WQ0040786_Permit (Issuance)_20190410

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ROY COOPER
Governor
MICHAEL S.REGAN
Secretary
LINDA CULPEPPER
Director NORTH CAROLINA
Environmental Quality
April 10, 2019
Kory Reimann, Managing Member
BOMA, North Carolina, LLC
14098 South Deer Trail Lane
Draper, UT 84020
Subject: Permit No. WQ0040786
BOMA, North Carolina, LLC
Calebs Creek—Amenities Center, Phase 1 (Construction Only)
Wastewater Collection System Extension Permit
Forsyth County
Dear Mr. Reimann:
In accordance with your application received April 8, 2019, we are forwarding herewith Permit No.
WQ0040786 dated April 10, 2019, to BOMA, North Carolina, LLC (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effective from the date of issuance until rescinded and shall be subject to the conditions and limitations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 1.1: This permit shall be for the construction of the wastewater collection facilities only.
No flow shall be made tributary to the subject facilities until a permit modification
application is submitted (with the appropriate fee), a modified permit is issued, and
the Engineer's Certification is received and approved by the Division.
Condition 11.1: This permit shall not be automatically transferable; a request must be made and
approved.
Condition IIA: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 02T.0403 or any individual system-wide collection system
permit issued to the Permittee.
Condition 11.7: Upon completion of construction and prior to operation of these permitted facilities,the
completed Engineering Certification form with checklist attached to this permit shall be
submitted with the required supporting documents to the address provided on the form.
Permit modifications are required for any changes resulting in non-compliance with
this permit, regulations, or the Minimum Design Criteria. [15A NCAC 02T.0116]
N�T��R�ND-EQ>
fYpa,hnmlM EnWrenme�l pu.
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road,Suite 300 1 Winston-Salem,NC 27105
336-776-9800

BOMA, North Carolina, LLC
Permit No.WQ0040786
It shall be 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.
If you need additional information concerning this matter, please contact Jenny Graznak at (336) 776-
9800 or via e-mail at [e-mail].
Sincerely,
DocuS�igfned<by:
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945B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
by Lon T. Snider,Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: Ravindra Bissram, P.E.—Fleming Engineering ([e-mail])
Courtney Driver. P.E.—City of Winston-Salem ([e-mail])
Winston-Salem Regional Office Files
Water Resources Central Files
PERCS (electronic copy)
Page 2 of 8

�OuoNVL�
NORTH CAROLINA
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
BOMA, North Carolina, LLC
Forsyth County
for the construction and operation of approximately 194 linear feet of 8-inch gravity sewer to serve future
development as part of the Caleb's Creek — Amenities Center, Phase 1 project, and the discharge of 0
gallons per day of collected wastewater (Construction Only Permit) into the City of Winston-Salem's
existing sewerage system, pursuant to the application received April 8, 2019 and in conformity with 15A
NCAC 02T;the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable;
the Division's Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains
adopted June 1, 2000 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 limitations contained therein.
EDocuS�igfned<by:
Lug l Smdcr
-4'B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0040786
Permit Issued: April 10, 2019
Page 3 of 8

SUPPLEMENT TO PERMIT COVER SHEET
BOMA, North Carolina, LLC 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 City of Winston-Salem's Archie
Elledge Wastewater Treatment Facility in accordance with Permit Number NC0037834.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 02T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable;and the Division's Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000 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
1. This permit shall be for the construction of the wastewater collection facilities only. No flow shall be
made tributary to the subject facilities until a permit modification application is submitted (with the
appropriate fee), a modified permit is issued, and the Engineer's Certification is received and
approved by the Division.
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.0116; 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 02T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for
the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 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 02T .0403. If an individual
permit is not required,the following performance criteria shall be met:
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 Winston-Salem
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:
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
Page 5 of 8

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 11 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 with checklist 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 main, 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, include travel timeframes, shall
be provided.
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 but not limited to pipe length changes of 10% or
greater, increased flow, pump station design capacity design increases of 5% or greater, and
Page 6 of 8

