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APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 1
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
SECTION 1: INSTRUCTIONS AND INFORMATION
A. The Division of Water Resources will accept this application package for review only if all of the items are provided and the
application is complete. Failure to submit all of the required items will result in the application package being returned as incomplete
per 15A NCAC 02T .0105(b).
B. A check or money order must be submitted in the amount of $1000.00 (except minor modifications) dated within 90 days of
application submittal and made payable to North Carolina Department of Environmental Quality (NCDEQ).
C. Plans and specifications must be prepared in accordance with 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General
Statute 133-3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES
Wastewater Treatment Facilities.
D. The plans and specifications submitted must represent a completed final design that is ready to advertise for bid.
E. Any content changes made to this Form ATC 10-23 shall result in the application package being returned.
F. The Applicant shall submit ONE ORIGINAL and ONE DIGITAL COPY (CD) of the application, all supporting documentation
and attachments. All information must be submitted bound or in a 3-ring binder, with a Section tab for each Section, except the
Engineering Plans.
G. Check the boxes below to indicate that the information is provided and the requirements are met.
H. If attachments are necessary for clarity or due to space limitations, such attachments are considered part of the application package
and must be numbered to correspond to the item referenced.
I. For any project that requires review under the State Environmental Policy Act (SEPA), an Authorization to Construct cannot be
issued prior to the completion of a State Clearinghouse advertisement period for a FONSI, EIS, etc. unless the project qualifies for
a Determination of Minor Construction Activity or the funding entity specifies that this requirement does not apply.
J. For more information, visit the Division of Water Resources web site at: http://portal.ncdenr.org/web/wq/swp/ps/npdes.
K. In addition to this Authorization to Construct, the Applicant should be aware that other permits may be required from other Sections
of the Division of Water Resources (for example: reclaimed water facilities permits; Class A or B biosolids residuals permit).
SECTION 2: APPLICANT INFORMATION AND PROJECT DESCRIPTION
A. APPLICANT
Applicant’s name Town of Mayodan
Signature authority’s name per 15A NCAC 02T .0106(b) Melody Shuler
Signature authority’s title Town Manager
Complete mailing address 210 West Main Street, Mayodan, NC 27027
Telephone number 336-427-0241
Email address mshuler@mayodannc.org
B. PROFESSIONAL ENGINEER
Professional Engineer’s name Stephen Francis, P.E.
Professional Engineer’s title Project Manager
North Carolina Professional Engineer’s License No. 049975
Firm name LKC Engineering, PLLC
Firm License number P-1095
Complete mailing address 140 Aqua Shed Court, Aberdeen, NC 28315
Telephone number 910-420-1437
Email address stephen@lkcengineering.com
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 2
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
C. NPDES PERMIT
NPDES Permit number NC0021873
Current Permitted flow (MGD) – include permit
flow phases if applicable 4.500 MGD
D. PROJECT DESCRIPTION
Provide a brief description of the project: This project consists of the construction of a new splitter box, a new Aeration Basin, a
new Clarifier, and the conversion of the existing chlorine contact to UV treatment. The new aeration basin and clarifier will
replace treatment trains #1 and #2. Existing Aeration Basins #1 and #2 will be used for equaliization. This project will not
increase the capacity in any way.
SECTION 3: APPLICATION ITEMS REQUIRED FOR SUBMITTAL FOR ALL PROJECTS
A. Cover Letter
The letter must include a request for the Authorization to Construct; the facility NPDES Number; a brief project description
that indicates whether the project is a new facility, facility modification, treatment process modification, or facility expansion;
the construction timeline; and a list of all items and attachments included in the application package.
If any of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North Carolina
General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES Wastewater Treatment
Facilities are not met by the proposed design, the letter must include an itemized list of the requirements that are not met.
If the project is funded by American Rescue Plan Act (ARPA) funds, please include the ARPA project number in the cover
letter and here SRP-W-ARP-0187.
B. NPDES Permit
Submit Part I of the Final NPDES permit for this facility that includes Part A (Effluent Limitations and Monitoring
Requirements) for the monthly average flow limit that corresponds to the work that is requested for this project.
C. Special Order by Consent
If the facility is subject to any Special Orders by Consent (SOC), submit the applicable SOC.
Not Applicable.
D. Finding of No Significant Impact or Record of Decision
Submit a copy of the Finding of No Significant Impact or Record of Decision for this project.
