SW6201004_Application_20210125

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater ManagemenJPIan
❑ Other WQ M t Plan:
State of North Carolina
Department of Environment and Natural Resources
tz
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM o
` 1021
This form may be photocopied for use as an original
I. GENERAf INFORMATION �
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Blackhawk Landing
2. Location of Project (street address):
Rockfish Road
City:Raeford County:Hoke Zip:28376
3. Directions to project (from nearest major intersection):
The project is located 2,492 ft. from the intersection of Rockfish Road and Posey Farm Road going west
towards Markus Place Drive.
4. Latitude:34° 59' 30.30" N Longitude:79° 07' 56.28" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New []Modification ❑ Renewal w/ Modificationt
tReneoals with modifications also requires SWAU-102 — Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 22.43 ac of Disturbed Area
0404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VL http:lZportal.ncdenr.org/web/wq,/ws/su/­statesw/rules laws
Form SWU-101 Version 06Aug2012 Page 1 of 6

III. CONTACT INFORMATION
a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization:Hendrix Brothers of Hoke LLC
Signing Official & Title:Rall2h Huff -Managing Partner
b. Contact information for person listed in item 1a above:
Street Address:2919 Breezewood Avenue Suite 100
CityTayetteville
Mailing Address (if applicable):
City:
Phone: (910 ) 302-3608
Email: [e-mail]
State:NC
Zip:28303
State: Zip:
Fax: ( 1
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the Iease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):
City:
Phone: ( )
Email:
State: Zip:
State:
Fax:
Zip:
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/ Organization:
Signing Official &
b. Contact information for person listed in item 3a above:
Mailing
City: —
Phone:
Email:
State:
Fax:
Zip:
4. Local jurisdiction for building permits: Hoke County Planning/Zoning
Point of Contact:Robert Farrell Phone #: (910 ) 875-8407
Form SWU-101 Version 06Aug2012 Page 2 of 6

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify a A
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verifij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book:1333 Page No:1051-1056 W
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per 15A NCAC 21-1.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http: / /www.secretaly.state.nc.us/Corporations/­CSearch.asl2x
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be
provided as an attachment to the completed and notarized deed restriction form. The appropriate deed
restrictions and protective covenants forms can be downloaded from
http:/ /portal.ncdenr.org/web/wg/ws/su/statesw/forms_docs. Download the latest versions for each
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ, and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer:Matt Lowder, PE
Consulting Firm: Triangle Site Design, PLLC
Mailing Address:4004 Barrett Drive, Suite 101
City:Raleigh State:NC Zip:27609
Phone: (919 ) 553-6570 Fax: ( )
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) 0.tQ h (4 +f M , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item 1a) KeocWt 6 rn 9 terry m-o- t-W--Ltcwith (pint or type name of organization listed in
Contact Information, item la)f-leadA& Bety� car ets to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 06Aug2012 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penaltiesj�f up to,25,000 pRer pursuant to NCGS 143-215.6.
Signature:_
I, St l
a Notary Public for
&'-M U-e1'(CL"d , do hereby certify that
Date: I - 5 -.2 c) �
of O A-1) CO -In L410L County of
personally appeared
before me this day of Jai Lt air r -1 , b Z-1 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
F XOTARY
PIPES �
a9�AND C+p;0�
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires ce-13r- 3 - at C) a �-
I, (print or type name of person listed in Contact Information, item 1a) Ralph Huff ,
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will b constructed in conformance with the approved plans, that the required deed restrictions
and protective c ven will be recorded, and that the proposed project complies with the requirements of the
applicable st rmwa u 15.� WCA�PQH . 000 and any other applicable state stormwater requirements.
I, ,Jet4 21
Date: I— S- — «C-),.
a Nota ublic for the State ofaC Ci>'z , County of
t, V'LO-ftACLO c-� , do hereby certify that 0. 44afF
personally appeared
before me this day of J C%'W 0;A a o L 1 , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
'OPO��� NRI�
�1N�
OTARP 1
MY
COMMISSION EXPIRES s
cliG e!'J/Z025 U $
AID 000
'rF1161"If it
SEAL
My commission expires 6 3 -20 e-s-
Form SWU-101 Version 06Aug2012 Page 6 of 6

North Carolina Secretary of State Search Results
Page 1 of 1
• File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online -
Add Entity to My Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print
an Amended a Annual Report form
Limited Liability Company
Legal Name
Hendrix Brothers of Hoke, LLC
Information
Sosld: 1954748
Status: Current -Active O
Date Formed: 2/26/2020
Citizenship: Domestic
Annual Report Due Date: April 15th
Registered Agent: Huff, D. Ralph, III
Addresses
Mailing
2919 Breezewood Ave, Suite 400
Fayetteville, NC 28303
Reg Office
2919 Breezewood Ave, Suite 400
Fayetteville, NC 28303
Company Officials
Principal Office
2919 Breezewood Ave, Suite 400
Fayetteville, NC 28303
Reg Mailing
2919 Breezewood Ave, Suite 400
Fayetteville, NC 28303
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
https://www.sosnc.gov/online_services/search/Business_Registration Results 1/26/2021