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 individual permit and 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 02T; the
Division's Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's
Minimum Design Criteria for the Fast-Track Permitting of Pump Station and Force Mains adopted June
1, 2000 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.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 maybe required by the
Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)]
Page 7 of 8

CERTIFICATION CHECKLIST
To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116.
Certifying Engineer:
Certification Review Date:
Project Name:
WQ00 Project County:
1) Has permittee information changed since the permit was issued (or last modified): change of mailing address,
change of ownership, transfer from developer to HOA/POA, etc. ❑ Yes ❑ No
• If yes, please provide either a change of ownership form or new contact information. Note that transfer of
permits from the developer to the HOA/POA must occur with the first certification.
2) Have the as-built drawings have been signed,sealed,and dated by an N.C. PE? ❑ Yes ❑ No
3) Final Engineering certification? ❑ Yes ❑ No
• If Partial Engineering certification, provide detailed narrative including what is being certified in the current
phase,what was previously certified (if applicable),and what is left to be certified.
4) Adequate information related to sewer lines: ❑ Yes ❑ No ❑ N/A
• Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed.
• Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines.
• Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all
intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches).
5) Adequate information related to pump stations: ❑ Yes ❑ No ❑ N/A
• Ensure power reliability option was selected per 15A NCAC 02T.0305(h).
6) Was project construction completed in accordance with all of the following: ❑ Yes ❑ No ❑ N/A
• 15A NCAC 02T, Minimum Design Criteria (MDC)for the permitting of Gravity Sewers (latest version), and MDC
for the Permitting of Pump Stations and Force Mains (latest version)?
If not, a variance approval is required in accordance with 15A NCAC 02T.0105(b), prior to certification and operation.
• Contact the Central Office to discuss the variance to determine a course of action.
• Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other
pertinent information to the Central Office (one hard copy, one digital copy).
• The central office will review the variance request, and if approvable, specific language regarding the variance
will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the
reissued permit with variance language or the variance letter must be maintained with the original documents.
7) Does the project contains high priority lines(15A NCAC 02T .0402(2))? ❑ Yes ❑ No
• If yes,ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC
02T.0403 (a)(5). If the permit does not include this language,the Fast Track reviewer will reissue the permit with
the appropriate language.
8) Are Permit modifications are required for any changes resulting in non-compliance with this permit(including but not
limited to pipe length changes of 10%or greater,change in flow,pump station design capacity design change of 5%or
greater,and/or change in the number/type of connections)? ❑ Yes ❑ No
• If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified
permit with revised certification must be issued prior to certification and operation.
NC DWR—Water Quality Regional Operations Section 450 West Hanes Mill Road,Suite 300,Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE: BOMA, North Carolina, LLC
PERMIT#: WQ0040786
PROJECT: Caleb's Creek—Amenities Center, Phase 1 (Construction Only)
ISSUE DATE: April 10, 2019
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
ENGINEERS CERTIFICATION
I, as a duly registered Professional Engineer in the State of North Carolina,
having been authorized to observe (❑ periodically, ❑ weekly, ❑ 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 following construction:
of approximately 194 linear feet of 8-inch gravity sewer to serve future development as part of the Caleb's
Creek—Amenities Center, Phase 1 project,and the discharge of 0 gallons per day of collected wastewater
(Construction Only Permit) into the City of Winston-Salem's existing sewerage system, pursuant to the
application received April 8, 2019; 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 as applicable;the Division's Minimum Design Criteria
for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and
other supporting materials.
...............................................
North Carolina Professional Engineer's Seal w/signature & date:
❑ Final ❑ Partial (include description)
...............................................:
Certification Comments/Qualifiers (attach if necessary):
NC DWR—Water Quality Regional Operations Section 450 West Hanes Mill Road,Suite 300,Winston-Salem, NC 27105
Winston-Salem Regional Office Phone: [phone] FAX: [phone]