Provide a brief description of any of the mitigating factors or activities included in the approved Environmental Document
that impact any aspect of design of this project, if not specified in the Finding of No Significant Impact or Record of
Decision. ___________________________________________________________________________________________
___
Not Applicable.
E. Engineering Plans
Per 15A NCAC 02T .0504(c)(1), submit one set of detailed plans that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
Per 21 NCAC 56 .1103(a)(6), the name, address and License number of the Licensee’s firm shall be included on each sheet of
the engineering drawings.
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 3
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
Plans must be labeled as follows: FINAL DRAWING – FOR REVIEW PURPOSES ONLY – NOT RELEASED FOR
CONSTRUCTION.
15A NCAC 02H .0124 requires multiple (dual at a minimum) components such as pumps, chemical feed systems, aeration
equipment and disinfection equipment. Is this requirement met by the design? Yes or No. If no, provide an explanation:
_____________________________ ___ ____ ____
Plans shall include:
Plans for all applicable disciplines needed for bidding and construction of the proposed project (check as appropriate):
Civil Not Applicable
Process Mechanical Not Applicable
Structural Not Applicable
Electrical Not Applicable
Instrumentation/Controls Not Applicable
Architectural Not Applicable
Building Mechanical Not Applicable
Building Plumbing Not Applicable
Plan and profile views and associated details of all modified treatment units including piping, valves, and equipment (pumps,
blowers, mixers, diffusers, etc.)
Are any modifications proposed that impact the hydraulic profile of the treatment facility? Yes or No. If yes, provide a
hydraulic profile drawing on one sheet that includes all impacted upstream and downstream units. The profile shall include
the top of wall elevations of each impacted treatment unit and the water surface elevations within each impacted treatment unit
for two flow conditions: (1) the NPDES permitted flow with all trains in service and (2) the peak hourly flow with one treatment
train removed from service.
Are any modifications proposed that impact the process flow diagram or process flow schematic of the treatment facility?
Yes or No. If yes, provide the process flow diagram or process flow schematic showing all modified flow paths including
aeration, recycle/return, wasting, and chemical feed, with the location of all monitoring and control instruments noted.
F. Engineering Specifications
Per 15A NCAC 02T .0504(c)(2), submit one set of specifications that have been signed, sealed and dated by a North Carolina
Licensed Professional Engineer.
Specifications must be labeled as follows: FINAL SPECIFICATIONS – FOR REVIEW PURPOSES ONLY – NOT
RELEASED FOR CONSTRUCTION.
Specifications shall include:
Specifications for all applicable disciplines needed for bidding and construction of the proposed project (check as appropriate):
Civil Not Applicable
Process Mechanical Not Applicable
Structural Not Applicable
Electrical Not Applicable
Instrumentation/Controls Not Applicable
Architectural Not Applicable
Building Mechanical Not Applicable
Building Plumbing Not Applicable
Detailed specifications for all treatment units and processes including piping, valves, equipment (pumps, blowers, mixers,
diffusers, etc.), and instrumentation.
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 4
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
Means of ensuring quality and integrity of the finished product including leakage testing requirements for structures and
pipelines, and performance testing requirements for equipment.
Bid Form for publicly bid projects.
G. Construction Sequence Plan
Construction Sequence Plan such that construction activities will not result in overflows or bypasses to
waters of the State. The Plan must not imply that the Contractor is responsible for operation of treatment
facilities. List the location of the Construction Sequence Plan as in the Engineering Plans or in the
Engineering Specifications or in both: Sequence plan is located in Section 01111 of the Engineering
Specifications.
H. Engineering Calculations
Per 15A NCAC 02T .0504(c)(3), submit one set of engineering calculations that have been signed, sealed and dated by a North
Carolina Licensed Professional Engineer; the seal, signature and date shall be placed on the cover sheet of the calculations.
For new or expanding facilities and for treatment process modifications that are included in Section 4.C, the calculations
shall include at a minimum:
Demonstration of how peak hour design flow was determined with a justification of the selected peaking factor.
Influent pollutant loading demonstrating how the design influent characteristics in Section 4.B.2 of this form were determined.
Pollutant loading for each treatment unit demonstrating how the design effluent concentrations in Section 4.B.2 of this form
were determined.
Hydraulic loading for each treatment unit.
Sizing criteria for each treatment unit and associated equipment (blowers, mixers, pumps, etc.)
Total dynamic head (TDH) calculations and system curve analysis for each pump specified that is included in Section 4.C.6.
