SW8140102_HISTORICAL FILE_20160421

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW8 )T 01 02
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
ZoJ6 0f 21
YYYYMMDD

Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
April 21, 2016
Haddon M. Clark, III, President
Sampson-Bladen Oil Company, Inc.
PO Box 469
Clinton, NC 28329-0469
Subject: Approved Plan Revision
Han-dee Hugo Rocky Point
Stormwater Permit No. SW8 140102
Pender County
Dear Mr. Clark:
PAT MCCRORY
Gommor
DONALD R. VAN DER VAART
Secretary
TRACY DAVIS
Director
On March 14, 2016, the Wilmington Regional Office received a request to revise the approved plans for
Stormwater Management Permit Number SW8 140102. The revisions include reconfiguring the
previously approved building and parking layout to accommodate a Little Caesar's Pizza restaurant, and
revisions to the runoff collection system along the west property line to address offsite drainage. It has
been determined that a formal permit modification is not required for the proposed changes. We are
forwarding you an approved copy of the revised layout and grading plan sheets and the outlet structure
detail sheet for your files. Please replace the previously approved site plan (sheet 1 of 8) and the outlet
structure detail plan (sheet 6 of 8) with the new layout plan and the new outlet structure detail plan. The
previously approved grading plan (sheet 2 of 8), the existing conditions plan (sheet 4 of 8), the site details
plan (sheet 7 of 8) and the stormwater BMP plan (sheet 5 of 8), remain in effect as part of the approved
plan set. The built -upon area listed on the application has been reallocated accordingly, and a revised
application SWU-101 is also attached.
Please be aware that all terms and conditions of the permit issued on January 10, 2014, remain in full
force and effect. The approval of this revision to the approved plans for the subject State Stormwater
project is done on a case -by -case basis. In this case, approval is also contingent on submitting the
completed and appropriately signed Name/Ownership Change form and addressing the compliance
issues described in the Compliance Inspection report dated February 17, 2016 and as.subsequently
clarified via email dated March 22, 2016. Any other changes to this project must be approved
through this Office prior to construction. The issuance of this plan revision does not preclude the
permittee from complying with all other applicable statutes, rules, regulations or ordinances which
may have jurisdiction over the proposed activity, and obtaining a permit or approval prior to
construction.
If you have any questions concerning this matter, please do not hesitate to call me at [phone].
Sincerely,
G�/��4u
Linda Lewis, E.I.
Environmental Engineer III
�5 GDS\arl: \\\Stormwater\Perrnits & Projects\2014\140102 HD\2016 04 permit pr 140102
cc: David K. Newsom, P.E., Crystal Coast Engineering
Bob Brantley, Bunn Brantley Enterprises, Inc. (389 Instrument Drive, Rocky Mount NC 27804)
Pat O'Mahony, Pender County Planning Department
Wilmington Regional Office
state of Noah Carolina I Environmental Quality I Energy, Mineral and Land Resources
127 Cardinal Drive Extension I Wilmington, NC 28405
9107%7215 T 1 9103502004 F I htm,//uortal.nodernorahveb/Ir/

Casmer, Jo
From: [DOTS] DENR Support <[e-mail]>
Sent: Thursday, April 21, 2016 11:57 AM
To: Casmer, Jo
Subject: [DOTS] Created: (HD-882921) BIMS correction
This message has been automatically generated in response to a Help Request regarding: "Ticket Submitted from
Portal", a summary of which appears at the bottom of this email.
There is no need to reply to this message right now. Your Help Request has been logged at the DENR ITS
Solution Center. Staff are being assigned and you will be contacted if we require further information or when
your request has been completed.
Please include the text: HD-882921
in the subject line of all future email correspondence about this issue. To do so, you may reply to this message.
NOTE: TICKETS SUBMITTED AFTER 5 PM WILL BE ADDRESSED THE NEXT BUSINESS DAY.
Sincerely,
DENR ITS Solution Center
Issue Details
Summary: BIMS correction
Issue#: HD-882921
Issue Created: Today u:56 AM
Issue Type: Issue
Reporter: jo L Casmer
Category: I have a request...
Division: Administration Division
Location: RO - Wilmington
NCID: jlcasmer
Number of Users Affected: io
Phone: [phone]
Queue: Solution Center Queue
Severity: Medium
Sub -category: BIMS
Subdivision: None
Description:
SW8 t4mo2, version m: please change status from "Active" to "In Review." This application was for an Ownership
Transfer which was cancelled at the request of the owner. The application should have been "withdrawn" and a
new application created for the Plan Revision that followed thereafter. Reviewer incorrectly "issued" the Plan
Revision under the Ownership Transfer application, with incorrect dates.
I will be withdrawing the application, then creating a new application for the Plan Revision, using the proper
dates for each event. Thank you.

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If you require assistance, please contact the DENR ITS Solution Center at:
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If you have an urgent or critical situation, please call the DENR ITS Solution Center at (919) 7o7-89oo after
submitting your help request.
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be
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:IOHN L. PIERCE & ASSOCIATES, P.A.
LAND SURVEYING — LAND PLANNING — MAPPING
P.O. BOX 1685
JACKSONVILLE, NC 28541
OFFICE: [phone] FAX: [phone]
E-MAIL: hettvb a jlpne.com
Or hrianjnjlpnc.com
TO: Ms. Linda Lewis
N.C. Department of Environment and Natural
Resources —Division of Energy. Mineral & Land
Resources/Land Quality Section
127 Cardinal Drive Extension
Wilmington, NC 28405
Letter of Transmittal
DAl'E:
March 28, 2016
ATTENTION:
Ms. Linda Lewis
Re:
Han -Dee Bugo-Rock Point-SW8140102
COPIES
DATE
NUMBER
DESCRIPTION
3
Copies of revised stormwater plan per your comments to Crystal Coast
Engineering on 3/23/16
v M A , k Nor 1, =4611-my-102

Lewis,Linda
From: Lewis,Linda
Sent: Tuesday, March 22, 2016 6:09 PM
To: 'David Newsom'
Cc: 'Bob Brantley'; Pat O'Mahony([e-mail]);'Ryan Stanley'
Subject: Han-dee Hugo SW8 140102
Mr. Newsom:
The name/ownership transfer was abandoned at the request of the owner as of March 14, 2016, and
the Division picked up the review of the plan revision for the subject project. The revised plans need
to be discussed:
The originally approved plan sheets from 2014 were numbered 1-8. The revised plans are
numbered 1-4. To avoid confusion for the permittee when trying to replace the previously
approved sheets with the new sheets, is it possible to renumber the revised plan sheets so that
they match up with the old ones? That will certainly make it less confusing for everyone.
Also, you provided sheets 2 of 4 and 3 of 4 which both depict the exact same outlet structure
details. I was unable to find any specific changes from the previously approved detail sheet 6
of 8. Please elaborate on the specific changes to the existing outlet structure. If there are no
changes, I propose that we just keep the originally approved detail sheet.
The existing conditions plan is simply a repeat of the previously proposed plan. I don't think it
serves any purpose to include it here as part of this plan revision.
I'd like to make two clarifications regarding the February 17, 2016 inspection report. Both of them
involve questions about the original review and permitting for the site.
The 2014 application states that there is no offsite drainage, however, the proposed grading
plan showed that the existing contour of the property to the west of the site will direct that
drainage toward the proposed Han-dee Hugo site. It does not appear that any means of
rerouting that offsite drainage around the wetland has been provided. Of particular concern is
the low area on Lot 29 of Hunter Hills Subdivision that can now drain into the wetland via the
Han-dee Hugo collection swale located behind the curbing. This swale is intended to only
convey the runoff from the rear portion of the parking area into the wetland. A means of routing
this offsite drainage around the site must be provided, or the wetland will need to be
redesigned to take all that additional drainage area into account at the ultimate built -out
potential (reference NCAC 02H.1008 (c)(1)).
2. Was there some consideration given by the original reviewer to redevelop the existing BUA?
The application reports "0" existing BUA and there are no notes, or emails, and nothing in the
narrative or calculations to suggest that some runoff from the site is allowed to be collected
and NOT treated under redevelopment. However there are curb inlets located along the
eastern edge of the paved area that appear to allow runoff from the site to enter a piped
collection system that discharges to a 3:1 swale and then into the existing drainage ditch,
bypassing the constructed wetlands BMP. My understanding of the plans is that the pipe is
only intended to convey offsite drainage through the site, not to collect runoff from the
site. Can you shed any light on this so I can understand what the intent is? I may need to add
some clarifying language to the permit.

