WQ0045811_Piedmont_Crossing_FTSSE_Final_App_20241113

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Division of Water Resources
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State of North Carolina
Department of Environmental Quality
Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: Ut'k (if 6 C /J (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
I. Applicant's name: Evervaae (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership
❑ Federal ❑ State/County ❑ Municipal
3. Signature authority's name: Lee Syria per 15A NCAC 02T .0106(bl
Title: President and CEO '
4. Applicant's mailing address: 100 Leonard Avenue
City: Newton ' State: NQ Zip: 28658-
5. Applicant's contact information:
Phone number: (BW 4_U-8568- Email Address: Isvria(d.evervaee.ore
11. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
L Project name: Piedmont Crossine
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Proicet
If a modification, provide the existing permit number: W000_ 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: W000_
3. County where project is located: Davidson
4, Approximate Coordinates (Decimal Degrees): Latitude: 35.8421° Longitude: -80 105 °
5. Parcel ID (if applicable): 1634600000031 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brian Trinn License Number: 027403
Firm: WK Dickson
Mailing address: 1213 West Morehead Street Suite 300
City: Charlott6 State: N!� Zip: 28208-_
Phone number: (ZO-4) 334-5348 Email Address: btrippewkdic §on com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Hamby Creek W WTP Permit Number: NCO024112
Owner Name: City of Thomasville
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): W OOQ 31787
2. Downstream (Receiving) Sewer Information: $ incl( ® 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 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 MN/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 HOA/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)
❑ I,Iesidential (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(fl? ❑ Yes ®ilo
➢ 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 tib
No. of Units
Flow
2 Bedroom Units -
75 gal/Bedroom'
32
4,800 GPD
gal/
GPD
gal/
GPD
gal/
OPD
gal/
GPD
gall
GPD
Total
4,800 GPD
a See 15A NCAC 02T .0114(b). (dl. (e)(I) 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-0).
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.
8. Wastewater generated by project: 4 806GPD (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
1,313
PVC
➢ 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: One 1
i
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.8421" Longitude:-80.1059'
3. Total number of pumps at the pump station: 2 "
3. Design flow of the pump station: 0.05184 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): 36 gallons per minute (GPM) at 46 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
950
PVC
If any portion of the force main is leis 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):
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
➢ 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) & (e)? ® Yes []No
15A NCAC 02T 0305M contains minimum separations that shall be tirrovided for sewer s stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
'Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
WWater 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 (¢). see Section X.1 of this application
*15A NCAC 02T.0305(¢) contains alternatives where separations in 0210305(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 webpa¢e
2. Does this project comply with the minimum separation requirements for water mains? N 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? N 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: _ N No
If yes, does the project comply with setbacks found in the river basin mles per 15A NCAC 02B .02007 ❑ 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 N 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.O105(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, storrrtwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" []Yes N 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/core ict 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 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 hermit and projects requiring a variance approval may be subject to longer
2. Professional Engineer's Certification:
I, Q (1 fi't L , �)
V / I t /Jn ,attest that this application for r er1 MOn� croa /ndi
(Professional Engineer's name from lo nation Item Ill.].) (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 Pumo 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 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:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I g IL.t!e SVi'fa z,attest that this application for i2dim o tfM.tM.
(Signature(SignaturcAutboriTyyMeme from Application Item 1.3.) (Project Name from Application Item IL 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 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.
8/27/2024
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
(FTSE 10-23)
Entity Requesting Allocation: City of Thomasville
Project Name for which flow is being requested: Piedmont Crossing
More than one FTSE maybe required for a singleproject (f 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: Hamby Creek WWTP
b. WWTP Facility Permit #: NC0O24112
AU flows are in MGD
c. WWTP facility's permitted flow 6.0
d. Estimated obligated flow not yet tributary to the WWTP 1.1723
e. WWTP facility's actual avg. flow 2.62
f. Total flow for this specific request 0.0048
g. Total actual and obligated flows to the facility 3.7971 '
It. Percent of permitted flow used 63.29%
H. 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 I pf),
Flow,
Daily Flow,
Obligated
Available
Number)
No.
MGD
MGD
MGD
MGD
Flow
Capacity***
East
TN-
R Q0036588
3.168
1.2672
0.8155
0.193485
1.009
0.2582
• 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 W WTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
Thomasville Collection System
WQCSO0057 '
Page 1 of 8
FTSE 10-23

III. Certification Statement:
I Morgan Huffman 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 H 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
Date
Page 2 of 8
FINE 10-23

NC Department of State of North Carolina
DWREnvironmental Quality Department of Environmental Quality
Received Division of Water Resources
SEP 11 2024 FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources Winston-Salem FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: �(i(VV T' ✓ �l (to be completed by DWR)
2offe94 t 30=xat!�a14
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Evervage (company, municipality, HOA, utility, etc.)
i
2. Applicant type: [I Individual ®Corporation ❑General Partnership ❑Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Lee Syri f per 15A NCAC 02T .0106(b)
Title: President and CEO
4. Applicant's mailing address: 100 Leonard venue
City: Newton State: NC Zip: 28658-_
5. Applicant's contact information] i
Phone number: 828 465-8568 Email Address: Isvria(ceveryage.org
II. PROJECT INFORMATION:
1. Project name: Piedmont Crossing
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project ❑ ARPA funded
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 part of a master plan, provide the existing permit number: W000_
3. County where project is located: Davidson /
/
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.8421' Longitude:-80.1059'
5. Parcel ID (if applicable): 1634600000031 (or Parcel ID to closest downstream sewer)
M. CONSULTANT INFORMATION:
1. Professional Engineer: Brian Tripp/ License Number: 027403
Firm: WKDickson
Mailing address: 1213 West Morehead Street. Suite 300
City: Charlotte State: NC Zip: 2&208-_
Phone number: 704 334-534e Email Address: btripnAwkdickson com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
i
1. Facility Name: Hamby Creek W WTP Permit Number: NC00 4112
Owner Name: City of Thomasville
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. PermitNumber(s): W00031787 /
2. Downstream (Receiving) Sewer Information: 8 inch ® Gravi/ty ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00057
Owner Name(s): City of Thomasville /
FORM: FTA 10-23 Page 1 of 5

Environmental
Received
VI. GENERAL REQUIREMENTS Srp 1 1 ^714
1. If the Applicant is a Privately -Owned Public Utility, had01:Gertificate of Public Convenience and Necessity been attached?
❑ Ybs , ❑ No, ON/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 I/
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?
ElYes ElNo ® 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(tl? ❑ Yes ® No
➢ If yes provide a cony of flow reduction approval letter with this application
Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow qb
No. of Units
Flow
2 Bedroom Units Y
75 gal/Bedroom
32
4,800 6PD
gal/
GPD
gal/
GPD
gay
GPD
gal/
GPD
gal/
GPD
Total
4,800 GPD
a See 15A NCAC 02T 0114(b) (d). (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S. 42A 4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 4 800'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/Forec 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) I Length (feet) I Material
1 8 Z 1 1,313 1 PVC
SEP
Winsto
Regionai
➢ 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
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: One 1
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.8421° Longitude:-80.1059°
3. Total number of pumps at the pum statiot
3. Design flow of the pump stati : 0.020 Ikons 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)6�ilons per minute (GPM) at 46 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
950
PVC
If any portion of the force main is lens 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 I SA 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

NC D0p?rtr",r:L cl i
Environmental Qual,ty
IX. SETBACKS & SEPARATIONS — (02B.0200 & 15A NCACO2T.0305(f)): Received
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T.0 �OE I 1 024 M Yes ❑ No
tins that shall be rovided for sewer s stems:
15A NCAC 02T.0305 corm uns mrmmum se ara o n s
n �rRion Required
Setback Parameter*
Storm sewers and other utilities not listed below (vertical)
UMLN 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 D(.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(t) or (gh see section X.1 or this application
* 15A NCAC 02T.0305(g) 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 webnage
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
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft senaration requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
® No
❑ Yes ❑ No
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name:
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 027B .0200?
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
❑ No ❑ N/A
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,
sipbon, 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:
NC Departs— -1
Environmental Qual[tLy
Received
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Ciltem tbr�th,N, x tttmg of 19
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (Tatest versionl`as applicable?
® Yeses ❑ 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
2. Professional Engineer's Certification:
I, g f i tv+ L% . T/ t iW , attest that this application for J 1 E'4 MOnT Croa llltl
(Professional Engineer's name from cation Item III.1.) (Project Name from Application Item ILI) �J
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:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
S I, Lee yryp ,attest that this application for Q h ,
(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 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:
J/
r ✓
Date: 8/27/2024
FORM: ETA 10-23 Page 5 of 5

64
hL [)' �;i r'fllEnl Gi
Envlrcniregtal Ouality
Received
SEP 11 2024 State of North Carolina
Department of Environmental Quality
Winston-Salem Division of Water Resources
Regional Office
Flow Tracking for Sewer Extension Applications
(FTSE 10-23)
Entity Requesting Allocation: —44 rossin �it 1 I v t
Project Name for which flow is being requested: nrt x ansion 2024
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: Hamby Creek W WTP
b. WWTP Facility Permit #: NCO024112
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
6.0
1.1723
2.62
0.0048
3.7971
63.29%
H. 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
n ,,;a ,
W00036588
3.168 "
1.2672
0.8155
0.193485
1.009
0.2582
* 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 he attached for each pump station located between the
project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer):
Downstream Permit Number:
FTSE 10-23

N% . _)-,rtrnent of
Environmental Quality
Received
III. Certification Statement:
SFP 11 20A
Winston-Salem
regional Office
I Morgan Huffman 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 H 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.
V
of Signing
Date
y
Page 2 of 8
FTSE 10-23

• Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings
Non -Profit Corporation
Legal Name
EveryAge
Prev Legal Name
The United Church Retirement Home
Prev Legal Name
The United Church Retirement Home, Inc.
Prev Legal Name
United Church Homes and Services
Prev Legal Name
United Church Retirement Homes, Inc.
Information
Sosld: 0153712
Status: Current -Active O
Date Formed: 11 /13/1961
Citizenship: Domestic
Annual Report Due Date:
Registered Agent: Syria, Lee B.
Addresses
Mailing
100 Leonard Ave
Newton, NC 28658
Officers
Principal Office
100 Leonard Ave
Newton, NC 28658
Reg Office
100 Leonard Ave
Newton, NC 28658
NC De ,arty-Ient of
Env; roninental quality
Received
SEP 1 1 20A
Winston-Salem
Regional office
Reg Mailing
100 Leonard Ave
Newton, NC 28658

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NC Department of
• �._.... ontal Quali
LE'T A24 OF TRANSMITTAL �DICKSON
Winston-Salem community Infrastructure consultants
Regional Office
1213 W. Morehead Street, Suite 300 Charlotte, North Carolina 28208 704.334.5348 tel.
TO: NCDEQ — Water Quality DATE: 9/10/2024
450 W. Hanes Mill Road
Suite 300 RE: EveryAge
Winston-Salem, NC 27105 Piedmont Crossing Cottages & Villas
Attn: WKD# 20230270.00.CL
We are sending via: ® Overnight ❑ Regular Mail ❑ Pick-up ❑ Hand Delivered
The following items: ❑ Correspondence ❑ Plans ❑ Specifications ® Other as listed below:
COPIES
DATE
NO.
DESCRIPTION
1
9/10/2024
Letter to NCDEQ
1
9/10/2024
USGS Topo Map
1
9/10/2024
FTSE
1
9/10/2024
Fast Track Sewer Application
1
9/10/2024
Application Fee — Check
THESE ARE TRANSMITTED as checked below:
❑ For Approval
® As Requested
❑ Approved as Submitted
❑ Returned for Corrections
❑ For Your Use
❑ For Review and Comment
❑ Approved as Noted
❑ Forward to Subcontractor
REMARKS:
To Whom this may concern,
Enclosed you will find the documentation required for the Sewer Fast Track Application for Piedmont
Crossing Cottages & Villas If you have any questions comments or concerns please reach out to
Weston Boles — [e-mail]
COPY TO: file SIGNED: Weston Boles, PE

F
DDICKSON
community Inirasiructure consultants
September 4", 2024
North Carolina Department of Environment
Quality Division of Water Resources
RE: NCDEQ Fast Track Sanitary Sewer Permit
Piedmont Crossing
To Whom It May Concern:
NC Departry�ont of
Environmental Quality
4- Received
SEP 11 2024
Winston-Salem
Regional Office
The attached submittal is for Piedmont Crossing which is a 32-lot multi -family subdivision. This is a
master planned development in Thomasville, Davidson County, North Carolina. This submittal is
permitting 32 multi -family lots with a total of 4,800 gal/day to be served by approximately 1,313 LF of
8" gravity sewer. The proposed sanitary sewer will connect to a proposed pump station located on the
eastern portion of the site. A proposed 2" forcemain will be installed from the proposed pump station to
an existing 8" trunk gravity sewer lines located at Hedrick Drive and Boyce Sink Court. The downstream
system is a part of Piedmont Crossing Collection System Permit #W00031787 and has been accepted for
operation.
Sincerely,
aO'C'
W.K. Dickson & Co.
Weston Boles, PE
Senior Consultant
wbolesna.wkdickson.com
1213 W. Morehead St., Suite 300
Charlotte, NC 28208
Tel. [phone]
Fax [phone]
www wkdickson.com
Transportation • Water Resources • Urban Development Resources • Geomatics

W ICK
community Infrastructure consultants
N i, i) p1, .r-Ienq of
Env'roMHi�ental Quality
Received
SE? 1 1 2024
Winston-Salem
^cgio: ' Oifice
Transportation • Water Resources • Urban Development Resources • Geomatics