WQ0045516_YMCA_Camp_Weaver_Sewer_Extension_FTSSE_Permit_App_Final_20240808

3rd submission received 7/26/24, second submission received 7/20/24 could not be printed, saved, edited, likely corrupted
State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
Division of Water Resources
Application Number:
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: YMCA of Greensboro, Inc. (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Rhonda Anderson per 15A NCAC 02T .0106(b)
Title: President and CEO
4. Applicant's mailing address: 4924 Tapawin og Trail
City: Greensboro State: NC Zip: 27406-
5. Applicant's contact information:
Phone number: [phone] Email Address: Gareth.clews(ae ymca,greensboro.org
II. PROJECT INFORMATION:
1. Project name: YMCA Sewer Extension
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'
5. Parcel ID (if applicable): 116415 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brent Sievers License Number: 27339
Firm: FEI Civil Engineers
Mailing address: 8518 Triad Drive
City: Colfax State: NC Zip: 27235-
Phone number: [phone] Email Address: bsieversAfeiconsulting com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: T.Z. Osborne Permit Number: NCO047384
Owner Name: City of Greensboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0037174
2. Downstream (Receiving) Sewer Information: 8" inch ❑X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 10-23 Page 1 of 5

X. CERTIFICATIONS:
1, Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Puml2 Stations
and Force Mains latest version and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrent!y with the approval of the permit, and projects reguirine a variance avproval may be subject to longer
review times. For nroiects requiring two or more variances or where the variance is determined by the Division to be a
significant Bortion of the prooect. the full technical review is re uired.
2. Professional Engineer's Certification:
attest that this application for MC.A s Uj. EX s 1611/
(Professional Engineer's name from Application Item III. I.) (Project Name from Application Item II.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers latest version , and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: mot* �*k
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, �h?4e JI attest that this application for
(Signature Authority Naive from Al5plication Item I.3.)
.y y•
�1••-
D3
YMCA Sewer Extension
(Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes I43-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
l Date:
FORM: FTA 10-23 Page 5 of 5

DWR
Division of Water Resources
Application Number:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: YMCA of Greensboro, Inc. (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal S /C unty ❑ Municipal ❑ Other
3. Signature authority's name: per 15A NCAC 02T .0106(b)
C
Title: 7f1 Sld' i [rr-6
4. Applicant's mailing address: 4924 Tapawin og Trail
City: Greensboro State: NC Zip: 27406-
5. Applicant's contact information:
Phone number: [phone] Email Address: Gareth.clewskymca,greensboro.org
II. PROJECT INFORMATION:
1. Project name: YMCA Sewer Extension
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'
5. Parcel ID (if applicable): 116415 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brent Sievers License Number: 27339
Firm: FEI Civil Engineers
Mailing address: 8518 Triad Drive
City: Colfax State: NC Zip: 27235-
Phone number: [phone] Email Address: bsievers(a-,feiconsultin_ cgom
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: T.Z. Osborne Permit Number: NCO047384
Owner Name: City of Greensboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0037174
2. Downstream (Receiving) Sewer Information: 8" inch ❑X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 10-23 Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
[:]Yes [:]No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement FORM: DEV been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOAIPOA Operational Agreement FORM: HOA and
supplementary documentation as required by 15A NCAC 02T.0I 15(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
® School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .01 14 ? ❑ Yes ❑ No
➢ If yes, provide a co pv of flo►s reduction a V p roval letter with this app Iication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
Summer camp with Food Prep and laundry
60 gal/Person
333
19980 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
19980 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. 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: 19980 GPD (per 15A NCAC 02T .01 14 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"
228
DIP
8"
2582
Truss
➢ 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: 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.050976 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): 35.4 gallons per minute (GPM) at 226 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2"
4240
PVC
2"
60
DIP
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.l.b. ® Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (a)? ® Yes ❑ No
1 5A NCAC 02T_0305(I) contains minimum separations that shall be provided for sewer 5YsteMS:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'--Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (g), see Section X.1 of this application
* 15A NCAC 02T.0305 contains alternatives where separations in 02T.0305(fl cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webnag
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: Capr Fear ❑ 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 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105 c 6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105 c 6 , directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ® Yes ❑ No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

