WQ0040854_Permit (Issuance)_20190510

a�STATE"
ROY COOPER
Governor ,� ~
MICHAEL S.REGAN
Secretary
LINDA CULPEPPER
Director NORTH CAROLINA
Environmental Quality
May 10, 2019
Kim Greenwood,Town Manager
Town of Walnut Cove
208 W Third Street
Walnut Cove, NC 27052
Subject: Permit No. WQ0040854
Town of Walnut Cove
R-5828 Roundabout on US 311 at SR 1918 in Stokes County
Wastewater Collection System Extension Permit
Stokes County
Dear Mr. Greenwood:
In accordance with your application received May 8, 2019, we are forwarding herewith Permit No.
WQ0040854 dated May 10, 2019, to the Town of Walnut Cove (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effective from the date of issuance until rescinded and shall be subject to the conditions and limitations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 request must be made and
approved.
Condition 11.4: 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]
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.
Moan.cnaouraaD E
dryhnml M EnWrenmenb]Oual�
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 W Hanes Mill Road,Suite 300 Winston-Salem, NC 27105
[phone]

Town of Walnut Cove
Permit No.WQ0040854
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 Justin Henderson at (336) 776-
9701 or via e-mail at [e-mail].
Sincerely,
EDocuS�igfned<by:
LJti l c. ,,Jcr
145B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
by Lon Snider,Assistant Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: Bryan Badey, PE-Rummel, Klepper& Kahl, LLP- [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
Town of Walnut Cove
Stokes County
for the construction and operation of approximately 186 linear feet of 10-inch gravity sewer to relocate
an existing sewer with no new connections as part of the R-5828 Roundabout on US 311 at SR 1918 in
Stokes County project, and the discharge of"0"gallons per day of collected domestic wastewater into the
Town of Walnut Cove's existing sewerage system, pursuant to the application received May 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.
Doc uS�igfned<by:
mdcr
-4'B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0040854
Permit Issued: May 10, 2019
Page 3 of 8

SUPPLEMENT TO PERMIT COVER SHEET
Town of Walnut Cove 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 Town of Walnut Cove's
Wastewater Treatment Facility in accordance with Permit Number NC0025526.
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. No flow in excess of the quantity permitted herein, "0" GPD, shall be made tributary to the subject
sewer system until an application for permit modification for an increase in flow has been submitted
to and approved by the Division. [15A NCAC 02T.0304(b)]
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.
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
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-
Page 6 of 8

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 .01161
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:
R-5828 Roundabout on US 311 at SR 1918 in Stokes County:
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 W Hanes Mill Road,Suite 300 Winston-Salem,NC 27105
Winston-Salem Regional Office Phone:[phone] FAX:[phone]

FAST TRACK SEWER ENGINEERING CERTIFICATION
PERMITTEE: Town of Walnut Cove
PERMIT#: WQ0040854
PROJECT: R-5828 ROUNDABOUT ON US 311 AT SR 1918 IN STOKES COUNTY
ISSUE DATE: MAY 8, 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 R-
5828 Roundabout on US 311 at SR 1918 in Stokes County 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:
for the construction and operation of approximately 186 linear feet of 10-inch gravity sewer to relocate
an existing sewer with no new connections as part of the R-5828 Roundabout on US 311 at SR 1918 in
Stokes County project, and the discharge of"0" gallons per day of collected domestic wastewater into the
Town of Walnut Cove's existing sewerage system.
; 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 W Hanes Mill Road,Suite 300 Winston-Salem,NC 27105
Winston-Salem Regional Office Phone:[phone] FAX:[phone]

..
May 6, 2019 NC Department of
Environmental Quality
Received
NC DEQ
Water Quality Section MAY 0 8 2019
450 West Hanes Mill Road, Suite 300
Winston-Salem,North Carolina 27105 Winston-Salem
Regional Office
Subject: NCDOT Project R5828
US 311 Roundabout
Stokes County
Sanitary Sewer Relocation
To whom it may concern,
Please find enclosed, the completed Fast Track Application and supporting documentation,
submitted for the above mentioned project. One original and one copy of the following are included
for your review and approval.
• Fast Track Application
• Permit Application Fee of$480.00 (check number 153145)
• USGS & Street Level Maps
Project Narrative
The enclosed documents are submitted for the relocation of existing portions of 10" gravity sanitary
sewer main pipes owned by the Town of Walnut Cove. This relocation is due to impacts to the
existing sanitary sewer system by the project construction associated with the NCDOT project R-
5828, Roundabout on US 311 (Main St.) at SR 1918 (First St). This relocation is located north of the
US 311 roundabout and will not result in any additional flow. The plans have been reviewed and
approved by Kim Greenwood with the Town of Walnut Cove.
Please do not hesitate to call 919-653-7342 if you have any questions or need additional
information.
Sincerely,
0
Bryan Badey, P.E.
Project Manager
Enclosures
cc: HTW

