SW4090301_Application

?,t'T'C,S 2 S. a✓
D WQ USti ONLY
Date Received Fee Paid Permit Number
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMITAPPLICATION FORM
This form may lye photocopied for use as an original
I. GENERAL INFORMATION
1. Applicants name (specify the name of the corporation, individual, etc. who owns the project):
McDonald's USA, LLC
2. Print Owner/Signing Official's name and title (person legally responsible for facility and compliance):
C. Nadine PerEy, Region Construction Manager
3. Mailing Address for person listed in item 2 above:
4601 Six Forks Road #200
City;Raleigh __ __ State:NC Zip:27609
Phone: (919 , 876-9716 Fax: (919 ) 326-4215
Email:
4. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
WDONALD'S, South Main St. -KING, NC _
5. Location of Project (street address):
INTERSECTION OF SOUTH MAIN SF. & BAILEY ROAD
City:Kl NG Co u n ty:Si'OKES Z i p:27021
6. Directions to project (from nearest major intersection):
HWY 52 North,' akeSouth Main St. Exit in Icing, NC, Head Eastlake Right) and Lot is atSW Quadrant of
South Main St. and Dailey Rd. Intersection_ _
7. Latit de:36° 15' 42" N Longihic1e:80° 21' 48" W of project
8. Contact person wlio can answer q"estioiis about tiie project:
Nance:Jessie Lester Telephone Number: (336 723-1067
Eilia iHlesterCstiIII meI va,com
11. PERMIT INFORMATION:
rot -III SWU-101 Version 09.2i.08 Page 1 of 4

1. Specify whether project is (check one): ❑New []Renewal ®Modification
2, if this application is being submitted as the result of a renewal or modification to an existing permit, list the
existing permit numherSW4090301 and its issue date (if knowo)4-7-09
3. Specify the type of project (check one):
❑Low Density []High Density ©Redevelop ❑General Permit [:]Universal SivlP []Other
4. Additional Project Requirements (check applicable blanks; information on required state perrnits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA lvlajor ©Sedimentation/Erosion Control ❑404/401 Permit ❑NPDES Industrial Stormwater
Ill. PROJECT INFORMATION
1. In the space provided below, summarize how stormwater will be treated. Also attach a detailed narrative
(one to two pages) describing stormwater management for the project.
Storwater will be treated byway of Bioretention Cells. Please Refer to Stormwa ter Report prepared by Shmmel
Associates PA for Stormwater Management Narrative. _
2. Stormwater runoff from this project drains to the Yadkin Diver basin.
3. Total Property Area: 1.229 acres 4. Total Coastal Wetlands Area. 0 acres
5. Total Property Area (3) — Total Coastal Wetlands Area (4) = Total Project Area"A.229 acres
6. (Total Impervious Area / Total Project Area) X 100 = Project Built Upon Area (BUA):73:29 %
7. How many drainage areas does the project have?3
8. Complete the following information for each drainage area. If there are more than two drainage areas in the
project, attach an additional sheet with the information for each area provided in the same format as below.
For hieh density proiects, complete the table with one drainage area for each engineered stormwater device.
Basin Information
Drainage Area I
Drainage Area 2
Receiving Stream Name
Barkers Creek
Barkers Creek
Stream Class & Index No.
Total Drainage Area (SO
20965
10257
On -site Drainage Area (sf)
209055
10257
Off -site Drainage Area (so
0
0
Existing Impervious* Area (sf)
25988
12326
Proposed Impervious+Area (so
18657
8718
% Impervious* Area (total)
89.0
85.0
Impervious' Surface .Area
Drainage Area 1
Drainage Area 2
On -site Buildings (sf)
3205
0
On -site Streets (sf)
0
0
On -site Parking (sf)
14424
8419
On -site Sidewalks (sf)
1028
299
Other on -site (sf)
0
0
Off -site 00
0
0
Total (so:
18657
8718
' Impervious area is defined its the built irpon area including, but 110t liatited to, Imildings, roads, parking areas,
sidernrrlks, gravel arerrs, etc.
Form SWU-101 Version 09.25.08 Page 2 of

