SW5231201_Application Form_20240410

DEMLR USE ONLY
Date Received Fee Paid Permit Number
Applicable Rules: 0 Coastal SW-1995 0 Coastal SW-2008 0 Ph II-Post Construction
(select all that apply) 0 Non-Coastal SW-HQW/ORW Waters ❑Universal Stormwater Management Plan
0 Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision,facility,or establishment name-should be consistent with project name on plans,
specifications,letters,operation and maintenance agreements,etc.):
Mavis Tires#2096
2. Location of Project(street address):
NC-Hwv 56
City:Louisburg County:Franklin Zip:27549
3. Directions to project(from nearest major intersection):
840 LF northwest from the intersection of NC-56 and US-401 on the right before the Domino's Pizza
4. Latitude:36°5'4.7754"N Longitude:-78°19'0.552"W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is(check one): New ['Modification ❑Renewal w/ Modificationt
tRenewals with 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 number ,its issue date(if known) ,and the status of
construction: ['Not Started ❑Partially Completed* ❑Completed* *provide a designer's certification
2. Specify the type of project(check one):
Low Density ❑High Density ®Drains to an Offsite Stormwater System ['Other
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application,list the stormwater project number,
if assigned, and the previous name of the project,if different than currently
proposed,
4.a.Additional Project Requirements(check applicable blanks;information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major ®Sedimentation/Erosion Control:1.84 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 Permit:Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name,Project/Permit Number,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport? ❑No ®Yes
If yes,see S.L.2012-200, Part VI:http://portal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31,2013 Page 1 of 6

III. CONTACT INFORMATION
1.a.Print Applicant/ Signing Official's name and title(specifically the developer,property owner,lessee,
designated government official,individual,etc.who owns the project):
Applicant/Organization:Mavis Southeast, LLC
Signing Official&Title: Anthony Suggs, Chief Development Officer
b.Contact information for person listed in item la above:
Street Address:200 Summit Lake Drive,Suite 350
City:Valhalla State:NY Zip:10595
Mailing Address(if applicable):200 Summit Lake Drive,Suite 350
City:Valhalla State:NY Zip:10595
Phone: (914 ) 984-2500 Fax: ,( )
Email: [e-mail]
c.Please check the appropriate box.The applicant listed above is:
❑The property owner(Skip to Contact Information,item 3a)
Lessee*(Attach a copy of the lease agreement and complete Contact Information,item 2a and 2b below)
❑Purchaser*(Attach a copy of the pending sales agreement and complete Contact Information,item 2a and
2b below)
[V]'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:
Jeffery Rentals, LLC
Signing Official&Title: Carson Douglas Culbreth, Manager
b.Contact information for person listed in item 2a above:
Street Address::9309 Hometown Drive
City:Raleigh State:NC Zip:27615
Mailing Address (if applicable):see above
City: State: Zip:
Phone: Fax: j )
Email:
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:
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
4. Local jurisdiction for building permits:Town of Louisburg
Point of Contact:Philip Slaytor Phone#: (919 ) 496-3406
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.
Runoff will be collected in yard inlets and catch basins around the site and drain into a Extended Detention
SWM Pond
2.a.If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑Approval of a Site Specific Development Plan or PUD Approval Date:
❑Valid Building Permit Issued Date:
❑Other: Date:
b.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 Tar-Pamlico River basin.
4. Total Property Area: 2.08 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+: 2.08 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
W)
between the banks of streams and rivers, the area below the`Normal High Water(NW line or Mean High Water
(MHW)line,and coastal wetlands landward from the NNW(or MHVV)line. The resultant project area is used to
calculate overall percent built upon area(BETA). 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 = '63.9%
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 1 Drainage Area_ Drainage Area Drainage Area
Receiving Stream Name Tar River
Stream Class * WS-V;NSW
Stream Index Number* 28-(24.7)
Total Drainage Area (sf) 90,604
On-site Drainage Area(sf) 90,604
Off-site Drainage Area (sf) 0.00
Proposed Impervious Area**(sf) 57,935
% Impervious Area**(total) 63.9%
Impervious"Surface Area Drainage Area 1 Drainage Area Drainage Area_ Drainage Area_
On-site Buildings/Lots(sf) 6,765
On-site Streets (sf) 12,000
On-site Parking (sf) 14,500
On-site Sidewalks (sf) 1,350
Other on-site (sf) 0
Future(sf) 23,320
Off-site (sf) 0
Existing BUA***(sf) 0
Total (sf): 57,935
Stream Class and Index Number can be determined at: http://portal.ncdenr.org/web/wa/ps/csu/classfuations
** 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 Oct. 31,2013 Page 3 of 6

