SW3130701_CURRENT PERMIT_20130708

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW �(%7e
DOC TYPE
� CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
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YYYYMMDD

AkN� 0 "V
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Thomas A. Reeder
Governor Acting Director
July 3, 2013
Ray Lackey
Ray Lackey Enterprises
1523 East Board Street
Stateville, North Carolina 28687
Subject: Stormwater Permit No. SW3130701
Village Inn Pizza
Dear Mr. Lackey:
<. �, `"s?
John Skvarla
Secretary
DIVIS,O�A tv_o
�Q' QUALITY
JUL 0 8 2013
MOORFSVltL L:. 1
4 r, ONAL OFFICE
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application
for the subject project on June 28, 2013. Staff review of the plans and specifications has determined
that the project, as proposed, will comply with the Stormwater Regulations set forth in Title 15A
NCAC 2H.1000 and Session Law 2006-246. We are forwarding Permit No. SW3130701, dated July 1,
2013, for the construction, operation and maintenance of the subject project and the stormwater
BMPs.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing by filing a written petition with the Office of Administrative
Hearings (OAH). The written petition must conform to Chapter 150E of the North Carolina General
Statutes. Per NCGS 143-215(e) the petition must be filed with the OAH within thirty (30) days of
receipt of this permit. You should contact the OAH with all questions regarding the filing fee (if a
filing fee is required) and/or the details of the filing process at 6714 Mail Service Center, Raleigh,
NC 27699-6714, or via telephone at 919-431-3000, or visit their website at www.NCOAH.com.
Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Mooresville Regional Office. if you have any questions, or
need additional information concerning this matter, please contact Mike Randall at (919) 807-
6374; or mike.randall@ncdenr:gov.
Sincerely,
for Thomas A Reeder
cc: Mooresville Regional Office, SW3130701 Pile
ec: J. Stephen Janowski, P.E.
Wetlands and Stormwaler Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. SaVisbury St. Raleigh, North Carolina 27604
Phone: [phone] FW 919-807-64941 Customer Service: 1-877-623-6746
Internet: www.ncwalerquality.org
An Equal Opportunity )Affirmalive Action Employer
None
rthCarolina
Natural
lb(

State Stormwater Permit
Permit No. SW3130701
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT 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
Ray Lackey Enterprises
Village Inn Pizza
Statesville North Carolina
Iredell County
FOR THE
construction, operation and maintenance of one dry extended detention basin in
compliance with the provisions of Session Law 2006-246 and 15A NCAC 2H .1000
(hereafter referred to as the "stormwaterrules'j and the approved stormwater
management plans and specifications and other supporting data as attached and on file
with and approved by the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until June 30, 3021, and shall
be subject to the following specified conditions and limitations:
1. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. The dry extended detention basin is approved for the management of
stormwater runoff as described in the application documents and as shown on
the approved plans.
3. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
4. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
5. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
Page 1. of 4

State Stormwater Nermii
Permit No. SW3130701
11. SCHEDULE OF COMPLIANCE
1. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
2. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted dry extended detention basin functions at optimum
efficiency. The approved Operation and Maintenance Plan must be followed in
its entirety and maintenance must occur at the scheduled intervals including, but
not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
3. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
4. The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance and inspection records for the dry extended detention
basin. The report shall summarize the inspection dates, results of the
inspections, and the maintenance work performed at each inspection.
5. The dry extended detention basin shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
supporting data.
6. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the dry extended detention basin certifying that
the permitted facility has been installed in accordance with this permit, the
approved plans and specifications, and other supporting documentation. Any
deviations from the approved plans and specifications must be noted on the
Certification. A modification may be required for those deviations.
7. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
8. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval was sought.
Page 2 of 4

State Stormwater t-emm
Permit No. SW3130701
Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
9. A copy of the approved plans and specifications shall be maintained on file' by
the Permittee for a minimum of eight years from the date of the completion of
construction.
10. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
Ill. GENERAL CONDITIONS .
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, -to the
Division of Water Quality, accompanied by the supporting documentation. The
approval of this request will be considered on its merits and may or may not be
approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (focal, state, and federal) having jurisdiction.
5. In the event that the 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 stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the ,permit.
Page 3of4

