WQ0041066_Permit (Issuance)_20190801 (2)

a�STATE"
ROY COOPER
Governor ,� ~
MICHAEL S.REGAN
Secretary
LINDA CULPEPPER
Director NORTH CAROLINA
Environmental Quality
August 1, 2019
Arthur Samet, Manager
A Samet 2390 Park Center Drive, LLC
309 Gallimore Dairy Rd.
Greensboro, NC 27409
Subject: Permit No. WQ0041066
A Samet 2390 Park Center Drive, LLC
Universal Preserv-A-Chem
Wastewater Collection System Extension Permit
Alamance County
Dear Mr. Samet:
In accordance with your application received July 25, 2019, we are forwarding herewith Permit No.
WQ0041066 dated August 1, 2019, to the A Samet 2390 Park Center Drive, 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permit shall be effective from the date of issuance until rescinded and shall be subject to the conditions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 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]

A Samet 2390 Park Center Drive, LLC
Permit No.WQ0041066
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,
DocuSigned by:
145B49E225C94EA...
for Linda Culpepper
Director, Division of Water Resources
by Lon Snider, Regional Supervisor
Water Quality Regional Operations Section
Winston-Salem Regional Office
Division of Water Resources, NCDEQ
cc: L. Allan Hill, P.E.-Triad Design Group, [e-mail]
Chris Rollins,Acting City Manager-City of [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
A Samet 2390 Park Center Drive, LLC
Alamance County
for the construction and operation of a 54—gallon per minute pump station with duplex pumps, on-site
audible and visual high water alarms, telemetry, and a permanent generator with automatic transfer
switch; as well as approximately 988 linear feet of 4-inch force main to serve an industrial business with
30-employees as part of the Universal Preserv-A-Chem project,and the discharge of 9,450 gallons per day
of collected domestic and industrial wastewater into the City of Mebane's existing sewerage system,
pursuant to the application received July 25, 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.
DocuS�igfned<by:
1 AIR49E92fircl FA
for Linda Culpepper
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0041066
Permit Issued: August 1, 2019
Page 3 of 8

SUPPLEMENT TO PERMIT COVER SHEET
A Samet 2390 Park Center Drive, 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 Mebane's Wastewater
Treatment Facility in accordance with Permit Number NC0021474.
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 become voidable unless the agreement between A SAMET 2390 PARK CENTER DRIVE,
LLC and CITY OF MEBANE for the collection and final treatment of wastewater is in full force and
effect. [15A NCAC 02T.0304(g)]
2. No flow in excess of the quantity permitted herein, 9,450 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)]
3. Each pump station shall be clearly and conspicuously posted using a weatherproof sign with a pump
station identifying name/number, 24-Hour Emergency telephone number, and name of the
owner/operator of the sewer system/pump station and instructions to call the number in the event
of alarm activation or other emergency. Simplex pump stations or vacuum sewer pits serving a single-
family residence may have a placard or sticker on the control panel in lieu of a sign. [15A NCAC 02T
.0305(h)(2)]
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
Page 4 of 8

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:
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.
Page 5 of 8

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
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(orthe 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.
Page 6 of 8

c. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting
in non-compliance with this permit (including 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-
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:
Universal Preserv-A-Chem:
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: A SAMET CORP 2390 PARK CENTER DRIVE, LLC
PERMIT#: WQ0041066
PROJECT: UNIVERSAL PRESERV-A-CHEM
ISSUE DATE: AUGUST 1, 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
Universal Preserv-A-Chem 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 a 54—gallon per minute pump station with duplex pumps, on-site
audible and visual high water alarms, telemetry, and a permanent generator with automatic transfer
switch; as well as approximately 988 linear feet of 4-inch force main to serve an industrial business with
30-employees as part of the Universal Preserv-A-Chem project,and the discharge of 9,450 gallons per day
of collected domestic and industrial wastewater into the City of Mebane'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]

NC Department of
Environmental Quality i
Received
JUL 2 5 2019
dae i i
tita Transmittal Letter Winston-Salem j
Regional Office
Date: July 23, 2019
To: NC Department of Environmental Quality
Water Quality Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Phone # [phone]
Project: Universal Preserv-A-Chem Project#: 18-022/D
Mebane, NC
We Transmit: For Your:
(X) herewith () approval
Q under separate cover (X) review and comment
() use
Copies Date Description
2 Fast Track Sewer System Extension Application (FTA 04-16)
1 $480.00 Application Fee
2 USGS Location Map, Vicinity Map
Comments:
The proposed project is to install a private pump station and force main to serve an industrial
building expansion located on Park Center Drive in Mebane, NC. The proposed force main will
tie into an existing public sanitary sewer main located in the northern right-of-way of Park Center
Drive. The total length of private force main to be permitted under this application is approximately
988 linear feet. If you have any questions or require additional information, please call.
Copies: File
Submitted by: L. Allan Hill, P.E.
L. AUa ,v}faV
Chief Civil Engineer
4807-C Koger Boulevard, Greensboro, NC 27407 1 T-336-218-8282 F-336-218-8010 1 www.triad-designgroup.com

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T.0300—FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16&SUPPORTING DOCUMENTATION
Application Number:-WO (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: A Samet 2390 Park Center Drive.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:Arthur Samet per 15A NCAC 02T.0106(b)
Title:Mamuz
NC Department of
4. Applicant's mailing address: 309 Gallimore Dairy Road, Suite 102 Environmental Quality
City: Greensboro State:NC Zip: 27409-_ R2C21Ved
5. Applicant's contact information: t x. JUL 2 5 2019 -;
Phone number: [phone] Email Address: asametna sametcom com 3 i Winston-Salem }
Regional Office
H. PROJECT INFORMATION:
1. Project name:Universal Preserv-A-Chem
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:WQ00_
3. County where project is located:Alamance
4. Approximate Coordinates(Decimal Degrees):Latitude: 36.086°Longitude: -79 302'
5. Parcel ID(if applicable): 172591
(or Parcel ID to closest downstream sewer)
M. CONSULTANT INFORMATION:
1. Professional Engineer: L.Allan Hill,P.E. License Number:NC 15809
Firm:Triad Design Group,PC
Mailing address: 4807 Koger Boulevard, Ste C
City:Greensboro State:NC Zip:27407
Phone number:[phone] Email Address:ahillntriad-designngrouo.com
IV. WASTEWATER TREATMENT FACILITY(WWTF)INFORMATION:
1. Facility Name:Ci1y of Mebane W WTP Permit Number:NC 0021474
Owner Name: City of Mebane
V. RECEIVING DOWNSTREAM SEWER INFORMATION(if different than W WTF):
1. Permit Number(s):WQ_ Downstream(Receiving)Sewer Size: _inch
System Wide Collection System Permit Number(s) (if applicable):WQCS_
Owner Name(s):
FORM: FTA 04-16 Pagel of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately-Owned Public Utility,has a Certificate of Public Convenience and Necessity been attached?
❑Yes ❑No ®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: 8%Domestic/Commercial N/A%Commercial
22%Industrial(See 15A NCAC 02T.0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ®No
6. Has a flow reduction been approved under 15A NCAC 02T.0114(f) ❑ Yes ®No
➢ If yes,provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type(see 02T.0114(f)1 Daily Design Flow',b No.of Units Flow
Manufacturing 25 gal/employee/shift 30 750 GPD
Process Waste 8700 gal/day 1 8700 GPD
gal/ GPD
gal/ GPD
gal/ GPD
gal/ GPD
Total 9450 GPD
a See 15A NCAC 02T .0114(bt(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; I
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S.42A-41.
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: 9.450 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
i
❑ Other(Explain):
FORM: FTA 04-16 Page 2 of 5

VIL 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:Private Pump Station 2
2. Approximate Coordinates(Decimal Degrees): Latitude: 36.086° Longitude:-79.302°
3. Design flow of the pump station: 0.00945 millions gallons per day(firm capacity)
4. Operational point(s)of the pump(s): 54 gallons per minute at 60 feet total dynamic head(TDH)
5. Summarize the force main to be permitted(for this Pump Station):
Size(inches) Length(feet) Material
4 988 HDPE
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.
FORM: FTA 04-16 Page 3 of 5
I