Please provide your responses / information by April 22, 2016.
Thank you.
Linda Lewis, E.I.
Environmental Engineer III
Division of Energy. Mineral and Land Resources
Department of Environmental Quality
910-796-7215 Office
Iinda.lewis(5)ncdenr.gov
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28403
!'"Nothing Compares�,
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

JOHN L. PIERCE & ASSOCIATES, P.A.
LAND SURVEYING — LAND PLANNING — MAPPING
P.O. BOX 1685
JACKSONVILI,r, NC 28541
OFFICE: [phone] FAX: [phone]
1 MAIL: beltyb a jlpnc.com
Or brianinj Innc.com
"CO: Ms. Linda Lewis
N.C. Department of Environment and Natural
Resources —Division of Energy, Mineral & Land
Resources/Land Quality Section
127 Cardinal Drive Extension
Wilmington, NC 28405
Letter of Transmittal
DATE:
March 11, 2016
ATTENTION:
Ms. Linda Lewis
Re:
Han -Dee Hugo — RockPoint-SW8140102
COPIES
DATE
NUMBER
DESCRIPTION
2
Stormwater permit applications with Narrative & BUA Summary
1
Copy of Deed of Record
1
Copy of Business Corporation Annual Report
n I I
t % , •- •-

Stormwater Treatment &
Erosion Control Narrative
Han -Dee Hugo — Pender County
Sampson-Bladen Oil Company, Inc. previously permitted and developed one tract, 2.37
acre, located at the intersection of US Hwy. 177 and NC Hwy 133, in Pender County. The
permitted development included a 2,800 sf C-Store and associated fuel pumps, a 1,500 sf
restaurant and a 6,000 sf building space with associated parking, loading zones &
sidewalks.
Some minor adjustment of BUA is required due to a slightly different configuration of the
restaurant as associated drive through. This BUA adjustment is depicted on the Attached
BUA Summary (see attached spreadsheet).
PLEASE DISCARD THE PREVIOUSLY SUBMITTED APPLICATION
AND NAME CHANGE FORM (in name of SBOC Pender EAT, LLC).
SINCE SUBMITTING THAT APPLICATION, TITLE TO THE
PROJECT HAS REVERTED BACK TO THE ORIGINAL (Sampson-
Bladen Oil Company, Inc.) OWNER (see attached Deed).
rM
CEVE
AR 1 4 2011

Project: Han -Dee Hugo
Permit: SW8140102
Date: 12/4/2015
BUA Summary
Imp. Surface Area
Per
Current
Permit
Proposed
Changes
(Little Ceasars)
Proposed
Permit
Modification
Buildings
5,170
-198
4,972
Streets
0
0
0
Parking
35,940
605
36,545
Sidewalks
1,392
199
1,591
Other
0
0
Future
14,935
-606
14,329
Offsite
0
0
Existing
1 0
0
Totall
57,4371
01
57,437
Crystal Coast Engineering, PA
205-3 Ward Road
Swansboro, NC 28584
910-325-0006
Business License: C-2553
No Net Increase in BUA
ECEIVE
MAR 14 2016
sGv_�14U«Z-

-_ Date Received
Fee
Applicabl4 Roves: ❑ 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 Mgmt Plan:
State of North Carolina e?:_WS / p
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 ro'ect name
specifications, letters, operation and maintenance agreements, etc.): B E dN
2. Location of Project (street address):
11795 US 1-1wy.117 S. BY:
City:Rocky Point County:Pender Zip:28457
3. Directions to project (from nearest major intersection):
Project is located at intersection of US Hwy. 177 & NC Hwy 133, Fender County.
4. Latitude:34° 23' 22.0" N Longitude:77° 53' 35.8" W of the main entrance to the project.
it. PERMIT INFORMATION:
1.a.Specify whether project is (check one): ❑New ®Modification ❑ Renewal w/ Modification}
tRenetnals urith modifications also requires SWU-102 - Reneuwl Application Fonn
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit numberSW8 140102 , its issue date (if known)1/10/14 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: <1.0 ac 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? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: httl2://12ortal.nedenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page I 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:Sampson-Bladen Oil Company, Inc.
Signing Official & Title:Haddon M. Clark, IIh President
b.Contact information for person listed in item la above:
Street Address:510 Commerce Street
City:Clinton State:NC Zip:28328 Sampson
Mailing Address (if applicable):P.O. Box 469
Phone: [phone]
Email:
State:NC Zip:28329-0469
Fax: ( )
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:
Signing Official & Title:
b.Contact information for person listed in item 2a above:
Street Address:
Mailing Address (if
City: State: Zip:
Phone: ( 1 Fax: ( )
Email:
3. a. (Optional) Print the name and title of another contact such as the project's
person who can answer questions about the project:
Other Contact
Signing Official &
b.Contact information for person listed in item 3a above:
Mailing Address:
City:
Phone: ( )
Email:
M
State: Zip:
Fax: ( )
4. Local jurisdiction for building permits: Burgaw
Point of Contact:laki Pace Phone #: (910 ) 259-1518
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.
Plan Revision to account for redistribution of previously permitted BUA. All runoff from BUA diverted to an
existing Constructed Wetland.
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 ❑ Ph II — Post Construction
3. Stormwater runoff from this project drains to the
4. Total Property Area: 2.37 acres
River basin.
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':1.74 acres
Total project area shall be calculated to exclude the followin the normal yool of imppounded structures, the area
between the banks of streams and rivers, the area below the Lrmal 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 = 75.70% %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stornutvater BMP. For low density and other projects, use I 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 a Area \
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Northeast Cape
Fear River
Stream Class
B;SW
Stream Index Number *
18-74-(47.5)
Total Drainage Area (so
75,871 sf sf
On -site Drainage Area (so
75,871 sf sf
Off -site Drainage Area (so
-0-
Proposed Impervious Area** (so
57,437 sf
Impervious Area** (total)
75.70
Impervious" Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
4,972 sf
On -site Streets (so
-0-
On-site Parking (so
36,545 sf
On -site Sidewalks (so
1,591 sf
N J
Ib
Other on -site (so
-0-
Future (so
14,329 sf
Off -site (so
-0-
Existing BUA*** (so
-0-
Total (so:
57,437 sf
* Stream Class and Index Number can be determined at: ham:/Poortal ncdenr.org/web/wq[ps/csu/classij cations
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

** 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. ACAD
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 http://12ortal.ncdenr.org/web/wq/ws/su/bmp-manua1.
V1. 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
httu://portal.ncdennorg web/wq/ws/su/statesw/forms dots. 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 htW://12ortal.ncdenr.org/web/wq/ws/su/mats.)
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 hU://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms does.
I
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one cagy of the signed and notarized Deed Restrictions &Protective Covenants
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
htto://www.envhelp.org/pages/onestol2exl2ress.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'h mile of the site boundary, include the'h
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. �p p�
h. Identify all surface waters on the plans by delineating the normal pool elevation @9
impounded structures, the banks of streams and rivers, the MHW or NW line o dal
waters, and any coastal wetlands landward of the MFiW or NFIW linHes. MAR 14 2016
o Delineate the vegetated buffer landward from the normal pool elevation of i unded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal WU S.
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.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

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).
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 DEMLR to veriJij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 4615 Page No: 1981-1982
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per 15A NCAC 21-1.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
httn:/ /www.secretary.state.tic.us/Corporations/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 http://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.
Vill. 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:David K. Newsom PE
Consulting Firm: Crystal Coast Engineering PA
Mailing Address:205-3 Ward Road
City:Swansboro State:NC Zip:28584
Phone: (910 ) 325-0006
Email:[e-mail]
Fax: (910 ) 325-0060
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has be j �Aer�O 4E§ eEs
section) ��511pf'— PPP
I, (print or type name of person listed in Contact Information, item 2a) 4 i MAR 1 4 70Mfy Ut I
own the property identified in this permit application, and thus give permission toU int or type name of pe t n
listed in Contact Information, item la) with (print or type BNtne-ofargnnizatinn_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: Date:
1, a Notary Public for the State of County of
do hereby certify that personally appeared
before me this _ day of . and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item la) Haddon M. Clark, III
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 21-1.1000 and any other applicable state stormwater requirements.
Date: 5-09-aotb
I, C r�}h:g R. �. fG' a Notary Public for the State of Not l� ,— County of
do h1iT ereby certify that vAOv. i'i•) GC"A- t-T personally appeared
before me this�I�day of M cty -k 01 OI �, and cknowledge ,t.hnee due a ecution of the application for
a stormwater permit. Witness my hand and official seal, P5 mro\ •
SEAL
My commission expires 1 / ao I a046
�V
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

--------------
SOSID: 0128585
Date Filed: 2/22/2016 11:59:00 PM
Elaine F. Marshall
0 BUSINESS CORPORATION ANNUAL REPOF North Carolina Secretary of State
CA2016 054 00067
NAME OF BUSINESS CORPORATION: Sampson-Bladen Oil Company Incorporated
SECRETARY OF STATE ID NUMBER: 0128585
REPORT FOR THE FISCAL YEAR END: 10/31/2015
1. NAME OF REGISTERED AGENT: Haddon M
2. SIGNATURE OF THE NEW REGISTERED AGENT:
3. REGISTERED OFFICE STREET ADDRESS & COUNTY
STATE OF FORMATION: NC
QX Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
4. REGISTERED OFFICE MAILING ADDRESS
510 Commerce Street PO Box 469
Clinton, NC 28328 Sampson Clinton, NC 28329-0469
1. DESCRIPTION OF NATURE OF BUSINESS: Retail Sales
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE
Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS & COUNTY 5. PRINCIPAL OFFICE MAILING ADDRESS
510 Commerce Street PO Box 469
Clinton, INC 28328 Sampson Clinton, NC 28329-M9
SECTION C: OFFICERS (Enter additional officers in Section E.)
NAME: David K. Clark NAME: David K. Clark
TITLE: Secretary TITLE: Treasurer
ADDRESS:
ADDRESS:
P O Box 469 P O Box 469
Clinton, NC 28329
Clinton, NC 28329
NAME: Haddon M. Clark III
TITLE: President
ADDRESS:
PO Box 469
Clinton, NC 28329
SECTION D: CERTIFICATION OF ANNUAL REPORT, Section D must be completed in its entirety by a person/business entity.
SIGNATURE
Form must be signed by an officer listed under Section C of this tans.
DATE
M. C-I" " Y res!JQ'�
Print or Type Name of Officer Print or Type Title of Officer
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $25 O. RE
TO: Secretary of State, Corporations Division, Post Office Box 29525, Raleigh, NC 2762&0525 ❑ `

