WQ0040844_Application (FTSE)_20190508

hq `V State of North Carolina
2 2019
Department of Environmental Quality
nwKDivision of Water Resources
®,q AR
�-AYFTI,?AR 0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources - S lR q'12f4 FWFORM. FTA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that has been
certified by a professional engineer and the applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minimum Design Criteria and that plans, specifications and supporting documents have been prepared in accordance with, 15A
NCAC 02T, 15A NCAC 02T .0300, Division policies and good engineering practices.
While no upfront engineering design documents are required for submittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prior to submittal of a fast track permit application to the Division. This would include plans, design
calculations, and project specifications referenced in ISA NCAC 02T .0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division.
Projects that are deemed permitted (do not require a permit from the Division) are explained in 15A NCAC 02T.0303.
Projects not eligible for review via the fast track process (must be submitted for full technical review):
i Projects that require an environmental assessment in accordance with ISA NCAC 1 C .0100;
➢ Projectsthat do not meet any part of the minimum design criteria (MDC) document;
➢ Projects that involve a variance fromthe requirements of 1.5A NCAC 2T;
S> Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps;
A STEP or simplex grinder pumps connecting to pressurized systems (e-g. force mains);
➢ Vacuum sewer systems.
General— When submitting an application, please use the following instructions as a checklist in orderto ensure all required items
are submitted. Adherence to these instructions and checking the provided boxes willhelp produce a quicker review time and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
0 Required unless otherwise noted
B. Cover Letter (Required for Ali Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
Be specific as to the system type, number of homes served, flow allocation required, etc.
➢ If necessary for clarity; include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
Y Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: FTA 04-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ if necessary for clarity or due to space restrictions, attaclnnents to the application may be made.
❑ If the Applicant Type in Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item I.2 is a. partnership or d/b1a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
• The Project Name in Item I1.1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
® The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional Engineer_
® The Applicant's Certification on Page 5 of the application shall be signed in accordance with 15A NCAC 02T .0106(b).
Per 15A,NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in ISA NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: FTA 04-16 &. SUPPORTING DOCUMENTATION Page I of

THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE
ADDRESS
COUNTIES SERVED
Asheville Regional Office
2090 US Highway 70
Avery, Buncombe, Burke, Caldwell, Cherokee,
Water Quality Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell,. Mitchell, Polk,
[phone] Fax
Rutherford, Swain,. Transylvania,Yancey
Fayetteville Regional Office
225 Green Street Suite 714
Anson,.Bladen, Cumberland, Harnett, Hoke,
Water Quality Section
Fayetteville, North Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Stanly, Union
[phone] Fax
Raleigh Regional Office
1628 Mail Service Center
Chatham, Durham, Edgeoombe, Franklin,
Water Quality Section
Raleigh, North Carolina 27699-1628
Granville, Halifax, Johnston, Lee, Nash,
[phone]
Northampton, Orange, Person, Vance, Wake,
[phone] Fax
Warren, Wilson
Washington Regional Office
943 Washington Square Mall
Beaufort, Bartle, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Duplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Alamanee, Alleghany, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Surry, Watauga, Wilkes, Yadkin
[phone]
INSTRUCTIONS FOR FORM: FTA 04-I6 & SUPPORTING DOCUMENTATION Page 3 of

E. Flow Tracking(Acceptance Form (Form: FTSE 04-16) (If Applicable): ¢V'e Adq/,'vh'�N b f F10 W
® Submit the completed and executed FTSE form from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE must not expire prior to permit issuance and must be dated less than one
year prior to the application date.
> Submittal of this application and forth FTSE indicates that owner has adequate capacity and will not violate G.S. 143-
215.67 a .
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE.
F. Site Maps (Alt Application Packages):
® Submit an 8.5-inch x 11-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
S Downstream connection points and permit number (ifknown) for the receiving sewer
N Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field-
G. Existing Permit (All Modification Packages):
❑ Submit the most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T .0305(h)(1), submit documentation of power reliability for pumping stations.
A This alternative is only available for average daily flows less than 15,000 gallons per day
It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station- The Division will accept a letter signed by the applicant (see 15A NCAC 02T .0106(b)) or proposed
contractor, stating that `the portable power generation unit or portable, independently -powered pumping units, associated
appurtenances and personnel are available for distribution and operation of this pump 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. (Required at time of certification)
L Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a)(1) provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or that
franchise approval is expected.
J. Operational Agreements (Applications from HOAlPOA and Developers for lots to be sold):
❑ HornelProuertv Owners' Associations
❑ Per 15A NCAC 02T .0I 15(c), submit the properly executed OOerational Agreetent {FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit a copy of the Articles of fncorpomtion, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV).
For more information, visit the Division's collection systems websile
INSTRUCTIONS FOR FORM: FTA 04-16 & SUPPORTING DOCUMENTATION Page 2 of 3