'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.
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 storm water 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://portal.ncdenr.org/web/wq/ws/su/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy,Mineral and
Land Resources(DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at http://portal.ncdenr.org/web/wq/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item.All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. _ARM
2. Original and one copy of the signed and notarized Deed Restrictions&Protective Covenants ARM
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s)(sealed,signed and dated) and O&M ARM
agreement(s)for each BMP.
4. Permit application processing fee of$505 payable to NCDENR. (For an Express review,refer to ARM
http://www.envhelp.org/pages/onestopexpress.html for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative(one to two pages)describing the stormwater treatment/management for
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the ARM
receiving stream drains to class SA waters within 1/2 mile of the site boundary,include the 1/2
mile radius on the map.
7. Sealed,signed and dated calculations (one copy). ARM
—
8. Two sets of plans folded to 8.5" x 14" (sealed,signed,&dated),including: ARM
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures,the banks of streams and rivers,the MHW or NHW line of tidal
waters,and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures,the banks of streams or rivers,and the MHW(or NHW)of tidal waters.
i. Dimensioned property/project boundary with bearings&distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours,proposed contours,spot elevations,finished floor elevations.
1. Details of roads,drainage features,collection systems,and stormwater control measures.
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).
Form SWU-101 Version Oct.31,2013 —Page 4 of 6

p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations(Please identify ARM
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 verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1557 Page No:748 ARM
11. For corporations and limited liability corporations(LLC):Provide documentation from the NC ARM
Secretary of State or other official documentation,which supports the titles and positions held
by the persons listed in Contact Information,item la,2a,and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State,otherwise the application will be returned.
http://www.secretary.state.nc.us/Corporations/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions,outparcels,and future development,the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary,a table listing each lot number,lot size,and the allowable built-upon area must be
provided as an attachment to the completed and notarized deed restriction form. The appropriate deed
restrictions and protective covenants forms can be downloaded from http://portal.ncdenr.org/web/lr/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:Andrew Mueller,PE
Consulting Firm:BL Companies
Mailing Address:3420 Toringdon Way,Suite 210
City:Charlotte State:NC Zip:28277
Phone: (704 ) 565-7070 Fax: ( )
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section) f� p ,�
I, (print or type name of person listed in Contact Information, item 2a) Oetr5arl ()a/.�J/4, A/4 that I
own the property identified in this pernikit a_p�p]�tica on, d thyis give permission to (print or type name of person
listed in Contact Information, item 1a) /juice l/I with(print or type name of organization listed in
Contact Information, item 1a
f ) Ma di S �/IZ'e, 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 includingincluding tyile assessment of civil pe ties o u to$2,, 0 per day,pursuant to NCGS 143-2 5.6./ /
Signature: ��� / � -c, �
Date: ?
P
I, j r i_ 4k,(1 , a//Noota„„ry Public for the
1State f A-) ,County of
do ereby cer ' y that Ccuip� 6 CLL personally appeared
before me this day of V .L Old and acknowledge th due exigajtion of the application for
a stormwater permit. Witness my hand and official seal, \,,,i (1 iiiL t.i!I
ORA R.
,,/' ARV 5 SEAL
P
�'''."AU �\G S My commission expires 1 b ML u - 0L-Dd T
COUNT,„.0
,,,,,,,Nod,,,,,,,,
X. APPLICANT'S CERTIFICATION [,/
I,(print or type name c f person listed in Contact Information, item la) \t‘4"\1 oytjS S jIii avl5 u rt ea5fcertify that the information included on this permit application form ,to the b of mow edge,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 u CAS 2H.1000 and any other applicable state stormwater requirements.
Signature: Date: /
I a/ oZoa3
I, ,a Notar, iblic for the State of New l vrk- ,County of
L )e5?1C 1 t1 es4 e r ,do hereby certify that kill
5115
personally appeared
-
before me this I3day of Ceps be( , 2O .3 and acknowled due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
EVIE THOMPSON 1
1 Notary Public-State of New York 1
( NO.01TH0013091
Qualified in Westchester County I
My Commission Expires Sep 5,2027 I
My commission expires 5 2 0 Z7
Form SWU-101 -Version Oct. 31,-2013 Page-6 of 6