WQ0045865_Tuscola_SD_FTSSE_Final_App_20241009_20241009

State of North Carolina
Received
Department of Environmental Quality
DWRReceived
Division of Water Resources
OCT 01 2024
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources Winston-Salem FTA 10-23 & SUPPORTING DOCUMENTATION
ce
Application Number: V &oD f (P 5 (to be wmpleted by DWR) LCyn� l Z t� *pp e Mai I
Sc. ZoZ� la N-=
All items must be completed or the application will be returned 41T
[. APPLICANT INFORMATION: T z istz2,
r
1. Applicant's name: ELAM TUSCOLA, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporafion ❑ General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: JOHN GRAMBER(�i per 15A NCAC 02T .0106(b)
Title: MANAGING MEMBER
i
4. Applicant's mailing address: 6903 MAYNARD ROAD
City: SUMMERFIELD State: NiC Zip: 27358-.
5. Applicant's contact information:
Phone number: 3( 36) 336-2627 Email Address: iohn.erambergaaforumsupply com
II. PROJECT INFORMATION:
i
1. Project name: TUSCOLA S/D
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
❑ Privately -Owned Public Utility
❑ Other
If a modification, provide the existing permit number: WQ00 and issued date: _,
❑ ARPA funded
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: FORSYTH i
1
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.01499' Longitude:-80.05767'
5. Parcel ID (if applicable): 6882-76-3263 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
i
1. Professional Engineer: THOMAS R. GLOVER_ JR, License Number: 027465
Firm: GLOVER ENGINEERING. PLLC/
Mailing address: 7021 ENDOTRAIL ROAD J
City: GREENSBORO ' State: Nt. Zip: 27409-_
Phone number: 336) 202.4163� Email Address: rich cloveleng com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
i
1. Facility Name: HIGH POINT WESTSIDE TREATMENT PLANTS Permit Number: NC 0024228
Owner Name: CITY OF HIGH POINT '
V. RECEIVING DOW AM -SEWER INFORMATION:
1. PermitNumbe WQ_ \
2. Downstream (Receivt ewer Inf rnation: 8 inch ® Gravity ' ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00010
Owner Name(s): CITY OF HIGH POINT
FORM: FTA 10-23 I
Page I of 5

