WQ0045867_Ethel_Drive_Subdivision_FTSSE_Final_App_20241009

NC Department of
Environmental Quality
Received
State of North Carolina
OCT 0 9 2024 Department of Environmental Quality
DWR Winston-Salem Division of Water Resources
Regional Office FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources - FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number..WN`tJY-6 % (tit be completed by Dtvit)
I. APPLICANT INFORMATION:
1. Applicant's name: City of Thomasville (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: Michael Brandt per I'A N(:'At' 02T.0t06tBt
Tale: City Manaeer
4. Applicant's mailing address: PO Box 368
City: Thomasville
5. Applicant's contact information:
State: NC Zip: 72 361-9368
Phone number..Q.&4754222 Email Address: �jj,�aeLbmndt�thamsville-nc.�v
U. PROJECT INFORMATION:
I. Project name: Ethel Drive Subdivision
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000 and issued date: _,
For modifications, also attach a detailed narrative description as described in Item G of the checklist
If new construction, but pan of a master plan, provide the existing perms number. W000_
3. County where project is located: Davidson
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.844167Longitude:-80,086389'
5. Parcel ID(if applicable): 1634700000050C (or Parcel ID to closest downstream sewer)
UI. CONSULTANT INFORMATION:
l . Professional Engineer. H. Mack Summev Jr. PE License Number. Z6447
Firm: Summev Enaincning Associates. PLLC
Mailing address: P.O.Box 968
City: Asheboro State: NC Zip: 27204-1106
Phone number. Q6}328-0902 Email Address: macktirsummevemmncerinaeom
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Hamby Creek WWTFPermit Number. NCO0241 l2
Owner Name: City ofThomasvilic
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): W000657
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00057
Owner Name(s): City of Thomasville
Vnng4. Cmn 1F 11 PunP I nFq

VJA
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 Arc na4tt-fi tR��: QM been attached?
❑ Yes ❑ No ® N/A _
3. If the Apllicant is a Elom taperty Owners' Association, has an HOA/POA Operatio€ta$ A mcnt.( t71 i:'.F OA7 and
Supplemen Lary documeri`tatipn�tO required by 15ANCAC 02T.011'S(c) becn.attached`�`
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
0 Resu[ent al (tlndzvrdually Owned) ❑ Retail (stores» duit0s, malls? ❑ Car Wash
❑`Rt- uWeiitia[(teased) ❑ Detail with foodtptepararionlseavicc ❑ Hotel and/or Motels
❑'Scliool./'piikhooU daycare ❑ Medtcall,dental l veterinary facilities ❑ ;Swunmmg PoollClubhouse
❑ Food aiid;dririk f fi.,M es ❑ Church ❑ Swiimmmg P.60VFilter :Backwz sh
❑ Businesses / offices / factories ❑ Nursing Home ❑` ttber(1?xpiam.in Atraciricat).
5. Nature of wastewater: 100 Domestic o Commerc aa.[ °a Industrial{,Seo 1'SA NCAC. 02T .0 03(20-�
If Industrial, is:tl erga i'retreatmentPri> , _'�
. gmea at effeoE. ❑ Y v o
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ❑ No
'If .1m Myide.a gopy of 'flow reduction agpcovat letter evitlt tlttc al pl16 lon
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f)) Daily Design Flow'b No. of Units Flow
SINGLE FAMILY RESIDENTAL(3 BR) 360 gal/DAY 5 l$00 GPD
ga1J GPD
clay GPD
l;aU GPD
Pav GPD
gall GPD
Total 1800 GPD
a See 15A -NCAC 02T A4 4tbl (dl c;)(1) and Wt2YJ for caveats to wastewaterdesign flow rates (ie. proposed unknown
non-residential develogmenit•riscs, public access facilities located near high public use areas; and re idential property
located south oreast df°thd Atlantic Intracoastal Wate'r'w'ay'16 be used as vacationrentalsas defined in G.S, 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishmentsnot identified [m table. 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8 Wastewater,gerteza_ted_by project: 1.500 GPP (per l 5ANCAC.02T 0114 and.f r S 143-215 1)
Do aot npiudz futur.e flows or DMViously perinitted,alitications
If permitted flow is zero, please indicate wby:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this One.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
El Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: T-7A 10-71