State Stormwater Permit
Permit No. SW3130701
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of .any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 3rd day of July, 2013.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
jor i nomas H. Keeaer, Hcung uirector
Division of Water Resources
By Authority of the Environmental Management Commission
Page 4 of 4

State Stormwater Herma
Permit No. SW3130701
Village Inn Pizza
Iredell County
Designer's Certification
I 1 as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
Village Inn Pizza, Statesville North Carolina
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved -plans and specifications.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
cc: NCDENR- Regional Office
SEAL
Page 1 of 1

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
S _
l
Applicable Rules: ❑ Coastal SW - 1.995 ❑ Coastal SW - 2008 ❑ Ph rl - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina pf-c l'ir-D
[)Jvl">!- 4 , . -
Department of Environment and Natural Resources ' :R QUALITY
Division of Water Quality JUL0 8 2013
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
T1ris orm runt be hotoco ncd or rise as an original
f l F fct ,i OFFICE
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Village Inn Pizza
2. Location of Project (street address):
Cinema Drive, Statesville NC
City:Statesviile County:Iredell Zip:28687
3. Directions to project (from nearest major intersection):
At the intersection of Cinema Drive and Folger Drive
4. Latitude:3Y 46' S8" N Longitude:-800 52' 47' W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): ®New ❑Modification
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 ®Sedimentation/Erosion Control: 1.3 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.Lf any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:
Form SWU-N] Version 07Jun2010 Page 1 of

Ill. CONTACT INFORMATION
1. 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:Ray Lackey Enterprises
Signing Official & Title:Ray Lackey _
b.Contact information for person listed in item 1a above:
Street Address:1523 East Borad Street
City:Statesville State:NC Zip:28687
Mailing Address (if applicable):
City: State: Zip:
Phone: ( } Fax:
Email:[e-mail]
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 lease 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:Ray Lackey Enterprises
Signing Official & Title:Elizableth Lackey Miller, President
b.Contact information for person listed in item 2a above:
Street Address:1523 East Broad Street
City:Statesville State:NC Zip:28687
Mailing Address (if applicable):
City:
Phone: (704 _ 73-2261
Email:[e-mail]
State:
Fax: (704 ) 873-2262
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/ Orga niza tion: 1. Stephen lanowski, PE
Signing Official & Title:l. S. Janowski Engineering, PA
b.Contact information for person listed in item 3a above:
Mailing Address:PO Box 30906
City:Greenville State:NC Zip:27833-0906
Phone: (252 ) 714-3002 _ Fax: ( , )
Email:[e-mail]
4. Local jurisdiction for building permits: City of Statesville
Point of Contact: Phone #: (
Form SWU-101 Version 07Jun2010 Page 2 of 6

IV, PROJECT INFORMATION
1. hi the space provided below, briefly summarize how the stormwater runoff will be treated.
The storm water will be collected and transported via closed storm drainage-ILiping system
The storm water will be treated in a dry detention pond.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 N Ph I1 -- Post Construction
3. Stormwater runoff from this project drains to the Yadkin River basbi.
4. Total Property Area: 2.17 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area':2.17 acres
Total project area shall be calculated to exclude lire follourin the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) lire or Mean Higir Water
(MHW) line, and coastal wetlands Iaxdzvard front the NHW (or MHM line. The resultant project area is used to
calculate overall percent built upon area (13t1A). Nori-coastal wetlands landward of the NHYV (or MHW) Iitie pray
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 77.93 %
9. How many drainage areas does the project have?1 (For high density, count 7 for each proposed engineered
stormwater BMP. For low density and other projects, use 7 for the whole property area)
'10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area
Receiving Stream Name
Fourth Creek
Stream Class *
Stream Index Number
Total Drainage Area (so
94,525 1
325,829
{
On -site Drainage Area (so
94,525
0
Off -site Drainage Area (so
0
325,829
Pro osed Im ervious Area** (so
73,660
271,379
% Impervious Area** total
77.93
183.29
Impervious- Surface Area
Drainage Area
Drainage Area
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
5,297
On -site Streets (sf)
0
On -site Parking (so
24,854
On -site Sidewalks (so
0
Other on -site (sf)
0
Future (so
43,509
Off -site (so
0
271,379
Existing BUA*** (sf)
0
Total (so)
73,660
271,379
Stream Class and Index Number can be determined at: htt �: �porhal.iu'denr.rr � i� h iriF 35 c'su/classiiicalim.,
#* Impervious area is defined as the built upon area including, but not liniited to, buildings, roads, parking areas,
sidc7oalks, gravel areas, etc.
Form SWU-101 Version 07Jun2010 Page 3 of 6

'Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by lIe70 13UA.
11. How was the off -site impervious area listed above determined? Provide documentation. Survey and
Computer calcualtions
Projects in Union County: Contact D;,VQ Central Office staff to check if the project is located within a Threatened c%
Endangered Species watershed that may be subject to more stringent stormwater requirements as per NC�IC 02B .0600.
V. SUPPLEMENT AND O&M FORMS .
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project, The latest versions of the forms can be downloaded
from httD://r)ortal.ncdenr.oriz/web/wo/ws/su/bmo-manual.
Vl. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://portal.ncdenr.orZ/web/wq/wsZsu/statesw/forLs_docs. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at hUR://portal,ncdenr.orjZ/webZw2/ws/su/mal2s.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs.
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part V11 below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M /►�
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
htt www.envhe! p.or a gesZ ones to ex ress.htn-1 for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor 0,0,W1
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name,
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
Form SWU-101 Version 071un2010 Page 4 of

n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
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"x11" 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 veriftj the SHW]" prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 2211 Page No: 41
11. For corporations and linuted 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 NCAC 2H.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.
htti2://www-secretary.state.nc.us/Corporatiotis/CSearch,aspx
VIL 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/wq/ws/su/statesw/forms flocs. Download the latest versions for each submittal.
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 inform' ation).
Consulting Engineer:. Stephen lanowski, PE
Consulting Firm:_ Janowski Engineering, PA
Mailing Address:PO Box 30906
City:Greenvdle State:NC Zip:27833-0906
Phone; 252 714-3002 Fax:
Emad:jstephenjanowski®jsjen ineering.com _
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled ont, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) Et 2Ahdh J q f LL u IYIi11r-✓ , certify that I
own the property identified in this permit application, and thus give permission to (pr�type natne of person
listed in Contact Information, item 1a) P qu L&(�GCi� et3JCYprJ 5PS with (print or hype name of organization listed in
Contact htformation, itent 1a) , sGCto develop the project as currently proposed. A copy of
the lease agreement or pending p operty 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 07Jun2010 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 oivil penalties of upt o $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
Date: 49 - Ll'_
I, _l, -Andes L. Roararlr a Notary Public for the State of �Or. nrr�li nr� . County of
do hereby certify that 1 + _ G __.Lac kit W, ��Va personally appeared
before me this LL day of ,e— j ,and acknowledge the due exe ution of the application for
a stormwater permit. Witness my hand and official seal
�mi'7da L& rnarcl
SEAL
My commission expires q - ?- i - 20 l l.e_
X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed fir Contact Information, item Ia) Elizabeth Lackey Miller
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2H .1000, SL 2006-246 (Ph. I1 - Post Construction) or SL 2008-211.
Signature: Date:
1, a Notary Public for the State of . County of
do hereby certify that
before me this _ day of
personally appeared
and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Form SWU-101 Version 07Jun2010 Page 6 of