05-14-'09 09:27 FACE]-Stimmel Assccc. P.A. 3367615@69 T-011 P006/006 F-027
Supplement to Stormwater Management P rrnit Application Form
1
Receiving Stream Name
Barkers Greek
Stream Class & index No.
Total Drainage Area (sD
9327
On -site Drainage Area (so
9327
Off -Site Drainage Areas
0
Existing Impervious Areas
6347
Proposed im ervivus Area sfi
70BB
0/6 Impervious Area total
76
w i
On -site Buiidin s s
2041
On -Site Streets s
On -Site Parkin2 (so
5017
On -Site Sidewalks s
30
Other on -sites
0
Off -site sf
0
Totals :
7088

"TWX project area shall he calcubricd to e.eclutIt, CosWal WeIlrands frem itse aohelr calodating the bailI report urea
percelfingz calculafion. This is fhc !bell resed to calculate 01xroll percent proled hitilt rrperu area WIA j.
9. How was the off -site impervious area listed above derived?Computer Generated Areas based on esiting
survev and desiet} of site
Projects in Union County: Contact the DIP'Q Central Office stuff fo check if) see f von project is located
it°ithin a Threatened & Etulaugered Species tralershed that may he subject to more .stringent storm+rater
requirements.
IV. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
One of the following property restrictions and protective covenants are required to be recorded for all
subdivisions, outparcels and future development prior to the sale of any lot. if lot sizes vary significantly, a table
listing each lot number, size and the allocVable built -upon area for each lot must be provided as an attachment.
Forms can be downloaded from hit!r//h2o.enr.state.nc.us/su/btnp fornns.htm - deed restrictions.
Form DRPC-1
High Density Commercial Subdivisions
Form DRPC-2
High Density Developments with Outparcels
Form DRPC-3 .
High Density Residential Subdivisions
Form DRPC4
Low Density Commercial Subdivisions
Form DRPC-5
Low Density Residential Subdivisions
Form DRPC-6
Low Density Residential Subdivisions with Curb Outlets
By your signature below, you certify that the recorded property restrictions and protective covenants for this
project shall include all the applicable items required in the above form, -that the covenants will be binding
on all parties and persons claiming under them, that they will run with the land, that the required covenants
cannot be changed or deleted without concurrence from the NC DWQ, and that they will be recorded prior to
the 'sale of any lot.
V. SUPPLEMENT FORMS
The applicable state stormwater management permit supplement form(s) listed below must be submitted for each
BNIP specified for this project. Contact the Stormwater Permitting Unit at (919) S07-6300 for the status and
availability of these forms. Forms can be downloaded from httl�:11112o.enr.st��te,nc�us/su/bmp forms.htm.
Form SW401-Low Density
Form SW401-Curb Outlet System
Form SW401-Off-Site System
Form SW401-Wet Detention Basin
Form SW401.-Infiltration Basin
Form SW401-infiltration Trench
Form SW401.-13ioretention Cell
Form SVV401-Level Spreader
Forth SVV401-Wetland
Form SW401-Grassed Swale
Form SW401-Sand Filter
Form SW401-Penneable Pavement
Form SW401-Cistern
Low Density Supplement
Cu rb Outlet System Supplement
Off -Site System Supplement
Wet Detention Basin Supplement
Infiltration Basin Supplement
Underground Infiltration Trench Supplement
Bioretention Cell Supplement
Level Spreader/Filter Strip/Restored Riparian Buffer Supplement
Constructed Wetland Supplement
Grassed Swale Supplement
Send Filter Supplement
Permeable Pavement Supplement
Cistern Supplement
Fonn SWU-101 .Version 09.23.08 Pale 3 of4