SECTION E: ADDITIONAL OFFICERS
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME: Rogers Clerk NAME:
TITLE: Vice President TITLE:
ADDRESS: ADDRESS:
PO Box 469
Clinton, NC 28329
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME: NAME:
TITLE: TITLE:
ADDRESS: ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
Name:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:

Lewis,Linda
From: Bob Brantley <bob@ bunnbrantley.com >
Sent: Tuesday, January 05, 2016 5:31 PM
To: Lewis,Linda; Betty Bullock; David Newsom
Cc: Larry LaVecchia
Subject: RE: Little Caesars - Rocky Point SW8 140102
Thank you, Linda.
Bob Brantley
President
Bunn Brantley Enterprises, Inc.
389 Instrument Dr.
Rocky Mount; NC 27804
252-977-9111 (office)
252-450-5433 (cell)
252-977-4605 (fax)
bob(@bunnbrantlev.com
www.bunnbrantley.com
From: Lewis,Linda [mailto:[e-mail]]
Sent: Tuesday, January 05, 2016 5:19 PM
To: Betty Bullock; David Newsom; Bob Brantley
Cc: Larry LaVecchia
Subject: RE: Little Caesars - Rocky Point SW8 140102
THII
DEMLR received the subject permit transfer request on December 30, 2015.
Linda Lewis, E.I.
Environmental Engineer III
Division of Energy, Mineral and Land Resources
Department of Environmental Quality
910-796-7215 Office
linda.lewis(cDncdenr.gov
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington; NC 28403
0 Nothing Compares.
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

From: Betty Bullock [mailto:[e-mail]
Sent: Tuesday, January 05, 2016 4:43 PM
To: David Newsom<[e-mail]>;'Bob Brantley' <[e-mail]>
Cc: Larry LaVecchia <[e-mail]>; Lewis,Linda <linda.lewis@ncdenr.9ov>
Subject: RE: Little Caesars - Rocky Point
Attached is the transmittal & certification sent to Linda Lewis in November of 2015.
Betty
From: David Newsom[mailto:[e-mail]
Sent: Tuesday, January 5, 2016 9:56 AM
To: 'Bob Brantley' <[e-mail]>
Cc: Betty Bullock <[e-mail]>; Larry LaVecchia <[e-mail]>
Subject: RE: Little Caesars - Rocky Point
My apologies for the tardy response. See if the below responses clarify status.
1) Regarding Stormwater Certification .... Yes ... I did indeed find the Certification in our files (dated 10/24/14). On
Nov 18, 2015 we delivered to John Pierces office with the note "Please forward to Linda Lewis'. Betty ..... can you
please confirm receipt and confirm delivery to DENR? Mr. Brantley ... If you like, I can either fax or pdf a copy of
that Cert for your records.
2) Betty .... Also please confirm that both the STORMWATER name change and Permit Modifcation applications
were forwarded to DENR.
From: Bob Brantley [mailto:[e-mail])
Sent: Monday, January 04, 2016 5:55 PM
To: David Newsom <[e-mail]>
Cc: Betty Bullock <[e-mail]>; Larry LaVecchia <[e-mail]>
Subject: RE: Little Caesars - Rocky Point
David:
Please see my questions below, in red letters and yellow highlights! Also, see if your buddy at Fender County Utilities
can get us a fee schedule and sewer hook up approval.
The owners did, in fact, call me today and quizzed me rather sternly. Please get me the answers I am seeking in the
yellow highlights below so I can get a little water on the fire. And soon. Thank you.
Bob Brantley
President
Bunn Brantley Enterprises, Inc.
389 Instrument Dr.
Rocky Mount, NC 27804
252-977-9111 (office)
252-450-5433 (cell)
252-977-4605 (fax)

bo b(%bunnbrantley.com
www.bunnbrantley.com
From: Larry LaVecchia[mailto:[e-mail]]
Sent: Monday, January 04, 2016 3:50 PM
To: Bob Brantley
Cc: Betty Bullock
Subject: FW: Little Caesars - Rocky Point
FYI
Larry
From: Pat O'Mahony[mailto:[e-mail]]
Sent: Monday, January 4, 2016 3:12 PM
To: Larry LaVecchia <[e-mail]>
Subject: RE: Little Caesars - Rocky Point
La rry,
Happy New Year to you as well.
I have not received an approval from NCDENR forwarded to my office from you or from the state — that is the last bit of
info needed for zoning approval. Also, just be aware that Pender County Utilities had comments that must be addressed
as well, however, those will not affect the zoning approval of this project. Those comments will need to be addressed
before receiving building permits.
The comments from NCDENR and Linda Lewis are below:
The Little Ceasars Pizza is a different story because it will be located on a site that currently holds a permit, the Han-
dee Hugo's under SW8 140102, permitted on January 10, 2014. As of this date, we have not received the Designer's
Certification for the constructed wetlands BMP_, =DAVID, I THOUGHT YOU SAID YOU HAD FOUND IT, BUT HAD
FORGOTTEN TO FILE IT BACK IN 2014 WHEN YOUR INSPECTION HAD PROVEN IT WAS TO SPEC. IS THAT NOT
RIGHT? HAVE YOU FORWARDED YOUR CERTIFICATION TO DENR VET?===The approved plans in our file do show a
building where a Subway was supposed to go, but I guess that it's been changed to Little Ceasars. It also appears that
some minor layout changes to the site will need to be done.
The permittee of record, i.e., Sampson-Bladen Oil Company, Inc., will need to submit the following information to the
Division in order to approve this proposed project:===DAVID, TO MY KNOWLEDGE, BETTY BULLOCK HAS ALREADY
FILED THOSE FORMS WITH DENR. BEFORE CHRISTMAS. PLEASE CONFIRM THAT THEY WERE FORWARDED TO DENR
1. A signed plan revision request form;
2. Two sets of the proposed layout changes to the approved plan and documentation that the proposed
amount of built -upon area after this new layout is constructed will not exceed the 42,502 sf of BUA currently
permitted and will leave the 14,935 sf of future BUA intact. If a portion of the future BUA needs to be tapped

to make the new site plan work, then a revised page 3 of 6 of the application will be required as well, showing
the revised BUA numbers;
3. The designer's certification for the project. The Division has copied this email to the design consultant, Dave
Newsom, P.E. No email address for the permittee was provided.
4. The owner is noted on the Pender County application as SBOC Pender Eat, LLC, which does not match up
with the state's permittee of record, which is Sampson-Bladen Oil Company, Inc. If the LLC now owns the
property, the permittee will need to submit a completed and signed Name/Ownership Change form to
document the ownership change.
Please feel free to pass this email on to the affected owner.
Thanks,
Linda
Let me know if you have any further questions. I can forward those PCU comments to you again if needed.
Sincerely,
Pat O'Mahony
Current Planner I
Pender County Planning and Community Development
Division of Planning
805 S. Walker Street (Physical Address)
PO Box 1519 (Mailing Address)
Burgaw, NC 28425
[phone]
[phone] (fax)
From: Larry LaVecchia[maiIto: LarryLaVecchia(&ilpnc.com]
Sent: Monday, January 04, 2016 2:42 PM
To: Pat O'Mahony
Subject: Little Caesars - Rocky Point
Pat,
Happy New year to You.
Question on Little Caesars.
What do we need to do (or finish doing) to get your (Pender Counties) official approval on this site?
Thanks,
Larry
Thank You,.
Larry M. LaVecchia

John E. Pierce & Associates, P.A.
405 Johnson Blvd.
P.O. Box 1685
Jacksonville, NC 28541
Phone:[phone]
Fax:[phone]
This email has been scanned by the Symantec Email Security.cloud service.
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Corporations Division Page 1 of 1
North, Caroilina
Elaine F: Marshall DEPAR"P MEN T' OF THE
Secretary ECRETARY oF, STATE3
PO BOX 29M WO. NC 27626-0622 (9/ 9)607.2000
Click Here To:
View Document Filings File an Annual Report Print a Pre -Populated Annual Report form
Amend a Previous Annual Report
Corporate Names
Legal: SBOC Pander EAT, LLC
Limited Liability Company Information
Sosld:
Status:
Annual Report Status:
Citizenship:
Date Formed:
Fiscal Month:
State of Incorporation:
Registered Agent:
Corporate Addresses
1364458
Current -Active
Current
Domestic
2/26/2014
January
NC
Berry, Harold W., Jr. 1
Reg Office:
327 Hillsborough St.
Raleigh, NC 27603-1725
Mailing:
One Columbus Center Ste 400
Virginia Beach, VA 23462-6759
Principal Office:
One Columbus Center Ste 400
Virginia Beach, VA 23462-6759
Reg Mailing:
P O Box 527
Raleigh, NC 27602-0527
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20
General Manager: Independent Trustees, Inc.
One Columbus Center, Ste 400
Virginia Beach VA 23462
http://www.secretary.state.nc.us/Search/protcorp/10460727 12/30/2015