Buoyancy calculations for all below grade structures.
Supporting documentation that the specified auxiliary power source is capable of powering all essential treatment units.
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 5
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
I. Permits
Provide the following information for each permit and/or certification required for this project:
Permit/Certification
Not
Applicable
Date
Submitted
Date
Approved
Permit/
Certification
Number
If Not Issued Provide
Status and Expected
Issuance Date
Dam Safety
Soil Erosion and Sediment Control 8/26/24
USCOE / Section 404 Permit
Water Quality Certification (401)
USCOE / Section 10
Stormwater Management Plan
CAMA
NCDOT Encroachment Agreement
Railroad Encroachment Agreement
Other:
J. Residuals Management Plan
For all new facilities, expanding facilities, or modifications that result in a change to sludge production and/or sludge processes,
provide a Residuals Management Plan meeting the requirements of 15A NCAC 02T .0504(j) and .0508; the Plan must include:
A detailed explanation as to how the generated residuals (including trash, sediment and grit) will be collected, handled,
processed, stored, treated, and disposed.
An evaluation of the treatment facility’s residuals storage requirements based upon the maximum anticipated residuals
production rate and ability to remove residuals.
A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department approved
residuals disposal/utilization program that has adequate permitted capacity to accept the residuals or has submitted a
residuals/utilization program application.
If oil, grease, grit or screenings removal and collection is a designated unit process, a detailed explanation as to how the
oil/grease will be collected, handled, processed, stored and disposed.
Not Applicable.
SECTION 4: PROJECT INFORMATION
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 6
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
A. WASTEWATER TREATMENT PLANT FLOW INFORMATION – COMPLETE FOR NEW OR
EXPANDING FACILITIES
1. Provide the following flow information:
Plant Flows
Existing Plant Design 4.500 MGD
Current NPDES Permit Limit 4.500 MGD
Current Annual Average
(past 12 months) 0.783 MGD
For Past 12 Months:
Start Date: May 2023
End Date: April 2024
For Past 24 Months:
Start Date: May 2022
End Date: April 2024
Maximum Month 1.106 MGD 1.387 MGD
Maximum Day 4.62 MGD 4.62 MGD
Peak Hour Unknown MGD Unknown MGD
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 7
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
B. WASTEWATER TREATMENT FACILITY DESIGN INFORMATION – COMPLETE FOR NEW OR
EXPANDING FACILITIES AND FOR TREATMENT PROCESS MODIFICATIONS
1. Have all of the requirements of 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General Statute 133-3, North
Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for NPDES Wastewater
Treatment Facilities been met by the proposed design and specifications? Yes or No. If no, provide justification as to
why the requirements are not met, consistent with 15A NCAC 02T .0105(n): _
_______________ ___ _
___
2. Provide the design influent and effluent characteristics that are used as the basis for the project design, and the NPDES
permit limits for the following parameters:
Parameter
Influent
Concentration
- Current
Annual
Average (past
12 months) if
Available
Project Basis of Design
NPDES Permit Limits
(monthly average)
Design Influent
Concentration
(Must be
supported by
Engineering
Calculations
[Section 3.H])
Design Influent
Load
(Must be
supported by
Engineering
Calculations
[Section 3.H])
Design Effluent
Concentration and/or
Load
Ammonia Nitrogen
(NH3-N) 10.4 mg/L 25 mg/L 22 lb/day
9.0 mg/L Summer 9.0 mg/L Summer
31.5 mg/L Winter 31.5 mg/L Winter
Biochemical
Oxygen Demand
(BOD5)
95.6 mg/L 2106 mg/L 210 lb/day
30 mg/L Summer 30 mg/L Summer
30 mg/L Winter 30 mg/L Winter
Fecal Coliform 200 per 100 mL 200 per 100 mL
Nitrate + Nitrite
Nitrogen (NO3-N +
NO2-N)
26.42 mg/L Monitor & Report mg/L
Total Kjeldahl
Nitrogen 16.8 mg/L
Total Nitrogen
30.69 mg/L Monitor & Report mg/L
423,740 lb/year Monitor & Report
lb/year
Total Phosphorus 4.5 mg/L 10 mg/L 375.5 lb/day
8.9 mg/L Monitor & Report mg/L
120,733 lb/year Monitor & Report
lb/year
Total Suspended
Solids (TSS) 103.8 mg/L 195.7 mg/L 7,348 lb/day 29.2 mg/L 30 mg/L
3. Based on the “Project Basis of Design” parameters listed above, will the proposed design allow the treatment facility to meet
the NPDES Permit Limits listed above? Yes or No. If no, describe how and why the Permit Limits will not be met :
_________________________________________________________
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 8
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
4. Per 15A NCAC 02T .0505(j), by-pass and overflow lines are prohibited. Is this condition met by the design? Yes or
No If no, describe the treatment units bypassed, why this is necessary, and where the bypass discharges:
5. Per 15A NCAC 02T .0505(k), multiple pumps shall be provided wherever pumps are used. Is this condition met by the
design? Yes or No. If no, provide an explanation:
6. Per 15A NCAC 02T .0505(l), power reliability shall be provided consisting of automatically activated standby power supply
onsite capable of powering all essential treatment units under design conditions, or dual power supply shall be provided per
15A NCAC 02H. 0124(2)(a). Is this condition met by the design? Yes or No. If no, provide (as an attachment to
this Application) written approval from the Director that the facility:
¾ Has a private water supply that automatically shuts off during power failures and does not contain elevated water storage
tanks, and
¾ Has sufficient storage capacity that no potential for overflow exists, and
¾ Can tolerate septic wastewater due to prolonged detention.