X. CERTIFICATIONS:
1, Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Puml2 Stations
and Force Mains latest version and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrent!y with the approval of the permit, and projects reguirine a variance avproval may be subject to longer
review times. For nroiects requiring two or more variances or where the variance is determined by the Division to be a
significant Bortion of the prooect. the full technical review is re uired.
2. Professional Engineer's Certification:
attest that this application for MC.A s Uj. EX s 1611/
(Professional Engineer's name from Application Item III. I.) (Project Name from Application Item II.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers latest version , and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: mot* �*k
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, �h?4e JI attest that this application for
(Signature Authority Naive from Al5plication Item I.3.)
.y y•
�1••-
D3
YMCA Sewer Extension
(Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes I43-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
l Date:
FORM: FTA 10-23 Page 5 of 5

Project Narrative
Public/ Private Sewer Extension for YMCA of Greensboro
The proposed project consists of a 125.9-acre parcel located at 4924Tapawingo Trail in Guilford County,
North Carolina. The development consists of 126-acre Summer Camp for children. The property will be
served by Private water and public/ private sewer from the City of Greensboro. Sanitary sewer installation
will consist of 228 lineal feet of 8" DIP and 2582 lineal feet of 8" PVC Pipe with 7 manholes of public
sanitary sewer. In addition, there will be 4240 LF of 2" PVC forcemain and 60 LF of 2" DIP forcemain for
the private portion of the sewer extension. Total flow is projected to be 19,980 GPD. A portion of the
sewer is located within 50' of wetlands. The sewer within 50' of the wetlands will flow in Ductile Iron
piping through steel encasement to meet the alternative design criteria for minimum separation for sewer
systems to wetlands.
The sanitary sewer installation will have segment classified as a high priority sewer due to the fact there is
a portion of the gravity sewer that will be aerial sewer that crosses the Little Alamance Creek. The aerial
sewer will span approximately 80' with 2- concrete piers to support the sewer crossing the creek. The 8"
DIP pipe will have mechanical joints and be encased in steel piping for support.

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C �-i V- r. /�'a��"2`1 State of North Carolina
11WR Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number:��Ci�.�j' (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: YMCA of Greensboro (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: per 15A NCAC 02T .0106(b)
Title:
4. Applicant's mailing address: 4924 Tapawingo Trail'
City: Greensboro State: NC Zip: 27406-
5. Applicant's contact information:
i
Phone number: [phone] Email Address: Gareth. clewsnaagreensboro.org
IL PROJECT INFORMATION:
1. Project name: YMCA Sewer Extension
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00_
i
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'
5. Parcel ID (if applicable): 116415 (or Parcel ID to closest downstream sewer)
II1. CONSULTANT INFORMATION:
l . Professional Engineer: Brent Sievers License Number: 27339
Firm: FEI Civil Engineers l
Mailing address: 8518 Triad Drive
City: Colfax State: N6 Zip: 27235/-
Phone number: [phone]' Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: T.Z. Osborne Permit Number: NCO047384
Owner Name: City of Greensboro �
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0037174 "
2. Downstream (Receiving) Sewer Information: 8" inch ❑X Gravity ❑ Force Main
i
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 10-23 Page 1 of 5

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 ® N/Af
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A'
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0I 15(c) been attached?
❑ Yes ❑ No ® N/A"
4. Origin of wastewater: (check all that apply):
❑ Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
® School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ❑ No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow e,b
No. of Units
/
Flow
Summer camp with Food Prep and laundry
60 gal/Person
333
19980 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
19980 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. 42A-4).
b Per 15A NCAC 02T .01 14(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
Wastewater generated by project: 19980 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

V11. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8"
228 l
DIP l
8"
2582 l
Truss
2 p
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
Vill. 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: I
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'Af >' u
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.05 millions gallons per day (fine 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): 35.4 gallons per minute (GPM) at 226 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2"
4240
PVC
2"
60
DIP
./r -7 i,
3b:
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01 C.l.b. ® Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
J
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 3 of 5

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (g,)? ® Yes ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer systems -
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
'-Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or (g), see Section X.1 of this application
*I 5A NCAC 02T.0305(e) contains alternatives where separations in 02T.0305(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 webpag
i
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: Capr Fear
❑ No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200?
® $es [:]No
This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ® Yes ❑ No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Pennitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I, aT__V ! ,attest that this application for lnCi'� It
1111ER. LXi�sl del
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item II.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Pennitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
•o
..
Applicant's Certification per 15A NCAC 02T .0106(b):
�j �
I, vfi�✓� attest that this application for
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of -my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this pen -nit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting infonnation 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:134 Date: // /21 A
FORM: FTA 10-23 Page 5 of 5

Project Narrative
Public/ Private Sewer Extension for YMCA of Greensboro
The proposed project consists of a 125.9-acre parcel located at 4924Tapawingo Trail in Guilford County,
North Carolina. The development consists of 126-acre Summer Camp for children. The property will be
served by Private water and public/ private sewer from the City of Greensboro. Sanitary sewer installation
will consist of 228 lineal feet of 8" DIP and 2582 lineal feet of 8" PVC Pipe with 7 manholes of public
sanitary sewer. In addition, there will be 4240 LF of 2" PVC forcemain and 60 LF of 2" DIP forcemain for
the private portion of the sewer extension. Total flow is projected to be 19,980 GPD. A portion of the
sewer is located within 50' of wetlands. The sewer within 50' of the wetlands will flow in Ductile Iron
piping through steel encasement to meet the alternative design criteria for minimum separation for sewer
systems to wetlands.
The sanitary sewer installation will have segment classified as a high priority sewer due to the fact there is
a portion of the gravity sewer that will be aerial sewer that crosses the Little Alamance Creek. The aerial
sewer will span approximately 80' with 2- concrete piers to support the sewer crossing the creek. The 8"
DIP pipe will have mechanical joints and be encased in steel piping for support.

FEI NC Department of
Environmental Quality
Received
CIVIL ENGIN E-RS AND LAND -SURVEYORS JUN 10 2024
I Winston-Salem
TI-an-sri,ilt-tal Memo Regional Office
To: Attention:
NCDWR- Water Quality Section Jenny Graznak
450 W. Hanes Mill Road, Suite 300 Assistant District Engineer
Winston Salem, NC 27105 336-776-9695
From:
Brent Sievers, PE
336-544-6432
[e-mail]
Date: Monday, June 10, 2024
FEI Project Number: 25003.001
Subject: Fast track application for Lift Station
Urgent: El Review:❑X Please Comment: El Please Reply:❑ Please Recycle:❑
Notes
Enclosed is the original and 1 copy of the Fast Track Sewer System Extension
Application with supporting documents and applicable fees. Please call with any
questions
Thanks,
Brent Sievers, PE
Senior Project Manager
FEI
F E I
Civil Engineers and Land Surveyors

City of Greensboro
Water Resources Department
rA J ld Engineering Division
Flow Tracking/Acceptance for Sewer
Ll—wu (COG-FTSE-10/07)
OREENSBORO
Application Number: 2019-078
Project Applicant Name: YMCA Greensboro
Project Name for which flow is being requested: Tapawingo Trail 4924 YMCA Sewer Extension J
More than one COG-FTSE-10107 maybe required for a single project if the owner of the WWTP is not responsible for all pump stations
along the route of the proposed wastewater flow. Flow acceptance is contingent upon City Council approval.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: T.Z. Osborne Water Reclamation Facility`
b. WWTP Facility Permit Number: NCO047384 <
c. WWTP facility's permitted flow
d. Estimated obligated flow not ye
e. WWTP facility's actual avg. flow
f. Total flow for this specific reque!
g. Total actual and obligated flows
h. Percent of permitted flow used
All flows are in MGD
56
CS - 34.7100 SIU - 1.4200
35.4100
0.0200
42.1986
75.4%
H. Complete this section for each pump station you are responsible for along the route of this proposed wastewater flow.
Are there any pump stations affect Yes
List pump station (if any) project initially goes t
Pump Station Name
1 Stewart Mill Road
2
3
4
5
III. Certification Statemen
Approx. Capacity, MGD
(Firm/Design)
10.22
#N/A
#N/A
#N/A
#N/A
If "Yes", starting where upstream?
Stewart Mill Road
Approx. Design
Current Avg.
Daily Flow, MGD
3.70
# N/A
# N/A
# N/A
# N/A
I, Wendy Messer certify that, to the best of my knowledge, the addition of the volume of wastewater to be permitted in this project has
been evaluated along the route to the receiving wastewater treatment facility and that the flow from this project is not anticipated to cause
any capacity related sanitary sewer overflows or overburden any downstream pump stations enroute to the receiving treatment plant. This
analysis has been performed in accordance with local established policies and procedures using the best available data. This certification
applies to those items listed above in Sections I and II for which I am the responsible party. Signature of this form indicates acceptance of
this wastewater flow.
��RC�4 7)�&4(zo
Wendy Messs
Signing Official Signature
611012024
Date