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
be completed by DWR)
All items must be completed or the application will be returned
L APPLICANT INFORMATION:
1. Applicant's name: Town of Dubl n (company, municipality, HOA, utility, etc.)
2. Applicant": ❑ Individual. ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County N Municipal ❑ Other
3. Signature authority's name: Jonathan Ward per 15A NCAC 02'r .0106(b)
Title: Operation Staff
4. Applicant's mailing address: Albert. Street
City: Dublin State: NC Zip:28322-
5. Applicant's contact information:
Phone number: [phone] Email Address: dublintownhallnnetscaue.net
H. PROJECT INFORMATION:
1. Project name: NCDOT Project: W-5706C Roundabout at the Intersection of NC 410 and NC 41
2. Application/Project status: ❑ Proposed (New Permit) N Existing PermiUProject
If a modification, provide the existing permit number: W000_ and issued date:
If new construction but pan of a master plan, provide the existing permit number. W000
3. County where project is located'. Bladen
4. Approximate Coordinates (Decimal Degrees): Latitude: ° Longitude:
5. Parcel fD (if applicable):
(or Parcel ID to closest downstream sewer)
Ill. CONSULTANT INFORMATION:
1. Professional Engineer: Corey Bonsquet License Number. 023041
Firm: Hinde Enajneerine
Mailing address: 401 Harrison Oaks Blvd., Suite 220
City: Cary State: NC Zip: 27513-
Phone number: [phone] Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION-
1. Facility Name: Permit Number: M10CS D004 ta-.
Owner Name: _Tbivt piA
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ Downstream (Receiving) Sewer Size: inch
System Wide Collection System Permit Number(s) (if applicable): WQCS
OwnerName(s): —7wq 0� Z" U,44
FORM: FTA 04-1,6 Page 1 of 5

VL GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No MNIA
2. If the Applicant is a Developer of lots to be sold, has a Derelone0crai ],I A,eoment (FORM: DEV Ibeen attached?
❑ Yes ❑No MNIA
3. If the Applicant is a Horne/Propertyy Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No MN/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))
L----*Is there a Pretreatment Program in effect? ❑ Yes M No
6. Has a flow reduction been approved under ) 5 A NCAC 02T .01 14(t)? ❑ Yes M No
Y If yes,. provide a copy of flow reduction approval letter
7. Summarize wastewater generated by project
Establishment Type (see 02T,0I I4M)
Daily Design Flow 2�b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gat/
GPD
gal/
GPD
gal/
GPD
Total
GPD
a See 15A NCAC 02T ,01 and ('e)(2) for caveats to wastewater design now 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. 42AA=1).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A KCAL: 02T.01 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
&. Wastewater generated by project _ GPD (per 15A NCAC 02T 0114)
9 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:
M 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
l:
1. Summarize gravity sewer to be permitted:
Size (ine Length (feet) Material
4 5 PVC 5DR21
2 241 ng SDR i 1
It�EEi
S `'J ,q
➢ 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 linestomeet minimum slope requirement is not allowed and a violation of the MDC
Vil1. 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: N/A
2. Approximate Coordinates (Decimal Degrees): Latitude: .N/A° Longitude: - .N/A'
3. Design flow of the pump station: N/a millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): N/A gallons per minute at N/A feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches)
Length (feet)
Material
2"
241
PE Tubing, SDR 9
4"
323-
PVC, SDR21
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(t):
❑ Standby power source or pump with automatic activation and telemetry -15A NCAC 02T .0305(h)(1)($)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Most 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 ease of a multiple station power outage.
FORM: F'TA 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 & g
➢ 15A NCAC 02T 0305fn contains minimum separation that shall be provided for sewer systems:
M Yes ❑ No
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
I8 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 11 impounded reservoirs used as a source of drinking water
100 feet
**Waters classified WS (except WS-1 or WS-V), B, SA, ORW,.HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305(e) contains alternatives where separations in 02T.030 M cannot be achieved.
➢ **Stream classifications canbe identified using the Division's NC Surface Water Classifications weboage
➢ If noncompliance with 02"f 0305(t) or (e). see Section X ofthis application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) 0 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
5. Does project comply with 15A NCAC. 02T.0105(c)(6) (additional permits/certifications)? J4 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 underminesor deteriorates the sewer
❑ Yes ® No ❑ N/A
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02I', 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/Altemative Design Request application (VADC 1044) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and suoportinE documents
2. Professional Engineer's Certification:
Engineer's name from Application Item Ill.] .)
that this application for
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design. -
NOTE — in accordance with General Statutes 143-215.6A and 143-215.613, 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.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicants Certification per ISA NCAC 02T .0106(b):
Or, Pt-'.ia`,C, (,JOr�G 1✓Y'iCCQ(-t7i_ attest that this application for
1,
(Signature Authority's name & title from Application Item 1.3.)
has been reviewed by we and is accurate and complete to the best of my knowledge. I understand that if all required parts of
Otis application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civilpenalties,
injunctive relief, and/or criminal. prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if all required parts of this application package are not completed and that if
all required supporting information and attachments are notincluded, 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 makesany false
statement, representation, or certification in any application package sball 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:— ) Date:
FORM: FTA 04-16 Page 5 of 5

