SW6140102_CURRENT PERMIT_20140313

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW < /K
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
//2
YYYYMMDD

r
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Tracy E. Davis, PE, CPM Pat McCrory, Governor
Director John E. Skvarla, III, Secretary
March 13, 2014
Mr. John Ellis - Town Manager
Town of Hope Mills
5770 Rockfish Road
Hope Mills, North Carolina 28348
Subject: Stormwater Permit No. SW6140102
Town of Hope Mills Drainage and BMP Retrofit Project
Cumberland County
Dear Mr. Ellis:
The Stormwater Program under the Division of Energy, Mineral, and Land Resources (DELMR),
received a complete Stormwater Management Permit Application for the subject project. 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. SW6140102, dated March 13, 2014, for the construction, operation
and maintenance of the subject project and the stormwater BMPs. This permit shall be effective
from the date of issuance until March 13, 2022, and shall be subject to the conditions and
limitations as specified therein, and does not supersede any other agency permit that may be
required.
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 150B 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 Fayetteville Regional Office. If you have any questions, or
need additional information concerning this matter, please contact Larry Wade PE at [phone]; or
[e-mail].
ncdenr.gov.
Since'APR 2 4 2014
for Tracy E. Davis, PE, CPM, Director
cc: SW6140102 File
Fayetteville Regional Office
Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-92001 FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: http://portal.ncdenr.org/web/Ir
An Equal Opportunity 1 Affirmative Action Employer - 50% Recycled 110% Post Consumer Paper

State Stormwater Permit
Permit No. SW6140102
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
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
Town of Hope Mills
Town Hall Drainage and BMP Retrofit Project
5770 Rockfish Rd., Cumberland County
FOR THE
construction, operation and maintenance of one Bioretention Cell in compliance with
the provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to
as the "stormwater rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved by
the State and considered a part of this permit.
This permit shall be effective from the date of issuance until March 13, 2022, and shall
be subject to the following specified conditions and limitations:
I. 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 Bioretention Cell 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 Permit
Permit No. SW6140102
II. 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 Bioretention Cell 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 an annual summary report of the maintenance and_
inspection records for the Bioretention Cell. The report shall summarize.the:
inspection dates, results of the inspections, and the maintenance work
performed at each inspection.
5. The Bioretention Cell 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 Bioretention Cell 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.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
Page 2 of 4

State Stormwater Permit
Permit No. SW6140102
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.
III. 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
State, 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.
Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the State, 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 (local, 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 3 of 4

State Stormwater Permit
Permit No. SW6140102
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 13`h day of March, 2014.
for Tracy E. Davis, P.E., CPM
Director Division of Energy, Mineral, and Land Resources
I
Page 4 of 4

State Stormwater Permit
Permit No. SW6140102
Town of Hope Mills — Town Hall Drainage Improvement Project
Cumberland County
Designer's Certification
I, w - I , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(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 'app.roved plans and specifications.
Noted deviations from approved plans and specification:
cc: NCDENR-DEMLR Regional Office
Page 1 of 1

DEMLR USE ONLY
Date Received
Fee Paid
Pe
it Number
0IUL
Applicable Rules: ❑ Coastal SW —1995 ❑ Coastal SW — 2008 ❑ Ph II - 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
Department of Environment and Natural Resources APR 2 4 2014
Division of Energy, Mineral and Land Resources
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.):
Town Hall Drainage and BMP Retrofit Project
2. Location of Project (sheet address):
City:Hooe Mills County:Cumberland Zip:28348
3. Directions to project (from nearest major intersection):
From intersection of Main Street (NC 59) and Rockfish Road (SR 1112)
West on Rockfish Road to Town Hall complex on right. Turn right on Park Boulevard to access parking area.
4. Latitude:34° 58' 21.4" N Longitude:78° 57' 217' W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
+Reneruals ruitlr modifications also requires S WU-102 — Renoval Application Farm
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
DEMLR requesting a state Stormwater management permit application, list the stonnwater 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
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 6 ac of
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport? ZINo UYe
If yes, see S.L. 2012-200, Part Vl: http://i2ortal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page I of 6