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Entity Requesting Allocation:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-23)
YMCA of Greensboro
Project Name for which flow is being requested: YMCA Camp Weaver Sewer Extension
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: T.Z. Osborne
b. WWTP Facility Permit #:
NCO047384
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
56.0
4.84
35.4100
0.020
42.1986
75.4%
Il. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Design
Obligated,
Pump
Pump
Average
Approx.
Not Yet
Total Current
Station
Station
Firm
Daily Flow**
Current
Tributary
Flow Plus
(Name or
Permit
Capacity, *
(Firm / p fl,
Avg. Daily
Daily Flow,
Obligated
Available
Number)
No.
MGD
MGD
Flow, MGD
MGD
Flow
Capacity***
StewartNAJI
38555
10.224
4.963
1.796
0.02
1.816
3.147
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow that can be
achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) not
less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located between the
project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Cite of Greensboro T.Z. Osborne
Downstream Permit Number: NC047384
Page 1 of 6
FTSE 10-23

III. Certification Statement:
I Wendy Messer certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
u�
Signing Official
7/a 5/2 y
Date
No
Page 2 of 6
FTSE 10-23

Entity Requesting Allocation:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-23)
YMCA of Greensboro
Project Name for which flow is being requested: YMCA Camp Weaver Sewer Extension
More than one FTSE maybe required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: T.Z. Osborne
b. WWTP Facility Permit #:
NCO047384
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
56.0
6.7886
35.4100
0.020
42.1986
75.4%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Design
Obligated,
Pump
Pump
Average
Approx.
Not Yet
Total Current
Station
Station
Firm
Daily Flow**
Current
Tributary
Flow Plus
(Name or
Permit
Capacity, *
(Firm / pf),
Avg. Daily
Daily Flow,
Obligated
Available
Number)
No.
MGD
MGD
Flow, MGD
MGD
Flow
Capacity***
Stewart
X.4.1 i
38555
10.224
4.963
1.796
0.02
1.816
3.147
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow that can be
achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pf) not
less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located between the
project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): City of Greensboro T.Z. Osborne
Downstream Permit Number: NC047384
Page 1 of 6
FTSE 10-23

III. Certification Statement:
I Wendy Messer certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official ignature
Title of SVgni*Official
713012 �Z
Date
Page 2 of 6
FTSE 10-23

3rd submission received 7/26/24, second submission received 7/20/24 could not be printed, saved, edited, likely corrupted
State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
Division of Water Resources
Application Number:
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: YMCA of Greensboro, Inc. (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Rhonda Anderson per 15A NCAC 02T .0106(b)
Title: President and CEO
4. Applicant's mailing address: 4924 Tapawin og Trail
City: Greensboro State: NC Zip: 27406-
5. Applicant's contact information:
Phone number: [phone] Email Address: Gareth.clews(ae ymca,greensboro.org
II. PROJECT INFORMATION:
1. Project name: YMCA Sewer Extension
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0253' Longitude:-79.6815'
5. Parcel ID (if applicable): 116415 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brent Sievers License Number: 27339
Firm: FEI Civil Engineers
Mailing address: 8518 Triad Drive
City: Colfax State: NC Zip: 27235-
Phone number: [phone] Email Address: bsieversAfeiconsulting com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: T.Z. Osborne Permit Number: NCO047384
Owner Name: City of Greensboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ0037174
2. Downstream (Receiving) Sewer Information: 8" inch ❑X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 10-23 Page 1 of 5

X. CERTIFICATIONS:
1, Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Puml2 Stations
and Force Mains latest version and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrent!y with the approval of the permit, and projects reguirine a variance avproval may be subject to longer
review times. For nroiects requiring two or more variances or where the variance is determined by the Division to be a
significant Bortion of the prooect. the full technical review is re uired.
2. Professional Engineer's Certification:
attest that this application for MC.A s Uj. EX s 1611/
(Professional Engineer's name from Application Item III. I.) (Project Name from Application Item II.1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers latest version , and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date: mot* �*k
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, �h?4e JI attest that this application for
(Signature Authority Naive from Al5plication Item I.3.)
.y y•
�1••-
D3
YMCA Sewer Extension
(Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes I43-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
l Date:
FORM: FTA 10-23 Page 5 of 5