WQ0045723_Original Application_20240816

Kimley>»Horn
March 29, 2024
North Carolina Department of Environmental Quality
Raleigh Regional Office
Water Quality Section
3800 Barrett Drive
Raleigh, North Carolina 27609
RE: City of Durham
Lutravil Lift Station Improvements
Fast Track Sewer System Extension Application
To Whom It May Concern:
AUG 1. !i -i
Kimley-Horn has designed improvements to Lutravil Lift Station on behalf of the City of Durham
Department of Water Management. Lutravil Lift Station is located at 2420 Old Oxford Road, Durham,
North Carolina. The project consists of the construction of a new wet well, valve vault, force main
connection, removal and replacement of existing pumps, fencing, electrical panels and a generator.
The firm capacity of the existing station is 0.5 MGD (350 GPM) per existing permit WQCS00005.
Additional flow will be added to the station, and the proposed firm capacity of the upgraded station is
1.14 MGD_ We request that the existing permit be modified to reflect the increased capacity
associated with these upgrades. On behalf of the City of Durham Department of Water Management,
and in accordance with 15A NCAC subchapter 02T and the Division of Water Resources Minimum
Design Criteria, we submit herewith the relevant documentation to modify the sewer permit for
Lutravil Lift Station. Please find enclosed:
• Fast Track Sewer System Extension Application
• Flow Tracking/Acceptance Form
• Existing Permit No. WQCS00005
• Figure 1 — Aerial and Contour Map
• A $600.00 check for the standard processing fee
Please feel free to contact me at [phone] if you have any questions or require additional
information. I can also be reached at [e-mail]
Sincerely, r
,} �c.� tom. 73
zl-
Daniel G. Bula, P.E.
Project Manager

DocuSign Envelope ID: CDF471F9-3A9543BE-85DI-3A7E87D4162F
State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources PTA 10-23 & SUPPORTING DOCUMENTATION
Application Number. oO 5t23,obetomptekd`yDWR�
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Qy of Durham Del2artmentof Water Management (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: Donald F. Greeley per.[ SA. NCAC 02T 0.1061b)
Title: Director of Water Management
4. Applicant's mailing address. 101 City Hall Plaza
City: Durham State: NC Zip: 27701-_
5. Applicant's contact information.
Phone number: (919) 5604381 Email Address: don.greeleyAdurhamnc.aov
11. PROJECT INFORMATION:
1. Project name: Lutravil Lift Station Improvements
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: Durham
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.070486 Longitude:-78.863495'
5. Parcel ID (if applicable): 178028 (or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION:
1. Professional Engineer: Daniel G. Bula License Number: 046031
Firm: Kimley-Horn & Associates, Inc.
Mailing address: 300 Morris Street, Suite 200
City: Durham State: NC Zip: 27701-�
Phone number: [phone] Email Address: dan.bulata`�Aimley-hom.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: North Durham Water Reclamation Facility Permit Number: W 000 32515 JjG o�
Owner Name: City of Durham
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream (Receiving) Sewer Information: 12 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00005
Owner Name(s): C i vj
FORM: FTA 10-23 Page 1 of 5

DocuSign Envelope ID: CDF471F9-3A95-43BE-85D1.3A7E8704162F
V1. GENERAL REQUIREMENTS
I. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® NIA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement FORM: DEV been attached?
❑ Yes ❑ No ® NIA
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational A reemert 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/Fi[ter Backwash
® Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic 100 % Commercial % Industrial See 15A NCAC 02T.0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114 ? ❑ 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.0I14(f))
Daily Design FIow',b
No. of Units
Flow
gal/
GPD
gall
GPD
gall
GPD
gall
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.0114] 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

DocuStgn Envelope ID: CDF471F9-3A95-438E-85D1-3A7E87D4162F
VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 01T .0305 & MDC (Gravity Sewers):
. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
➢ Section It & 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 ado€ation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC(Pump 'tat( ns/Force.Mains r
PROVIDE A SEPARATE COPY OF THIS PAGE FOR. EACH PUMP STATION INCLUDED IN THIS PR03ECT
1. Pump station number or name: Lutravil Lift Station
2. Approximate Coordinates (Decimal Degreesy Latitude- 36.070486 Longitude:-78.863495'
3. Total number of pumps at the pump station 2
3. Design flow of the pump station: 1.12 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): —0400JQ 1100 gallons per minute (GPM) at 1 55 160.3. 126.8 04.5 feet total dynamic
head (TDH)
5. Summanze 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.I.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) .
6. Power reliability in accordance with 15A NCAC 02T .0305Ih1f 1):
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(13)_
➢ Required for all pump stations with an average daily flow greater than or equal to € 5,000 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.
FORM: FTA 10-23 Page 3 of 5

DocuSign Envelope ID: CDF471 F9-3A95-43BE-85D 1-3A7E87D4162F
9 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 timefranles, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 4 of 5

DocuSign Envelope ID: CDF471F9-3A9543BE-85D1-3A7E87D4162F
IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(1)):
1. Does the project comply with all separations/alternatives found in l5A NCAC 02T .0305(t) 6" (a)? ® Yes ❑ No
15A NCAC 02T.0305 contains minimum se arations that shall be Drovided for sewers 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 II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal).
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (e), see Section X.I of this application
* 15A NCAC 02T.0305(t;) contains alternatives where separations in 02T.03G5(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications %vebuage
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/scaled 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.
A See the Division's draft sepilratign.requirements for situations where separation cannot be met.
No variance is required of the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river bashl subject to any State buffer rules9 ❑ Yes Basin name; ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .02009 ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 28.020
5. Does the project require coverage/authorization under a 404 Nationwide individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit numberipermitting status to the cover letter if eoverage/autlmorization is required.
6. Does project comply with 15A NCAC 02T.0105;c)t6) (additional permits�certifrcations)? ® 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 I SA NCAC 02 r.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siplmon, 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 sit -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 5 of 5

DocuSign Envelope ID: COF471F9-3A9543BE-85D1-3A7E87D4162F
X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Mininnini Design Criteria for the Permitting of Pum2 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 Ionger
review times. For projects rote luirine two or more variances or where the variance is determined by the Division to be a
significant portion of the protect, the full technical review is required.
2. Professional Engineer's Certification:
I, Daniel G. Bula , attest that this application for Lutravil Lift Station Improvements
(Proressional Engineer's name from Application Item 111.1.) (Project Name from Application Item ti.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 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 tinder my signature and sea] 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 143-215.6B, 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 tip 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 15A NCAC 02T .0106(b):
'H CA
G.
lilt
I, Donald F. Greeley , attest that this application for Lutravil Lift Station Improvements
(Signature Authority Name from Application Item 1.3.) (Proiect Name from Application Item 11.1)
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. 1 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.
Signature: Date: SZ-1-
FORM: FTA 10-23 Page 6 of 5

DocuSign Envelope ID: CDF471F9-3A95-43BE-85Di-WE87D4162F
AUG ] 6 Z024 State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources INSTRUCTIONS FOR FORAM: FTA 10-13 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of I SA NCAC 02T and the Division's
Minimum Design Criteria (Gravity Sewer & Pump Stationsforce Mains) and that plans, specifications and supporting documents
have been prepared in accordance with 15A NCAC 01T, 15A NCAC 02T.0300, Division policies, and good engineerinp practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in 15A NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be immediately available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in I SA NCAC 02T 0303.
Projects not eligible for review via the fast track process (mast be submitted for full technical review):
➢ Projects that do not meet any part of the minimum design criteria (MDC) documents;
➢ Projects that involve more than one variance from the requirements of 15A NCAC 02T;
➢ Pressure sewer systems utilizing simplex septic tank -effluent pumps (STEPS) or simplex grinder pumps;
➢ Simplex STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains);
➢ Vacuum sewer systems.
General When submitting an application, please use the following instructions as a checklist in order to ensure all required items are
submitted. Adherence to these instructions and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information. Failure to submit all required items will necessitate additional processing and review
time, and may result in return of the application Unless otherwise noted, the Applicant shall submit one original and one copy of
the application and supporting documentation.
A. One Original and One Copy (second copy may be digital) of Application and Supporting Documents
® Required unless otherwise noted. Signatures c+n original must be "wet ink" or secure digital signatures.
Please do not suamit engineering design plans with the application unless specifically requested.
B. Cover Letter/Narrative Description (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ Include the permit number/status of any other required sewer permits (down 5tream/upstream)
➢ If necessary for clarity, include attachments to Ute application form.
C. Application Fee (All New and Modification Application Packages):
® Submit a check or money order in the amount of $600.00, dated no more than 90 days prior to application submittal.
➢ Payable to North Carolina Department of Environmental Qual.ty (NCDEQI
D. Fast Track Application (Required for All Application Packages, Form FTA 10-23):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with the
North Carol iva Secrelaiy of Slate.
• If the Applicant Type in Item I.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of Deeds in
i he county of business.
❑ The Project Name in Item 11.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina
licensed Professional Engineer.
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per
15A NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from
a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 1 of 3

