington Avenue, P.O._Box_ 1358
City: Burli ,n ton State: NC Zip: 272154200
5. Applicant's contact information:
Phone number: 3( 36) 222-5056 Email Address: dbowman �i-:burlingtonnc.vov
II. PROJECT INFORMATION:
1. Project name: Penn Burlington '
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: Alamapia
r
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.07187' Longitude:-79.5212'
5. Parcel ID (if applicable): 8844558174 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
r
1. Professional Engineer: Andrew Plato. PE License Number: 056417
Firm: Kimley-Horn & Associates, InE
Mailing address: 421 Fayetteville Street. Suite 600
City: Raleigh / State: NC Zip: 276014388
Phone number: (9M 653-5857 Email Address: andrew.platoaq kimlev- om,com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: South Burlington WWTP Permit Number: NCO023876
Owner Name: Cin of Burlington
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0038892'
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS000008
Owner Name(s): Citti__of Burlington I
FORM: FTA 10-23 Page 1 of 5

NC Department of
Environmental Quality
Received
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 Acreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A z
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA 1 and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes^L=3S6 X❑ 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: % Domestic 100 % Commercial % Industrial (See 15A NCAC 02T .0103t20!)
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 ves, 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 °,b T
No. of Unitsj Flow
Retail (stores, centers, malls) 100 gal/1,000 Sl�
6,807 SF ! 681 GPD
Retail with food preparation/service
40 gal/seat
112 Seats
4,480 GPD
gal/
GPD
gal/
gal/
GPD
GPD `..
gal/
Total
GPD
5,161 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. 42A4).
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: .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):
l . Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
i
Material
8"
115
DI
------------
%?C Departmc^.ni Ci
Environm-,�ntai Oulality
Received
AUUG 2 6 20, 24
Winston-S<',.=m
R ;icon
➢ 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:
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
i
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 .0305th)(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 XQ:
❑ 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

NC Dep@1'tt1_ Ili ni
Envit'Dmi—IE'Rtal t�uaiiiy
Received
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)): A Uu ? 6 2024 11
1. Does the project comply with all separations/alternatives found in 15A NCAC 021.Q 9fiU c "? ® Yes ❑ No
15A NCAC 02T.0305(1) contains minimum separations that shall be provides, fqr-sewer-stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'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 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
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
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 (2), see Section X.1 of this application
* 15A NCAC 02T.0305i g 1 contains alternatives where separations in 02T.03051 ft 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.0105tc ►(6) (additional permits/certifications)? ® Yes_OIvo
Per 15A NCAC _02T.0105 c�,+6,ii, 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 permtttee 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

NC Departanent of
Environmental Quality
Received
X. CERTIFICATIONS:
Does the submitted system comply with 15A_ NCAC 02T, the Mini
and Force Mains i latest version r. and the Gravit\ Sewer Minimum I
® Yes ❑ No
AUG 2 C 20A
onai Gifilre
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 proiects requiring a variance approval may be subject to longer
review times. For proiects 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:
I, 11(A��/�!y attest that this application for
(Professional Engineer's name from Application Item III.1.) (Project Name from Appli • ion item It.1)
bas 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 Desi:n_Criteria for Gravi(N Sewers (latest versionl, and the Minimum Design Criteria tQr the Fast -Track PermittitL.
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 1 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 Carol ina-licensed Professional Engineer to referral to the licensing board. (21 NCAC 56,0701)
North Carolina Professional Engineer's seal, signature, and date: ���N�'�m'++►+.•••�
A / ••.,
n / �4zo
3. Applicant's Certification per 15A NCAC 02T .0106(b):°°a°���0o
1, <<;�t1��' attest that this application for /lve- 4:..�/'�.�A -i
(Signature Authority Name from Application Item 1.3.) (Project Name from Ap�pllcation Item 11.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 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 retumed to the as incomplete.
NOTE — In accordance with General Statutes 143-21-5.6A and 14_ -2_1 4�.6L , 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.
r� \
Signature:
`s0 /�4'�
-
Date:
FORM: FTA 10-23 Page 5 of 5

NC Departrlent of
tnvironrriental Quality
Received
AUGG 2 2 20211
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Winston -Salem FTA 10-23 & SUPPORTING DOCUMENTATION
,n l (7ff-ice
Application Number: (f aM ?55,3 (to be completed by DwR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City_ of Burlin gton (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: Craie Fone�4cutt per 15A NCAC 02T .0106rb)
~
Title: City Manager
4. Applicant's mailing address: 425 S. Lexington Avenue, P.O._Box .1358
City: Burlinnton State: NC
Zip: 27215-4200
5. Applicant's contact information:
-
Phone number: 3( 36) 222-5050
Email Address: dbowmaneri.burlingtonnc.i4ov
II. PROJECT INFORMATION:
1. Project name: Penn Burlington
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: Alamance
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.07197' Longitude:-79.5212'
5. Parcel ID (if applicable): 8844558174 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Andrew Plato. PE License Number: 056417
Firm: Kimlev-Horn & Associates, Inc.
Mailing address: 421 Fayetteville Street. Suite 600
i
City:Raleigh-' State: NC Zip: 27601-1388
Phone number: (9M 653-5857 ' Email Address: andrew.plato4i)kimley-hom.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: South Burlington WWTP Permit Number: NC6023876
Owner Name: City of Burlington
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0038892
2. Downstream (Receiving) Sewer Information: 8 inch
® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS000008
Owner Name(s): City of Burlington
FORM: FTA 10-23 Page 1 of 5