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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:Town of Hope Mills, North Carolina
Signing Official & Title:lohn Ellis, Town Manager
b.Contact information for person listed in item la above:
Street Address:5770 Rockfish Road
City:Hope Mills StateNC Zip:28348
Mailing Address (if applicable):
Phone: (910 ) 424-4555
Email:[e-mail]
Fax: (910 ) 424-4902
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/,
Signing Official &
b.Contact information for person listed in item 2a above:
Street Address:
Mailing Address (if
Phone:
State: Zip:
State: Zip:
Fax: ( )
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 Address:
Phone: ( ) Fax:
Email:
4. Local jurisdiction for building permits: Town of Hope Mills
Point of Contact:Mike Bailey Phone #: (910 ) 424-4555
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Bioretention Area drains to a retrofitted infiltration basin with no direct discharge.
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 PUDApproval 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 ❑ Ph II — Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 38.87 acres
5. Total Coastal Wetlands Area: 0.0 acres
6. Total Surface Water Area: 0.0 acres
7. Total Property Area (4) — Total Coastal Wetlands Area (5) — Total Surface Water Area (6) = Total Project Area':
38.87 acres
Total project area shall be calculated to exclude the folloeving: the normal ool of impounded structures, the area
between the banks of streams and rivers, the area below the �Ior nal 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.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 13.0 0
9. How many drainage areas does the project have?2 (For high density, court 1 for each proposed engineered
stormwater BMA. 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.
Basin Information
Drainage Area 1
Draina e Area 2
Drainage Area.
Area _
Receiving Stream Name
NA
NA
-Drainage
Stream Class *
NA
NA
Stream Index Number *
NA
NA
Total Drainage Area (sf)
121,042
1,310,730
On -site Drainage Area (sf)
121,042
799,538
Off -site Drainage Area (sf)
0.0
511,192
Proposed Impervious Area** (sf)
55,433
292,881
%4 Impervious Area** (total)
45.8
22.3
Impervious** Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
0
0
On -site Streets (sf)
0
0
On -site Parking (sf)
45,176
0
On -site Sidewalks (sf)
3,961
0
Other on -site (so
0
0
Future (sf)
0
0
Off -site (sf)
0
158,931
Existing BUA*** (sf)
6,296
133,950
Total (so:
55,433
292,881
Stream Class and Index Number can be determined at: http:14;ortal.ncdetir.orglzveblzvqlpslcstilclassificatioiis
* In ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
**" Report only that arnount 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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation. The off -site
impervious area was based on digitized aerial photography and LiDAR topographic data available from
NCFMP to delineate the drainage areas.
Projects in Union County: Contact DEMLR Central Office staffto check ifthe project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per 15A 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://12ortal.ncdenr.org/web/`wq/ws/su/bmp-manua1. _
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://portalmcdennorg/web/wq/ws/su/statesw/forms docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at h!V:/ /porLal.ncdenr.org/web/wq/ws/su/maps.)
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://portaI.ncdenr.org/web/wq/ws/su/statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. TL M
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants AM
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
http://www.envhelp.org/pages/onestopexpress.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.)
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 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
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.
in. 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.
TLM
r4-.4f
-rT-J,
Ti. 'Al
"2M
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

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 �M
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"xl1" 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 DEMLR to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: y36Ff Page No: paZ S ��
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC %Vii
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 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.iic.us/Coi-12orations/CSLircl).asi2x
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 littp://12ortal.ncdenr.org/web/Ir/state-stormwater-
forms does. 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 DEMLR, 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:Thomas Murray, PE
Consulting Firm: WK Dickson & Co.. Inc.
Mailing Address:720 Corporate Center Drive
City:Raleigh State:NC Zip:27607
Phone: (919 ) 782-0495
Eiiiail:[e-mail]
Fax: (919 ) 782-9672
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled ont, complete this
section)
I, (print or type mmne of person listed in Contact Information, item 2a) 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 1n) with (print or type name of organization listed in
Contact Information, item 1a) 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 Oct. 31, 2013 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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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:
a Notary Public for the State of County of
do hereby certify that
before me this _ day of
stormwater permit. Witness my hand and official seal,
X. APPLICANT'S CERTIFICATION
SEAL
personally appeared
and acknowledge the due execution of the application for a
My commission expires
I, (print or type name of person listed in Contact Information, item 1a) J l hr, Vy 1E I I IS
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 15AA NC, AC�2H .1000 and any other applicable state stormwater requirements.
Signature: �/7�ihJ ��• C+�Giy (jL DateS—gahT.P/G(/ �6r ge
I, H I sa.be- h k. Bro wr) a Notary Public for the State of ND1'• K Coyolr nQ , County of
40ye , do hereby certify that —JOh 11 personally appeared
before me this �hday of (�[?m%el' OI and acknowledge
� the due execution of the application for a
stormwater permit. Witness my hand and official seal, Y-1.b0..�11Y-ki 0, • 1" M'
SEAL
My commission expires 10/1 o / ` ()l 7
Form SWU-101 Versiou Oct. 31, 2013 Page 6 of 6