VI.
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/Ae
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 _H_OA/POA Operational Agreement (FORM HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church
El Businesses / offices / factories ❑ Swimming Pool/Filter Backwash
❑ Nursing Home El Other (Explaainin in n Attachment)
i
5. Nature of wastewater: I00 % 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:
8.
Establishment Type (see 02T.0114(f))
Daily Design Flow 0
No. of Units
Flow
SINGLE BEDROOMS FAMILY HOMES WITH 4
75 gal/BEDROOM
44
13,200 GPD
gal/
GPD
gal/
GPD
Y
gal/
GPD
gall
GPD
gal/
GPD
Total
13,200 6PD
a See 15A NCAC 02T .0114(b). (d). (e)(D and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
Wastewater generated by project: ly GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 10-23 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8"
1,495
PVC(SDR-26)�
8"
248
DUCTILE IRON
➢ Section 11 & 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
VIH. 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
I. 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.1.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(hxl)(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 - (028.0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/altematives found in 15A NCAC 02T .0305(f) & UP
® Yes []No
I5A NCAC 02T WAM(Fl .,�: +U -L n �_
-- -- _ ------- ... .... ............. ...uu wauu w rv..... m.
Setback Parameter*
"WOI 5 SLGlf15[
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred including in benched trenches)
18 inches
'Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
"Any private or public water supply source, including any wells, WS-I waters of Class I or
Class 11 impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
"Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
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
D If noncompliance with 02T.0305(f) or (e), see Section X.1 of this application
"15A 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 webRa e
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 NG licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ® �'es [:]No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
D See the Division's draft separation requirements for situations where separation cannot be met.
D No variance is required if the alternative design criteria specified is utilized in design and construction.
i
4. Is the project located in a river basin subject to any State buffer rules? ❑Yes Basin name: _ ®No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes [-]No
D This includes Trout Buffered Streams per I5A NCAC 213.0202
i
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is 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 permttee 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:
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 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 oroiects requiring a variance anoroval 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 oroiect, the full technical review is required.
2. Professional Engineer's Certification:
1, An^As g. IJL.OVEIZ . R . , attest that this application for VSOLa 5 ��
(Professional Engineer's time from Applicat n Item III.1.) (Project Name from Appl' ation 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 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 seat signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties 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 t
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1,__.vA Lirey�6ce attest that this application for u;,f
(Signature Authority Name firn7i Application Item 1.3.) (Project Name from Application Item II.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 included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date:
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
'J;a;or. , - 4.4t='. t•�.:ns i (EISE10-23)
Fifty Requesting Allocation Elam Tuscola, LLC - - - — - --
Project Nacre for which flows being requested: Tuscola S/D
More than one ME maybe required for a single project if the owner of the WWTP is not responsiblefor all pump stations along the
route of the proposed wastewaterflow
1. Conpiete this section only if you are the owner of the wastewater treaft et8 pfatnt,
a. W WTP Facility nrarre: Westside W WIP
b. WWTP Facility Penrit #: WQ0024228
All flows are in MGD
c. WWTP facility's Pemitted flow
10 '
d. Fstfrmted obligated flow not yet tributary, to the WWI?
1.0366
e. WWTP facilitys actual average flow
3.0841'
f Total flow for this specific request
0.0132 '
g Total actual and obligated flows to the tacky
4.1339'
h Percent of pemrtted flow used
41.340V
D. Complete this section for each pump station your are responsible for along the route of this proposed wastewater flow
List purrp station located between the project connection pose and the W WTP
(A)
(B)
(C)
(D)=(B}C)
(E)—(A-D)
Purip
Pump
Design
Approx
Obligated
Total Current
Staten
Station Fran
Average Daily
Current
Not Yet
Flow Plus
Available
(Name or
Pemit Capacity, *
en
Fbw**
Avg. Daily
Tributary
Obligated
Capacity***
Nord er)
MGD
(FinnYpf)
Flow
Daily Flow
Flow
MGD
MGD
MGD
MGD
MGD
* The Firm Capacity of any pure station is defined as the Fmxinwm punped flow that can be
achieved with the largest pur p taken out of service.
** Design Average Daily Flow is the Finn capacity of the puny station divided by a peaking factor (pi)
not less than 2.5, per Section 2.02(A)(4)(c) of the MinimunDesign Criteria.
*** A Nanning Assessment Addenduan shall be attached for each punp station located between the
project connection point and the WWPP where the Available Capacity is 5 0.
DownstreamFacilayName(Sewer): WestsideWWfP
Downstream PemY Number (Sewer): VV"24228
Page 1 of 8
r FTSE 10-23

M. Certification Statement
I, Detrick Boone, certify to the best of try knowledge that the addition of the voirm of
wastewater to be pemt6ted in this project has been evaluated along the route to the receiving wastewater
treatment facility and that the flow fromths projects not anticipated to cause any capacity related sanitary
sewer overflows or overburden any downstream pure station en route to the receiving treatrnent plant
under mural circuar stances, given the irplerrentation of the planned iuprovenents idea ified in the
planning assessruen t where applicable. Ibis analysis has been perfumed in accordance with local
established policies and procedures using the best available data This ceri ficati n applies to those iterns
listed above it Sections I and II plus all attached planning assessment adderduns for which I am the
responsible party. Signature ofths form indicates acceptance of this wastewater flow.
Official
191
Tile ofSigning Official / \ 1
'/SS;S+ANT ,61,'c X'�ViCLr (J/iEs.Mr,
9 2r12q
Date
Page 2 of 8
FTSE 10-23