7. Per 15A NCAC 02T .0505(o), a minimum of 30 days of residual storage shall be provided. Is this condition met by the
design? Yes or No. If no, explain the alternative design criteria proposed for this project in accordance 15A NCAC
02T .105(n):
8. Per 15A NCAC 02T .0505(q), the public shall be prohibited from access to the wastewater treatment facilities. Explain how
the design complies with this requirement: Fence with a locked gate._____________________
9. Is the treatment facility located within the 100-year flood plain? Yes or No. If yes, describe how the facility is
protected from the 100-year flood: The proposed clarifier #5 is located within the 100-year floodplain, but the top of wall of
this structure is 3.2' above the base flood elevation to protect it.
C. WASTEWATER TREATMENT UNIT AND MECHANICAL EQUIPMENT INFORMATION – COMPLETE
FOR NEW OR EXPANDING FACILITIES AND FOR MODIFIED TREATMENT UNITS
1. PRELIMINARY AND PRIMARY TREATMENT (i.e., physical removal operations and flow equalization):
Treatment Unit No. of
Units Type Size per Unit Plan Sheet
Reference
Specification
Reference
Calculations
Provided?
(Yes or No)
Manual Bar Screen MGD at peak hourly flow
Mechanical Bar
Screen MGD at peak hourly flow
Grit Removal MGD at peak hourly
flow
Flow Equalization 2 -- 1,876,975 gallons M-18 11322 No
Primary Clarifier Circular ft diameter; ft side
water depth
Primary Clarifier Rectangular square feet; ft side
water depth
Other
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 9
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
2. SECONDARY TREATMENT (BIOLOGICAL REACTORS AND CLARIFIERS) (i.e., biological and chemical
processes to remove organics and nutrients)
Treatment Unit No. of
Units Type Size per Unit Plan Sheet
Reference
Specification
Reference
Calculations
Provided?
(Yes or No)
Aerobic Zones/
Tanks 1 Extended
Aeration 1,765,080 gallons M-6 11374 Yes
Anoxic Zones/
Tanks gallons
Anaerobic
Zones/Tanks gallons
Sequencing Batch
Reactor (SBR) -- gallons
Membrane
Bioreactor (MBR) -- gallons
Secondary
Clarifier 1 Circular 70 ft diameter; 12.5 ft side
water depth M-9 11331 Yes
Secondary
Clarifier Rectangular square feet; ft
side water depth
Other
3. TERTIARY TREATMENT
Treatment Unit No. of
Units Type Size per Unit Plan Sheet
Reference
Specification
Reference
Calculations
Provided?
(Yes or No)
Tertiary Clarifier Circular ft diameter; ft
side water depth
Tertiary Clarifier Rectangular square feet; ft
side water depth
Tertiary Filter square feet
Tertiary Membrane
Filtration square feet
Post-Treatment
Flow Equalization -- gallons
Post-Aeration gallons
Other
4. DISINFECTION
Treatment Unit No. of
Units Type Size per Unit Plan Sheet
Reference
Specification
Reference
Calculations
Provided?
(Yes or No)
Ultraviolet Light 4
Series
(Parallel; in
series)
2,812,500 gal/day per bank at
peak hourly flow; 2 number of
banks; 2 number of
lamps/bank
M-12 11376 Yes
Chlorination (Gas;
tablet; liquid)
gallons of contact
tank/unit
Dechlorination (Gas;
tablet; liquid)
gallons of contact
tank/unit
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 10
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
5. RESIDUALS TREATMENT
Treatment Unit No. of
Units Type Size per Unit Plan Sheet
Reference
Specification
Reference
Calculations
Provided?
(Yes or No)
Gravity Thickening
Tank square feet; ft side
water depth
Mechanical
Thickening/
Dewatering
dry lb/hour
Aerobic Digestion gallons
Anaerobic
Digestion gallons
Composting dry lb/hour
Drying dry lb/hour
Other
6. PUMP SYSTEMS (include influent, intermediate, effluent, major recycles, waste sludge, thickened waste sludge and plant
drain pumps)
Location No. of
Pumps Purpose Type
Capacity
of each
pump
Plan Sheet
Reference
Specification
Reference
GPM TDH
7. MIXERS
Location No. of
Mixers Purpose Type
Power of
each Mixer
(HP)
Plan Sheet
Reference
Specification
Reference
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 11
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
8. BLOWERS
Location No. of
Blowers Purpose Type
Capacity of
each Blower
(CFM)
Plan Sheet
Reference
Specification
Reference
9. ODOR CONTROL
Location No. of
Units Purpose Type Plan Sheet
Reference
Specification
Reference
D. SETBACKS – COMPLETE FOR NEW WASTEWATER TREATMENT STRUCTURES
1. The minimum distance for each setback parameter to the wastewater treatment/storage units per 15A NCAC 02T .0506(b) are
as follows:
Setback Parameter
Minimum Distance
Required from Nearest
Treatment/Storage
Unit
Is Minimum Distance
Requirement met by the
Design? If “No”, identify
Setback Waivers in Item D.2
Below
Any habitable residence or place of assembly under separate
ownership or not to be maintained as part of the project site 100 ft Yes No
Any private or public water supply source 100 ft Yes No
Surface waters (streams – intermittent and perennial, perennial
waterbodies, and wetlands) 50 ft Yes No
Any well with exception of monitoring wells 100 ft Yes No
Any property line 50 ft Yes No
2. Have any setback waivers been obtained per 15A NCAC 02T .0506(d)? Yes or No. If yes, have these waivers been
written, notarized and signed by all parties involved and recorded with the County Register of Deeds? Yes or No. If no,
provide an explanation: ___________________
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT (FORM ATC 10-23) Page 12
State of North Carolina
Department of Environmental Quality
Division of Water Resources
APPLICATION FOR AUTHORIZATION TO CONSTRUCT PERMIT
FORM ATC 10-23
SECTION 5: APPLICATION CERTIFICATION BY PROFESSIONAL ENGINEER
Professional Engineer's Certification per 15A NCAC 02T .0105:
I, Stephen Francis, P.E., attest that this application package for an Authorization to Construct
(Typed Name of Professional Engineer)
for the Mayodan Wastewater Treatment Plant Upgrades
(Facility and Project Name)
was prepared under my direct supervisory control and to the best of my knowledge is accurate, complete and consistent
with the information supplied in the engineering plans, specifications, calculations, and all other supporting
documentation for this project. I further attest that to the best of my knowledge the proposed design has been prepared in
accordance with all applicable regulations and statutes, 15 NCAC 02H. 0100, 15A NCAC 02T, North Carolina General
Statute 133-3, North Carolina General Statute 143-215.1, and Division of Water Resources Minimum Design Criteria for
NPDES Wastewater Treatment Facilities, and this Authorization to Construct Permit Application, except as provided for
and explained in Section 4.B.1 of this Application. I understand that the Division of Water Resources’ issuance of the
Authorization to Construct Permit may be based solely upon this Certification and that the Division may waive the
technical review of the plans, specifications, calculations and other supporting documentation provided in this application
package. I further understand that the application package may be subject to a future audit by the Division. Although
certain portions of this submittal package may have been prepared, signed and sealed by other professionals licensed in
North Carolina, inclusion of these materials under my signature and seal signifies that I have reviewed the materials and
have determined that the materials are consistent with the project design.
I understand that 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.
North Carolina Professional Engineer's seal with written signature placed over or adjacent to the seal and dated: