WQ0039953_Issuance of Permit_20180504

Govei not
MICHAEL S REGAN
6.'6;
e.
'.? Sec,etaiy
' LINDA CULPEPPER
Intel sin Dii ecto,
Water Resources
ENVIRONMENTAL QUALITY •
May 4, 2018
Amy Ratliff, P.E., City Engineer
City of Oxford
300 Williamsboro Street
Oxford, NC 27565
Subject: Permit No.WQ0039953
City of Oxford
2017 USDA Water&Sewer Improvements, Contract 1—Water System
Wastewater Collection System Extension Permit
Granville County
Dear Ms. Ratliff:
In accordance with your application received March 20, 2018, we are forwarding herewith Permit No.
WQ0039953 dated May 4,2018,to the City of Oxford (Permittee)for the construction and operation upon
certification of the subject wastewater collection system extension. This permit shall be effective from
the date of issuance until rescinded and shall be subject to the conditions and limitations as specified
therein. This cover letter shall be considered a part of this permit and is therefore incorporated therein
by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 11.1: This permit shall not be automatically transferable; a permit modification request for a
name change must first be approved by this office.
Condition 11.4: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 2T.0403 or any individual system-wide collection system
permit issued to the Permittee.
It shall be the responsibility of the Permittee to ensure that the as-constructed project meets the
appropriate design criteria and rules. Failure to comply may result in penalties in accordance with North
Carolina General Statute §143-215.6A through §143-215.6C, construction of additional or replacement
wastewater collection facilities, and/or referral of the North Carolina-licensed Professional Engineer to
the licensing board.
If any parts, requirements, or limitations contained in this permit are unacceptable,you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This
request must be in the form of a written petition, conforming to Chapter 150B of North Carolina General
Statutes, and filed with-the Office -of-Administrative-Hearings,- 6714 Mail Service Center,-Raleigh,-NC
27699-6714. Unless such demands are made,this permit shall be final and binding.
Division of Water Resources,Raleigh Regional Office,Water Quality Operations Section www.ncwaterquality.org
1628 Mail Service Center,Raleigh,NC 27699-1628 Phone [phone]
Location. 1800 Rarrett Drive Raleigh_NC 27609 Fax• (9191 788-7159

City of Oxford
Permit No.WQ0039953
If you need additional information concerning this matter, please contact Ted Cashion at [phone]
or via e-mail at [e-mail].
Sincerely,
- ----- ----- -
----------------- --------- --------- - - -for Linda Culpepper
Interim Director,ir� Division of Water Resources
by S.Dap+ , Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
cc: Courtney M. Gamble, P.E.,The Wooten Company (via email:
[e-mail])
Granville County Health Department
Raleigh Regional Office Files
Water Resources Central Files •
Page 2 of 8

North Carolina Department of Environmental Quality
STATE OF NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
City of Oxford
Granville County
for the construction and operation of approximately 648 linear feet of 8-inch gravity sewer to replace
existing sewer lines as part of the 2017 USDA Water&Sewer Improvements, Contract 1—Water System
project, and the discharge of no additional gallons per day of collected wastewater into the City of
Oxford's existing sewerage system,pursuant to the application received March 20,2018 and in conformity
with 15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 and
updated in March 2008, as applicable; the Division's Minimum Design Criteria for the Fast-Track
Permitting of Pump Stations and Force Mains adopted June 1, 2000 and updated March 2008, as
applicable; and other supporting data subsequently filed and approved by the Department of
Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limita 'ons contained therein.
Linda Culpepper
Interim Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0039953
Permit Issued: May 4, 2018
Page 3 of 8

SUPPLEMENT,TO PERMIT COVER SHEET
The City of Oxford is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension. The
sewage and wastewater collected by this system shall be treated in the Oxford Wastewater Treatment
Facility in accordance with Permit Number NC0025054.
—._ P_ermitting_of.this_pr_oject does not constitute an acceptance of any part of the project that does not meet `_,
15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 and
updated March 2008, as applicable; and the Division's Minimum Design Criteria for the Fast-Track
Permitting of Pump Stations and Force Mains adopted June 1, 2000 and updated March 2008, as
applicable, unless specifically mentioned herein. Division approval is based on acceptance of the
certification provided by a North Carolina-licensed Professional Engineer in the application. It shall be the
Permittee's responsibility to ensure that the as-constructed project meets the appropriate design criteria
and rules.
Construction and operation is contingent upon compliance with the Standard Conditions and any Special
Conditions identified below.
I. SPECIAL CONDITIONS
NONE
II. STANDARD CONDITIONS
1. This permit shall not be transferable. In the event there is a desire for the wastewater collection
facilities to change ownership, or there is a name change of the Permittee, a formal permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be considered
on its merits and may or may not be approved. [15A NCAC 02T.0104; G.S 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 2T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996 and updated March 2008, as applicable; the Division's
Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted
June 1, 2000 and updated March 2008, as applicable; and other supporting materials unless
specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .0110]
4. The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system-wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 2T .0403. If an individual
permit is not required,the following performance criteria shall be met: [15A NCAC 02T .0108(b)]:
Page 4 of 8

a. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface waters, and to prevent any contravention of groundwater standards or surface
water standards.
b. A map of the sewer system shall be developed and shall be actively maintained.
c. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
d. Pump stations that are not connected to a telemetry system shall be inspected every day(i.e. 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at
least once per week.
e. High-priority sewer lines shall be inspected at least once per every six-months and inspections are
documented.
f. A general observation of the entire sewer system shall be conducted at least once per year.
g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance
with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina
General Statute §143-215.1C.
h. A Grease Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the'legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease-related sanitary sewer overflows.
i. Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
j. Documentation shall be kept for Subparagraphs(a)through (i)of this Rule for a minimum of three
years with exception of the map, which shall be maintained for the life of the system.
5. The Permittee shall report by telephone to a water resources staff member at the Raleigh Regional
Office, telephone number [phone], as soon as possible, but in no case more than 24 hours,
following the occurrence or first knowledge of the occurrence of either of the following:
Page 5 of 8

a. Any process unit failure,due to known or unknown reasons,that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line .
blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume,that reaches surface water
Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside normal business hours may also be reported to
the Division of Emergency Management at telephone number [phone] or [phone].
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
�
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part II of Form CS-SSO (or the most current Division approved
form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)]
6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State. [15A NCAC 02T.0108(b)]
7. Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form attached to this permit shall be submitted with the required supporting
documents to the address provided on the form. A complete certification is one where the form is
fully executed and the supporting documents are provided as applicable. Any wastewater flow made
tributary to the wastewater collection system extension prior to completion of this Engineer's
Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions.
If the permit is issued to a private entity with an Operational Agreement,then a copy of the Articles
of Incorporation, Declarations/Covenants/Restrictions, and Bylaws that have been appropriately
filed with the applicable County's Register of Deeds office shall be submitted with the certification.
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings (plan & profile views of sewer lines&force
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media (CD or DVD disk) and are defined as the design drawings that are
marked up or annotated with after construction information and show required buffers,
separation distances, material changes, etc.
b. One copy of the supporting applicable design calculations including pipe and pump sizing,velocity,
pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge
protection, detention time in the wet well, and force min, ability to flush low points in force
mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or
pump is dedicated to multiple 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.
Page 6 of 8

c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
• Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting in
non-compliance with this permit (including pipe length increases of 10% or greater, increased flow,
pump station design capacity design increases of 5%or greater, and increases in the number/type of
connections), regulations, or the Minimum Design Criteria. Requested modifications or variances to
the Minimum Design Criteria will be reviewed on a case-by-case basis and each on its own merit.
Please note that variances to the Minimum Design Criteria should be requested and approved during
the permitting process prior to construction. After-construction requests are discouraged by the
Division and may not be approved, thus requiring replacement or repair prior to certification &
activation. [15A NCAC 02T.0116]
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case-by-case basis. Resolution of such request shall be evident prior to completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
9. A copy.of the construction record drawings shall be maintained on file by the Permittee for the life of
the wastewater collection facilities. [15A NCAC 02T.0116]
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2T;the Division's
Gravity Sewer Design Criteria adopted February 12, 1996 and updated March 2008,
as applicable; the Division's Minimum Design Criteria for the Fast-Track Permitting of Pump Station
and Force Mains adopted June 1, 2000 and updated March 2008 as applicable; and other supporting
materials may subject the Permittee to an enforcement action by the Division, in accordance with
North Carolina General Statutes §143-215.6A through §143-215.6C, construction of additional or
replacement wastewater collection facilities, and/or referral of the North Carolina-licensed
Professional Engineer to the licensing board. [15A NCAC 02T .0104; 15A NCAC 02T.0108(b-c)]
11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions,the Permittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities.
[15A NCAC 02T.0110; 15A NCAC 02T.0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes,
rules,regulations,or ordinances that may be imposed by the Division any other Federal,State,or Local
government agencies which have jurisdiction or obtaining other permits which may be required by
the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 8