VI.
N- Department of
Environmental Quality
GENERAL REQUIREMENTS Received
I. if the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenj; W aBd2gjjr ity been attached?
❑ Yes ❑ No ®N/A Winston-Salem
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreeea4Igt1U been attached?
❑ Yes ❑ No NIA
3. If the Applicant is a Home/Property Owners' Associatio , has an HOA OA Operational Agreement i FORM: HOA1 and
supplementary documentation as required by 15A N C'02T.0115(c) • een attached?
/❑ es ® No 0' 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: % Domestic 100 % Commercial % Industrial (See 15A NCAC 02T .0103r20 ))
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 ves. provides copv of flow reduction approval letter with this apr)lication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f)) Daily Design Flow ° b
No. of Units
Flow
Retail (stores, centers, malls) 100 gal/1,000 SF
6,807 SF
681 GPD
Retail with food preparation/service 40 gal/seat
112 Seats
4,480 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
5,161 GPD
a See 15A NCAC 02T .01 14(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. 42A4).
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 flodata_, water using fixtures, occupancy or operation patterns. and other measured data.
8. Wastewater generated by project: 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" 115 DI N.0 Department of
- Environmental Quality
Received
AUG 2 2 7094
Regicn.=.,,'' e
➢ 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:
2. Approximate Coordinates (Decimal Degrees): Latitude: r-° Longitude: - 0
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 2.01C.Lb. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305q.h►(1 e
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(11):
➢ 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

NC Department of
Environi'lientai Quality
Received
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305i e U � 2024 � Yes []No
15A NCAC 02T.0305(i) contains minimum separations that shall be rovided MT)
Setback Parameter* Re io&,1Jab#1gwRequired
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer) ^ -
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class ll 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 (2), see Section X.1 of this application
*15A NCAC 02T.0305i g) contains alternatives where separations in 02T.0305t I-) 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 web age
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 A200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
i
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 require .-_
6. Does project comply with 15A NCAC 02T.0105(c1(6) (additional permits/certifications)? ❑ Yes ® No
Per 15A NCAC 02T.01 O5jc)t6J, 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 dependeftt-permits (�rfosioi
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

_ - NC Department of
Environmental Quality
Received
X. CERTIFICATIONS: AUG 2 2 20?4
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria,fg;the Z- =ittinL of P
and _Force Mains i latest version f. and the Cravii SeNver Minimum Design Criteria (latest version i as applicable?
® Yes ❑ No �e Ion
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, andyroieets reauirin,_a variance approval 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
siinificant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
__JJ l
1, 11.(J (-W P l Wl b , attest that this application for P�YI�I U f�.ltlGj
(Professional Engineer's name from Application Item III.(.) (Project Name from Applih ion item I1.1)
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 GravirN Sewers (latest versions, and the Minimum Design Criteria for the Fast -Track Permittjns
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 1 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:
3. Applicant's Certification per 1 SA NCAC 02T .0106(b):
:.......................................................................--.--.---......
,NN�tl�tH IIH°j°,,
CAi� .,
O •. i
err¢ S`',.."!
2 QQ-
SEAL
s9 Q
°4•,,,un n����aNa
attest that this application for 1%40 °r' %!.�/'�.•fdl
(Signature Authority Name from Application Item 1.3.) (Project Name from App cation Item It. 1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 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 1.43-215.6B, 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: fz Date:
FORM: FTA 10-23 Page 5 of 5

NC Department of-
X.
CERTIFICATIONS: EnvironMentat QuaIl_rtL
,
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria foP EPVttdjtting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latestjyoionhas licable?
® Yes No eluv V rM
Winston-r ;,
If no, for projects requiring a single variance, complete and submit the Variance/Alteernative D�esIJ Request application
(VADC 10-14) and supporting documents for review to the Central Office. APVrNiP �`'lt6�t`rk4Vest will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to loneer
review times. For proiects 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:
I, 4RA(, l►! ?! 6(7115 , attest that this application for V tXtA &.(, illm+M
(Professional Engineer's name from Application Item I11.1.) (Project Name from Appli • ion item Ii_ l)
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 Desiim Criteria for Gravity Sewers (latest version). and the Minimum Design Criteria for the Fast -Track Permittin_
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 1 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: ��r/pN" CA►�.,,���.,
a'�r•0�,.�FESS�O"y�� `��
Applicant's Certification per 15A NCAC 02T .0106(b): ti'�Iw„C;•�.��`����
attest that this application fori��U/'�i��+1tza•�
(Signature Authority Name from Application ltem` l.3.) (Project Namc from Ap-plIcation Item 1t.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 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 the 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.
y !Q
Signature: � v1 Date: �al
FORM: FTA 10-23 Page 5 of 5