Permit Number;
(to be pros iderd by DIVQ)
Drainage Area Number:
Dry Extended Detention Basin
Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient 13MP elements noted in the inspection will be
corrected, repaired or replaced immediately. "I'liese deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the 13MP.
'I'he dry extended detention basin system is defined as the dry detention basin, outlet
structure, pretreatment including forebays and die vegetated filter if one is provided.
This system (check one):
❑ does ® does not incorporate a vegetated filter at the outlet.
This system (check otie):
❑ does ® does not incorporate pretreatment other than a forebay.
Important maintenance procedures:
— The drainage area will be managed to reduce the sediment load to the dry
extended detention basin.
— Immediately after the dry extended detention basin is established, the vegetation
will be watered twice weekly if needed until the plants become established
(commonly six weeks).
— No portion of the dry extended detention pond will be fertilized after the first
initial fertilization that is required to establish the vegetation.
— I will maintain the vegetation in and around the basin at a height of
approximately six inches.
— Once a year, a dam safety expert will inspect the embankment.
After the dry extended detention basin is established, it will be inspected once a quarter
and within 24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in
a Coastal County). Records of operation and maintenance will be kept in a known set
location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash debris.
The perimeter of the dry
Areas of bare soil and/or
Regrade the soil if necessary to
extended detention
erosive gullies have formed.
remove the gully, and then plant a
basin
ground cover and water until it is
established. Provide time and a
one-time fertilizer application.
Form SW401-Dry Detention O&M-Rev.3

BMP element:
Potentialproblem:
How I will remediate theproblem:
The inlet device: pipe or
The pipe is clogged (if
Unclog the pipe. Dispose of the
Swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the Swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated
Search for the source of the
and reduced the depth to 75%
sediment and remedy the problem if
of the original design depth
possible. Remove the sediment and
(see diagram below).
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred or
Provide additional erosion
riprap is displaced,
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticides are used, wipe
them on the plants rather than
spraying.
The main treatment area
Sediment has accumulated
Search for the source of the
and reduced the depth to 75%
sediment and remedy the problem if
of the original design depth
possible. Remove the sediment and
(see diagram below).
dispose of it in a location where it
will not cause impacts to streams or
the BMP. Revegetate disturbed
areas immediately with soil
(preferred) or seed protected with
securely staked erosion mat.
Water is standing more than
Check outlet structure for clogging.
5 days after a storm event.
If it is a design issue, consult an
appropriate rofessional.
Weeds and noxious plants are
Remove the plants by hand or by
growing in the main
wiping them with pesticide (do not
treatment area.
spray).
Form 5W401-Dry Detention O&M-Rev.3 Page 2 of 4

BMP element:
Potentialproblem:
How I will remediate theproblem:
The embankment
Shrubs or trees have started
Remove shrubs or trees
to grow on the embankment.
immediately.
Grass cover is unhealthy or
Restore the health of the grass cover
eroding.
— consult a professional if necessary.
Signs of seepage on the
Consult a professional.
downstream face.
Evidence of muskrat or
Use traps to remove muskrats and
beaver activity is present,
consult a professional to remove
beavers.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair.
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose
of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
ou tlet.
733-178E.
The measuring device used to determine the sediment elevation shall be such that it will
give an accurate depth reading and not readily penetrate into accumulated sediments.
When the basin depth reads 115 feet in the main pond, the sediment shall be removed.
When the basin depth reads .5 feet in the forebay, the sediment shall be removed.
BASIN DIAGRAM
(Jill it) file blanks)
Sediment Removal E 74 Te porar
----�25%
olume
Bottom Elevatim 73
Sediment
Storage
FOREBAY
Temporary Pool Elevation 74.52
Pool . Y
'em orar ool
P
Sediment Removal Elevation 73 - ---- Volume
---------------------------- ---
Bottom Elevation
MAIN POND
Form SW401-Dry Detention O&M-Rev.3 Page 3 of 4
25%o ediment
Storage

Permit Number:
(to he provided by DYNQ)
I acknowledge and agree by my signature below that I am responsible for the
perfonnance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project nameNilla ge Inn Pizza Statesville
BHP drainage are(! number:
Print name: Elizabeth Lackc - Miller
TitleTresident
Address:1523 East Broad Street
Phone:[phone]
Signature:
Date:
Note: The legally responsible party should not be a homeowners association unless more than 50%, of
the lots have been sold and a resident of the subdivision has been named the president.
I, , a Notary Public for the State of
, County of' , do hereby certify that
personally appeared before me this
clay of' , , and acknowledge the due execution of the
forgoing dry detention basin maintenance requirements. Witness my hand and official
seal,
SEAL
My commission expires
Form SW401-Dry Detention O&M-Rev.3 Page 4 of 4