FAS I I WALK StWtK tIVC319Vtt1-ctmu um I irILi•%i IvIv
PERMITTEE: City of Oxford
PERMIT#: WQ0039953
PROJECT: 2017 USDA Water&Sewer Improvements, Contract 1—Water System
ISSUE DATE: May 4, 2018
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of
this permit until the Division has received this Certification and all required supporting documentation. It
should be submitted in a manner that documents the Division's receipt. Send the required documentation
the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom.
Any wastewater flow made tributary to the wastewater collection system extension prior to completion
of this Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up
until a final certification is received. A Final Certification shall be a complete set of record drawings and
design calculations regardless of whether partials have been submitted.
PERMITTEE'S CERTIFICATION
I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant
to the applicable standards & requirements, the Professional Engineer below has provided applicable
design/construction information to the Permittee, and the Permittee is prepared to operate & maintain
the wastewater collection system permitted herein or portions thereof.
Printed Name,Title Signature Date
ENGINEER'S CERTIFICATION
I, , as a duly registered Professional Engineer in the State of North Carolina,
having been authorized to observe (I I periodically, I I weekly, I I full time) the construction of the
project name and location as referenced above for the above Permittee hereby state that,to the best of
my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance of this permit; 15A NCAC 02T; the
Division of Water Resources' (Division)Gravity Sewer Minimum Design Criteria adopted February 12,1996
and updated March 2008, as applicable; the Division's Minimum Design Criteria for the Fast-Track
Permitting of Pump Stations and Force Mains adopted June 1, 2000 and updated March 2008, as
applicable; and other supporting materials.
North Carolina Professional Engineer's Seal w/signature & date:
I I Final Partial (include description)
•
•
•
Certification Comments/Qualifiers (attach if necessary):
Division of Water Resources,Raleigh Regional Office,Water Quality Operations Section www.ncwaterquality org
1628 Mail Service Center,Raleigh,NC 27699-1628 Phone:[phone]
T nrafinn• 152nn Rsnatt Tlr;va Rolairrb NC'77Fno Fa,•(010l-M.:7150

/ _
State of North Carolina
. DwR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T.0300—FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16&SUPPORTING DOCUMENTATION
Application Number: i40 Q 3 LT 5 3 (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: City of Oxford(company,municipality,HOA,utility,etc.)
2. Applicant type: El Individual ❑Corporation 0 General Partnership 0 Privately-Owned Public Utility
El Federal ❑State/County ®Municipal El Other
3. Signature authority's name:Amy Ratliff.P.E. per 15A NCAC 02T.0106(b)
Title:City Engineer
4. Applicant's mailing address:300 Williamsboro Street,P.O.Box 506 NC Dept of Environmental Quality
City:Oxford State:NC Zip:27565-
5. Applicant's contact information: BAR 2 0 2W8
Phone number:[phone] Email Address:aratliff{a,oxfordnc.org
IL PROJECT INFORMATION: Raleigh Regional Office
1. Project name:2017 USDA Water&Sewer Improvements,Contract 1 -Water System
2. Application/Project status: Z Proposed(New Permit) ❑Existing Permit/Project
If a modification,provide the existing permit number:WQ00 and issued date:
If new construction but part of a master plan,provide the existing permit number:WQ00
3. County where project is located:Granville
4. Approximate Coordinates(Decimal Degrees):Latitude: 36.311592' Longitude:-78.587653'
5. Parcel ID(if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer.Courtney M.Gamble,P.E. License Number:044691
Firm:The Wooten Company
Mailing address:300 South Main Street,Lower Level
City:Winston-Salem State:NC Zip:27101-
Phone number:[phone] Email Address:[e-mail]
IV. WASTEWATER TREATMENT FACILITY(WWTF)INFORMATION: 4-0 tl W 3.--i)
1. Facility Name:City of Oxford Wastewater Treatment Plant Permit Number:N 10078 t
Owner Name:City of Oxford
V. RECEIVING DOWNSTREAM SEWER INFORMATION(if different than WWTF):
1. Permit Number(s):WQ Downstream(Receiving)Sewer Size: inch
System Wide Collection System Permit Number(s)(if applicable):WQCS
Owner Name(s):
FORM:FTA 04-16 r 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 ZN/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 ZN/A
3. If the Applicant is a Home/Propertv Owners'Association,has an Operational Agreement(FORM:HOA)been attached?
❑Yes ❑No ZN/A
4. Origin of wastewater:(check all that apply):
0 Residential Owned 0 Retail(stores,centers,malls) 0 Car Wash
0 Residential Leased 0 Retail with food preparation/service ❑Hotel and/or Motels
0 School/preschool/day care ❑Medical/dental/veterinary facilities ❑ Swimming Pool/Clubhouse
❑Food and drink facilities 0 Church
❑Swimming Pool/Filter Backwash
❑Businesses/offices/factories
0 Nursing Home 0 Other(Explain in Attachment)
5. Nature of wastewater: %Domestic/Commercial %Commercial
%Industrial(See 15A NCAC 02T.0103(20))
�Is there a Pretreatment Program in effect? 0 Yes ❑No
6. Has a flow reduction been approved under 15A NCAC 02T.0114(f)? ❑Yes ❑No
> If yes,provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type(see 02T.0114(f)) Daily Design Flow a'b No.of Units Flow
gal/ GPD
gal/ GPD
gal/ GPD
gal./ GPD
gal/ GPD
gal/ GPD
Total GPD
a See 15A NCAC 02T.0114(b), (d),(e)(1) and(e)(2)for caveats to wastewater design flow rates(i.e.,minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use
areas; and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals
as defined in G.S.42A-4).
b Per 15A NCAC 02T.0114(c),design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall
be determined using available flow data,water using fixtures,occupancy or operation patterns,and other measured data.
8. Wastewater generated by project:0 GPD(per 15A NCAC 02T.0114)
Do not include future flows or previously permitted allocations
If permitted flow is zero,indicate why:
❑Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
0 Flow has already been allocated in Permit Number:
Z Rehabilitation or replacement of existing sewer with no new flow expected
❑Other(Explain):
FORM:FTA 04-16 Page 2 of 5

1•
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 43 PVC
8 605 DIP
sy 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)
i Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA(If Applicable)—02T.0305&MDC(Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates(Decimal Degrees):Latitude: . ° Longitude:- . °
3. Design flow of the pump station: millions gallons per day(firm capacity)
4. Operational point(s)of the pump(s): gallons per minute at feet total dynamic head(TDH)
5. Summarize the force main to be permitted(for this Pump Station):
Size(inches) Length(feet) Material
6. Power reliability in accordance with 15A NCAC 02T.0305(h)(1):
❑ Standby power source or pump with 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
sv Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
9 Portable power source with manual activation,quick-connection receptacle and telemetry- 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry- 15A NCAC 02T.0305(h)(1)(C):
Y It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant(draft agreement)
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 in the case of a multiple station power outage.
FORM:FTA 04-16
Page 3 of 5

/ �
,IX. SETBACKS&SEPARATIONS—(02B.0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T.0305(f)&(g) ®Yes ❑No
.- 15A NCAC 02T.0305(f)contains minimum separations that shall be provided for sewer systems:
Setback Parameter* Separation Required
Storm sewers and other utilities not listed below(vertical) 24 inches
Water mains(vertical-water over sewer 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 1 or
Class II impounded reservoirs used as a source of drinking water 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(see item IX.2) 50 feet
-
**Any other stream,lake,impoundment,or ground water lowering and surface drainage
ditches 10 feet
Any building foundation 5 feet
Any basement
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
r 15A NCAC 02T.0305(g)contains alternatives where separations in 02T.0305(f)cannot be achieved.
'v **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
If noncompliance with 02T.0305(f)or(g),see Section X of this application
2. Does the project comply with separation requirements for wetlands?(50 feet of separation) ❑Yes ❑No ®N/A
> See the Division's draft separation requirements for situations where separation cannot be meet
No variance is required if the alternative design criteria specified is utilized in design and construction
> As built documents should reference the location of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑Yes ❑No ®N/A
>. This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or 0 Yes X/ No
individual permits or 401 Water Quality Certifications?
> Information can be obtained from the 401 &Buffer Permitting Branch
5. 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 are 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.).
6. Does this project include any sewer collection lines that are deemed"high-priority?"
Per 15A NCAC 02T.0402, "high-priority sewer"means"any aerial sewer, sewer contacting surface waters,siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑Yes ®No ❑N/A
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 permitee's individual System-Wide Collection permit.
FORM:FTA 04-16
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?
►Z1 Yes ' ❑No
If No, complete and submit the Variance/Alternative Design Request application(VADC 10-14) and supporting documents
for review. Approval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification: I
I, Co La +hE . (-�b� attest that this application for
(Professional k Engineer's name from Application Item 1II.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, Gravity Sewer
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 143-215.6B, 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.
•
North Carolina Professional Engineer's seal,signature,and date: i \t t t I i 1 f l
!C
CCtWL
SEAL �r:
044691 —
0
-0 •`�VGiti • •`•'�'�
�/./ T4TY M• P\�
�{rrl►11111
3. Applicant's Certification per 15A NCAC 02T.0106(b): � '
I, A rig'I L. RAT-t i 7 4- - ,i1 4.to i,..1".3 S.s.li- attest that this application for
(Signature Authority's name&title from Application Item I.3.)
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: V // Date: 3/VI l Y
FORM:FTA 04-16 Page 5 of 5

•
U.S.0€PARTMENT OF THE RREWOR OXFORD QUADRANGLE
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