Permit
(to be provided by DWO)
1
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
NCD n NR 401 CERTIFICATION APPLICATION FORM
BIORETENTION CELL SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information.
Project name
Contact name
Phone number
Date
Drainage area number
J919-782-0495.,, .. .... ., ... ,.. ,. , - ;,...... - 1
IDecembe(5, 2013 'r ' r, a"
IIADES IG N11NP,ORMAT_IO_N
Site Characteristics
Drainage area
12L042 ft2
Impervious area
I .: - 55,4331ft2
Percent impervious
45.8% %
Design rainfall depth
j -' 1.01 inch
Peak Flow Calculations
1A C
Is pre/post control of the 1-yr, 24-hr peak flow required?
(T" N (Y or N)
r ,
1-yr, 24-hr runoff depth
I - ' r 'NAI in
1-yr, 24-hr intensity
I��-..�iNAlin/hr
�i ,�
Pre -development l-yr, 24-hr peak Flow
I- NAlft3lsecn.`.
Post -development 1-yr, 24-hr peak flow
I NAIft3lsec
Pre/Post 1-yr, 24-hr peak control
#VALUE! ft'Isec„rtF?,
ti
Storage Volume: Non -SA Waters
° '���,•;''�,
Minimum volume required
F- - " 4,662.1 ft3
Volume provided
I -"-6,937.01ry3
OK
Storage Volume: SA Waters
1.5' runoff volume
Pre -development 1-yr, 24-hr runoff
Post -development 1-yr, 24-hr runoff
Minimum volume required
0 ff3
Volume provided
L"- `_?--M1f13
Cell Dimensions
Fording depth of water
inn-.: ; .�: 2I inches
OK
Fording depth of water
1.00 ft
Surface area of the tap of the bioretention cell
1 .8,580.0:ft2
OK
Length:
1` '14511
OK
Width:
P^ • `- "' 601it
OK
-or-Radius
I ,:- .'Ift
Media and Soils Summary
Drawdown time, ponded volume
._ -. 12, hr
OK
Drawdown time, to 24 inches below surface
I' - .. 361 hr
OK
Drawdown time, total:
48 hr
In -situ soil:
Soil permeability
".,.,.._22.50i1n/hr
OK
Planting media soil: -
-
Soil permeability
,- - >. 1A0 inlhr
OK
Soil composition
% Sand (by volume)
F�-7 . '.85%
OK
% Fines (by volume)
I- `';-- r .10%1
OK
% Organic (by volume)
t m..,-' : , .5%1
OK
Phosphorus Index (P-Index) of media
Form SW401-Bioretention-Reve
June 25, 2010 f
Total: 100%
I,_"" .,201(unitless) OK
Parts I and II. Design Summary, Page 1 of 2

