SW4231002_Application Form_20240409

DEMLR USE ONLYDate Received 1 Fee Paid
1 —
Permit NumberApplicable Rules: 0 Coastal SW-1995 CI Coastal SW-2008 0 Ph II-Past Construction
(select all that apply) 0 Non-Coastal SW-HQW/ORW Waters 0 Universal Stonnwater Management Plan
0 Other WQ Airint 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
L GENERAL INFORMATION
1. Project Name(subdivision,facility,or establishment name-should be consistent with
specifications,letters,operation and fiance agreements,etc.): project name on plans,
Dollar MT-Welcome,NC
2. Location of Project(street address):
5744 Old US Highway 52
City:Wek apse County: .
Zip2TZ9l5
3. Directions to project(from nearest major intersection):
2.86 miles south of the intersection of Old US Highway 52 ands 285/USH`vy52 in Welcome.NC.
4. Iatitnde5°54'09.9"N Longitade:80°15'24.5"W
of the main entrance to the project.
IL PERMIT INFORMATION;
1.a.Specify whether project is(check one): �f New
['Modification 0 Renewal w/Modificatio,nt
tRenavcls with modifications also requires SWU-102-Renewal Application Form
b.lf this application is being submitted as the result of a
Permit number ,r1s issue date(if known)
to an existing Psi;list the existing
construction: [Not Started ['PartiallyCom let:ed'� Completed*
and the status of
P 0 Cmn lased "pranide a designer's certification
2. Specify the type of project(check one):
0Low Density NHlSh Density ODrains to an Offsite Stonnwater System Daher
3. If this application is being submitted as the result of a
DEMI.R requesting a state sfiopreviously returned application or a letter from
if assigned, and management name application,list the srtormwater project number,
proposed, project,if different than currently
4.a.Additional Auject Requirements(check applicable blanks;information on
required
obtained by contacting the Customer Service Center at 1-8T7-i23-6748): state permits can be
EICAMA Major on/Erosion Control:
ac of Dishufied Area
DNPDES industrial Storniwater []404/401 Permit Proposed imps
b.lf any of these permits have already been acquired please provide the Project Name,Project/pit Number,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport? IgNo
If yes,see S.L.2012 200,Part VI:,...y.,,yarrat.ricatenr.org/web/hirules-and-regtdations
��,�,.�u7l.rtccrenrorg/webnr/rules-and-regulatioms

III. CONTACT INFORMATION
1.a.Print Applicant/Signing Official's name and title(specifically the developer,
designated government official,individual,etc.who owns the : property owner,lessee,
Applicant/urga zatiun.cect:tr Run( p'tal. LI.0
Signing Official&Title' erne,Boy kin-Me m he r/Martel*er
b.Contact information for person listed in item la above:
Street Addres:2405 Nash Street N
City:ti4ilson
State-'v C .
Mailing Address(ifapplicable).
mite• State: ZIP.
Pho
Fax
Emafi:
G Please check the appropriate box,The applicant listed above e 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 Infarmation,item 2a and 2b below.)
2.a.Print Property Owner's name and title below,if you are the lessee,purchaser or developer.
person who owns the property that the project is located on): the
Property Owner/Organized.n.t.eclat Run capital,tic
Signing Official&Title•iiariwc Boykin-Mem her/ktanat e! -
b.Contact information for person listed in item 2a above:
Street r>ddrr-ss:2405 Nish Street N
City:Nilson
State:NC Zip:27896
Mailing Address(if applicable):
City: State:
Phone: Fax
Entail•
3.a. (Optional)Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:
Signing Official&Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
Phone: . State: Zip:
Fax
Email
4. Local jurisdiction for building permits: lea vidson Cs2unty
Point of Contacttcott Leonard
Phone#: 036 ) 242 2229