NORTH CAROLINA
atrQf�Y Department of the Secretary of State
To all whom these presents.shall come, Greetings:
I, ELAINE F. MARSHALL, Secretary of State of the State of North Carolina, do hereby
certify the following and hereto attached to be a true copy of
ARTICLES OF ORGANIZATION
OF
ELAM TUSCOLA, LLC
the original of which was filed in this office on the 15th day of August, 2024.
IN WITNESS WHEREOF, I have hereunto set my
hand and affixed my official seal at the City of .
Raleigh, this 15th day of August, 2024.
Scan to verify online.
Certification# C202422600958-1 Reference# C202422600958-1 Page: 1 of 4 Secretary of State
Verify this certificate online at https://www.sosnc.gov/verification

SOSID: 2897518
Date Filed: 8/15/2024 2:27:00 PM
Elaine F. Marshall
State of North Carolina North Carolina Secretary of State
Department of the Secretary ofState C2024 226 00958
Limited Liability Company
ARTICLES OF ORGANIZATION
Pursuant to .§57D-2-20 of the General Statutes of North Carolina, the undersigned does hereby submit these Articles of
Organization for the purpose of forming a limited liability company.
The name of the limited liability company is: ELAM Tuscola, LLC
(See Item 1 of the Instructions for appropriate entity designation)
2- The name and address of each person executing these articles of organization is as follows: (State whether each
person is executing these articles of organization in the capacity of a member, organizer or both by checking all
applicable boxes). Note: This document must be signed by all persons listed.)
Name Business Address Capacity
James F. Goodwin 404 N. Marshall Street, Winston-Salem,
❑
NC 27101 (] Member Organizer
❑Member ' ❑Organizer
3. The name of the initial registered agent is: Blanco Tackabery & Matamoros, P.A.
4. The street address and county of the initial registered agent office of the limited liability company is:
Number and Street 404 N. Marshall Street
City Winston-Salem State: NC Zip Code: 27101 County: Forsyth
5. The mailing address, if different from the street address, of the initial registered agent office is:
Number and Street P.O. Drawer 25008
City Winston-Salem State: NC Zip Code: 27114 County: Forsyth
6. Principal office information: (Select either a or b.)
a. © The limited liability company has a principal office.
The principal office telephone number: [phone]
The street address and county of the principal office of the limited liability company is:
Number and Street: 6903 Maynard Road
City: Summerfield State: NC Zip Code: 27358 County: Guilford
CORPORATIONS DIVISION
(Revised August 2017)
P.O. Box 29622
1
RALEIGH, NC 27626-0622:
(Form L-01)
BT:987259vl
Certification# C202422600958-1 Reference# C202422600958- Page: 2 of 4