PAR n�r E-Fi led Annual Report
3" y� LIMITED LIA131LITYCOMPANY 10460727
ANNUAL REPORT Do not data enter manually.
� b.3
NAME OFLIMITF.DLIABILITY COMPANY: S130C1'endet-LAT LLC
REPORT FOR TTiE WAR: 2015 STAIT OF INCORPORATION: NC
SECRE I'ARY OFSTATE L.L.C. ID NUMBER: 1364458
NATURE OP BUSINESS: Real estate erchange accommodation entity
REGISTERED AGENT: Berry, Harold W. Jr. '
REGISI'F.RED 0I71.ICE MAILING ADDRL'SS: 10 Box 527
Raleigh, NC 27602-0527
REGISTERED OFFICE STRE1 I' ADDRESS: 327 Hillsborough Si.
Raleigh, NC 27603-1725 Mike County
PRINCIPAL OFFICE TL'LEPI IONE NUMBER: [phone]
PRINCIPAL OFFICE MAILING ADDRESS: One Columbus Center Ste 400
Virginia Beach, VA 23462-6759
PRINCIPAL. OFFICE SI'REL''I' ADDRESS: One Columbus Center Sle 400
Virginia Beach, VA 23462-6759
Company Officials:
Name. lndependenl trustees, Inc.
Tide: General Manager
Address:
One Columbus Center, Ste 400
Virginia Bench, VA 23462
CERTIFICAT ION 01; ANNUAL REPORTMUST11F, COMPLGIL'D 13Y ALL LIMITED LIABILITY COMPANIES
lndependenl Trustees, Inc., by Jeffrey Powell Smith - CPO 3/9/2015
FORM MUST BE SIGNEDBY A MANAGER/MI MBE,R DATE
lndependenl Trustees, Inc., by Jaffrey Powell Smith,- CPO General Manager
TYPE OR PRIM' NAMF TYPF OR PRIM' TPfLE
ANNUAL REPORT PEE: E-Paid MAIL TO: Secretary of State • Corporations Division • Post Office Box 29525 • Raleigh, NC 27626-0525

State of North Carolina
Department of the Secretary of State
Limited Liability Company
ARTICLES OF ORGANIZATION
SOSID: t364458
Date Filed: 2/26/2014 2:04:00 Pbf
Elaine F. Marshall
North Carolina Secretary of State
C2014 056 01153
Pursuant to §5713-2-20 of the General Statutes of North Carolina, the undersigned does hereby submit these
Articles of Organization for the purpose of forming a limited liability company.
1. The name of the limited liability company is: SBOC Pender EAT. LLC
(See Item 1 of the Instructions for appropriate entity designation)
2. The name and address of each person executing these articles of organization is as follows: (State whether
each person is executing these articles of organization in the capacity of a member, organizer or both.
Note: This document must be signed by all persons listed.)
Pamela J. Faber, Vice President of INDEPENDENT TRUSTEES OF VIRGINIA, INC., a Virginia
Corporation, which is the sole member and manager of the newly form NC limited liability company
as well as its organizer
Independent Trustees of Virginia, Inc., One Columbus Center, Suite 400 Virginia Beach, VA 23462
3. The name of the initial registered agent is: Harold W. Berry, Jr.
4. The street address and county of the initial registered agent office of the limited liability company is:
Number and Street _ 327 Hillsborough Avenue
City Rnleieh State: NC Zip Code: 27603 County:
5. The mailing addressif different from the street address, of the initial registered agent office is:
Number and Street
City Raleigh State: NC Zip Code: 27602 County:
6. Principal office information: (Select either a orb.)
a. ❑ XX The limited liability company has a principal office.
The principal office telephone number: _757-605-2015_
The street address and county of the principal office of the limited liability company is:
Number and Street: One Columbus Center. Suite 400
City: Virginia Beach State: VA Zip Code: 23462 County
CORPORATIONS DIVISION P.O. Box 29622 RALEIGH, NC 27626-0622
(Revised January 2014) 2 (Form L-01)

The mailing address, if different from the street address, of the principal office of the company is:
Number and Street:
City: State: Zip Code: County:
b. ❑ The limited liability company does not have a principal office.
7. Any other provisions which.the limited liability company elects to include (e.g., the purpose of the entity)
are attached.
Privacy Reduction
8. (Optional): Please provide a business e-mail address. -
The Secretary of State's Office will e-mail the business no
cost when a document is filed. The e-mail provided will not be viewable on the website. For more
information on why this service is offered, please see the instructions for this document.
9. These articles will be effective upon filing, unless a future date is specified:
This is the 251day of February, 2014
Independent Trustees of Virginia, Inc.
By:
Signature
Pamela J. Faber, Vice President
Type or Print Name
The below space to be used if more than one organizer or member is listed in Item #2 above.
Signature
Signature
Type and Print Name and Title Type and Print Name and Title
Signature
Signature
Type and Print Name anTit e Type an Pnnt Name and Title
CORPORATIONS DIVISION P.O. Box 29622 RALEIGH, NC 27626-0622
(Revised January 2014) 3 (Form L-01)

Corporations Division
14
k
Page 1 of 2
Click Here To:
North Carolina
Elaine F Marshall DEPARTMENT OFTPiE
Secretary SECRETARYOFSTATE
PO Berx 20M 11818i+, h, NC 2M'b&W22 (94907-2000
View Document Filings File an Annual Report Print a Pre -Populated Annual Report form
Amend a Previous Annual Report
Corporate Names
Legal: Sampson-Bladen Oil Company, Incorporated
Business Corporation Information
Sosld:
0128585
Status:
Current -Active
Annual Report Status:
Current
Citizenship:
Domestic
Date Formed:
3/3/1939
Fiscal Month:
October
State of Incorporation:
NC
Registered Agent:
Clark, Haddon M, III
Corporate Addresses
Principal Office: 510 Commerce Street
Clinton, NC 28328
Reg Office:
510 Commerce Street
Clinton, NC 28328
Reg Mailing:
PO Box 469
Clinton, NC 28329-0469
Mailing:
PO Box 469
Clinton, NC 28329-0469
Officers
Secretary:
David K. Clark
P O Box 469
Clinton NC 28328
Treasurer:
David K. Clark
P O Box 469
Clinton NC 28328
Chief Executive Officer:
Haddon M. Clark
PO Box 469
Clinton NC 28328
President:
Haddon M. Clark
PO Box 469
Clinton NC 28328
http://www.seci-etary.state.nc.us/Search/profcorp/4592599 12/30/2015

Corporations Division a Page 2 of 2
Vice President: Rogers Clark
PO Box 469
Clinton NC 28328
Stock
Class:
Common Class A Voting
Shares:
400
Par Value:
100
Class:
Common Class B Non Voting
Shares:
39600
No Par Value:
Yes
Class:
Preferred
Shares:
100
Par Value:
100
http://www.secretary.state.nc.us/Search/profcorp/4592599 12/30/2015

Completeness Review Checklist
Project Name:„ (,� y a Received Date: �C- M ?Zmt1�N
Project Location: rYY� Accepted Date:'. _`-
�T-
Rule(s) El2008 Coastal ®1995 Coastal Phase II (WiRO.) ❑Universal F-11988 Coastal
Type of Permit: New or Mod or PR Existing Permit # (Mod or PR): I LfD I o2 nPE Cert on File?
Density: HD or LD Type: Co mercial or Residential F-1NCG:
%: n(% OK?) Stream Cla s: MSA Map nOffsite to SW8„
Subdivided?: Subdivision or Sing" 11 (ORWMap I ) (Exempt /I 11;�' f U - aJ
Paperwork Emailed Engineer on: /- IV
nSupplement(s) (1 original per BMP) BMP Type(s): /la
F-1O&M with correct/original signatures (1 on final per BMP except LS/VFS and swales) /
plication with correct/original signature El Deed
.13 Corp or LLC: Sig. Auth. per SoS or letter -5&A.44 nEmail Address: Design Engineer
❑$505 (within 6mo)
❑Soils Report with SHWT �j
Calculations (signed/sealed)
�"I
11
�No obvious errors �b
Density includes common areas, etch
nDeed Restrictions, if subdivided: t/
ed & Notarized
Email Address: Owner
ote to Reviewer.
�J-Yf-L' Svr�."►o�i"'- B i--o't�^'—Oo f Co, �c�
sec. Covenants & Rest.
Plans
r---l3'Sets
Details (roa
, cul-de-sacs, curbs, sidewalks, BMPs, Buildings, etc)
Grading
Wetlands:
elineated or No Wetlands
Vicinity Map
Layout (p oposed BUA dimensions)
❑Legend
�DA Map
Project Boundaries
Infiltration
Wet P�/ d
offsite
Soils Report
�SoJls Report
F-1PE Cert for Master Lot #:
SHWT:
/WT:
Deed Rest for Master Lot # Matches Master
Bottom:
P:
BUA Permitted (Master): sf
Visited:
BUA Proposed (Offsite): sf
Additional Information:
Permitted
BUA (sf)
DA (sf)
PP (el)
SHWT (el)
Depth (ft)
SA (sf)
Proposed: Proposed:
Proposed:
AN
1A
�
M

JOHN L. PIERCE & ASSOCIATES, P.A.
LAND SURVEYING — LAND PLANNING — MAPPING
P.O. 130X 1685
JACKSONVILLE, NC 28541
OFFICE: [phone] FAX: [phone]
EMAIL: hettvh(1ylpnc.com
Or hrianjkljlnnacom
TO: Ms. Linda Lewis
N.C. Department of Environment and Natural
Resources —Division of Energy, Mineral & Land
Resources/Land Quality Section
127 Cardinal Drive Extension
Wilminf,jon, NC 28405
Letter of Transmittal
DATE:
December 14 2015
ATTENTION:
Ms. Linda Lewis
Re:
Han -Dee Huge, — "Plan Revision'
COPIES
DATE
NUMBER
DESCRIPTION
2
Sets of revised stonnwater plans
2
State Stonnwater Permit Name/Ownership Change Form
2
Stormwater applications with Narrative & BUA Summary for Plan
Revision
C 17
2015

DEMLR USE ONLY
' Date Received
Fee Paid
Permit Number
-�-ZO/
"A
56V ¢O/O
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph I1- 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
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
1. 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.):
2. Location of Project (street address):
City:Rocky Point County:Pender Zip:28457
3. Directions to project (from nearest major intersection):
Project is located at intersection of US Hwy.177 & NC Hwy 133, Pender County.
4. Latitude:34° 23' 22.0" N Longitude:77* 53' 35.8" W of the main entrance to the project.
I1. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ❑New ®Modification ❑ Renewal w/ Modificationt
tRenemals toith modifications also requires SWU-102 - Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit numberSW8140102 , its issue date (if known)1/10/14 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
❑NPDES Industrial Stormwater
❑Sedimentation/Erosion Control: <1.0 ac ac of Disturbed Area
❑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? �No LJYe
If yes, see S.L. 2012-200, Part VL httl2://12ortal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page I of 6
EGEIV
DEC 17 2015
I3Y:�—

III, CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Signing Official &
b.Contact information for person listed in item I above:
Street Address:3 09 Drake Circle
City:C R Cn e ( C\,\
Mailing Address (if applicable):P.O. Box 469
State:NC Zip:27607
City:Clinton State:NC Zip:27607
Phone: [phone] Fax:
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: c- ��t L N V L, K 1-. I�T L L
Signing Official&Title:
b.Contact information for person listed in 1item 2a above:
Street Address: 32oc1 Drn1 e C; rcAe
City: e State: iJ( Zip: ry.07
MailingAdd(rress ifapplicable): 33o Dface
City: I State: N C Zip: 6 0
Phone: Mil) ICIOL, Fax: ( 1
Email:_��a �O/1 l �GfIC®.S�iml�stln�la en•Cor.
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
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing
Phone: ( 1 Fax:
Email:
4. Local jurisdiction for building permits:
Point of Contact:laki Pace Phone #:
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6
910 259-151
f'-vDEC 11 20b
BY:_------

IV.. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Plan Modification to account for redistribution of previously permitted BUA. All runoff from BUA diverted
to an existing Constructed Wetland.
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 ❑ I'll II — Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 2.37 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':1.74 acres
Total project area shall be calculated to exclude the followin the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Umal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landrard from the NHW (or MH W) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (orMHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 75.70% %
9. How many drainage areas does the project have?1 (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
Drainage Area \
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Northeast Cape
Fear River
Stream Class *
B;SW
Stream Index Number*
18-74-(47.5)
Total Drainage Area (so
75,871 sf sf
On -site Drainage Area (so
73,871 sf sf
Off -site Drainage Area (sf)
-0-
Proposed Impervious Area** (so
57,437 sf
% Impervious Area** (total)
Impervious" Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
4,972 sf
On -site Streets (so
-0-
On-site Parking (so
36,545 sf
On -site Sidewalks (so
1,591 sf
Other on -site (so
-0-
y
Future (so
14,329 sf
11
Off -site (so
-0-
BY:
Existing BUA*** (sf)
-0-
Total (so:
57,437 sf
* Stream Class and Index Number can be determined at: ham://uortal.ncdenr.org ebhuq/js csu/classifications
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

' 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. ACAD
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 13MP specified for this project. The latest versions of the forms can be downloaded
from ham://12ortal.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
http://portal.ncdennorg/web/wq/ws/so/statesw/forms does. 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 ham://_12ortal.ncdenr.org/web/wq/ws/su/maps.)
Please indicate that the followine 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 does.
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
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
htto://www.enviiell2.org/12ages/onestopexi2ress.htmlforinformation 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/ managemen tfor
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 1h mile of the site boundary, include the V2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (seated, 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 MI-fW or NFIW 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 impounde p
structures, the banks of streams or rivers, and the MHW (or NFIW) of tidal fEm—
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned. LADEC 9 7 2��5
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control m ures.
[3Y:--
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

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.
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"x1l" 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: 4387 Page No: 261 _
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC _
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per 15A NCAC 21-I.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.
hU://www.secretary.state.nc.us/Co[porations/CSearch.asi)x
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/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:David K. Newsom PE
Consulting Firm: Crystal Coast Engineering. PA
Mailing Address:205-3 Ward Road
City:Swansboro
Phone: (910 ) 325-0006
Email:crysta lcoa sten ob izec. rr.com
State:NC Zip:28584
Fax: (910 ) 325-0060
IX, PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section) , �J� I �--t-
1, (print or type name of person listed in Contact Information, item 2a) M • l�GOr`4�.LL1. , certify that I
own the property identified in this per it placation��rr n thus give permission to (print or type name of person
listed in Contact Information, it�n 1a) NM .0 with (print or type name of organization listed in
Contact Information, item la) J Oe, _(to develop the project as curre ����$$$����'''yyy
the lease agreement or pending property sales contract has been provided with the sub i tCF—in cc�attesszt) e
party responsible for the operation and maintenance of the stormwater system. SEC 17 2015 ptl
Form SWU-101 Version Oct. 31, 2013 Page 5 of 6 BY:

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 1 will be operating a stormwater
treatment facility without a valid permit. 1 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.
Date: 1-1 -09-'4 01s,
I, t- uq . a Notary Public for the /State of / County of
�7�yy do hereby certify that ���ln �.l �(�4��T� personally appeared
before me this,), -day of 4L-eK) f an ackno ledge theJue a ecutio of the application for
a stormwater permit. Witness my hand and official
P, HUry a
p,RV
_
J
' 1� `y p u �� `a�r••r
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires-7121yCJ/ Y
1, (print or type name of person listed in Contact Information, item Ia) Haddon M. Clark 1I1
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 21-I .1000 and any other applicable state stormwater requirements.
do hereby certify that
Date: ),4--O-t —,,;lot Y-
for the State of t t / County of
personally appeared
before me this day of rf�? and ckno ledge the ue exec tio� of the application for
a stormwater permit
Witness my hand and official seasQ LL-= L -
i
R- P, Ft(/Gy,
�01NRy F
z m
comm.
20120�0Pulav
i
Z9 �coo'�
SEAL
My commission expires s p/AOl
ECEIVE
DEC 11 2015
BY:--------'
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATE STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION
1. Stormwater Management Permit Number: SW8 140102
2. Project Name: Han -Dee Hugo
3. Current Permit Holder's Company Name/Organization: Sampson -Braden oil Company, Inc.
4. Signing Official's Name: Haddon Clark III Title: President
5. Mailing Address: 3309 Drake Circle
City: *- P,a IP i Qh State: NC Zip:
6. Phone: [phone] Fax: (
27607
II. PROPOSED PERMITTEE / OWNER / PROJECT / ADDRESS INFORMATION
This request is for: (please check all that apply)
8✓ Name change of the owner (Please complete Items 1, 2 and 3 below)
Name change of project (Please complete Item 5 below)
❑✓ Change in ownership of the property/company (Please complete Items 1, 2, 3, and 4 below)
❑ Mailing address / phone number change. (Please complete Item 4 below)
❑ Other (please explain):
1. Proposed permittee's company name/organization: SBOC PENDER EAT, LLC
2. Proposed permittee's signing official's name: Haddon Clark Ili
3. Proposed permittee's title:
4. Mailing Address: 3309 Drake Circle
State: NC Zip: 27607
Phone: 21g 785-1904 Fax: (
5. New Project Name to be placed on permit:
Please check the appropriate box. The proposed permittee listed above is:
❑ HOA or POA (Attach documentation showing that the HOA or POA owns, controls, or has a
recorded easement for all areas that contain stormwater system features. Print name of HOA or
POA in #1 above and provide name of HOA/POA's authorized representative in #2 above)
❑✓ The property owner
❑ Lessee (Attach a copy of the lease agreement and complete Property Owner Information on
page 4)
❑ Purchaser (Attach a copy of the pending sales agreement. Final approval of this transfer !! be
granted upon receipt of a copy of the recorded deed) ®� `A
❑ Developer (Complete Property Owner Information on page 4) r,
p�C 1 � 2p15
SSW N/O Change Rev24Sept2012 Page 1 of 4