1V. PROJECT INFORMATION
1. In the space provided below,briefly sammariw how the stormwater runoff will be treated.
w in a d t
a detention basin.• i tint,the site in the southeast corner
2.a.If claiming vested rights,identify the supporting documents provided and the date the were
El Approval of a Site Specific Development Plan or PUDy approved:
Valid Building Permit Approval Date:
Issued Date:
DI Other: _ Date:
b.If claiming vested rights,identify the regulation(s)the project has been designed in accordance with:
❑Coastal SW-1995 0 Ph II-Post Construction
3. Stormwater runoff from this project drains to the Yadkin P's' Dee River basin.
4. Total Pi uperty Area:1,38 acres 5. Total Coastal Wetlands Area:
acres
6. Total Surface Water Area: aCres
7. Total Property Area(4)-Total Coastal Wetlands Area(5)-Total Surface Water Area(6)=Total Project
Areal:1.38 acres
+ Total area shall be calculated to exclude the following: the normalo
between of streams and rivers, the area below the Normal Hi h poolater lind structures,High
area
(MHW)line,and coastal wetlands landward_ from the NHW(or line. The ultant or Mean Nish Water
calculate overall percent built upon area(BIM). Non-coastal wetlands ears used to
be included in the total project area. Tmud AII�MFJ
8. Project percent of impervious area:(Total Impervious Area/Total Project Area)X 100 =58.64
9. Flow many drainage areas does the project have?2(For high density, count 1 for each proposed engineered
storrmnater 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.
Basinlnformation Drainage Area 1 Drainage Area,, Drainage Area Drainage Area,
Reti e ivin`Stream Name Easter Creek Easter Creek
Stream Class
Stream Index Number• 12119-8-4-1 12-119-8-4-1
Total Drainage Area(sf) 45,681 14,356
On-site Drainage Area(sf) 45,681 14,356
Off-site Drainage Area j sf) 0 0
Proposed lnrpe'rvow., Area'(si) 31,850 3,400
% Impervious Area" (total) 69.72 23.7
Impervious'Surface Area Drainage Area 1 Drainage Area 2 Drainage —
On-site Buildings/Lots(sf) 10,000 �, Area DrainaFeAr+ea
On-site Streets (sf)
On-site Parking (sf) I 19,050 3,400
On-site Sidewalks (sf) 2,800
Other on-site (c i Future(,r
Off-site (' )
Existing BUA""*(sf) 0
0
Total (sr): 31,850 3A00
* Stream Class and Index Number can be determined at: h ,f al.ncdenr.
gyp' m'g/u- - - 'r►s/csulclassijications
'. Irrna us area is defined as the built upon area includi n&brit not limited to,buildings,roads,parking areas,,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.
No offsite impervious
Prom 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 1 SA 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 farms can be downloaded
from-+t;p:/,vv.'taut*uenr.cfrg/web/wq/ws/su/bmpmanual.
VL SUBMTITAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy.Mineral and
Land Resources(DEMLR). A complete lackage includes all of the Items listed below. A detailed application
instruction sheet and BhtlP checklists are available from
ht .:/ ' '7/tabu' -ir.org/web/ vwse suisch 'norms doc. The complete application package should be
on"' to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at ' L://portalncdenr,org/web/wn/wct�*,I,,,�- }
Please e ll vided y initialing in the space provided
for each item.All original documents MUST be signed and initialed m blue ink. Download the latest versions
for each submitted application package from `+.n_//nnitaincdevr /wdl/ws/su/statesw/forms
1. Original and one copy of the Stormwater Management Permit Application Foam. I>
dtials
2. Original and one copy of the signed and notarized Deed Restrictions&Protective Covenants
Form.(if required as per Part VCI below)
3. Original of the applicable Supplement Form(s)(sealed.signed and dated)mg O&M
agreement(s)for gal BMP.
4. Permit application processing fee of$505 payable to NCDENR.(For an Express review,refer to
http://www.envhelp.org/pages/onestopexpress.html for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative(one to two pages)describing the stonuwater treatment/management for
6. A USGS map identifying the site location. If the receiving stream is reported as dass SA or the
receiving stream drains to dass SA waters within'mile of the site boundary,include the�
mile radius on the map.
7. Sealed,signed and dated calculations(one copy).
8. Two sets of plans folded to 8.5"x 14"(sealed,signed,&dated),including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures,the banks of streams and rivers,the MHW or NHW line of tidal
waters,and anycoastal wetlands landward of the MHW or NHW lines.
• Delineate t vegetated buffer landward from the normal pool elevation of impounded
structures,the banks of streams or rivers,and the MHW(or NHW)of tidal waters.
i. Dimensioned prop y/project boundary with bearings&distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours,proposed contours,spot elevations,finished floor elevations.
L Details of roads,drainage features,collection systems,and stormwater control measures.
m.Wetlands delineated,or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n Existing drainage(including off-site),drainage easements,pipe sizes,runoff calculations.
o. Drainage areas delineated(included in the main set of plans,not as a separate document).