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T . 30 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
➢ 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. PUW STATION DESIGN CRITERIA (If Applicable) — 027.0305 & MDC. Purr St tionstForee. 3hi ;
PR.O-'1D A SEPAl2A"1'g _ copy OF TUIS-PAGE FOR iiACH PUMP STATIONt INCi 3DHD tN.` .HIS P OJEC'T
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons,per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Opemtional.point(s) per pump(s): gallons per minute (GPM) at feet totatdynamic head ('I'DH)
5. Summarize the force main to be permitted (for this Pump Station):
Size Cinches) Length (feet) Material
If any ppttron of the force main is, less Than 4=inches in diameter•, please identify the method of solids reduction per
MDCFSFM Section 2.01C.Lb. ❑ Grnider Pump ❑ mecizanicaI Bar Screen Other(ptease specify)
6. Power reliability in accordance with 15ANCAC 02T .03005(h)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry -15ANCAC 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'storaw
capacities and the rotation schedule of the portable power source or pump, including traveltimeframes,sball be provided
as part of this permit application in the case of a multiple station power outage.
Vl"ATIAS, UT A t.A '12. n- '1 nr 9

IX. SETBACKS & SEPARATIONS (02B .0200 & ISA NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15XN1C°<`,A4C:02 .0305(f'1--& i )`? ® Yes ❑ No
15ANCAC 02T.0305(f)contaihsriminirirum-s6barationsthat shall beaovided'for sewer:cvstems:
Setback Parameter*
Separation Required_
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical-water over sewer preferred, including in benched trenches)
18 inches
ZWatermains (horizontal) ,..,
10 feet
Reclaimed water lines (vertical -reclaimed over sewer)
18 inches
Reclaimed waterlines (horizontal-reclaimed"over sewer)
2 feet
"Any private orpublic watersupply 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 1X.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 verticalheight
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools .. _
10 feet
Final earth grade (vertical)
36 inches
If noncompliance'with 22T.0305(f) or (a), see Section X.1 of this application
* 15�A, CA 02T.0305W,contains alternatives where separations in 021.0305(f) cannot be achieved. Please check "yes"
above if these alteratives are used and provide narrative information to explain.
"*Stream classifications can be identified using the Division's 1�1t Surfaceliatesla:ica Boras wclxlxa
2. Does this project comply with the minimum separation requirements for water mains? ® Yes ❑ No ❑ N/A
D 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, verify mg 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.
D Seethe Division's draft sepgration requircnients 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: 0 No
If yes, does the project comply with setbacks found in the riverbasin rules per 15.E NQkC. 02B •.0'200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require covetage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or401 Water Quality Certifications?
D Please provide the permit number/permittmg status in the cover letter if coverage/authorization is required.
6. Does project comply with 1 SANCAC 02T.0 1 05(c)(6) (additional permits/certifications)? ®' Yes ❑ No
Per 15ANi7 C i12T.0105(cl(- - directly related eavitonmentalpermits or certification applications must be bemg,prepafed,
have been.a . plied for; or havebeen obtained. Issuance ofthis permit is contingent on issuance of dependent permits (erdsion
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 15ANCAC 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 lime, 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.

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A. NCAC 02T, the t41ihstntttn; Dc.( nt na.fo�tiic Fit nnittir�n crl'i'usp'tticAns
Arad Force Ktirts /la test version), and the Orgvity Sewer minih,tast 'o6ija Criteria "(la test v ersibri i as applicable?
Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Altemative Design Request application
(VADC t0-14) and supporting documents for review to the Central Office. ,Atnnrovat of the �reauest wilI_. be issued
2. ProfessionalEnginee►'s Certification:
T,,4�1LtQ-:lsttybYY�,Qt•{ dT ,attest thatthisapplicationfor 'vbaiyt's.ic
0I 0fessionat EnIff6cerN name from Applicattoit Item III. l.) (Project Name from Application Item II.I )
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and allother 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,
,,xlii iinturx Dasi t Cnieria fur O]Eo c ity Sewers QIate.st v i nl.. and the Mxn' imur fn Rg,,-O xn Critd& 'for the ast 'T""rtrk Penn itting
of.:Pump%ationsand fore1Wains tcstvenrsititi.-Atthotighother professionaIsmayhavedevelopedcertaiaportionsofthis
submittal package, inclusion of these materisels:under my signature and sealsignifies 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 I43 215.68, 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, aswell ascivil penaltiesup.to $25,000 perviolation. Misrepresentation of the applicatim
information, including failure todisclose any design non-compliance with the applicable-Rulesanddesigncriteria, ay subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 50.0 01)
North Carolina Professional Engineer's seal, signature, and date:
Is
x
26447
3. Applicant's Certification per 15A NCAC 02T .0106(b):
[, ' , a . 1�.:. ,-�,,J4,attestthat this application for ,e t yt fs st dx,, ursr`crrx
(Signature Authority Name from Application Item'1.3.)
(Project Larne £ivtnt 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 surfacewaters orthe land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/orcriminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE - In accordance with General Statutes 143-215.6A and 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.
WNT) P_.d• L'V A 111. 112