E C
NC®ENR
...:..:::...... :.t�iorti���uroli a.�epUri�e�t--of-E�-ironment and Nature! Resources--
I� .......
Pat McCrory
Governor
May 22, 2014
Mr, Ray Lackey
Ray Lackey Enterprises
1523 East Broad Street
Statesville, NC 28687
John E. Skvarla, III
Secretary
Subject: Compliance Evaluation Inspection
Stormwater Permit No. SW3130701
Village Inn Pizza
Iredell County, NC
Dear Mr. Lackey:
Enclosed is a copy of the Compliance Evaluation Inspection (CEI) report for the
inspection conducted on May 21, 2014 by Mr. Samar Bou-Ghazale of this Office.
The report should be self-explanatory; however, should you have any questions
concerning the report, please do not hesitate to contact Mr. Bou-Ghazale at (704) 663-
1699 Ext.2199.
Sincerely,
Zahid S. Khan, CPM, CPESC, CPSWQ
Regional Engineer
-- ----- --- - ---Land_Quality Section-_----------._ --- - - — - -
Attachment
Division of Energy, Mineral, and Land Resources
Land Quality Section - Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Telephone: [phone] FAX: [phone] • Internet: http:llportal.nodenr.org/webtlr/land-quality
An Equal Opportunity / Alf rmative Action Employer — 50% Recycled / 10% Post Consumer Paper
1 01

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Compliance Inspection Report
„_Permit: SW313i�701;--.,,Fffecti4e:.Q7J01/13;,,. , Expiration:. 08/29/21 Owner::, Ray Lackey. Enterpriras.,,;
Project: Village Inn Pizza
County: Iredell Cinema Or
Region: Mooresville
Contact Person: Ray Lackey Title:
Directions to Project:
At the intersection of cinema dr and folger dr.
Type of Project: State Stormwater - General Permit
Drain Areas:
On -Site Representative(s):
Related Permits:
Inspection Date: 05121/2014 Entry Time: 01:30 PM
Primary Inspector: Samar E Bou Ghazale
Secondary Inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ■ Compliant ❑ Not Compliant
Question Areas:
0 State Stormwater
(See attachment summary)
Statesville NC 28687
Phone: [phone]
Exit Time: 02:10 PM
Phone: [phone]
Ext.2199
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW3130701 Owner - Project: Ray Lackey Enterprises
Inspection Dato: C5121!^_0' ! lnspeclion Type: Compliance Evaluation Reason.for Visit: �^r tine
Inspection Summary:
Talked to Stephen Janowsk, The designer Engineer for the site and requested a signed copy of the operation and
maintenance agreement. He informed me that he will be inspecting the site next week and will also provide an
Engineering Certification for the site. The site was built according the permit and no problems were noted during the
inspection. The building is still under construction, However, the BMP has been recently constructed and it is built
according to plan.
File Review
Is the permit active?
Signed copy of the Engineer's certification is in the file?
Signed copy of the Operation & Maintenance Agreement is in the file?
Copy of the recorded deed restrictions is in the file?
Comment: No Engineer's Certification as of this date. There is no signed copy in the
file for the operation and maintenance agreement. Also, no recorded deed restrictions
in the file.
Built Upon Area
Is the site BUA constructed as per the permit and approval plans?
Is the drainage area as per the permit and approved plans?
Is the BUA (as permitted) graded such that the runoff drains to the system?
Comment:
SW Measures
Are the 5W measures constructed as per the approved plans?
Are the inlets located per the approved plans?
Are the outlet structures located per the approved plans?
Comment:
Yes No NA NE
® p p ❑
®00D
®D00
Yes No NA NE
■ppp
■ppp
■pnn
Page: 2