p, Vegetated buffets(where required).
9. Copy of any a. .usable soils report with the associated SHWT elevations(Please identify
elevations in a. •'tion 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 NRCSproject area dearly 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.
anfilttation Devices submitted to WIRO1 Scheduk a site visit for DEMLR to verify the SHWT prior
to submittal,[phone].)
10. A copy of the most current property deed.Deed book:2623 Page No:600-604
11. For corporations and limited liability corporations(LLC):Provide documentation from the NC
Secretary of State or other official documentation,which supportsthe titles and
by the persons listed in Contact Information,item la,2a,and positions held
/or 3a per 15A NCAC 2H,1003(e).
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State,otherwise the application will be returned.
http://www.seczetary.state.no.us/CorporationsiCSearch.aspx
Vii. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions,outparcels,and future development,the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary,a table listing each lot number,lot size,and the allowable built-upon area must be
provided as an ac orient to the coin. • . and notarized deed restriction form. The appropriate deed
restrictions and protective covenants . • .. can be downloaded from ://portai.ncstenr oraweb/lr/state-
,rma .Download the latest versions for each submittal.
hi the instances where the applicant is different than the property owner,it is the responsibility of the property
owner to
that the d esidgn the
deed
stet ordeons al. protective cow form while the applicant is responsible for ensuring
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%ebsite,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).
ConsultingConsulting EngineerJoshuaCrumnier Pt
Consulting Firm;Crumiger ConsultingServh i c; PLLC
Mailing Address:2308 Ridge Road
City:galeig_h _ Statp•NC
Zip:27 =
Phone: f 410 ) 4l 3-1704 Fax:
[e-mail]
IX. PROPERTY OWNER AUTHORIZATION(if Contact Information,item 2 has been filled out,complete this
section)
I,(print or type none of person listed in Contact Information,item 2a)Barnes_Boykin certify that I
own the property identified in this permit application,and thus give permission to(print or type name of person
listed in Contact Information, item 1a)Barnes Boykin with(print or type name
Contact Information,item/a)cedar Runof organization listed y
the lease agreementor ��LLC to develop the project as currently proposed. A copy of
pending property sales contract has been provided with the submittal,which motes the
party responsible for the operation and maintenance of the stormwater system.

As the legal
owner
agent(entity listed in
Contact acknowledge,understand,and agree by my signature below,
l won,item 1)dissolves their companythat if my ontheir
designated
tome,,or pig sale, for compliance with the D ortonnwater defaults ve is backr
rty owner.As the property owner,it is m
submit a completedpermit reverts
Name/Ownership Change Form within to notify DF Immediately and
treatment f adlity without a valid permit. I understand that the , I will be operating a facility
ter
without a valid permit is a violation of NC General Statue 143-215.1operationmay of a stormwater iatee action including the assessment of civil penalties of up to$25,000 result in appropriate enforcement
per day,pursuant to NC016 143-215.6.
Signature' v 13a
'� Date: 3A .:2.0
x e k Ja Notary Public for the State of
County of
do hereby certify that • �Y
appearedbefore me this �aay � o
and acknowledge the due execution of the
a stormwater permit. Witness my hand and official seal, C _ 1 on for
CRYSTAL B. CASE I SEAL
Notary Public
Wayne County,NC
My commission expires a.a oat
X. APPLICANTS CERTIFICATION
I,(print or type name of person listed in Contact Information,
certify the information included on this item la)Burnes Brnikin
projectwill be information
iclud din permit��form is,to the best of my knowledge,correct and
and protective will b o will constructede conformance with
the
approved plans,that the required deed restrictions
applicable stormwatPr rules under lib recorded,and
2H.20�00 and proposed��complies wikh the requirements of the
any other applicable state stormwater requirements.
signature: 8.1".441..2, l
e14m2/32
Date: •
I, `� LS Co � .a Notary Public for the State of U _
U
, of
GJ iVSkj(1 _do hereby certify that o-r i n Y d
before me this day of Man" ��E» �� � — — �Y aPPe8t'e-( the due condition of the application for
a stormwater permit. Witness my hand and official seal,
•
SEAL
CRYSTAL B. CASE
Notary Public
Wayne County, NC ti y, commissionexpi g2.D-C��