WQ0041203_Application (FTSE)_20190925

DWR
Dlvlslon 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:
(to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
1. Applicant's name: New Covenant Partners IX 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: James Michael Brammer per 15A NCAC 02T .0106(b)
NC Debar ment of
Title: Manager Environmenral Quality
Received
4. Applicant's mailing address: 3135 Indiana Avenue
SEP City: Winston-Salem State: NC Zip: 27105-_ ? 2919
5. Applicant's contact information: Winston-Salem
Phone number: 336 725-7799 Email Address:mbrammer(a)specialeventservicescom Regional Office
H. PROJECT INFORMATION:
1. Project name: Special Event Services
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: W000_ and issued date:
If new construction but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Davie County
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.912816' Longitude:-80.586983°
5. Parcel ID (if applicable): 5729506809
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Brian Crafford, P.E. License Number: 044053
Firm: Stinunei Associates P.A.
Mailing address: 601 N. Trade St.
City: Winston-Salem State: NC Zip: 27101-_
Phone number: 336 723-1067 Email Address: bcmffordAstimtnelpa.com
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
1. Facility Name: Cooleemee W WTP Permit Number: NC 0024872
Owner Name: Davie County
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than W WTF):
1. Permit Number(s): WQ_ Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System Permit Number(s) (if applicable) WQCSCS00156
Owner Name(s): Town of Mocksville
FORM: FTA 04-16 Page I 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 NN/A
3. If the Applicant is a Home/Property Owners' Association has an Operational Agreement (FORM: HOA) been attached?
❑ Yes ❑No NN/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
N Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic/Commercial _%Commercial
_ % Industrial (See 15A NCAC 02T .0103(20))
"Is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(t) ❑ Yes N No
➢ If Yes provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(fl)
Daily Design Flow "bM602,100
Factory or Business w/ Showers
35 gal/employee/shiftWarehouse
100 gal/loading bayFuture
Expansion - Business w/ Showers
35 gal/employee/shiftFuture
Building - Business w/ Shower
35 gal/employee/shift
Future Warehouse
100 gal/loading bay
2
200 GPD
gal/
GPD
Total
4,450 GPD
a See 15A NCAC 02T .01 Nib), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east ofthe 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 I5A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 4 450 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
❑ 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
6 220 PVC
➢ 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
VIIL PUMP STATION DESIGN CRITERIA (If Applicable) —02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: - °
3. Design flow of the pump station: _ millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): _ gallons per minute at _ feet total dynamic head (TDI-1)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T .0305(In)(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 timeftames, 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) ® Yes ❑ No
e , e A %Tr A r Al r ne135 ..on!.:,,E ",i"i"n,w, S,. n,ntinnc that dull he nrnvided 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
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 swimmin pools
10 feet
Final earth pyade vertical
36 inches
➢ 15A NCAC 02T.0305(g) contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
➢ If noncompliance with 02T.0305(fl 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 2B.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 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Piano Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the request is required prior to submittal of the Fast Track Application and supporting documents
2. Professional Engineer's Certification:
Pig
name from Application Item III.1.)
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: (,
- T'q SEAL
0440r
�p 4N W. CRP�.����\
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I,Jrnmnr, Pgichnel 11rammer, Mannaor 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 penalties up to $25,000 per violation.
Signature: 1, MJ Date:
FORM: FTA 04-16 Page 5 of 5

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of water Resom(es Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: New Covenant Partners IX, LLC
Project Name for which flow is being requested: Special Event Services
More than one FTSE nvay be required for a single praject if the owner of the IVIVT is not respon1sible for pomp
stations along the route of the proposed ivasteivater flow. ���
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. W WTP Facility Name: _
b. W WTP Facility Permit #:
, Ail flows are in MGD
c. W WTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the W WTP
e. W WTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
It. Percent of permitted flow used
11. 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 W WTP:
(A)
Design
Pump
Average Daily
Station
Firm Flow**
(Name or
Capacity, "` (Firm / p0,
Number)
MGD MGD
Bear
1.656 0.552
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Approx.
Not Yet
Total Current
Current Avg.
Tributary
Flow Plus
Daily Flow,
Daily Flow,
Obligated
Available
MGD
MGD
Flow
Capacity***
0.221
.001
0.222
.330
* 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): Cooleemee W WTP (Davie County)
Downstream Permit Number: NC0024872
Page l of 6
FTSE 04-16

III. Certification Statement:
I Matt Settlemyer 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 addeidunis for which I am the responsible party. Signature of this
fonn indicates acceptance of this wastewater flow.
Signing Official Signature
►Z-
Date
Page 2 of 6
PTSE 04-16

State of North Carolina
/ ( Department of Environmental Quality
Division of Water Resources
Division of Water Resources Flow Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
Entity Requesting Allocation: New Covenant Partners IX, LLC/
Project Name for which flow is being requested: Specil Event Center
More than one FTSE may be required for a single project ifthe owner ofthe 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: Cooleemee Waste Water Treatment Plant
b. WWTP Facility Permit #: NC0024872
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
1.5MGD
154
.420
.004
.568
36%
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)
Design
Pump
Average Daily
Station
Firm
Flow**
(Name or
Capacity, *
(Firm / pf),
Number)
MGD
MGD
Cooleemee
n.. e
3.0
1.5
(B)
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Approx.
Not Yet
Total Current
Current Avg.
Tributary
Flow Plus
Daily Flow,
Daily Flow,
Obligated
Available
MGD
MGD
Flow
Capacity***
.420
.154
.568
.932
* 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): Cooleemee WWTP
Downstream Permit Number: NCO024872
Page 1 of 6
FTSE 04-16

l'
III. Certification Statement:
I Johnny Lambert 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.
Signature
Date
Page 2 of 6
FTSE a4-16