APR 2 4 2019
Serial No. 18-00051
Water Main Relocation
WQROS
AYE' '?ot
' 4.7c R�EC"0 iNA L OFF iCE
SUMMARY OF CHANGES TO PLANS
UC-1 CHANGED THE TITLE SHEET TO INDICATE UPDATED
CHANGES TO UC-4 AND UC-6
UC-2 NO CHANGES
UC-3 NO CHANGES
UC-3A NO CHANGES
UC-4 WATER
AFTER RECEIVING UPDATED INFORMATION FROM THE
TOWN OF SOUTHERN PINES (OWNER), CHANGED SIZE AND
LENGTH OF 10" WATERLINE FROM 946 LF TO 454 LF OF 8"
WATER LINE AND CHANGED 10 LF OF 12" WATER LINE TO 504
LF. REMOVED 2 10" TAPPING VALVES AND WILL GO WITH
TEE AND GATE VALVES AT CONNECTION POINTS. CHANGED
THE SUMMARY TO:
2 8" GATE VALVES
2 12" GATE VALVES
435' ABANDON 8" UTILITY LINES
530' REMOVE 12" UTILITY LINES
SEWER
AFTER RECEIVING UPDATED INFORMATION FROM THE
TOWN OF SOUTHERN PINES (OWNER), CHANGED 10" SEWER
LINE TO 8" SEWER LINE. CHANGED 18" ENCASEMENT LINE
TO 16" ENCASEMENT. CHANGED THE FOLLOWING IN THE
SUMMARY FOR SEWER:
516' 8" SEWER LINE
360' ABANDON 8" UTLITY PIPE
250' REMOVE 8" UTILITY PIPE
120' 16" ENCASEMENT PIPE
ADDED NOTE TO ABANDON EXISTING SEWER LINE BY
FILLING WITH FLOWABLE FILL.
UC-5 CHANGED THE LINE SIZES TO MATCH THE CHANGES
OUTLINED IN UC-4 ABOVE.

State of North Carolina
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
REttivrZO
Application Number: (to be complmd by D") D E Ifs H' R
All items must be completed or the application will be returned
MAY Q 2 2019
1. APPLICANT INFORMATION:
1. Applicaut's name: Town of Dubl n (company, municipality, HOA, utility, etc.)r
��-�f-TJl
2. Applicant type: ❑ Fndividrml ©Corporation ❑General Partnership ['�•'['rr4ateljr O.me `d,'�l?, u'611c L7fil(yr"G-f (: L
❑ Federal ❑ State/County ® Municipal ❑ Other
3. Signature authority's name: Jonathan Ward per 15A NCAC 02T .0I06(b}
Title: Operation Staff
4. Applicant's mailing address: Albert Street
City: Dublin State: NC Zip:2&322-
5. Applicant's contact information:
Phone number. 919 $62-4301 Email Address: dubiintownhallAa netscapem
H. PROJECT INFORMATION:
1. Project name: NCDOT Project: W-5706C Roundabout at the Intersection of NC 410 and NC 41
2. Application/Project status: ❑ Proposed (New Permit) 0 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-: Bladen
4. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - °
5. Parcel ID (if applicable):
(or Parcel ID to closest downstream-sewert
PAYTOTHE NCDEQ
ORDER OF
DOLLARS
xe+xx+xxa•,exx:�z++e�+::ex:�«�>az+xswx x+«xztx»x:rx:t����x�:ues e�«x+.x+z+xxe:e:e<x�z •< x< xa xe+
Four Hundred Eighty and 00/100
FORM: FTA 04-16 Page I of 5

Central Files: APS _ SWP _
5/8/2019
Permit Number WQ0040844
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, & Pressure Sewer Extensions
Primary Reviewer
trent.allen
Coastal SWRule
Permitted Flow
Facility
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
NCDOT Project: W-5706C Roundabout at the Intersection of NC 410 and 41 Minor Fayetteville
Location Address County
Bladen
Facility Contact Affiliation
Owner
Owner Name Owner Type
Town of Dublin Government - Municipal
Owner Affiliation
Jonathan Ward
Albert St
Dates/Events Dublin
NC 28332
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
5/8/2019 5/2/2019 5/8/2019 5/8/2019
Regulated Activities Requested /Received Events
Wastewater collection Additional information requested
Additional information received
Outfall
Waterbody Name Streamindex Number Current Class Subbasin