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,)&(a) ®Yes ❑No
➢ 15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
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 Df.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.0305(f)cannot be achieved. j
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webnee
➢ If noncompliance with 02T.0305()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
5. Does project comply with 15A NCAC 02T.0105(c)(6)(additional permits/certifications)? ®Yes [-]No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications are being prepared,have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits(erosion and
sedimentation control plans,stormwater management plans,etc.).
6. Does this project include any sewer collection lines that are deemed"high-priority?"
Per 15A NCAC 02T.0402, "high-priority sewer"means "any aerial sewer,sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑Yes ®No ❑N/A
➢ If yes,include an attachment with details for each line,including type(aerial line,size,material,and location).
High priority lines shall be inspected by the permittee or its representative at least once every six-months and inspections
documented per 15A NCAC 02T.0403(a)(5)or the permitee's individual System-Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with I SA NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains(latest version),and the Gravi1y Sewer Minimum Design Criteria(latest versionl as applicable?
® Yes ❑No
If No,complete and submit the Variance/Altemative 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 supportive documents
2. Professional Engineer's Certification:
I, L. Allan Hill, PE 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 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:
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3. Applicant's Certification per 15A NCAC 02T.0106(b): 7193
I, Arthur Samet Manager attest that this application for
(Signature Authority's name&title from Application Item I.3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non-
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief,and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if all required parts of this application package are not completed and that if
all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed$10,000 as well as civil enalties up to$25,000 per violation. 1{✓/� t
Signatur . Date:
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
Department of Environmental Quality
Division of Water Resources
,K t Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Ijequesting Allocation: A Samet 2390 Park Center Drive, LLC
Project Name for which flow is being requested: Universal Preserv-A-Chem (PRIVATE)
More than one FTSE may be required for a single project ifthe owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: City of Mebane
b. WWTP Facility Permit M NCO021474
All flows are in MGD
c. WWTP facility's permitted flow 2.5
d. Estimated obligated flow not yet tributary to the WWTP .620
e. WWTP facility's actual avg. flow 1.45
f. Total flow for this specific request 0.00945 MGD
g. Total actual and obligated flows to the facility 2.07
h. Percent of permitted flow used 83%
II. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (D)=(B+C) (E)=(A-D)
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station Firm Flow** Current Avg. Tributary Flow Plus
(Name or Capacity, * (Firm/po, Daily Flow, Daily Flow, Obligated Available
Number) MGD MGD MOD MGD Flow Capacity***
Fieldstone 1.58 .633 .372 .142 .514 0.119
*The Firm Capacity of any pump station is defined as the maximum pumped flow that
can be achieved with the largest pump taken out of service.
**Design Average Daily Flow is the firm capacity of the pump station divided by a peaking
factor(pf) not less than 2.5.
***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.
Downstream Facility Name(Sewer): City of Mebane-NCIC Phase 3
Downstream Permit Number:
Page 1 of 6
FTSE 04-16

III. Certification Statement:
I Chris Rollins,Acting City Manager 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 facility and that the flow from this project is not anticipated to
cause any capacity related sanitary 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 with local established policies and procedures using the best
available data. This certification applies to those items listed above in Sections I and II plus all
attached planning assessment addendums for which I am the responsible party. Signature of this
form indicates acceptance of this wastewater flow.
RgA � .
Signing Official Signature Date
Page 2 of 6
FTSE 04-16

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elcome to the Alamance County GIS Site.THIS IS NOT A LEGAL DOCUMENT.Alamance County shall assume no liability for any errors,omissions,or Inaccuracies in the inl
made or actions taken or not taken by user in reliance upon any information or data furnished hereunder.The user knowingly waives any and all claims for damages s
OUNTY GIS SYSTEM that may arise from the mapping data.The well&septic layer is a representation of well and septic data collected or plotted by the Alamance Cou
qulpment and training.GPS data collection began in 2013,it is not a complete representation of all parcels within the county that have wells and septic systems.This d
'IMPORTANT NOTE:This web map is intended to provide general information as to the individual school attendance zones.The completeness or accuracy of the mapping
uarantee of student placement at any school.Addresses that are on or near an attendance line should be confirmed by the Alamance-Burlington School District Trans orts

Henderson, Justin L
From: Allan Hill <[e-mail]>
Sent: Thursday, August 1, 2019 8:22 AM
To: Henderson,Justin L
Subject: [External] RE: Universal Preserv-A-Chem FTA
Good morning Justin. Hope you are doing well. The owner of the building and property located at 2390 Park Center
Drive (A Samet 2390 Park Center Drive, LLC)will retain ownership of the sewer extension. The system will remain
private and under single ownership. Do you need a letter from the owner stating this or will my email response be
sufficient? Thanks!
Best regards,
L. Allan Hill, P.E.
Principal
triaddesigngroup
4807-C Koger Boulevard
Greensboro,NC 27407
T-336-218-8282
F-336-218-8010
w triad-desianarouo.com
From: Henderson,Justin L[mailto:[e-mail]]
Sent: Thursday,August 01, 2019 8:03 AM
To:Allan Hill <[e-mail]>
Subject: Universal Preserv-A-Chem FTA
Allan,
Please confirm that the applicant intends to retain ownership of the sewer extension proposed by the subject project.
Thanks.
Justin Henderson
Environmental Specialist II
Winston Salem Regional Office
Division of Water Resources
[phone]
lusti n.henderson @ ncdenr.gov
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