0:c u &gn Envelope ID: CDF471F9-3A95438E-85D1-WE87134162F
E. Flow Tracking/Acceptance Form (Form: FTSE 10-23) (If Applicable):
❑ Submit the completed and executed FTSE fort from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one year
prior to the application date.
➢ Submittal of this application and form FTSE indicates that owner has adequate capacity and will not violate G.S. 143-215.67(a)
> Intergovervnental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project area,
including the closest surface waters.
➢ General location of the project components (gravity sewer, pump stations, & force main)
➢ Downstream connection points and permit number (if known) for the receiving sewer
® Include an aerial location map showing general project area (such as street names or latitude/longitude) so that Division staff
can easily locate it in the field.
C. Existing Permit (Application Packages for Modifications to an Existing Permit):
® Submit a copy of the most recently issued existing permit.
® Include a descriptive and clear narrative identifying the previously permitted items to remain in the permit, items to be
added, and/or items to be modified (the application form itself should include only include items to be added/modified). The
narrative should also include whether any previously permitted items have been certified.
® The narrative should clearly identify the requested permitting action and accurately describe the sewers to be listed in
the final permit.
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(I ), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible with
the station The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed contractor,
stating that "the portable power generation unit or portable, independently -powered pumping units, associated appurtenances
and persc innel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall
be provided in the case of a multiple station power outage. (Required at time of certification)
Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115 a 1 provide the Certificate of Public Convenience and Necessity from the North Carolina Utilities
Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by the sewer
extension, or
❑ Provide a letter from the North Carolina Utilities Conunission's Water and Sewer Division Pubic St.ifl'stating an application
for a franchise has been received and that the service area is contiguous to an existing franchised area or that franchise approval
is expected.
J. Operational Agreements (Applications from HOA/POA and Developers for lots to be sold):
❑ Home/Prop" Owners' Associations
❑ Per 15A NCAC 02T .01„15(cl, submit the properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0l ' 5(h), submit the properly executed Operational Agreement (FORM: DEV).
For more h for nritron, visit the Division's collection systems wehsite
INSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: CDF471F9-3A9543BE-85D1-3A7E8704162F
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778-8211
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Reglonal Office
225 Green Street Suite 714
Anson, Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5095
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
MOCUsyllle Rellonal Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Wator Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
BAleiah Regional Office
3800 Barrett Drive
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27609
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
WasMngton Reglopal_Office
943 Washington Square Mall
Beaufort, Bertie, Camden, Chowan, Craven,
WaterOualily Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
ftne -,g.lem Rejoonal Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Watsr Qraliiy Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
[phone] Fax
MSTRUCTIONS FOR FORM: FTA 10-23 & SUPPORTING DOCUMENTATION Page 3 of 3

f •fly `�', I4Y � �'l/{ � 1�.� ��
isLUTRAVIL PU P STATIONII! �
` f,{�jJ,{Jrrjl'Jrfrl/1rrJrr(J- �
/ � r� � �' �• k 5 .S^1 i '
A.
All
74
Legend
Sewer
Pump Station
Force Main
RiversidGravity Main
esnManhole
-
'" If