Central Files: APS _ SWP
4/10/2019
Permit Number WQ0040786 Permit Tracking Slip
Program Category Status Project Type
Non-discharge Active New Project
Permit Type Version Permit Classification
Gravity Sewer Extension,Pump Stations,&Pressure Sewer Extensions 1.00 Individual
Primary Reviewer Permit Contact Affiliation
jennifer.graznak
Coastal SWRule
Permitted Flow
Facility
Facility Name Major/Minor Region
Calebs Creek-Amenities Center, Phase 1 Minor Winston-Salem
Location Address County
Teage Ln Forsyth
Facility Contact Affiliation
Kernersville NC 27284
Owner
Owner Name Owner Type
Boma North Carolina LLC Non-Government
Owner Affiliation
Mark Brown
7206 Sw 146th Street Cir
Dates/Events Palmetto Bay FL 33158
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
4/10/2019 4/8/2019 4/10/2019 4/10/2019
Regulated Activities Requested/Received Events
Subdivision Additional information requested
Wastewater collection Additional information received
Outfall
Waterbody Name Streamindex Number Current Class Subbasin

i
4
Flemin En ineerin Inc.
FEI 9 9 9 ,
Consulting Engineers G' Land Surueyors
April 5 2019 Frra 'cn �'ientalief t or
Quality
Received
Winston-Salem Regional Office
Water Quality Section A""R 00 2 °`
450 W. Hanes Mill Road \ftiinston-Salem
Suite 300 f
Winston Salem, NC 27105. Regional Office
RE: Sewer Application FTA 04-16 for Calebs Creek—Amenities Center, Phase 1
To Whom it may Concern:
We are requesting the approval of a sewer Fast Track Permit Application for the Calebs Creek—
Amenities Center, Phase 1. The applicant for this project is the Developer, BOMA, North
Carolina, U-C. The sewer line extension will currently have zero flow; in the future, a proposed
sewer main will extend from and existing outfall along the public right-of-way of future Club
View Drive. Once the main is extended, sewer installed in this phase will tie into the new
extension. The amenity clubhouse (constructed in this phase)will then be converted from the
septic system to the municipal sewer network. The sewer main along Club View Drive will be
maintained by City County Utility Commission. Beyond the public right-of-way,the sewer {
extensions will be privately maintained.
As sewer is not currently available to the site,the clubhouse will be permitted to utilize an
existing septic drain field. The sewer installation taking place in this phase will be installed
under pavement; installation at this time will prevent the need to open cut the new roadway for
service in the future.
All supporting documents including the review fee have been included with this package.
Please call me with any questions or concerns.
Sincerely,
RWd �-
Ravindra Bissram, PE
Fleming Engineering, Inc.
Consulting Engineers and Land Surveyors
8518 Triad Drive
Colfax,NC 27235
336-215-6807
www.FleminffEn2bueerin2.eon:
85IB Triad Drive Colfax, NC 27235 Phone: [phone] Fax: 336-B52-9766

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
f
Application Number: �lSl. 0 (to be completed by DWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: BOMA North Carolina LLC(company,municipality,HOA,utility,etc.)
2. Applicant type: ❑ Individual ® Corporation ❑ General Partnership ❑Privately-Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑Other
3. Signature authority's name:Kory Reiman n per 15A NCAC 02T.0106(b)
Title:Managing Member
4. Applicant's mailing address: 14098 S. Deer Trail Lane Envii-onryiental Quality
Received
City:Draper State:UT Zip: 84020-_
C '�n<ly
5. Applicant's contact information: f'.'i e d u 2IM59
Phone number: 336 669-8189 Email Address: v.'inston-Salem
II. PROJECT INFORMATION:
I. Project name: Calebs Creek-Amenities Center,Phase I
2. Application/Project status: ®Proposed(New Permit) ❑ Existing Permit/Project
If a modification,provide the existing permit number: W000 and issued date:
If new construction but part of a master plan,provide the existing permit number: W000_
3. County where project is located: Fors
4. Approximate Coordinates(Decimal Degrees): Latitude: 36.03'52° Longitude: -80.05'26°
5. Parcel ID(if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer:Ravindra Bissram License Number: 027436
Firm: Flemine Eneineering
Mailing address: 8518 Triad Drive
City: Colfax State:NC Zip:27235-
Phone number: [phone] Email Address:rbissram@flemingen ing Bering com
IV. WASTEWATER TREATMENT FACILITY(W WTF)INFORMATION:
1. Facility Name:Archie ElledRe Permit Number:NCO037834
Owner Name: Winston-Salem/Forsyth County Utility Commission
V. RECEIVING DOWNSTREAM SEWER INFORMATION(if different than W WTF):
1. Permit Number(s): WQCS00003 Downstream(Receiving)Sewer Size: 8 inch
System Wide Collection System Permit Number(s)(if applicable): WQCS00003
Owner Name(s): WS/FC Utility Commission
I
FORM: FTA 04-16 Page 1 of 5