Permit
(to be provided by DWQ)
Basin Elevations
Temporary pool elevation
Type of bioretention cell (answer "Y" to only one of the two
following questions):
Is this a grassed cell?
Is this a cell with trees/shrubs?
Planting elevation (top of the mulch or grass sod layer)
Depth of mulch
Bottom of the planting media soil
Planting media depth
Depth of washed sand below planting media soil
Are underdrains being installed?
How many clean out pipes are being installed?
What factor of safety is used for sizing the underdrains? (See
BMP Manual Section 12.3.6)
Additional distance between the bottom of the planting media and
the bottom of the cell to account for underdrains
Bottom of the cell required
SH WT elevation
Distance from bottom to SHWT
Internal Water Storage Zone (IWS)
Does the design include IWS
Elevation of the top of the upturned elbow
Separation of IWS and Surface
Planting Plan
Number of tree species
Number of shrub species
Number of herbaceous groundcover species
Additional Information
Does volume in excess of the design volume bypass the
bioretention cell?
Does volume in excess of the design volume flow evenly distribute
through a vegetated filter?
What is the length of the vegetated filter?
,.157.00,fmsl
(Y or N)
I Y I(Y or N)
OK media depth
I -' _.. 155.41fmsl
I ,_ 41inches
OK
1152.41fmsl
3ft
1, 0.33Ift
-Y
I(YorN)
L.
I - 9i
OK
I31
OK
1ft
151.07 fmsl
149iimsl
2.07 ft
OK
N (Y or N)
fmsl
155.4 ft
I 31
3!
OK
IN (Y or N) Excess volume must bypass cell.
N I (Y or N) Excess volume must pass through filler.
Does the design use a level spreader to evenly distribute flow? I. N I (Y or N) Show how Flow is evenly distributed.
Is the BMP located at least 30 feet from surface waters (50 feet if
"
Y
-: - (Y or N)
SA waters)?
Is the BMP located at least 100 feet from water supply wells?
1` Y
. I (Y or N)
Are the vegetated side slopes equal to or less than 3:1?
i .Y .
• , 1(Y or N)
Is the BMP located in a proposed drainage easement with access
I N
I(Y or N)
to a public Right of Way (ROW)?
Inlet velocity (from treatment system)
'' '
`,3.3If1sec
Is the area surrounding the cell likely to undergo development in
I �' `�". N
. ' - I (Y or N)
the future?
Are the slopes draining to the bioretention cell greater than 20°70?,'_,
IN
I (Y or N)
Is the drainage area permanently stabilized?
I. .-Y,
j(Y or N)
Pretreatment Used
(Indicate Type Used with an W in the shaded cell)
Gravel and grass
(81nches gravel followed by 3-5 it of grass)
Grassed swale
I
Forebay
Other
(.
. XI
OK
OK
OK
Insufficient ROW location.
Insufficient inlet velocity unless energy dissipating devices are
being used.
OK
Lon
#VALUE!
Form SW401-13ioretenbon-Rev.e
June 25, 2010
Pans I and I. Design Summary, Page 2 of 2

Permit Number:
(to be provider/ by DWQ)
Drainage Area Number:
Bioretention 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 BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
Important operation and maintenance procedures:
— Immediately after the bioretention cell is established, the plants will be watered
twice weekly if needed until the plants become established (commonly six
weeks).
— Snow, mulch or any other material will NEVER be piled on the surface of the
bioretention cell.
— Heavy equipment will NEVER be driven over the bioretention cell.
— Special care will be taken to prevent sediment from entering the bioretention cell.
— Once a year, a soil test of the soil media will be conducted.
After the bioretention cell is established, I will inspect it once a month 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:
Potentialproblems:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
bioretention cell
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
The inlet device: pipe,
The pipe is clogged (if
Unclog the pipe. Dispose of the
stone verge or 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.
Stone verge is clogged or
Remove sediment and clogged
covered in sediment (if
stone and replace with clean stone.
applicable).
Form SW401-Bioretention O&M-Rev3 Page I of 4