III. REQUIRED ITEMS
A request to transfer a permit will not be approved by the Division of Water Quality (DWQ) unless all
of the applicable required items listed below are included with the submittal. Failure to provide the
listed items may result in processing delays or denial of the transfer.
1. This completed and signed form. This certification must be completed and signed by both the
current permit holder and the new applicant if this is a change of ownership.
2. Legal documentation of the property transfer to a new owner.
3. A copy of any recorded deed restrictions, covenants, or easements, if required by the permit.
4. The designer's certification (DWQ Engineer and Designer Certification Forms are available from
each DWQ Regional office), if required by the permit and if not already submitted to DWQ.
5. If the proposed permittee is a firm, partnership, association, institution, corporation, limited liability
company, or other corporate entity, provide documentation showing the authority of the named
representative to act on behalf of the proposed permittee.
6. The $40.00 processing fee. If this is an initial transfer from the original permittee the processing
fee is not required. Subsequent ownership transfers will require the $40.00 processing fee.
IV. CURRENT PERMITTEE'S CERTIFICATION
Please check one of the following statements and fill out the certification below that statement:
❑ Check here if the current permittee is only changing his/hedits name, the project name, or mailing
address, but will retain the permit. I, , the current
permittee, hereby notify the DWQ that I am changing my name and/or I am changing my mailing
address and/or I am changing the name of the permitted project. I further attest that this application
for a name/ownership change is accurate and complete to the best of my knowledge. I understand
that if all required parts of this application are not completed or if all required supporting information
and attachments listed above are not included, this application package will be returned as
incomplete.
M Check here if current permittee is transferring the property to anew owner and will not retain
ownership of the permit.
I, Haddon Clark. III on behalf of Sampson Bladen oil Ca, the current permittee, am submitting this application
for a transfer of ownership for permit # SWs 1Z02 . I hereby notify DWQ of the sale or
other legal transfer of the stormwater system associated with this permit. I have provided a copy of
the most recent permit, the designer's certification for each BMP, any recorded deed ' ns,
covenants, or easements, the DWQ approved plans and/or approved as -built pla Irr�� ved
operation and maintenance agreement, past maintenance records, and I
stormwater inspection report to the proposed permittee named in Sectio Y2nd V or I
further attest that this application for a name/ownership change is accura aAi o t best
of my knowledge. I understand that if all required parts of this application rlaf completed or If all
required supporting information and attachments listed above are not incl d, this a eats n
package will be returned as incomplete. I assign all rights and obligations a8 I ee to the
proposed permittee named in Sections II and V of this form. I understand that this transfer of
ownership cannot be approved by the DWQ unless and until the facility is in compliance with the
permit.
Signature: M. d L,, _0 Date:
I, r tt V t 1ci� a Notary Public for the State of
County of do hereby certify that
In r personally appeared before me this the
4W)_ day of -2YY1 � � g �lv u!
20 "� and acknowledge �"i�, �-�ion of the
,a° Q` �' 4,••
rgoi g instrument. tness m�hand ndofficial seal, : �s�j 15e+ o�
�,
o ary Signature '= 0012 j20,9 2 i
�C
pugs
SSW N/O Change Rev24Sept2012 Page 2 of 4

V. PROPOSED PERMITTEE CERTIFICATION: (This section must be completed by the
Proposed Permittee for all transfers of ownership)
I, Haddon Clark, 111 on behalf of SBOC Pander Eat, LLC , hereby notify the DWQ that I have acquired
through sale, lease or legal transfer, the responsibility for operating and maintaining the permitted
stormwater management system, and, if applicable, constructing the permitted system. I
acknowledge and attest that I have received a copy of: (check all that apply to this permit)
ethe most recent permit
✓ the designer's certification for each BMP
❑✓ any recorded deed restrictions, covenants, or easements
0 the DWQ approved plans and/or approved as -built plans
✓ the approved operation and maintenance agreement
past maintenance records from the previous permittee (where required)
✓ DWQ stormwater inspection report showing compliance within 90 days prior to this transfer
I have reviewed the permit, approved plans and other documents listed above, and I will comply with
the terms and conditions of the permit and approved plans. I acknowledge and agree that I will
operate and maintain the system pursuant to the requirements listed in the permit and in the
operation and maintenance agreement. I further attest that this application for a name/ownership
change is accurate and complete to the best of my knowledge. I understand that if all required parts
of this application are not completed or if all required supporting information and attachments listed
above are not included, this application package will be returned as incomplete.
Date: 1A -0i-dot f
a Notary Public for the State of
County of 1 V LXAC V , do hereby certify that
1 i 'Sly X, uk_� personally appeared before me this the
i
day of �aj5NW , 20t_�2_, and acknowledge the due execution of the
(orgoin - instrument. Wit less m, y hand and official seal, ..``R A. HUG&'4.
I` • Imo, (fllX„/�`J ��' os AR Y tit�`'�-;
(P
ary Signature =_ Comm• 19
07izolzo c)
°UB��£
coo
Additional copies of the original permit and the approved Operation and Maintenance agreement can
be obtained from the appropriate Regional Office of the Division of Water Quality.
This completed form, including all supporting documents andprocessing fee if required), should be
sent to the appropriate Regional Office of the North Carolina Department of Environment and Natural
Resources, Division of Water Quality, as shown on the attached map.
Please note that if the Proposed Permittee listed above is not the property owner, the property owner
must complete and sign page 4 of this document. Both the lessee /developer and the property
owner will appear on the permit as permittees.
SSW N/O Change Rev24Sept2012
ECEIVE
DEC 17 2015
Page 3 of 4 By:

VI. PROPERTY OWNER CONTACT INFORMATION AND CERTIFICATION
If the Proposed Permittee listed in Sections II and V of this form is not the Property Owner, the
Property Owner must provide his/her Contact Information below and sign this form:
Printed Name:
Organization:.
Title within the Organization:
Street Address:
City:
State:
Zip:
Mailing Address:
(if different from street address)
City: State: Zip:
Phone:
Email:
Fax:
I certify that I own the Property identified in this permit transfer document and have given permission
to the Proposed Permittee listed in Sections II and V to develop and/or, lease the property. A copy
of the lease agreement or other contract, which indicates the party responsible for the construction
and/or operation and maintenance of the stormwater system, has been provided with the submittal.
As the legal property owner I acknowledge, understand, and agree by my signature below, that I will
appear as a permittee along with the lessee/developer and I will therefore share responsibility for
compliance with the DWQ Stormwater permit. As the property owner, it is my responsibility to notify
DWQ by submitting a completed Name/Ownership Change Form within 30 days of procuring a
developer, lessee or purchaser for the property. I understand that failure to operate and maintain the
stormwater treatment facility in accordance with the permit is a violation of NC General Statute
(NCGS) 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 of the property owner
Date:
I, , a Notary Public for the State of
County of , do hereby certify that
personally appeared before me this the
day of , 20, and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
Notary Signature
SSW N/O Change Rev24Sept2012 Page 4 of 4
(Notary Seal)
EC;EIVEFJ
DEC 17 2015
BY:

Mr. / Ms. Permittee
Date
On December 17, 2015, the Division received your request to transfer the permit to the new owner. A
preliminary in-depth review of that information has determined that the application is not complete. The
following information is needed to continue the stormwater review:
1. 02H.1003(e)(1) —In the case of a corporation (Inc. or LLC), the application must be signed by a
principal executive officer of at least the level of vice-president.
The NC Secretary of State indicates that the sole member and manager of SBOC Pender EAT, LLC is
Independent Trustees of Virginia, Inc. In that case, the only person who can sign the transfer form on
behalf of the "Proposed Permittee' is someone of at least the level of vice-president in Independent WE Nip 7W I t
Trustees of Virginia, Inc., such as Ms. Pamela J. Faber. If you are a vice-president in Independent Do" - A4AP —
Trustees of Virginia, Inc., or if you have signature authorization, then please submit the necessary b&L&- )
documentation in order to accept your signature on behalf of the proposed permitter. Otherwise, Ms.. .d"
Faber will need to sign the transfer form.
Failure to provide the requested information, or to respond to this letter with a plan of action, including a
timeline to resolve the identified deficiencies, by March 18, 2016, are considered violations of the I V
permit. If the requested information is not submitted to this office by the due date, then DEMLR staff' I{A0f
will re -inspect the site and may issue a Notice of Violation. Please also note that any individual or entity Zaz,�TJnt)sn iP
found to be in noncompliance with the provisions of a stormwater management permit or the stormwater A SMP
rules is subject to enforcement action as set forth in NCGS 143 Article 21, including the assessment of W1 am aac'
civil penalties of up to $25,000 per day. flRt"t 7
If you have any questions, please contact me at the Wilmington Regional Office, telephone number (910)-
796-7215 or via email at [e-mail].
Sincerely,
Linda Lewis, E.I.
Environmental Engineer III
Enc: Compliance Inspection Report
GDS\arl: \AStormwater\Permits & Projects\2014\I40102 I ID\2016 02 CEI_deficient 140102
cc: Dave Newsom, P.E., Crystal Coast Engineering
Independent Trustees of Virginia, Inc. Pamela J. Faber, VP
(One Columbus Center, Ste 400 Virginia Beach, VA 23462)
Ponder County Planning Department
Georgette Scott, Wilmington Regional Office Stormwater Supervisor
WiRO Stormwater Permit File
Page 2 of 2

JOHN L. PIERCE & ASSOCIATES, P.A.
LAND SURVGYING — LAND PLANNING — MAPPING
P.O. 13OX 1685
JACKSONVILLE, NC 28541
OFFICE: [phone] FAX: [phone]
E-MAIL: bettvbnilnnc.com
Or [e-mail]
'r0: Ms. Linda Lewis
N.C. Department of Environment and Natural
Resources —Division of Energy, Mineral & Land
Resources/Land Quality Section
127 Cardinal Drive Extension
Wilmington, NC 28405
Letter of Transmittal
DATE:
November 19, 2015
ATTENTION:
Linda Lewis
Re:
I]an-Dce Ilu o-RockyPoint-Permit No. SW8140102
COPIES
DATE
NUMBER
DESCRIPTION
1
Original "Engineer's Certification"
COVE
REMARKS:

Lewis,Linda
From: Lewis,Linda
Sent: Wednesday, October 21, 2015 9:00 AM
To: 'Pat O'Mahony'
Cc: 'David Newsom'
Subject: RE: Pender County TRC: Minor Site Developments - Little Ceasars Pizza & Smith Funeral
Home
Pat -
There's no problem with the Smith Funeral Home, since there is no existing permit that I am aware of being impacted
and the project is simply an interior upfit of an existing building.
The Little Ceasars Pizza is a different story because it will be located on a site that currently holds a permit, the Han-dee
Hugo's under SW8 140102, permitted on January 10, 2014. As of this date, we have not received the Designers
Certification for the constructed wetlands BMP. The approved plans in our file do show a building where a Subway was
supposed to go, but I guess that it's been changed to Little Ceasars. It also appears that some minor layout changes to
the site will need to be done.
The permittee of record, i.e., Sampson-Bladen Oil Company, Inc., will need to submit the following information to the
Division in order to approve this proposed project:
1: A signed plan revision request form;
2. Two sets of the proposed layout changes to the approved plan and documentation that the proposed amount of
built -upon area after this new layout is constructed will not exceed the 42,502 sf of BUA currently permitted and
will leave the 14,935 sf of future BUA intact.If a portion of the future BUA needs to be tapped to make the new
site plan work, then a revised page 3 of 6 of the application will be required as well, showing the revised BUA
numbers;
3. The designer's certification for the project. The Division has copied this email to the design consultant, Dave
Newsom, P.E. No email address for the permittee was provided.
4. The owner is noted on the Pender County application as SBOC Fender Eat, LLC, which does not match up with
the state's permittee of record, which is Sampson-Bladen Oil Company, Inc. If the LLC now owns the property,
the permittee will need to submit a completed and signed Name/Ownership Change form to document the
ownership change.
Please feel free to pass this email on to the affected owner.
Thanks,
Linda
From: Pat O'Mahony(mailto:[e-mail]]
Sent: Tuesday, October 20, 2015 5:15 PM
To: Allen Serkin (Cape Fear COG) <[e-mail]>; Bill McDow (Wilmington MPO)
<[e-mail]>; Bill Wilder (Duke Energy) <[e-mail]>; Bryan McCabe
<[e-mail]>; Carson Smith Ext<[e-mail]>; Charles Newman
<[e-mail]>; Charlie Ring <[e-mail]>; Sams, Dan <[e-mail]>;
Jones, Daniel F <[e-mail]>; David Smith (PC Schools) <[e-mail]>; Dee Turner
<[e-mail]>; Grady, Don H <[e-mail]>; Racine, Douglas W <[e-mail]>; Emily
Greer (USACE) <[e-mail]>; Gene Jackson ([e-mail]) <[e-mail]>;

Gr'acie Contreras<gcontreras@pen dercountync.gov>; GRAY, WALLACE <[e-mail]>; Blake, Hagen
< Hagen. [e-mail]>; Upchurch, James H <[e-mail]>; Jan Dawson
<[e-mail]>; Dail, Jason <[e-mail]>; Jason Turner <[e-mail]. net>;
Jimmy Smith - Four County <[e-mail]>; Steenhuis, Joanne <[e-mail]>; Josh
Norwood <[e-mail]>; Hite, Katie E <[e-mail]>; Kyle Breuer
<[e-mail]>; Lewis,Linda <[e-mail]>; Margaret Gray
<[e-mail]>; Dunn, Maria T. <[e-mail]>; Melissa Pedersen
<[e-mail]>; Michael Mack <[e-mail]>; Mike Kozlosky
([e-mail]) <[e-mail]>; Mike Taylor <[e-mail]>;
Henry, Nathan <[e-mail]>; Randy Hoffer <[e-mail]>; Vause, Robert A
<[e-mail]>; Robert Walker <[e-mail]>; Scott Sills ([e-mail])
<[e-mail]>; Tom Collins <[e-mail]>; Tommy Batson
<[e-mail]>; Tommy Garriss <[e-mail]>; James, Trentt
<[e-mail]>; Vencent Dodge <[e-mail]>
Cc: Megan O'Hare <[e-mail]>
Subject: Pender County TRC: Minor Site Developments - Little Ceasars Pizza & Smith Funeral Home
Good afternoon Pender County'FRC members,
As outlined in the Pender County Unified Development Ordinance § 2.9.2 A, the'I'echnical Review Committee shall make a
recommendation on the following TWO site development submittals.
Case #59-2015:
Bob Brantley, applicant, on behalf of SBOC PENDER EA'r LLC, owner, is requesting approval of a minor site development plan for
the construction of a full service restaurant (NAICS 7221). The request consists of constructing a f 1233' quick service restaurant and
drive -that connected to an existing convenience store. The subject property is located at southwest comer of the intersection of US
HWY 117 and NC H WY 133 at 11795 US I I WY.I 17, Rocky Point, NC. The property is zoned GB, General Business zoning district
and may be identified as Pender County PINS 3233-34-7640-0000 and 3233-34-7403-0000.
Project Highlights:
- f 1233' quick service restaurant and drive-thrn.
- Paved parking existing on -site, with 13 spaces being striped.
- Current landscaping and buffer requirements meet UDO standards.
- Public water and sewer connections through Pender County Utilities.
- Master Development Plan approval given approval May 6, 2014.
Please find the applicant's application and site plan for the minor site development plan attached.
Case #60-2015:
Shellie Smith, applicant, on behalf of Beverly P. Dale, owner, is requesting approval of a minor site development plan for the up -fit of
an existing commercial structure for the use of a funeral home (NAICS 812210). The request consists of utilizing an existing structure
to conduct small viewings and funeral services. The subject property is located at the corner of Grandview Drive (SR 1702) of US
IiWY 17 at 16076 US IiWY 17, Hampstead, NC. The property is zoned GB, General Business zoning district and may be identified
as Pender County PIN 3293-42-0480-0000.
Project highlights:
- Paved parking existing on -site, with 18 spaces available.
- Current landscaping and buffer requirements meet UDO standards.
- Private water and septic connections.
- No cremation will be done on -site. Embalming will be done on -site.
Please find the applicant's application and site plan for the minor site development plan attached.
Please have your comments to staff by Tuesday, October 27, 20151 if possible. If you need any further information or have questions,
please let me know.
Sincerely,

Pat O'Mahony
Current Planner I
Pender County Planning and Community Development
Division of Planning
805 S. Walker Street (Physical Address)
PO Box 1519 (Mailing Address)
Burgaw, NC 28425
[phone]
[phone] (fax)
Disclaimer: Pursuant to North Carolina General Statutes, Chapter 132, etseq., this electronic mall message and any attachments hereto, as well as any
electronic mall messages) that may be sent in response to it may be considered public record and as such are subject to requests for review. If you
are not the Intended recipient, please destroy this message and Inform the sender immediately. The information contained In this email may be
confidential and, In any event, Is Intended only for the use of the entity or Individual to whom it Is addressed.

Pender County
Planning and Community Development
Planning Division
805 S. Walker Street . Phone: [phone]
PO Box 1519 Fax: [phone]
Burgaw, NC 28425 wpy,oeadercountvnc dov
�i SITE DEVELOPMENT APPLICATION
C 1tSG(.i')AeS4'. 7n, l
V V p 4 L
TNIS SECTION,FOR OFFICE USE
Date:
Permit Number:
Permit Fee: St,
Recelpt Number:
*Zoning Approval ONLY: E / NO
Final Zoning Compliance Approved: YES / ' 1@ / N/A
Type of Site Development Plan
❑ Ma
Minor
❑ Up Fit
° Name
Change of Current Use:
Yes
❑
❑ Does Not Apply
`^
Previous Use:
SECTION 1: GENERAL INFORMATION
Applicant's Name:
Bob BrantleyOwner's
Name:
Haddon Clark DBA SBOC EAT Ll
Applicant's Address:
389 Instrument Cr
Owners Address:
3309 Drake Circle
City, State, & Zip
Rock Mount, NC 27804
City, State, & Zip
Raleigh, NC 27807
Phone Number.
252 977 9111
Phone Number:
(919)
785-1904
Legal relationship of applicant to
land owner:
Design/Build General Contractor
SECTION 2: PROJECT INFORMATION
PIN (Property tat f):
3z33-3,1-7d Va U33-34-7'ktl
Total property acreage:
2.37
Zoning :
GB
Acreage to be disturbed:
1.073
Directions to Site:
From 140, take exit 408 to Hwy 210, head West on Hwy 210 for.30 miles to Hwy 117, go South on Hwy
117 3.6 miles to intersection of Hwys 117 and 133, Site is Southwest corner
Lot Size: 2.37 acres
Sq Ft of Building: adding 1233.79
Building Height: 20.00'
Setbacks
I Front: 25
Side: 25 & 10
Rear. 10
NAILS Code/Use:
7 2
Business Name:
To be "Little Caesars" lake out restaurant
Describe activities to be
undertaken on project site:
We will add this addition to existing Han Dee Hugo's #39, keeping the existing architectural
teatures that are on existing HH #38, This addition was originally planned, and the site plan
was originally
approve tl showing the site with a small 1250 SF .- future restaurant
Ownership:
Private
m Public
Number of Employees:
Number
of Members:
zero
Seating
Capacity'
zero
,. __...._._...... ,,. I—", o 11-1-•c mrro nwn um Properryownermayaeregtl/re0.
'Zoning aDProvel is for the use being proposed ON Y, other department approvals maybe required l.e. Fire Marshal,
Envitonmet)tal Health, Permitting, etc...
ce Case Tat l//Y4 r fff 3 8 r, , vq j t 'Lwr Page I
N� S%<