NC Departiment of
Environmental Quality
Received
AUG 2 Q 2024 State of North Carolina
W i n sto n-S a l e department of Environment and Natural Resources
Division of Water Resources
Regional Office
Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE 10-23)
Entity Requesting Allocation City of Burlington'
Project Name for which flow is being requested: Penn Burlington
More than one PISE may be required jor a single project ij the owner of the WWI P is not responsible jor 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: South Burlington WWTP
b. WWTP Facility Permit 4: NC0023876
All flaws are in MGD
c. WWTP facility's permitted flow 12.00
d. Estimated obligated flow not yet tributary to the WWTP 1.506664
e. WWTP facility's actual avg. flow 6.922000
f. Total flow for this specific request 0.005161
g. Total actual and obligated flows to the facility 8.433825
h. Percent of permitted flow used 70.28%
I1. 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
Average Approx. Obligated, Total
Pump Daily Current Not Yet Current
Station Pump Firm Flow** Avg. Daily Tributary Flow Plus Available
(Name or Station Capacity, * (Firm/pf), Flow, Daily Obligated Capacity**
Number) Permit No. GPD GPD GPD Flow, GPD Flow
* The Firm Capacity 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 pumpstation divided by a peaking
factor (pf) not less than 2.5.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity < 0.
Downstream Facility Name (Sewer) : LIDL US -NC 23 Burlington
Downstream Permit Number: WQ0038892
Page I of 6 FTSE 10-23

NL. Department of
Environmental QL'!ahty
Received
III. Certification Statement: AW�tk
1, W. Todd Lambert, P.E. certify to the best of k�c}Qw gdgah that the addition of the
\W s� ,
volume of wastewater to be permitted in this project has i gen. ev µat�d alpng the route to the receiving
,e ion ,Lt.
wastewater treatment facility and that the flow from this i`olect 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 asssessment 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 11 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.
Signing Official Signature Date
City Engineer
Title of Signing Official
Page 2 of 6 FTSE 10-23

Kimley>>> Horn - NI Department of
Environmental Quality 421 Fayetteville Street, Suite 600
Rn received Raleigh. North Carolina 27601
Transmittal G 1 p U �� '; a 024 TEL: [phone]
L`i FAX: [phone]
Winston-Salem a.,
s
Date: Augusto7, 2024 Regional iDj ftNumber: 016562000
Project Name: Penn Burlington
To: NCDEQ Winston-Salem Regional Office
Water Quality Section
450 W Hanes Mill Rd
Winston-Salem, NC 27105
Telephone: [phone]
We are sending these by:
❑ U.S. Mail ® FeclEx ❑ Hand Deliver
❑ Other:
We are sending you:
® Attached ❑ Under separate cover via
❑ Shop Drawings ❑ Prints/Plans ❑ Samples ❑ Specifications
❑ Other:
Copies Date No. Description
the following items:
❑ Change Orders
Paper
8/2/2024
2
Cover Letter
Paper
8/5/2024
2
Fast Track Sewer System Extension Application (FTA 10-23)
Paper
8/2/2024
2
Flow Tracking/Acceptance for Sewer Extension Permitting (FTSE
10-23)
Paper
8/5/2024
2
USGS Map Exhibit
Paper
8/5/2024
2
Aerial Map Exhibit
Paper
8/5/2024
2
Utility Plan & Profile Sheet
Paper
8/5/2024
1
$600.00 Check for Application Fee
Remarks:
Copy to: Andrew Plato
Page 1 1
Signed.

Kimley>»Horn
Penn Burlington
I:�C Department of
Environmental Quality
Received
AUG 2 0 2024
Winston-Salem
Regional Gfiice
FAST TRACK PRIVATE SEWER SYSTEM EXTENSION APPLICATION COVER LETTER
Description: The proposed development consists of two (2) retail buildings with six
(6) tenant spaces totaling 9,641 square feet. A total sanitary sewer
flow discharge of 5,161 GPD (see FTA 10-23, Section V1.7) has been
calculated. To service the development, a sanitary sewer main
extension of 115 linear feet of 8" Ductile Iron pipe is proposed.
Maintenance of the proposed sanitary sewer extension will be
covered by shared maintenance agreements.
Attachments: 1. Fast Track (Form FTA 10-23) Application
2. Flow Tracking for Sewer Extension (FTSE 10-23) Application
3. USGS topographic Map
4. Aerial Map
5. Utility Plan

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