7. (a)
7. (b)
8.
10.
The mailing address, if different from the street address, of the principal office of the company is:
Number and Street
City:
State: Zip Code: County:
b. ElThe limited liability company does not have a principal office.
To the fullest extent permitted by applicable law, as it now exists or may hereafter be amended, the limited
liability company shall indemnify all members and managers of the limited liability company against all
liability and litigation expense, including, but not limited to, reasonable attorney's fees, arising out of their
status as such or their activities in the foregoing capacity, regardless of when such status existed or activity
occurred and regardless of whether or not they are members or managers of the limited liability company at
the time such indemnification is sought or obtained. Without limiting the generality of the foregoing
indemnity, such persons may also recover from the limited liability company all reasonable costs, expenses
and attorneys fees in connection with the enforcement of rights to indemnification granted herein. The
provisions of this paragraph are in addition to and not in limitation of the power of the limited liability
company with respect to, and the rights of any manager or member of the limited liability company to receive
the benefits of, any other or further indemnification, insurance, elimination of liability or the right or benefit
which is either required by THE NORTH CAROLINA LIMITED LIABILITY COMPANY ACT or permitted
thereby and duly adopted by the limited liability company in accordance therewith.
To the fullest extent permitted by applicable law, as it now exists or may hereafter be amended, no member.or
manager of the limited liability company shall have any personal liability arising out of any action, whether by
or in the right of the limited liability company or otherwise, for monetary damages for breach of his or her duty
as a manager or member. This paragraph shall not impair any right to receive indemnity or insurance from the
limited liability company or any third party which any member or manager may now or hereafter have. Any
repeal or modification of this paragraph shall not impair or otherwise adversely affect any limitation on, or
elimination of, the personal liability of a member or manager affected hereby with respect to acts or omissions
occurring prior to such repeal or modification are attached.
(Optional): Listing of Company Officials (See instructions on the importance of listing the company officials
in the creation document.
Name
Title
Business Address
ELAM Investments, LLC
Manager
6903 Maynard Road, Summerfield, NC 27358
(Optional): Please provide a business e-mail address:
The Secretary of State's Office will e-mail the business automatically at the address provided above at no cost
when a document is filed. The e-mail provided will not be viewable on.the website. For more information on
why this service is offered, please see the instructions for this document.
These articles will be effective upon filing, unless a future date is specified:
CORPORATIONS DIVISION P.O. Box 29622
(Revised August 2017) 2
RALEIGH, NC 27626-0622:
(Form L-01)
BT:987259v1
Certification# C202422600958-1 Reference# C202422600958- Page: 3 of 4

w
This is the 13th day of _ August_
James F. Goodwin, Organizer
Type or Print Name and Title
The below space to be used if more than one organizer or member is listed in Item #2 above.
Signature
Type and Print Name and Title
Signature
Type and Print Name and Title
Signature
Type and Print Name and Title
Signature
Type and Print Name and Title
NOTES:
1. Filing fee is $125. This document must be filed with the Secretary of State.
CORPORATIONS DIVISION
(Revised August, 2017)
P.O. Box 29622
3
RALEIGH, NC 27626-0622:
(Form L-01)
BT:987259v 1
Certification# C202422600958-1 Reference# C202422600958- Page: 4 of 4

r L. LIMITED LIABILITY COMPANY ANNUAL REPORT
1/6/2022
NAME OF LIMITED LIABILITY COMPANY: ELAM Investments, LLC
SECRETARY OF STATE ID NUMBER: 1451198 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2023
E - Filed Annual Report
1451198
CA202410606563
4/15/2024 12:15
SECTION A: REGISTERED AGENT'S INFORMATION luChanges
1. NAME OF REGISTERED AGENT: Blanco Tackabery & Matamoros, P.A.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
404 N. Marshall Street
Winston Salem, NC 27101 Forsyth County
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Development
404 N. Marshall Street
Winston Salem, NC 27101
2. PRINCIPAL OFFICE PHONE NUMBER: (336) 339_2627 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5. PRINCIPAL OFFICE MAILING ADDRESS
6903 Maynard Rd 6903 Maynard Rd
Summerfield, NC 27358-9206 Summerfeild, NC 27358-9206
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME:, John Robert Gramberg
TITLE: General Manager
ADDRESS:
NAME:.
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
6901 Maynard Rd
Summerfield, NC 27358
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
John Robert Gramberg 4/15/2024
SIGNATURE DATE
Form must be signed by a Company Official listed under Section C of This form.
John Robert Gramberg General Manager
Print or Type Name of Company Official . Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

STATE OF NORTH CAROLINA
COUNTY OF FORSYTH
Permit No.
DEVELOPER'S OPERATIONAL AGREEMENT
This AGREEMENT made pursuant to G.S. 143-215.1 (dI) and entered into this day of
by and between the North Carolina Environmental Management
Commission, an agency of the State of North Carolina, hereinafter known as the COMMISSION; and
ELAM TUSCOLA, LLC , a corporation/general partnership registered/licensed to do
business in the State of North Carolina, hereinafter known as the DEVELOPER.
WITNESSETH:
1. The DEVELOPER is the owner of the certain lands lying in FORSYTH County, upon
which it is erecting and will erect dwelling units and other improvements, said development to beknown
as TUSCOLA S/D (hereinafter the Development).
2. The DEVELOPER desires, to construct a wastewater collection system with pumps, wastewater treatment
works, and/or disposal facilities (hereinafter Disposal System) to provide sanitary sewage disposal to serve
the Development on said lands.
3. The DEVELOPER has applied to the COMMISSION for the issuance of a permit pursuant to G.S. 143-
215.1 to construct, maintain, and operate the Disposal System.
4. The DEVELOPER has created or shall create unit ownership in said dwellings units, other improvements
and lands through filing of a Declaration of Unit Ownership (hereinafter Declaration), pursuant to Chapter
47C or 47F of the North Carolina General Statutes.
5. The DEVELOPER has caused to be formed or will cause to be formed at the time of filing of the
Declaration, TUSCOLA HOMEOWNERS ASSOCIATION (hereinafter
Association), a non-profit corporation organized and existing under and by the virtue of the laws of the State
of North Carolina, for the purpose, among others, of handling the property, affairs and business of the
Development; of operating, maintaining, re -constructing and repairing the common elements of the lands
and improvements subject to unit ownership, including the Disposal System; and of collecting dues and
assessments to provide funds for such operation, maintenance, re -construction and repair.
6. The COMMISSION desires to assure that the Disposal System of the Development is properly constructed,
maintained and operated in accordance with law and permit provisions in order to protect the quality of the
waters of the State and the public interest therein.
NOW, THEREFORE, in consideration of the promises and the benefits to be derived by each of the parties
hereto, the COMMISSION and DEVELOPER do hereby mutually agree as follows:
1. The DEVELOPER shall construct the Disposal System in accordance with the permit and plans and
specifications hereafter issued and approved by the COMMISSION, and shall thereafter properly operate
and maintain such systems and facilities in accordance with applicable permit provisions and law.
2. The DEVELOPER shall not transfer ownership and/or control of the Disposal System to the Association
until construction has been completed in accordance with the permit and approved plans, and the staff of
the Division of Water Resources has inspected and approved of the facilities. In order to change the name
of the permit holder, the DEVELOPER must request that the permit be reissued to the Association. The
request must include a copy of the Association Bylaws and Declaration.
3. The DEVELOPER shall not transfer, convey, assign or otherwise relinquish or release its responsibility for
the operation and maintenance of its Disposal System until a permit has been reissued to the DEVELOPER's
successor.
FORM: DEV 12-23 r Page 1 of 2

4. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System and
appurtenances thereto are part of the common elements and shall thereafter be properly maintained and
operated in conformity with law and the provisions of the permit for construction, operation, repair, and
maintenance of the system and facilities. The Declaration and Bylaws shall identify the entire wastewater
treatment, collection and disposal system as a common element which will receive the highest priority for
expenditures by the Association except for Federal, State, and local taxes and insurance.
5. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System will
be maintained out of the common expenses. In order to assure that there shall be funds readily available to
repair, maintain or construct the Disposal System, beyond the routine operation and maintenance expenses,
the Declaration and Association Bylaws shall provide that a fund be created out of the common expenses.
Such fund shall be separate from the routine maintenance funds allocated for the facility and shall be part
of the yearly budget.
6. In the event the common expense allocation and separate fund are not adequate for the construction, repair,
and maintenance of the Disposal System, the Declaration and Association Bylaws shall provide for special
assessments to cover such necessary costs. There shall be no limit on the amount of such assessments, and
the Declaration and Bylaws shall provide that such special assessments can be made as necessary at any
time.
7. If a wastewater collection system and wastewater treatment and/or disposal facility provided by any city,
town, village, county, water and sewer authorities, or other unit of government shall hereinafter become
available to serve the Development, the DEVELOPER shall take such action as is necessary to cause the
existing and future wastewater of the Development to be accepted and discharged into said governmental
system, and shall convey or transfer as much of the Disposal System and such necessary easements as the
governmental unit mayrequire as condition of accepting the Development's wastewater.
8. Recognizing that it would be contrary to the public interest and to the public health, safety and welfare for
the Association to enter into voluntary dissolution without having made adequate provision for the continued
proper maintenance, repair and operation of its Disposal System, the DEVELOPER shall provide in the
Association Bylaws that the Association shall not enter into voluntary dissolution without first having
transferred its said system and facilities to some person, corporation or other entity acceptable to and
approved by the COMMISSION by the issuance of apermit.
9. The agreements set forth in numbered paragraphs 1, 2, 3, 4, 5, 6, 7, and 8 above shall be conditions of any
permit issued by the COMMISSION to the DEVELOPER for the construction, maintenance, repair and
operation of the Disposal System.
10. A copy of this agreement shall be filed at the Register of Deeds in the County(ies) where the Declaration is
filed and in the offices of the Secretary of State of North Carolina with the Articles of Incorporation of the
Association.
IN WITNESS WHEREOF, this agreement was executed in duplicate originals by the duly authorized
representative of the parties hereto on the day and year written as indicated by each of the parties named below:
Michael Montebello
Supervisor, NPDES Branch Chief
Division of Water Resources
(Date)
ELAM TUSCOLA. LLC
Name of DEVELOPER
(Signature)
JOHN GRAMBERG, MANAGING MEMBER
Print Name and Title
Y'
(Date)
FORM: DEV 12-23 Page 2 of 2

C I T Y O F
PUBLIC SERVICES
Robby Stone, P.E. MPA
Public Services Director
January 4, 2024
NCDENR
Winston-Salem Regional Office
450 W. Hanes Mill Rd, Suite 300
Winston-Salem, NC 27105
Project: Tuscola Subdivision
Applicant: Elam Tuscola
Dear Sir or Madam:
high
point.
This is to acknowledge that the City of High Point will accept for treatment in the
Westside Wastewater Treatment Plant (Permit #NC0024210), wasterwater flow from the
above referenced project in the amount of 0.0132 MGD, which will be discharged to
facilities operated and maintained by the City of High Point.
If further information is needed, please let me know.
Sincerely,
7 0� '
Robby D. Stone
Public Services Director
RDS/tab
0 211 South Hamilton St. High Point, NC 27260 ` 336.883.3111 :: HighPointNC.gov 0

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GLOVER
ENGINEERING
September 27, 2024 LAND -WATER -INFRASTRUCTURE
Re: Sewer Line Extensions
Servicing Tuscola Subdivision
City of High Point
Forsyth County
GE File No. 23-21
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
To whom it may concern:
Environmental Quality
Received
OCr 1 My
wlul1fm
0-TaI! tp
With regards to the referenced project, and on behalf of Elam Tuscola, LLC and the City of High
Point, we have enclosed one original and one copy of the following for your review:
- Fast Track Sewer Application (10-23)
- Form FTSE (10-23) completed by the City of High Point
- Letter of Flow Acceptance
- 8.5" X 11" color USGS topographic map
- Street level map
- Developer's Operational Agreement (DEV 12-23)
- LLC Documentation
- $600.00 Application Fee
Sewer service to the Tuscola Subdivision includes 44 residential single-family homes (13,200
gpd) located along Cedarwood Trail and Maize Drive. Flow allocations are included in the
attached FTSE form for the 44 residential lots. Upon completion of the sewer line installation and
testing, and acceptance by the City, the system will be turned over to the City of High Point for
maintenance and ownership. The downstream sewer system is owned by the City of High Point
and the treatment facility is owned by the City of High Point.
If there are any questions or additional information required, please call.
Sincerely,
Glover Engineering, PLLC
Thomas R. (Rich) Glover, Jr., PE
GLOVER ENGINEERING, PLLC
7021 ENDOTRAIL ROAD GREENSBORO, NC 27409
RICHQGLOVERENG.COM 336.202.4163