BMP element:
Potentialproblems:
How I will remediate theproblem:
The pretreatment area
Flow is bypassing
Regrade if necessary to route all
pretreatment area and/or
Flow to the pretreatment area.
gullies have formed.
Restabilize the area after grading.
Sediment has accumulated to
Search for the source of the
a depth greater than three
sediment and remedy the problem if
inches.
possible. Remove the sediment and
restabilize the pretreatment area.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand.
The bioretention cell:
Best professional practices
Prune according to best professional
vegetation
show that pruning is needed
practices.
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the
dying.
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Tree stakes/wires are present
Remove tree stake/wires (which
six months after planting.
can kill the tree if not removed).
The bioretention cell:
Mulch is breaking down or
Spot mulch if there are only random
soils and mulch
has floated away.
void areas. Replace whole mulch
layer if necessary. Remove the
remaining much and replace with
triple shredded hard wood mulch at
a maximum depth of three inches.
Soils and/or mulch are
Determine the extent of the clogging
clogged with sediment.
- remove and replace either just the
top layers or the entire media as
needed. Dispose of the spoil in an
appropriate off -site location. Use
triple shredded hard wood mulch at
a maximum depth of three inches.
Search for the source of the
sediment and remedy the problem if
possible.
An annual soil test shows that
Dolomitic lime shall be applied as
pH has dropped or heavy
recommended per the soil test and
metals have accumulated in
toxic soils shall be removed,
the soil media.
disposed of properly and replaced
with new planting media.
Form SW401-Bioretention O&M-Rev.3 Page 2 of 4

BMP element:
Potentialproblems:
How I will remediate theproblem:
The underdrain system
Clogging has occurred.
Wash out the underdrain system.
(if applicable)
The drop inlet
Clogging has occurred.
Clean out the drop inlet. Dispose of
the sediment off -site.
The drop inlet is damaged
Repair or replace the drop inlet.
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-
outlet.
733-1786.
Form SW401-Bioretention O&M-Rev.3 Page 3 of 4

Permit Number:
(to be provided bY DWQ)
I" aC- Noo& �kAkk 1S
acknowledge and agree by my signature below that.•1-mvA responsible for the
performance 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 name:Town Hall Drainage and BMP Retrofit Project
BMP drainage area number:
Print name: .J ivy✓
Title: 7o .✓ /Yl:4A'W9F12.
Address:5770 Rockfish Road Hope Mills, NC 28348
Date: //,t G016
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 suhdivision has been named the president.
I, OISa-beW A- ero-Lor-\ a Notary Public for the State of
�60V+ c"OI I ✓1eL ,, County of -4o� do hereby certify that
Tohn W. 0 � 15 ll-I- personally appeared before me this
day of 9?(4PW bW 203 , and acknowledge the due execution of the
forgoing bioretention maintenance requirements. Witness my hand and official seal,
SEAL
uaka-y �-
My commission expires O c)2n l
Form S W401-Bioretention 1&M-Rev. 2 Page 4 of 4