NC Department of Received State of North Carolina
DWR Environmental Quality Department of Environmental Quality
I
Division of Water Resources
OCT 0 2 2024 FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources Winston-Salem FTA 10-23 &SUPPORTING DOCUMENTATION
Application Number. l,�nANS�b 7 (to be completed by DWR) SG� Zd2 /,6 d �
It. 3-) = Zv37
All items must be completed or the application will be returned
f. APPLICANT INFORMATION:
1. Applicant's name: City of Thomasville (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: Michael Brandt per 15A NCAC 02T .0106(bl
Title: City Manaeer
4. Applicant's maifing address: PO Box 368
City: Thomasville /
5. Applicant's contact information:
State:NQ' Zip:27361-0368
Phone number. Q 6)475-4222 Email Address: Michaelbrandt�'thamsvi8e-nc.gov
U. PROJECT INFORMATION:
1. Project name: Ethel Drive Subdivision ,
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Pemtit/Prvject
If a modification, provide the existingpermit number: W000 and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist
If new construction, but pan of a master plan, provide the existing permit number. W000_
3. County where project is located: Davidson - /
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.844i67° Longitude: -80.086389°
5. Parcel ID(if applicable): 1634700000050C (or Parcel ID to closest downstream sewer)
III CONSULTANT INFORMATION:
1. Professional Engineer. H. Mack Summev Jr. PE License Number. 26447
Firm: Summev Eneirerrinn Associates. PLLC
Mailing address: P.O.Box %8
City: Asheboro State: K Zip: 27204-1106
Phone number. (8L6) 3284402 Email Address: mackisummevenaineerms.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Hamby Creek WWTF/Permit Number: NCO024112
Owner Name: City of Thomasville
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): W000057
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00057 '
Owner Name(s): City of Thomasville
FORM: FTA 10-23 Page I of 5

Yd.
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 Developerof lots to be sold, has a Developer's Operational Agreement (FORM. DES) 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.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Orig¢y 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 drunk facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 190 % Domestic °/. Commercial_ % Industrial (See 15A NCACO2T.0103j201)
If industrial, is there a Pretreatment Program it effect? ❑ Ye. No
6. Hasa flow reduction been approved under 15A NCAC 02T .0I 14(f)? ❑ Yes ❑ No
➢ If yes provide a copy of flow reduction approval letter with this application
7. Summarize waslewater eyetatedbyproject.
Establishment, pe (see o2 AI14(n)
Dailv Design Flow'h
No. of Units
Flow
SINGLE FAMILY RESIDENTAL
360 gaI,DAY
=
1800 GPD
p
ga V
GPD
gat'
GPD
gav
GPD
ga V
GPD
ga V
GPD
Total
1800 GPD
a See 15ANCAC 02T.0114(b).(d). (eX1) and (el(2) for caveats to wa stewater design flow rates (ie. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A4 -
b Per 15ANCAC 02T.0114(c),design Flow rates forestablishmentsnot identified [in table 15A NCAC 02T.0I 141shallbe
determined using available flow data, water using fixtures, occupancy or operation pattems, and other measured data.
8. Wastewater generated by project: 1800 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 orreplacement of existingsewers 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
8 290 SDR26
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section Ill 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
VIIL PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & 'MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude:
3. Total number of pumps at the pump station: _
3. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): _ gallons per minute (GPM) at_ feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C. Lb. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)( I ):
❑ 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
D 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)(1xC):
❑ 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 ofallthepump stations'storage
capacities and the rotation schedule of the portable power source or pump, including traveltimefmmes, 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 theproject comply with a0 separations/ahematives found in 15A NCAC 02T .0305(t) & UP
15A NCAC 02T.0305(f) contains minimum separations that shall be orovided for sewer systems:
Setback Parameter'
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Watermains(vertical -wateroversewerpreferred, including in benched trenches)
18inches
2 Water mains (horizontal)
10 feet
Reclaimed water lines (vertical -reclaimed oversewer)
18 inches
Reclaimed water lines (horizontal -reclaimed over sewer)
2 feet
"Any private or public water supply source, including any wells, WS-1 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 venica 1 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(t) or (e). see Section X.1 of this application
"I5A 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 weboaw
2. Does this project comply with the minimum separation requirements for water mains? ®Yes ❑ No ❑ NIA
D If no, please referto 15A NCAC I8C.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 reauiements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: _ ® No
If yes, does the project comply with setbacks found in the riverbasin mks per 15ANCAC 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
or401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coveragelauthorization is required.
6. Does project comply with 15ANCAC 02T.0105(c)(6)(additionalpermrtslcertifwations)? ® Yes ❑ No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be beingprepared,
have been applied for, or havebeen obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
i
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per I5A 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).
Mgh 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 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 applicator
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrentiv with the anoroval of the permit, and oroiects requiring a variance approval may be subject to longer
review times. For projects requiring two ormore variances orwhere the variance is determined by the Division to be a
significant portion of the project. the full technical review is renuired.
2. Professional Engineer's Certification:
I, H, --1 sbvnvried Jr ,attest that this application for EYAAy2nlle Sv "Ws; otJ
(Professional Eneineer's name from Application Item I11.1.) (project Name from Application Item 11.1)
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 forGravity Sewers (latest version), and the Minimum Design Criteria forthe 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 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be gushy 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 noncompliance with the applicable Rules and design criteria, ry}ay subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701) r 1
North Carolina Professional Engineer's seal, signature, and date:
0I
26447
V.,, F 0IN Sly.
3. Applicant's
/Certification pejr�15ANCAC 02T.0106(b): / T ,/
I, ///;okwa / 171. fl-J4 ,attest that this apphcationfor c—do,% -(Ilya- 'CUVise`on
(Signature Authority Name from Application Item 13.) (Project dame from .Application Item IL I
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 inchrded, 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/orcriminal 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 a0 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 143-215.613, 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 violatio n.
Signature:
Date: f& 120?, *
FORM: FTA 10-23 Page 5 of 5