f
VI: GENERAL REQUIREMENTS
I
1. If the Applicant is a Privately-Owned Public Utility,has a Certificate of Public Convenience and Necessity been attached?
❑Yes ❑No ®N/A
2. If the Applicant is a Developer of lots to be sold,has a Developer's Operational Agreement(FORM: DEV)been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners'Association,has an Operational Agreement(FORM: HOA)been attached?
❑ Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
❑Residential 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)
I
5. Nature of wastewater: 100%Domestic/Commercial %Commercial
%Industrial(See 15A NCAC 02T.0103(20)) t
"Is there a Pretreatment Program in effect? ❑Yes ®No �
6. Hasa flow reduction been approved under I5A NCAC 02T.0114(f)? ❑ Yes ®No
➢ If yes, provide a eopv of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type(see 221.01140 Daily Design Flow',' No.of Units Flow
i
Amenity Area 0 gal/day 0 0 GPD
gal/ GPD
gal/ GPD
gal/ GPD
gal/ GPD
gal/ GPD
i
Total 0 GPD
i
r
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (00 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.01141 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
❑Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other(Explain):
FORM: FTA 04-16 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
i
8 194 VCP
E
I
I�
I
➢ Section I1&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 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
I. Pump station number or name:NA
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
f
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
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ 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):
➢ 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.
i
i
FORM: FTA 04-16 Page 3 of 5

IX. SETBACKS&SEPARATIONS—(02B.0200 & 15A NCAC 02T.0305(f)):
I. Does the project comply with all separations found in 15A NCAC 02T.0305(f)&(g) ®Yes ❑No
➢ 15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter* Separation Required j
Storm sewers and other utilities not listed below(vertical) 24 inches
Water mains vertical-water over sewer including in benched trenches 18 inches k
Water mains horizontal 10 feet j
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 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 36inches
➢ 15A NCAC 02T.0305(g)contains alternatives where separations in 02T.0305(f)cannot be achieved.
➢ **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 213.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes ®No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 &Buffer Permitting Branch I
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,stornwater 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
i
documented per 15A NCAC 02T.0403(a)(5)or the permitee's individual System-Wide Collection permit.
I
FORM: FTA 04-16 Page 4 of 5

CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T,the Mininmm 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,complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents k
for review. Approval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification:
g�r
I, ON11AAM 91�,j5 t W1 . I G attest that this application for
(Professional Engineer's name from Application Item III.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
materiall and have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6E, 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: """""""""""""""""...... ""a """"""""..""""
/S^yE�A�Lc
27436 r
` ae ee t7` I
3. Applicant's Ce ific per 15A NCAC 02T.0106(b): " """.
I, 44nA4Q e_ /�«'1Q^Iv attest that this application for t
(Signature Authority's name&title from Application Item 1.3.)
has b /nreviewed 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
i
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 f
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 143-215.613, 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.
Signature: , t../ Date: 3 ZLe 1
f
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FORM:FTA 04-16 Page 9 of 5