7Ir
WF
AA .
NC®ENR
i,v ri'r� Car linc—1 bepartt'nent f:�t Iriv;ror; merit a-nd Nat Ora I esburces~= -
Pat McCrory
Governor
Mr. Ray Lackey
Ray Lackey Enterprises
1523 East Broad Street
Statesville, NC 28687
Dear Mr. Lackey. -
John E. Skvarla, III
Secretary
May 22, 2014
Subject- Compliance Evaluation Inspection
Stormwater Permit No. SW3130701
Village Inn Pizza
Iredell County, NC
Enclosed is a copy of the Compliance Evaluation Inspection (CEI) report for the
inspection conducted on May 21, 2014 by Mr.Samar Bou-Ghazale of this Office.
The report should be self-explanatory; however, should you have any questions
concerning the report, please do not hesitate to contact Mr. 'Bou-Ghazale at (704) 663-
1699 Ext.2199.
Sincerely,
�Z
Zahid S. Khan, CPM, CPESC, CPSWQ
Regional Engineer
----._...--- ----- ._... - -Land. Quality Section__ -----
Attachment
Division of Energy, Mineral, and Land Resources
Land Quality Section - Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Telephone: [phone] FAX: [phone] • Internet: http://portal.ncdenr.orglweb/Ir/land-quality
An Equal Opportunity 1 Affirmative Action Employer— 50% Recycled 110% Post Consumer Paper

`�
.. . .�. .. r, � .... � :art r ��:'�...... �'_'iy-�ii �n ��. 1:. .« .. �N...r�,�... !t ��. L}� ... .. .=Jt�1y. �.� i�V ��,._.. .i4 �.. ._,.. •-. .... _�.._....

Compliance Inspection Report
Perrr.it,,.SW3i3i?701. �Tfect;�c: ,07�J�/.�3:.._.. Expira:ign:.0612912 f ... ,.:Owner::l? y Lac!(ey.EnterArises...
Project: Village Inn Pizza
County: Iredell Cinema Dr
Region: Mooresville
Contact Person: Ray Lackey Title:
Directions to Project:
At the intersection of cinema dr and folger dr.
Type of Project: State Stormwater - General Permit
Drain Areas:
On -Site Representative(s):
Related Permits:
Inspection Date: 05/2112014 Entry Time: 01:30 PM
Primary Inspector: Samar E 8ou Ghazale
Secondary Inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ■ Compliant r1 Not Compliant
Question Areas:
0 State Stormwater
(See attachment summary)
Statesville NC 28687
Phone: [phone]
Exit Time: 02:10 PM
Phone: [phone]
Ext.2199
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW3130701 Owner - Project: Ray Lackey Enterprises
Inspection Da;a: 0,Y21 )IJ Inspec!ion Type: Compliance Evaluation Ronson for Visit -Pvitine-
Inspection Summary:
Talked to Stephen Janowsk, The designer Engineer for the site and requested a signed copy of the operation and
maintenance agreement. He informed me that he will be inspecting the site next week and will also provide an
Engineering Certification for the site. The site was built according the permit and no problems were noted during the
inspection. The building is still under construction, However, the BMP has been recently constructed and it is built
according to plan.
File Review
Is the permit active?
Signed copy of the Engineer's certification is in the file?
Signed copy of the Operation & Maintenance Agreement is in the file?
Copy of the recorded deed restrictions is in the file?
Comment: No Engineer's Certification as of this date. There is no signed copy in the
file for the operation and maintenance agreement. Also, no recorded deed restrictions
in the file.
Built Upon Area
Is the site BUA constructed as per the permit and approval plans?
Is the drainage area as per the permit and approved plans?
Is the BUA (as permitted) graded such that the runoff drains to the system?
Comment:
SW Measures
Are the SW measures constructed as per the approved plans?
Are the inlets located per the approved plans?
Are the outlet structures located per the approved plans?
Comment:
Yes No NA NE
Yes No NA NE
MOOD
®non
®non
Yes No NA NE
®❑ Q n
®Inn
®non
Page: 2