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-23)
Entity Requesting Allocation: City of Thomasville
Project Name for which flow is being requested: Ethel Drive Subdivision
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 wastewaterflow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: Hamby Creek WWTP
b. WWTP Facility Permit #: NCO024112
AU flows are in MGD
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
1.1802
2.57
0.0018
3.752
62.53%
11. 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
Approx.
Obligated,
Total
Pump Pump Average
Current
Not Yet
Current Flow
Station Station Firm Daily Flow**
Avg. Daily
Tributary
Plus
(Name or Permit Capacity, * (Firm / pf),
Flow,
Daily Flow,
Obligated
Available
Number) No. MGD MGD
MGD
MGD
Flow
Capacity***
East WQ0036588 3.168 1.2672
0.70g1
0.204285
0.912385
6.3548
* 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
project connection point and the W W�T
Downstream Facility Name (;
Downstream Permit Number:
the Available Capadty is < 0.
between the
Page 1
FTSE 10-23

M. Certification Statement:
I Morgan Huffman l 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.
Title of Signing Official
Page 2 of 8
FTSE 10-23

Summey Engineering Associates, PLLC
Alk Engineering • Land Planning • Consulting
PO Box 968 — Asheboro, NC 27204
p;C Cr
[phone] / Fax: [phone] / Mack@sumtaepe lqeriflg.com
TRANWEr�NyC� Department of
WRR , a�d4uality SEP 19 20 't
OCT 0 2 2024 winston-Sa,e"'
Date: September 18, 2024 Regional CTf1Ce
t.
To: Jenny Graznak
NCDEQ-DWR
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
We are sending you attached the following items:
❑ Shop Drawings ❑ Samples
❑ Prints ❑ Specifications
® Plans ❑ Disk
Ethel Drive Subdivision
Davidson County, NC
Sanitary Sewer Extension
Sea Job No. E-9258
❑ Copy of Letter
❑ Other
# Copies
Drawing #
Description
Disposition
1
ication Fee
1
Cover Letter
2
Fast Track Sewer Application
(1 original & 1 copy)
2
Flow Tracking Acceptance Form
(1 original & 1 copy)
1
USGS Topo Map
1
Aerial Photo
Remarks:
Jenny,
We have enclosed the information for your review. Please let us know if you have any
questions, concerns or need any additional information from us.
Thank you,
Christian Vestal
Christian a[7.summeyengineering.com
336-328-0902

Project Narrative
For
City of Thomasville
8" Sewer Line Extension
For the
Ethel Drive Subdivision
The purpose of this sewer line extension is to provide a new residential development with
an adequate sewage disposal source and to meet their future sewer needs. The new
development is located near the intersection of May Rd and Cedar Lodge Rd road in
Thomasville NC.
There will be one 8" sewer line connected to an existing 8" Sanitary Sewer system
located on the east side of the property. There will be a total of 290 LF of 8" sewer main
extension with this project. The City of Thomasville waste water treatment System has
the capacity to serve this new development and many other residences.
Prepared By: H. Mack Summey, Jr., P.E.
Address: P.O. Box 968 Asheboro, NC 27204
Phone: [phone]
Project: Ethel Drive Subdivision

9/12124, 8:54 AM
tv_browse.pl (7366.8837)
zUSGS OLIS`TOPO
hitps:lingmdb.usgs.gov/ht-binitv_browse.pl?id=1774Od7Oec5l6c2a6O8827a6l7aca4dl 1/1

Ale
OHalraw8y }
Electrolysis -Laser { K•
Al
1� y�
i+
atiarNtl BerkyNa9Me�{ding 11--,��
and Fabrication, LLC
% s 3
klw i Cedar Lodge O., �+K
Ingram Nursery Lot Baptist Church '� ! a+
caraewatler �O' CommunWeityChurchllspring
Childress Really Q o°nders Pad
5 Star
aseball
all Park