II 1

. 'DEMLR'USE':ONLY.?
Date Received
Fee Paid
Permit Number
SSoS
SW/oltiotoA
Applicable Rules:
❑ Coastal SW —1995
❑ Coastal SW —
2008 ❑ Ph 11- Post Construction
(select all that apply)
❑ Non -Coastal
SW- HQW/ORW Waters
❑ Universal Stormwater Management Plan
❑ Other WQ M
ant Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
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.):
Town Hall Drainage and BMP Retrofit Project
2. Location of Project (street address):
City:Hooe Mills County:Cumberland Zip:28348
3. Directions to project (from nearest major intersection):
From intersection of Main Street (NC 59) and Rockfish. Road (SR 1112)
West on Rockfish Road to Town Hall complex on right. Turn right on Park Boulevard to access parking area.
4. Latitude:34° 58' 21.4" N Longitude:78° 57' 21.7" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New []Modification ❑ Renewal w/ Modifications
+Renewals with modifications also requires SWU-102 —Renewal Application Form
b.If this application is being subrrtted 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
DEMLR 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: 6 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 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? [�gNo UYe,
If ties, see S.L. 2012-200, Part VI: httl2://12ortal.ncdetir.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 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 oroiect):
Applicant/Organization:Town of Hope Mills, North Carolina
Signing Official & Title:Iohn Ellis, Town Maier
b.Contact information for person listed in item 1a above:
Street Address:5770 Rockfish Road
City:Hope Mills State:NC Zip:28348
Mailing Address (if applicable):
City: State: Zip:
Phone: [phone] Fax: (910 ) 424-4902
Einail:[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/Organza
Signing Official &
b.Contact information for person listed in item 2a above:
Street Address:
Mailing Address (if
Phone: ( ) Fax:
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 Address:
Zip:
Phone:
Fax:
4. Local jurisdiction for building permits: Town of Hope Mills
Point of Contact:Mike Bailey Phone #: (910 ) 424-4555
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, brefly summarize how the stormwater runoff will be treated.
Bioretention Area drains to a retrofitted infiltration basin with no direct discharge
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 PUDApproval 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 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 38.87 acres 5. Total Coastal Wetlands Area: 0.0 acres
6. Total Surface Water Area: 0.0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project Area':
38.87 acres
Total project nrea shall be calculated to exclude the following the normal pool of imppounded 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 maybe
included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 13.0 %
9. How many drainage areas does the project have?2 (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.
Basin Information
Draina e Area 1
Draina e Area 2
Draina e Area _
Draiina e Area _
Receiving Stream Name
NA
NA
Stream Class *
NA
NA
Stream Index Number *
NA
NA
Total Drainage Area (sf)
121,042
1,310,730
On -site Drainage Area (sf)
121,042
799,538
Off -site Drainage Area (sf)
0.0
1 511,192
Proposed Impervious Area** (sf)
55,433
292,881
% Impervious Area** (total)
45.8
22.3
Impervious- Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
0
0
On -site Streets (sf)
0
0
On -site Parking (sf)
45,176
0
On -site Sidewalks (sf)
3,961
0
Other on -site (sf)
0
0
Future (sf)
0
0
Off -site (sf)
0
158,931
Existing BUA*** (sf)
6,296
133,950
Total (sf):
55,433
292,881
Stream Class and Index Number can be determined at: lu�://yoctal acdenr.ororghueb/zorl[ps/csu/classifications
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 nezo BUA.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation. The off -site
impervious area was based on digitized aerial photogrhv and LiDAR tovogravhic data available from
NCFMP to delineate the drainage areas.
Projects in Union County: Contact DEMLR 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 15A 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 hqp://portal.ncdenr.org/web/­wq/ws/su/bmp-manual. _
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
bft://portal.ncdenr.org/web/wq/ws/su/statesw/­­forms-docs.
The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online mapatht!p://portal.ricdeny.org/web/wq/­ivs/­su/maps.)
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 htt ://portal.ncdem.org/web/wgLws/su/statesw/forms flocs.
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 AJA
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
http://www.envhelp.org/pages/onestoMxpress.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.)
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 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
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.
in. 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.
TLIJ
-1'l
T(I M,
Tt_ J- .
TLC
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the maul 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"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 DEMLR to verify the SHWT prior
to submittal, [phone].) _ l
10. A copy of the most current property deed. Deed book: y36 Page No:
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC AIA
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item In, 2a, and/or 3a per 15A 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.
httl2://www.secretary.state,nc.tis/Cori2oratioiis/CSearch.asi2x
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 httu://portal.ncdenr.org/web/Ir/state-stormwater-
forms does. 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 DEMLR, 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:Thomas Murray, PE
Consulting Firm: WK Dickson & Co., Inc.
Mailing Address:720 Corporate Center Drive
City:Raleigh State:NC Zip:27607
Phone: (919 ) 782-0495
Email:[e-mail]
Fax: (919 ) 782-9672
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) 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) with (print or hype name of organization listed in
Contact Information, item la) 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 Oct. 31, 2013 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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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.
before ire this
a Notary Public for the State of
do hereby certify that
day of
stormwater permit. Witness my hand and official seal,
SEAL
Date:
County of
personally appeared
and acknowledge the due execution of the application for a
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item la) b11n IS
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 15AA NC,AC 2H .1000 and any other applicable state stormwater requirements.
Signature: �''�/NJ �• C �✓Y (11— DatQ�o(i me'G(/ %Ol
I, Ui so-b4h 1K• 1?)1'D lL)Y,) a Notary Public for the State of HiA l At y%2 , County of
F 0yeI do hereby certify that 0115 TO personally appeared
before me this f f - day of _D6ce21' 01and ack��nowle��dg��e�� the due execution of the application for a
stormwater permit. Witness my hand and official seal, t X�.A.0...1lX9'Vl . Q, -i?A 7u m,
.
=„t......;;
t ,.
..•,,�.�..:
n)�
SEAL
My corrunission expires 10/1o / ` 017
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6