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SOSID: 1763271
Date Filed: 10/22/2018 7:47:00 AM
State of North Carolina Elaine F. Marshall
Department of the Secretary ofState North Carolina Secretary of State
C2018 292 01057
Limited Liability Company
ARTICLES OF ORGANIZATION
Pursuant to §57D-2-20 of the General Statutes of North Carolina, the undersigned does hereby submit these Articles
of Organization for the purpose of forming a limited liability company.
1. The name of the limited liability company is: New Covenant Partners IX, LLC
(See Item lot the Instructions for appropriate entity designation)
2. The name and address of each person executing these articles of organization is as follows: (State whether each
person is executing these articles of organization in the capacity of a member, organizer or both by checking
all applicable boxes.) Note: This document must be signed by all persons listed.
Name Business Address Capacity
Benjamin C. Williams 1076 W. Fourth Street, Winston-Salem, NC 27101 ❑Member *Organizer
91
The name of the initial registered agent is: James M. Brammer
❑Member ❑Organizer
❑Member ❑Organizer
4. The street address and county of the initial registered agent office of the limited liability company is:
Number and street 3135 Indiana Avenue
City Winston-Salem
State: NC Zip Cede: 27105 County: Forsyth
5. The mailing address, if different from the street address, of the initial registered agent office is:
Number and Street
City State: NC Zip Code:
6. Principal office information: (Select either a or b.)
a The limited liability company has a principal office.
The principal office telephone number:
County:
The street address and county of the principal office of the limited liability company is:
Number and Street: 3135 Indiana Avenue
City: Winston-Salem
State: NC Zip Cede: 27105 County: Forsyth
BUSINESS REGISTRATION DIVISION P.O. BOX 29622 Raleigh, NC 27626-0622
(Revised August, 2017) Farm L-01

/l
The mailing address, if different from the street address, of the principal office of the company is:
Number and Street:
City:
State: Zip Code: County:
b. F The limited liability company does not have a principal office.
Any other provisions which the limited liability company elects to include (e.g., the purpose of the entity) are
attached.
(Optional): Lisfing of Company Officials (See instructions on the importance of listing the company officials in the
creation document.
Name
Title
Business Address
James M. Brammer
Manager
3135 Indiana Avenue, Winston-Salem, NC 27105
Michael Brammer
Manager
3135 Indiana Avenue, Winston-Salem, NC27105
9. (Optional): Please provide a business a-m Privacy Redaction
The Secretary of State's Office will e-mail the - en a
document is filed. The e-mail provided will not be viewable on the website. For more information on why this service is
offered, please see the instructions for this document.
10. These articles will be effective upon filing, unless a future date is specified:
This is the 19th day of October 12048
Benjamin C. Williams, Organizer
Type or Print Name and Title
The below Space to be used if more than one organizer or member is listed in Item #2 above.
Type and Print Name and Title
Signature
Type and Print Name and Title
NOTE:
1. Filing fee is $125. This document must be filed with the Secretary of State.
BUSINESS REGISTRATION DIVISION P.O. BOX 29622
(Revised August. 2017)
Raleigh, NC 27626-0622
Form L-01

aLIMITED LIABILITY COMPANY ANNUAL REPORT
1012017
NAME OF LIMITED LIABILITY COMPANY: New Covenant Partners IX, LLC
SECRETARY OF STATE ID NUMBER: 1763271 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2019
SECTION A: REGISTERED AGENT'S INFORMATION
E - Filed Annual Report
1763271
CA201906702865
3/8/2019 04:21
Changes
1. NAME OF REGISTERED AGENT: Brammer, James M.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED OFFICE STREET ADDRESS & COUNTY 4. REGISTERED OFFICE MAILING ADDRESS
3135 Indiana Avenue 3135 Indiana Avenue
Winston Salem, NC 27105 Forsyth County Winston Salem, NC 27105
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Property Rental
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] x242 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS & COUNTY
3135 Indiana Avenue
Winston Salem, NC 27105
5. PRINCIPAL OFFICE MAILING ADDRESS
3135 Indiana Avenue
Winston Salem, NC 27105
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME:
James M. Brammer
NAME:
Michael Brammer
TITLE:
Manager
TITLE:
Manager
ADDRESS:
3135 Indiana
Winston Salem, NC 27105-4343
ADDRESS:
3135 Indiana Avenue
Winston Salem, NC 27105
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
James M. Brammer
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
3/8/2019
James M. Brammer Manager
Print or Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

NCDEQ 9/13/2019
Private Sewer Application Fee for NCP IX Angel Kno
1
FAO
C
tp�v�-O
1015
i
480.00
First Bank Private Sewer - NCP IX Angel Knoll Rd Mocksvil 480.00