Compliance Inspection Report
Permit: SW3130701 Effective:07/01/13 Expiration: '06/29121
Project: Village Inn Pizza
Owner: Ray Lackey Enterprises
County: Iredell
Region: Mooresville
Contact Person: Ray Lackey
Directions to Project:
At the intersection of cinema dr and folger dr.
Type of Project: State Stormwater - General Permit
Drain Areas:
On -Site Representative(s):
Related Permits:
Inspection Date: 01/30/2018
Primary Inspector: James D Moore
Secondary Inspectors):
Adress: Cinema Dr
City/State/Zip: Statesville NC 28687
Title:
Entry Time: 01:25PM
Reason for Inspection: Routine
Permit Inspection Type: State Stofmwater
Facility Status: ❑ Compliant Not Compliant
Question Areas:
State Stormwater
(See attachment summary)
Phone: [phone]
Exit Time: 01:40PM
Phone:
Inspection Type: Compliance Evaluation
page: 1

permit SW3130701 Owner - Project: Ray Lackey Enterprises
Inspection Date: 01/30/2018 inspection Type Compliance Evaluation Reason for Visit: Routine
File Review Yes No NA NE
Is the permit active? E ❑ ❑ ❑
Signed copy of the Engineer's certification is in the file? ❑ E ❑ ❑
Signed copy of the Operation & Maintenance Agreement is in the file? ❑ ❑ ❑
Copy of the recorded deed restrictions is in the file? ❑ ❑ ❑
Comment: No enaineer's certification. no sinned operation and maintenance agreement and no recoreded deed
restrictions in the file.
Built Upon Area Yes No NA NE
Is the site BUA constructed as per the permit and approval plans? 0 ❑ ❑ ❑
Is the drainage area as per the permit and approved plans? E ❑ ❑ ❑
Is the BUA (as permitted) graded such that the runoff drains to the system? 0 ❑ ❑ ❑
Comment:
SW Measures Yes No NA NE
Are the SW measures constructed as per the approved plans? 0 ❑ ❑ ❑
Are the inlets located per the approved plans? 0 ❑ ❑ ❑
Are the outlet structures located per the approved plans? ❑ ❑ ❑
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ■ ❑ ❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to ❑ ❑ 0 ❑
DWQ upon request?
Comment:
page: 2

Compliance Inspection Report
Permit: SW3130701 Effective:07/01/13 Expiration: 06/29/21
Project:
Village Inn Pizza
Owner:
Ray Lackey Enterprises
County:
Iredell
Region:
Mooresville
Contact Person: Ray Lackey
Directions to Project:
At the intersection of cinema dr and folger dr.
Type of Project: State Stormwater - General Permit
Drain Areas:
On -Site Representative(s):
Related Permits:
Inspection Date: 01/30/2018
Primary Inspector: James 0 Moore
Secondary Inspector(s):
Adress: Cinema Dr
City/State/Zip: Statesville NC 28687
Title:
Entry Time: 01:25PM
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ❑ Compliant Not Compliant
Question Areas:
State Stormwater
(See attachment summary)
Phone: [phone]
Exit Time: 01:40PM
Phone:
Inspection Type: Compliance Evaluation
page: 1

Permit: SW3130701 Owner - Project: Ray Lackey Enterprises
Inspection pate: 01/30/2018 Inspection Type Compliance Evaluation Reason for Visit: Routine
File Review Yes No NA NE
Is the permit active? 0 ❑ ❑ ❑
Signed copy of the Engineer's certification is in the file? ❑ ■ ❑ ❑
Signed copy of the Operation & Maintenance Agreement is in the file? ❑ 0 ❑ ❑
Copy of the recorded deed restrictions is in the file? ❑ MCIO
Comment: No enaineer's certification, no signed operation and maintenance agreement and no recoreded deed
restrictions in the file.
Built Upon Area Yes No NA NE
Is the site BUA constructed as per the permit and approval plans? 0 ❑ ❑ ❑
Is the drainage area as per the permit and approved plans? 0 ❑ ❑ ❑
Is the BUA (as permitted) graded such that the runoff drains to the system? 0 ❑ ❑ ❑
Comment:
SW Measures Yes No NA NE
Are the SW measures constructed as per the approved plans? ■ ❑ ❑ ❑
Are the inlets located per the approved plans? M ❑ ❑ ❑
Are the outlet structures located per the approved plans? 0 ❑ ❑ ❑
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ❑ ❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to ❑ ❑ ■ ❑
DWQ upon request?
Comment:
page: 2