V1. SUBMIT['AL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ),
A complete package includes all of "the items listed below. The complete application package should be
submitted to the appropriate DWQ Office. (Appropriate office may he found by locating project on the
interactive online map at http_/rh2o.enr.st;►le�nc.irslsuiinsi M; I 1m_ii)
1. Please indicate that you have provided the following required information by initialing in the Space provided
next to each item.
Original and oue copy of the Storniwater Management Permit Application Corm
Original and one copy of the Deed Restrictions & Protective Covenants Form (if
rcgrrirerf as per Part IV above)
• Original of the applicable Supplement Form(s) and O&M agreement(s) for each BNIP
• Permit application processing fee of $505 (Express: $4,000 for HD, $2,000 for LD)
payable to NCDENR
Calculations & detailed narrative description of store►water treatment/management
• Copy of any applicable soils report
• Two copies of plans and specifications (sealed, signed & dated), including:
- Development/Project name
- Engineer and firm
- Legend
- North arrow
- Scale
Initials
K1
- Revision number & date
- Mean high water line
- Dimensioned property/project boundary
- Location map with named streets or NCSI� numbers
- Original contours, proposed contours, spot elevations, finished floor elevations
- Details of roads, drainage features, collection systems, and stormwater control measures
- Wetlands del'uleated, or a note on plans that none exist
- Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations
- Drainage areas delineated
- Vegetated buffers (where required)
VIi. AGENT AUTHORIZATION
If you wish to designate authority to another individual or firm so that they may provide information on your
behalf (such as additional information requests), please complete this section. (ex. designiiigengincer oi• Firm)
Designated agent (individual or firm):Stimmel Associates Pa
Mailing Address:601 N. Trade St. Suite 200
City:Winston-Salem State:NC l_ip;27101
Phone: (336 �723-1067
Email:ilesterOstimmelpa.com
VUL APPLICANT'S CERTIFICATION
Fax: (336 _ ) 761-5069
i, (print or type nacre of person listed in General Information, dear 2)
certify that the information iiyclucied 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 15A
rNCAC 2H .1000,
Signature:
Form SWU-IQI Version 09.25,08 rage 4 or 4
Da te: �1

05-14-'09 09:25 FROM-Stimmel Asscoc, P,A, 3367615069 T-011 P001/006 F-027
FAX TRANSMISSION
TO: ROBERT PATTERSON
RE: MCDONALD'S KING
FAX # [phone]
Robert,
I have tried twice to send the additional information via email, but it is getting bounced
back. I am now faxing you the information requested to complete your review. I will try
to follow up by phone to see if you have received the information or if you send me an
email letting me know you have everything ready to complete the revision it would be
greatly appreciated. If I am lacking anything just let me know and I will be happy to
assist you.
Thanks,
Ken Bink-ley
336-723-1067
[e-mail]

DWQ USE ONLY
Pate eceived Fee Paid Permit Number
5a5� Sw °t o 11 a3o
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
1. GENERAL INFORMATION
1. Alicants name (specify the name of the corporation, individual, etc. who owns the project)
--ac Dmw- g u6, , aC.
nno �r
IrJ
c�
�m
r?n�
as'
I
Q
:
a
a V
LU
2. Print Owner/SignOfficia4[,I'm
'name and title (person legally responsible for facility and compliance):
e. g ads ni . I-Ke ry Cl cIrrII !'1 m rllnm w.r
3. Mailing Address for
AOU Si v
n 1_._ k
City: 4111
Phone: 091
Email:
in item 2 above:
LL .42m
State: n[t% Zip: "tool
Fax: 3 2 5
4. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
MCDONALD'S, South \Main St. -KING, NC
5. Location of Project (street address):
INTERSECTION OF SOUTH MAIN ST. & BAILEY ROAD
City:KING County:STOKES Zip:27021
6. Directions to project (from nearest major intersection):
HWY 52 North Take South Main St. Exit in King, NC Head Eas!CFake Right) and Lot is at SW Quadrant of
South Main St. and Bailey Rd. Intersection
7. Latitude:36' 15' 42" N Longitude:80° 21' 48" W of project
8. Contact person who can answer questions about the project:
NameJessie Lester Telephone `lumber: (336 ) 723-1067
Email Jlester@stimmelpa com
I1. PERMIT INFORMATION:
Form SWU-101 Version 09.25.08 Page 1 of 4