AIR.
15A NCAC 02T.0300—FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources /�[ FTA 04-16&SUPPORTING DOCUMENTATION
Application Number: V vV� (to be mmpleted by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Town of Walnut Cove.NC(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:Mr.Kim Greenwood per 15A NCAC 02T.0106(bl
NC Department
Title:Walnut Cove Town Manager
Environmental Qualili
ty
4. Applicant's mailing address:208 W Third Sheet Received
City:Walnut Cove State:NC Zip:27052-_ Vi P;t( 0 9 2019
5. Applicant's contact information:
Winston-Salem
Phone number:[phone] Email Address:townm manaperwc0lembanimail.co
Regional Office n— �
II. PROJECT INFORMATION: 0
1. Project name:R-5828 Roundabout on US 311 (Main St.)at SR 1918(First SO in Stokes County 1
2. Application/Project status: ❑Proposed(New Permit) ®Existing Permit/Project
If a modification,provide the existing permit number:W000191 and issued date: 06/11/2014 C0116
�y fr,.ac
If new construction but part of a master plan,provide the existing permit number:W000_
3. County where project is located:Stokes County
4. Approximate Coordinates(Decimal Degrees):Latitude: 36.2928' Longitude:-80.1415°
5. Parcel ID(if applicable):
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer:Bryan Badey,PE License Number:32634
Firm:Rummel,Klepper&Kahl.LLP
Mailing address:900 Ridgefield Drive
City:Raleigh State:NC Zip:27609
Phone number: 9( 10)878-9560 Email Address:bbadev(orkk.com
IV. WASTEWATER TREATMENT FACILITY(W WTF)INFORMATION:
1. Facility Name: Walnut-Cove Permit Number: NCO 5526
Owner Name: Walnut-Cove
V. RECEIVING DOWNSTREAM SEWER INFORMATION(if different than WWTF):
1. PetnritNumber(s):WQ_

i. ii-meApppcantisarrlvateiy vwiicuruuuc
❑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)
5. Nature of wastewater: 100%Domestic/Commercial _%Commercial
_%Industrial(See 15A NCAC 02T.0103(20))
"Is there a Pretreatment Program in effect? ❑Yes ❑No
6. Hasa flow reduction been approved under 15A NCAC 02T.0114(f) ❑Yes ❑No
➢ If yes provide a copy of now reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type(see 021.01140 Daily Design Flow'" 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.01141 shall be
determined using available flow data,water using fixtures,occupancy or operation patterns,and other measured data.
g. Wastewater generated by project:_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

1. Summarize gravity sewer to be permitted:
Size(inches) Length(feet) Material
10 186 PVC SDR 35
➢ 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 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): I
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
➢ 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

a. uo ..,F.J...,..,.....a... .......". r
➢ 15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter" Separation Re uired
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 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
An swimmin ools 10 feet
Final earth ade vertical 36 inches
➢ 15A NCAC 02T.0305(g)contains alternatives where separations in 02T.0305 cannot be achieved.
➢ "Stream classifications can be identified using the Division's NC Surface Water Classifications webnage
➢ If noncompliance with 02T.0305(f)or(2),see Section X of this application
2. Does the project comply with separation requirements for wetlands?(50 feet of separation) ®Yes ❑No
➢ 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 all setbacks found in the river basin rules per 15A NCAC 02B.0200? ®Yes ❑No
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ®Yes ❑No
➢ Wetland-related permits shall be requested,obtained,and adhered to for projects that impact wetlands or surface waters
➢ Information can be obtained from the 401 a&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 0 No

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,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 sunuorting documents.
2. Professional Engineer's Certification:
l fk� '\.` attest that this application for
(Professional Engineer's nami from Application Item 111.1.)
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. 1 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.
:.......................................................................
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North Carolina Professional Engineer's seal,signature,and date: \�0\ C A d///�
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3. Applicant's Ce ' nation per 15A NCAC 02T.0106(b):
I �` �`�e�,��00� \i,,W•r, n ti A4(r attest that this application for
(Signature Authority's name&title ImYn Application item U.)
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. 1 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. 1 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 cX d$10. s well as civil penalties up to$25,000 per violation.
Date:
Signature: '�

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