WQ0040826_Application (FTSE)_20190603

Permit Number WQ0040826
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
dean.hunkele
Coastal SWRuIe
Permitted Flow
FaCiiit
Facility Name
Affinity Health at Pine Forest Private Pump Station
Location Address
Owner
Owner Name
Brunswick Propco Holdings LLC
Central Files- APS SWP
4/26/2019
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit classification
A
Individual
Permit Contact Affiliation
Major/Minor Region
Minor Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Non -Government
Owner Affiliation
Charles E. Trefzger Jr.
PO Box 2568 4
Dates/Events Hickory NC 28603256
I
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice issue Effective Expiration
4/25/2019
i
Regulated Activities Requested /Received Events
Additional information requested
Additional information received
-., ..,.•.

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To NCDENR — Public Water Supply Section Date 04.25.19
512 N. Salisbury St. 131h Floor
Raleigh, NC 27604 Re: Affinity Health
Fast Track Sewer
Attri = Dean Hunkele Pro'ect No. 18426.PE
*e..aresenamg, Z Originals Z Prints
Thefollowin items: ❑ Correspondence ®Plans
❑ Shop Drawings Z Calculations
❑ Specifications Z Other as listed below
Quantity
Date
Dw.1V o.
Descripiari
2
-
Fast Track Sewer Permit FTA 04-16 — Brunswick County Permit
2
Flow Tracking/Acceptance Sewer Extension Application FTSE 04-16
(original and 1 co
1
Sanitary Sewer Narrative cover
1
USGS Map
1
Brunswick County Approval Letter
1
Check $480
1
NC Secretary Of State Information
s ue`'Status Z For Approval ❑ As Requested ❑ Construction ❑ Bid
❑ For Your Use Ej For Review and Comment Ej Approved as Noted ❑ See Remarks
KC11641TA'kend ❑ No Exceptions Taken ❑ Make Corrections Noted ❑ Amend & Resubmit
❑ Re)ected - See Remarks ❑ Approved as Submitted ❑ Other
R marks
Contact us with any
additional information or questions. Thank you.
Dan Withers, PE
Dwithers aramounte-en . com 910-791-6707
Cc:
Signed:, oeig� z oe
Christina Ricks

P..A RAMOUNTE
April 15, 2019
NCDEQ — DWR
127 Cardinal Dr. Ext
Wilmington, NC 28405
RE: Affinity Health
NCAC 02T.0300 Fast Track Sewer System Extension
Town of Oak Island, Brunswick County, NC
To Whom It May Concern,
Enclosed is a sewer extension application with supporting documentation for the proposed assisted living
facility in the Town of Oak Island. The proposed facility will have building sewer draining directly to a
duplex grinder pump station constructed in accordance with Brunswick County's standards. The pump
station will discharge through approximately 30 feet of HDPE force main before tying into the existing
force main permitting under WQ0039819. The facility is permitted at 80 beds, with a flow of 120
gpd/bed in accordance with 02T rules.
The enclosed documents include the following items:
• Check in the amount of $480.00 .
• Fast Track Sewer System Extension Application
• Flow Tracking for Sewer- Extension Applications
• Site Map
On behalf of the permittee, Brunswick Propco, LLC, we request that you grant a permit for construction
of this sewer system.
Sincerely,
Paramounte Engineering, Inc.
Dan ers, PE
1 2 2 C I N E M A D R I V E, W I L M I N G T O N, NC 2 8 4 0 3
o u r in r*1 I o - = n n ■ 7 e- n v 6 r c I n I n o I - = rs n

Application n Number: W (" 0#V (to be completed by DWR
)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: Brunswick Propco Holdings, LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ® Corporation El General Partnership EJ Privately -Owned Public Utility
❑ Federal EJ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Charles E. Trefzger, Jr. per 15A NCAC 02T .0106(b)
Title: Manager
4. Applicant's mailing address: PO Box 2568
City: HickoKy State: NC Zip: 28603-
5. Applicant's contact information:
Phone .number: [phone] Email Address: cetgaffinitylivinggroup.com
II. PROJECT INFORMATION:
1. Project name: Affinity Health
2. Application/Project status: ® 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: Brunswick
4. Approximate Coordinates (Decimal Degrees): Latitude: 33.9684' Longitude:-78.0988'
5. Parcel ID (if applicable): 2030001714
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: J. Dantzler Withers License Number: 3 8746
Firm: Paramounte Engineering, Inc•
Mailing address: 122 Cinema Drive
City: Wilmin tg_on State: NC Zip: 28403-
Phone number: [phone] Email Address: dwithers ckparamounte-eng_com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: West Brunswick Regional WWTF Permit Number: WQ0023693
Owner Name: Brunswick County
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0039819 Downstream (Receiving) Sewer Size: 2 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00284
Owner Name(s): Brunswick County
FORM: FTA 04-16 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?
E]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?
E]Yes [—]No ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement (FORM: HOAJ been attached?
El Yes ❑No ®N/A
4. Origin of wastewater: (check all that apply):
❑ Residential Owned EJ Retail (stores, centers, malls) El Car Wash
❑ Residential Leased ❑ Retail with food preparation/service EJ Hotel and/or Motels
❑ School / preschool / day care El Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church EJ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories Z Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: % Domestic/Commercial 100 % Commercial
Industrial (See 15A NCAC 02T .0103(20�)
)o-Is there a Pretreatment Program in effect? ❑Yes ❑ No
6. Has a flow reduction been approved under 15A NCAC 02T .0114(fZ? El Yes Z 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
Assisted Living Facility
120 gal/bed
80
%600 GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
%600 GPD
a See 15A NCAC 02T .0114(b),(d), (e)(1)and (e. ((22) 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: 9,600 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
El 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
➢ 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: Affinity Health
2. Approximate Coordinates (Decimal Degrees): Latitude: 33.9684' Longitude:-78.0988'
3. Design flow of the pump station: 0.0288 millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): 20 gallons per minute at 160 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2
30
CTS Tubing, SDR
9
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 .03 05 (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.
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) 0 Yes E]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 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
building foundation
5 feet
-Any
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
swimming pools
10 feet
-Any
Final earth grade vertical
36 inches
➢ 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 webpae
➢ 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) E 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 0 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 E]Yes 0 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 02TA105(c)(6) (additional permits/certifications)? 0 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.
El 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 021-, the MinilllUin Design Criteiia for the Pernu'ttincy Of PLIMP Stations
-(
and Force M, ins (latest vets and the Gravity Sewer Minimum Design Criteiia latest version) as applicable?
10 Yes 0 No
IfNo., complete, and submit the Variance/Alternative Design Request application (VADC 10- 14) and supporting documents for
review. AProval of the re nest is
reguired. 12rior.to submittal of the Fast Track Application and suppactin p, documents.
2.. Profcksional Engineer's Certification. -
(professional Engineer's name
Application Item TIT. 1.)
attest that this application fog -
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 Dcsign Criteria for the Fast -Track Pennitting
of Pump Stations andForce Mains (latest version.). Although other professionals may have developed certain portions of this
submittal packagc, inclusion of these inatcrials 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 flne'not to:exceed $ 10,000, as well as civil penalties Lip to $25,000 per violation.
North, Carolina Professional Engineer's seal, signature, and date:
... Afril
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SEAL Iq
is r 38746 wa
00
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........... ....... .. ......
3. AI)plicant'SCertification .per .15A*NCACO2T.0106(b):
T$. dIMA44S .4.7susr- eo-0*4d, ZPg,,1�),JV,44 6 & attest that this application for
(Signature, Authority's name & title from Application Item 1.3.)
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 cornp leted and. that if all required supporting documenuition and attachments are not included, this
application package is subject to beingretarned as incomplete. I t m.dcrstand that any discharge of wastewater from this non-
di.schargc system to surface waters or the land. will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or crimial prosecution. I will make no claim against the Division of Water Resourecs should a condition
of this permit be violatcd. I also underkand 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 ine as
incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6% any person who knowingly makes any false
statement, representation i or certification in any application package shall be. guilty of a Class 2 misdemeanor, which may
include a fine -not to exceed $ 1 0,90(fqs well as civil penalties up to 525,000 per violation.
015
Si nature: Date:
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: Brunswick Propco Holdings, . LLC
Project Name for which flow is being requested: Affinity Health (at, Pine Forest}
lore than one TS 'may be required far a -singleproject if the owner of the WWTP is not responsible for allpump
stations along the route of the proposed wastewaterflow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: WEST BRtJNSWICK WRF
b. WWTP Facility Permit #. W(�0023693
All flows are in MGD
c. WWTP facility's permitted flow 6.00
d. g Estimated obli ated flow not yet tributary to the WWTP 0.862
e. WWTP facility's actual avg. flow 2.998
Total flow for this specific request 0.00960
g. Total actual and obligated flows to the facility 3.870
h. Percent of permitted flow used 64. 5 %
' um station you are responsible for along the route of this proposed
II. Complete this section for each pump y p
wastewater flow.
List um stations located between the project connection point and the W WTP:
pump
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump pump Average Approx. Not Yet Total Current
Station Station Firm Daily Flow* * Current Tributary Flow Plus
Permit Capacity,* Firm / f}, Avg. Daily Daily Flow, Obligated Available
(Name or Pe ( p
Number). No. MGD MGD Flow, MGD MGD Flaw Capacity***
*
The Firm Capacity (design ) any pump station is defined as the maximum pumped flow
p g flow Y
that can be achieved with the largest pump taken out of service.
* * g Designy Average Dail Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02'(A)(4)(c) of the Minimum Design Criteria.
* * * A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
o
Down
stream FacilityName (Sewer): Pine Forest Blvd. Force Main
Downstream Permit Number: WQ0039819
Page 1 of 6

III. Certification Statement:
I Willi
' ll' am L. Pinnix . P.E. certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facilityand that the flow from this project is not anticipated to cause any capacity
related sanitary
itar sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given. the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
ident�f p g
established policies and procedures using the best available data. This certification applies to
with local esta p
' in Sections I and II plus all attached planning assessment addendu�ms for which I
those Items listed above p
am the Si. res onsible art nature of this form. certifies that the receiving collection system or treatment
p p y g
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official Signature
� _R5�7e1Jz o a
Title of Signing Official
.Date
Page 2 of 6
IIx

4/12/2019
North Carolina Secretary of State Search Results
• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online •
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an Amended a Annual Report form
Limited Liability Company
Legal Name
Brunswick Propco Holdings, LLC
Information
Sosid: 1457852
Status: Current -Active
Annual Report Status: Current
Citizenship: Domestic
Date Formed: 7/14/2015
Registered Agent: Stoneville Acceptance, LLC
Addresses
Reg Office Reg Mailing Principal Office
101 S Stratford Rd Ste 210 101 S Stratford Rd Ste 210 328 1st Ave NW
Winston Salem, NC 27104 Winston Salem, NC 27104 Hickory, NC 28601
Mailing
PO Box 2568
Hickory, NC 28603
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
Manager
Charles E Trefzger , Jr.
PO Box 2568
Hickory NC 28603
https://www.sosnc.gov/onI!ne_services/search/Business_Registration_ResuIts 1 /1

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Map data ©2019 Google 1000 ft i
4/26/2019