SW4100201_Application_20100201

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
I / o
Applicable Rules: ❑ Coastal SW —1995 ❑ Coastal SW
— 2008 h II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters
❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
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.):
Proposed Sheetz Parcel
2. Location of Project (street address):
US Hwy 601, Tax PIN 5729931266
City:Mocksville County:Davie Zip:27028
3. Directions to project (from nearest major intersection):
Approx. 2000 feet south of intersection of Hwy 601 and I-40 Parcel located adjacent to corner parcel
at southwest intersection of US Hwy 601 and Koontz Road
4. Latitude:35° 55' 7.2" N Longitude:-80° 35' 4.9" 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 numberNA , its issue date (if known)NA , 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, NA and the previous name of the project, if different than currently
proposed, NA
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: 3.6 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:NA
Form SWU-101 Version 07July2009 Page 1 of 6

III. 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: M ocksvill e Development Group LLC
Signing Official & Title:
b. Contact information for person listed in item 1a above:
Street Address:121 North Crutchfield Street
City:Dobson State:NC Zip:27017
Mailing Address (if applicable):PO Box 341
City:Dobson
Phone: (336 ) 386-9790
Email:[e-mail]
State:NC Zip:27017
Fax: (336 ) 386-9785
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: Betty G. Frost Trust
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:205 Gaston Avenue
City:Bessemer City State:NC Zip:28016
Mailing Address (if applicable):
City:
State:
Phone: (336 ) 751-7137 Fax:
Email:
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: Scott Miller / Miller Landscape Architecture P.A.
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:120 Club Oaks Court, Suite 100
City:Winston-Salem State:NC Zip:27104
Form SWU-101 Version 07July2009 Page 2 of 7

Phone: (336 ) 765-1923 Fax: (336 ) 765-5023
Email:[e-mail]
4. Local jurisdiction for building permits: Town of Mocksville
Point of Contact:William Whaley
IV. PROJECT INFORMATION
Phone #: (336 ) 753-6050
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater from site to be treated in a bio-retention 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.Identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW — 1995 ® Ph II — Post Construction
3. Stormwater runoff from this project drains to the Yadkin River basin.
4. Total Property Area: 4.42 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+: 4.42 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 54.52 %
9. How many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 1 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.
Form SWU-101 Version 07July2009 Page 3 of 7

Basin Information
Receiving Stream Name
Drainage Area _
Bear Creek
Drainage Area _
Drainage Area _
Drainage Area —
Stream Class *
WS-IV
Stream Index Number
12-108-18-(3)
Total Drainage Area (sf)
192,535
On -site Drainage Area (sf)
72,818
Off -site Drainage Area (sf)
1191717
Proposed Impervious Area** (sf)
104,980
% Impervious Area** (total)
54.52%
impervious** Surface Area
Drainage Area —
Drainage Area —
Drainage Area
On -site Buildings/Lots (sf)
0
_
On -site Streets (sf)
2,874
On -site Parking (sf)
0
On -site Sidewalks (sf)
0
Other on -site (sf)
0
Future (sf)
96,006
Off -site (sf)
6,100
Existing BUA*** (sf)
0
Total (so:
104,980
01,,Gunc i.cu,7a urtu ireuuc Number can ne determined at: httti:11h2o.enr.state. nc us/bims/reports/reportsWB html
** Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
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 new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. Topographic
Projects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per NCAC 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 http://h2o.enr.state.nc.us/su/bmp forms htm.
VI. 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://h2o.enr.state.nc.us/su/bmp forms htm. 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 http://h2o.enr.state.nc.us/su/msi maps htm.)
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://h2o.enr.state.nc.us/su/bmp forms htm.
Initials
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 f7-
Form. (if required as per Part VII 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
httl2://www-envhelp-org/pages/­­­onestol2exi2ress.html 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.)
Form SWU-101 Version 07July2009 Page 4 of 7

5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
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 lh mile of the site boundary, include the/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.
a
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.
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).
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 verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 664 Page No: 996
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 1a, 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.
http: / /www.secretary.state.nc.us/Corporations/CSearch.aspx
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://h2o.enr.state.nc.us/su/bml2 forms.htm#deed restrictions. 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.
Form SWU-101 Version 07July2009 Page 5 of 7

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:Scott Miller
Consulting Firm: Miller Landscape Architecture P.A.
Mailing Address:120 Club Oaks Court Suite 100
City: Winston-Salem
Phone: (336 ) 765-1923
Email:
State:NC Zip:27104
Fax: (336 ) 765-5023
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) Betty G. Frost 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) Sam Holder with (print or type name of organization listed in
Contact Information, item 1 b) Mocksville Development Group LLC 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.
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 penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
Date: J - 4?— 16
On �_I Chi ^ C�� Notar Public for the State of 1.
Y .County of
do hereby certify that Fro r personally appeared
before me this day of and cknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
VERLIENE l' ST: 1?4PK
NOTARY FU3a i
Dav,o
North CaLgil v
My Commission Expires
My commission expires_(
Form SWU-101 Version 07July2009 Page 6 of 7

X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 2) Betty G. Frost
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. II — Post Construction) or SL 2008-211.
Signatu
Da te: .� LQ
I' , a Notary Public for the State of
Gdo hereby certify that ,County of
personally appeared
before me this � day of �� rL � , �U 10 , anq acknowledge the e executi
g on of th application for
a stormwater permit. Witness my hand and official seal, l ,
VERLIEr�+I .�
SEAL
North Ca, �„ J
-r cWW"Sbn EXDrMS
My commission expires Q
Form SWU-101 Version 07July2009 Page 7 of 7