SECTION 3: CONDITIONS OF PERMIT STAFF ONLY) Check all that a l
Subject to compliance with all local state and federal regulations
Compliance with the site plan and application submitted for this permit
Compliance with setbacks
Located within the Special Flood Hazard Area (SFHA):
No
❑ Yes
SFHA Zone: AE, A, VE, AEFW (circle one)
❑ Flood -proofing Certification Required
❑ Elevation certificate required
❑ No -Rise Certiflcation Required
❑ Electrical and Mechanical to be Elevated
❑ Hydrostatic Openings Required
Foundation survey required
,JP
Pender County Environmental Health Approval
❑ Septic Permit
❑ Well Permit
J
Community Water System Approval
7Q Pender County Utilities (PCU) Water
❑ Private Water
Community Wastewater Approval
Pender County Ublltles (PCU) Sewer
Private Wastewater
Sediment and Erosion Control Permit if requiredN -2-014- IS 3 so
Storm Water Permit If re uired I 0 OL io ,
NC DOT Drivewa Permit es - fn 3 S n W
A
Army CorpEngineers Wetland Permit
A A
CAMA oermit required
Landscape, buffer, parking compliance required Sip-L e ,
tk
Compliance wl Special Use Permit Case Number Vif al d i ued
Variance approval
Sin Permit
Additional Use Plot Plan
Additional Conditions staff or TRC :
Additional Conditions staff or TRC :
Additional Conditions staff or TRC :
SECTION 4: ADDITIONAL COMMENTS
The Idea of a small restaurant was originally planned for thls site, but due to market conditions the shell was not built, just shown
as a future restaurant space. The only difference in the proposed site plan and what was originally planned Is that this Little
Caesars concept, since it has no seating, is a lake out" restaurant, thus requiring a pick up lane In addition to walk in customer
S VC vi L � ervice.
SECTION : SIGNATURES
Applicant:
E v - I _
Date:
1L.15. rs
Owner:
Date:
Planning Staff:
Date:
Permit Technician:
Date:
Final Zoning Compliance
Approved
Date:
Page 2
Mrint f orm �I B

w
Pender County
Planning and Community Development
Planning Division
805 S. Walker Street �) Phone: [phone]
PO Box 1519 Fax: [phone]
Burgaw, NC 28425 www.ogndercountync.gov
THIS SECTION FOR OFFICE USE
Dater= c) (
Permit Number:
Permit Fee ,)rd.
Receipt Number:
*Zoning; Approval ONLY: YES NO
Final Zoning Compliance, Approved: YES / O, .N/A
Type of Site Development Plan
Major
❑ Minor
❑ Up -Fit
°
Changebf Current Use:
❑ Nos
❑ Does Not Apply
Previous Use: UGC t
SECTION 1: GENERAL INFORMATION
Applicant's Name:
John L.Pierce & Associates, P.A.
�.QwniName:
Sampson-Bladen Oil Co. Inc.
Applicant's Address:
P.O. Box 1885
ewhWs Address:
P.O. Box 469
City, ate' 8: Zip
Jacksonville, NC 28541
City,/State, 8: Zip
Clinton, NC 28329
Phone Number:
(910346-9800
Phone Number: [phone]
Legal relationship of applicant to
land owner:
Surveyor/Agent
SECTION 2: PRO]ECr INFORMATION
PIN (Property Id #):
3233347536
Total property acreage:
2.37 acres
Zoning :
GB
Acreage to be disturbed:
13.00 acres
Directions to Site:
From Interstate 40 take exit 408 to Highway 210, head West on Highway 210 0.30 miles to Highway 117,
head South on Highway 117 3.60 miles to the intersection of Highway 117 & Highway 133, property is on
Southwest comer
Lot Size: 2.37 acresll 03,132.17 s.f.
Sq Ft of Building: 2,800 s.f.
Building Height: 22' 3•
Setbacks
Front :2,5'
Side :107121 corner yard
Rear: 10•
NAICS Code/Use:
Business Name:
Han -Dee Hugo
Describe activities to be
undertaken on project site:
Convenience store & fuel sales
Ownership:
m Private
❑ Public
Number of Employees:
A )) (Air 1 YL
y�' h V� y5
Number of Members:
jV )/
Seating
Capa ity:
ii
*If the applicant is not the owneF of the property, a notarized letter from the property owner maybe required.
Environmental Health, Permitting, etc...
Page I

:StCTAO1611;3'COIVDIGLONS.OF..'PERMIIrSTAFF;ONLY G7ieblra//U�a?a t ' .,;: "+ ;. •_<<
Subject to comp(lance with all local state and federal regulations
Compliance with the site plan and application submitted for this permit
Compliance with setbacks
Located within the Special Flood Hazard Area ($FHA):
❑ No
❑ Yes
SFHA Zone: AE, A, VE, AEFW (circle one)
Cl Flood -proofing Certlflcadon Required
❑ Elevation certificate required
❑ No -Rise Certlficatlon Required
Cl Electrlcal and Mechanical to be Elevated
❑ Hydrostatic Openings Required
Foundation survey required
Pender County Environmental Health Approval
❑ Septic Permit
❑ Weil Permit
Community ter System Approval
FJ Pender County Utilities (PCU) Water
❑ Private Water
Community Wastewater Approval
Gi Pender County Utilities (PCU) Sewer
❑ Private Wastewater
ediment and Erosion Control Permit if required)
Storm Water Permit ifrequired)
NC DOT Driveway Permit
rtn -CorpEngineers Wetland Permit
CAMA permit required
Landscape, buffer, parking compliance required
Compliance wl Special Use Permit Case Number : if already issued
Variance approval
Sign Permit
Additional Use Plot Plan
Additional Conditions staff or TRC :
Additional Conditions staff or TRC :
Additional Condltlons staff or TRC :
SECTION 4: ADDITIONAL COMMENTS
t0'1,j1hjkq G '✓ V 4,
SECTIONS: SIGNATURES
Applicant:
Date:
b
Owner: p'^
h
Date:
Plannino Staff.
Date:
Permit Technician:
Date:
Final Zoning compliance
Approved
Date:
<`Print' .prim.
Page 7

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SECTION 1: APPLICANT INFORMATION
Applicant's John
L. Pierce & Associates P.A.
Owner's Name:
Sampson•Bladen Oil Co. Inc.
Name:
Applicant's
Owner's
Address: P.O.
Box 1685
Address:
P.O. Box 469
Gam' State' 8 Jacksonville,
NC 28541
City, State' 9
Clinton, NC 28329
Zip
Zip
Phone Number: (910)
346-9800
Phone Number:
(910) 4984358
Legal relationship of
applicant to land owner: Survey0rlA9ent
SECTION 2: PRO3ECT INFORMATION
Type of Nester
❑ Residential
m Commercial
a6sow
❑ Mixed Use
❑ Exempt
Development Plan
RP, PD, RM MH a/ fticr
GB, Ol, rr GI
PD
Property
i }33 -3y- (,-a,,)
Total property acreage:
Identification
y,34ggq_
2.37 acres
Number PIN
Zoning
Acreage to be disturbed:
Classification:
GB
3.00 acres
Project Address :
11795 U.S. Highway 117 South
Description of
from interstate 40 take exit 408 to Hwy.210, head West on Hwy. 210 0.30 miles to Hwy. 117,
Head south oe Hwy. 117 &so auim m me imerseawn of Hwy. 117 & ffwy. 133. property to on swthw t comer
Project Location:
Describe activities
construct a convenience store, future quick service restaurant & propose auto parts/retail store, obtain
undertaken
to beon
stormwater permit, driveway permit, application for erosion control permit
projectsita:
oproject
SECTION 3: SIGNATURES
Applicant's Signature
Date:
y. yvj
Owner's Signature
M
area:
Date:
3 ]o-dot

NOTICE TO AP.PLIS�T
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;cpq dl�Ral •o Y < tPlanSets salaige - i'a1ix17 '"- Otliery rir < a c ❑.F:y,H r;
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I . MASTER DEVELOPMENT PLAN CHECKLIST
SI wed A Ikatbn Form Both Applicant and Owner
Application fee
Legible list of all property owners adjacent to the property upon which the use is to be located. The list shall Include
the malling address & physical address of these property owners (The application will not be advertised for public
heating until the list Is accurate & complete)
One business size envelope legibly addressed with first class postage for each of the adjacent property owners on the
above list.
Protect Narra --Written description of the project (max of 3 paces) Including the following:
Location of the project and type of aces to project site
e,' Detailed description of the activities to be undertaken on the site, including hrs. of operation,# of employees, etc.
Cli Description of all construction activities to be undertaken on the site
fY Describe type of utilities that will serve project and stabs of approval from applicable providers
@' XISt of all state and federal permits that will be required for the project
Describe any potential impacts the project will have on the community or adjacent propeNes such as tralflc, noise, etc.
and explain efforts to mitigate these Impacts (this_ item must be addressed by the applicant). The applicant may also
wish to describe any positive benefits the project will provide for the community or neighbors of the project.
Master Development Plan Contents
AR MDP's shall be prepared in accordance with the following specifications:
The scale shall be one Inch equals 100 feet or larger (the ratio offeet to Inches shall be no more than one hundred feet to
one Inch) or at a sale acceptable to the Director. The scale shall be sufficient so that all features are discernible.
No sheet shall be smaller than 24"x36" in size unless approved by the Administrator. If the MDP is prepared on more than
one sheet match lines shall clearly Indlcate where the sheets join.
North arrow, a sale of 1:100 or larger and a legend describing all symbols.
A boundary survey of the entire property related to true meridian & certified by a registered surveyor with all dimensions
in ft & decimals of ft. A vicinity map at a suitable scale shall be provided showing the location of the project along with the
location of all existing or approved public roads streets or rights -of -way within 2,000 ft of the boundaries of the project.
The total area of the property shall be specified.
The topography shall be shown at 2 foot contour intervals.
The title of the proposed project; the date, month, year the plan was prepared or revised; the name of the applicant(s),
owners and contract owners • and the names of the Individuals or firms preparing the plan shall be clearly specified.
A schedule of phases, with the approximate loatlon of phase boundaries & the order In which the phases are to be
developed, shall be provided.
The use of all adloinina properties by mining, parcel Identification number PIN and current property owners .