1. Specify whether project is (check one): ®New ❑Renewal []Modification
2. If this application is being submitted as the result of a renewal or modification to an existing permit, list the
existing permit number and its issue date (if known)
3. Specify the type of project (check one):
Flow Density ❑High Density ®Redevelop ❑General Permit ❑Universal SMP []Other
4. 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 ❑404/401 Permit ❑NPDES Industrial Stormwater
III. PROJECT INFORMATION
1. In the space provided below, summarize how stormwater will be treated. Also attach a detailed narrative
(one to two pages) describing stormwater management for the project.
Storwater will be treated -by way of Bioretention Cells. Please Refer to Stormwater Report prepared by Stimmel
Associates PA for Stormwater Management Narrative.
2. Stormwater runoff from this project drains to the Yadkin River basin.
3. Total Property Area: 1.229 acres 4. Total Coastal Wetlands Area: Q acres
5. Total Property Area (3) - Total Coastal Wetlands Area (4) = Total Project Area**:1.229 acres
6. (Total Impervious Area / Total Project Area) X 100 = Project Built Upon Area (BUA):73.29 %
-.- 7. How many drainage areas does the project have?3
8. Complete the following information for each drainage area. If there are more than two drainage areas in the
project, attach an additional sheet with the information for each area provided in the same format as below.
For high density Proiects, complete the table with one drainage area for each engineered stormwater device.
Basin Information
Drainage Area 1
Drainage Area 2
Receiving Stream Name
Barkers Creek
Barkers Creek
Stream Class & Index No.
Total Drainage Area (so
21127
10324
On -site Drainage Area (sf)
21127
10324
Off -site Drainage Area (so
0
0
Existing Impervious* Area (so
25988
12326
Proposed Impervious*Area (so
18803
8878
Impervious* Area (total)
89.0
86.0
Impervious* Surface Area
Drainage Area 1
Drainage Area 2
On -site Buildings (so
3205
0
On -site Streets (so
0
0
On -site Parking (so
14570
8579
On -site Sidewalks (so
1028
299
Other on -site (so
0
0
Off -site (so
0
0
Total (so:
18803
8878
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
Sidewalks, gravel areas, etc.
Form SWU-101 Version 09.25.08 Page 2 of

Supplement to Stormwater Management Permit Application Form
Basin Informationi,
Draina9e.Areb 3
Receiving Stream Name
Barkers Greek
Stream Class & Index No.
Total Drainage Area (sf
9327
On -site Drainage Areas
9327
Off -Site Drainage Area (s
0
Existing Impervious Area (so
6347
Proposed Impervious Areas
7088
Impervious Area (total)
76
Dr'ainagd'Ar&t-3
On -site Buildings (so
2041
On -Site Streets (so
0
On -Site Parking (sq
5017
On -Site Sidewalks (sq
30
Other on -sites
0
Off -site (sf
0
Total (so:
7088

* Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
**Total project area shall be calculnted to exclude Coastal Wetlands from use when calculating the built upon area
percentage calculation. This is the area used to calculate overall percent project built upon area (BUA).
9. How was the off -site impervious area listed above derived?Computer Generated Areas based on esiting
survey and design of site
Projects in Union County: Contact the DWQ Central Office staff to check to see ifyou project is located
within a Threatened & Endangered Species watershed that may be subject to more stringent stormwater
requirements.
IV. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
One of the following property restrictions and protective covenants are required to be recorded for all
subdivisions, outparcels and future development prior to the sale of any lot. If lot sizes vary significantly, a table
listing each lot number, size and the allowable built -upon area for each lot must be provided as an attachment.
Forms can be downloaded from htt h2o.enr.state.nc.us su m forms.htm - deed restrictions.
Form DRPC-1
High Density Commercial Subdivisions
Form DRPC-2
High Density Developments with Outparcels
Form DRPC-3
High Density Residential Subdivisions
Form DRPC4
Low Density Commercial Subdivisions
Form DRPC-5
Low Density Residential Subdivisions
Form DRPC-6
Low Density Residential Subdivisions with Curb Outlets
By your signature below, you certify that the recorded property restrictions and protective covenants for this
project shall include all the applicable items required in the above form, that the covenants will be binding
on all parties and persons claiming under them, that they will run with the land, that the required covenants
cannot be changed or deleted without concurrence from the NC DWQ and that they will be recorded prior to
the sate of any lot.
V. SUPPLEMENT FORMS
The applicable state stormwater management permit supplement form(s) listed below must be submitted for
each BNIP specified for this project. Contact the 5tormwater Permitting Unit at [phone] for the status and
availability of these forms. Forms can be downloaded from http://h'o.enr.state.nc.us/su/bmp forms.htm.
Form SW401-Low Density
Form SW401-Curb Outlet System
Form SW401-Off-Site System
Form SW401-Wet Detention Basin
Form SW401-Infiltration Basin
Form SW401-Infiltration Trench
Form SW401-Bioretention Cell
Form SW401-Level Spreader
Form SW401-Wetland
Form SW401-Grassed Swale
Form SW401-Sand Filter
Form SW401-Permeable Pavement
Form SW401-Cistern
Low Density Supplement
Curb Outlet System Supplement
Off -Site System Supplement
Wet Detention Basin Supplement
Infiltration Basin Supplement
Underground Infiltration Trench Supplement
Bioretention Cell Supplement
Level Spreader/ Filter Strip/ Restored Riparian Buffer Supplement
Constructed Wetland Supplement
Grassed Swale Supplement
Sand Filter Supplement
Permeable Pavement Supplement
Cistern Supplement
Form SWU-101 Version 09.25.08 Page 3 of 4

VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. The complete application package should be
submitted to the appropriate DWQ Office. (Appropriate office may be found by locating project on the
interactive online map at hit://h2o.eiiI-.si'Ite.[IC.LIS/sti/rnsi ma s.htm)
1. Please indicate that you have provided the following required information by initialing in the space provided
next to each item.
Initials
• Original and one copy of the Stormwater Management Permit Application Form
• Original and one copy of the Deed Restrictions & Protective Covenants Form (if
required as per Part IV above)
• Original of the applicable Supplement Form(s) and O&M agreement(s) for each BMP
• Permit application processing fee of $505 (Express: $4,000 for HD, $2,000 for LD)
payable to NCDENR
• Calculations & detailed narrative description of stormwater treatment/management
• Copy of any applicable soils report
• Two copies of plans and specifications (sealed, signed & dated), including:
- Development/Project name
- Engineer and firm
-Legend
- North arrow
- Scale
- Revision number & date
- Mean high water line
- Dimensioned property/project boundary
- Location map with named streets or NCSR numbers
- Original contours, proposed contours, spot elevations, finished floor elevations
- Details of roads, drainage features, collection systems, and stormwater control measures
- Wetlands delineated, or a note on plans that none exist
- Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations
- Drainage areas delineated
- Vegetated buffers (where required)
VIL AGENT AUTHORIZATION
If you wish to designate authority to another individual or firm so that they may provide information on your
behalf (such as additional information requests), please complete this section. (ex. designing engineer or firm)
Designated agent (individual or firm):Stimmel Associates Pa
Mailing Address:601 N. Trade St, Suite 200
Citv: Winston-Salem State:NC Zip:27101
Phone: (336 ) 723-1067 Fax: (336 } 761-5069
Email:[e-mail]
VIII. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in General Information, item 2) 0. ��nL 4YN
certify that the information included on this permit application form is, to the best of my k owledge, 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 15A
NCAC 211.1000.
Signature:
Form SWU-101 Version 09,25.08 Page 5 of 4
Date: