SW5240102_Application Form_20240423

DEMLR LSE ONLY
Date Received Fee Paid Permit Number
Applicable Rules: ❑ Coastal SW- 1905 7 Coastal - 2008 7 Ph 11 - Post Construction
(sclrct all that apply) ❑ Non-Coastal SW- I iQW,i OR11: Waters ❑ Universal Stormwater management Plan
❑ 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
Thi t;lrla Mal/he pholocopro l as 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.):
2. Location of Project(street address):
TaLT f 7vt-c G: l c��� l $
City:— ( cam t-SG-i S�t��-� County:_ �--t 275 5
lip:
3. Directions to project(from nearest major intersection):
A ? o,
cJ0 53 3.4,
-I. Latitude'C ° 02 N Longitude:75 ° " 1V of the main entrance to the project.
II. PERMIT INFORMATION:
l.a.Specify whether project is (check one): XNew Modification
❑ Renewal w/ Modifications
'Rcn'o c;rl<,� nr�,lihrai��n< S110-10'-R�ll,;l�:r; lt�t,11 �h��r Llrnl
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(it known)) , and the status of
construction: ❑Not Started Partially Completed* [l Completed* Tr000,..a,Ici'in'r certification
2. Specify the type of lroject(check one):
❑I.ow DensityI-ligh Density Drams 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 1-87 -623-6i4t):
❑CAMA Major Sedimentation/Erosion Control: 1- 9-7 ac of Disturbed Area
❑NPDLS Industrial Stormwater ❑4U4/40I 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:_
3. Is the project located within ; miles of a public airport? gNo Yes
If tics, ;r't'SL 20i22-2(H), Part VI: �.
Form SWL-ItlI Version Oct. 31. 2013 Pal_cc I el()

CONTACT-INFORMATION
1.a.Print Applicant/ Signing Oflicial's name and title(specifically the developer, property owner, lessee,
designated government official, individual, etc. ii ho owns the project):
Applicant/Organization:
Signing Official l itle: ,\'"/( '"t-3-L17- /01
h.Contact information for person listed in item la above:
Street Address: ']Q QO = '4>M._ �5�
City: r l-\ State: }'L -- /i Z7 Co
Mailing Address Of a/1,11,41 ):- --
Cit1 - Mate: lip:
Phone: ( ) `f"�` " "` �� 1 a\:
Email:
in se check the appropriate bov. 1 he applicant listed a ho e
(he property oo nee(Ship to Conti I Information, item ;a)
iJ Lessee' (Attach a copy of the lease agreement and complete Contact Information, item 2a and '_h bcloo)
❑ Purchaser" (Attach a copy of the pending sales agreement and complete Contact Information, item?a and
2h below)
❑ Developer*(Complete Contact Information, item 2a and Tb belmv.)
2.a.Print Property Owner's name and title betoci, it e on are the lessee, purchaser or developer. (this is the
person who owns the property that the project is located on)
J/
Property Owner/Organization:_ r �"�L �`�t e 5 .�1� C r 1 -
Signing Official el tit /t� f ajtC .e/`
_..........._.
h.Contact information for person listed in item ?a above:
Street .Address: cl C O
l; City: \ '7'' ` ' l-� State: (� C- -�
_...-. Tip: c._ �( �.---Mailing Address 01 ipplir,rhle):_-
City: State:
Phone: 1_._ I a\: ( .....1.
[mail:
3.a. (Optional) Print the name and title of another conta).t soch as the project's construction supervisor or other
person who can,inswcr yuestionti ahcnit ilu•
Other Contact Person/Organization: I w �`!� }�� G� �� �c7N S"5'(Lvcc t
X Signing Official&Title
h.Contact information for person listed in item sa abos,r:
Mailing Address: -1._2..e7 �` �1l't 2� S
City: yo J G Stif f ... State: 1"ti C /ip Z-) J c7 Ca
Phone: ( r't t ) 6 1..
L1:›9 l C, C ' "
4. Local jurisdiction for building permits: ( - `�\r (�- L- V� N- w ��
Point of Contact:f_ 1.\ 5j 5 .% Phone ». ( I�) Z C1 "JZ 2'°
Y'o re-9 13 0`
l orm S\fit -101 \er,ion(ht. H. '_0 of

IV. PROJECT INFORMATION
I. In the space provided below, briefly sunurlarize belly the stori)iater runoff will he treated.
10
t �� + k -
2.a.If claiming vested rights, identity the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PCi) Approval Date:
❑ Valid Building Permit Issued Date:
7 Other: I)ate:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW- i995 ❑ I'h II - Post ConstruCtion
3. Stormwater runoff from this project drains to the (maces S River basin.
4. 'Total Property Area: '2 - acres 5. 'total Coastal Wetlands Area: 95. acres
6. Iotal Surface Water Area: ce. acres
7. 'total Property Area (4)-Total Coastal 1-A'c'tlands Area (3) - total Surface Neater Area (h) _'total Project
Area : 2.0 <o acres
- Total project area shall he calculated to e-t.clhcle the lollou'I)y: the Hornell pool of iral'unmh'il structure , the area
between the yanks of strearlis anti rii�c es the 111 Pa h�lc>u�the A''ornxil 1-11 h I\uher(tA,l-1I1) lime or Ahearn High IVater
(MHhV) line, and ccuistal wetlands laucluvu'cl from the NI Ii V(or 1-1l-Ilb) line. T he resultant project nna is used to
calculate overall l)errrnt Guilt r11'ra (ova (OL/A1) :Aloe(uaslal rIS lIuocl.�lruict�c'nrct of the'iv!HIV(or;A lift-V)line may
lu'inductee/in the total project area.
8. Project percent of impervious area: (total Impervious :Area ' 'total Project Area) X 100
9. I low many drainage areas does the project have? (i or high cieasiht, c( urtt 1 /or each proposed cagincercd
storm-water 13A1P. For lea'density allot ether ia-ofects, hsc I jOr 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
Stream Class * � S t.f
Stream Index Number* 2:7...Z� t;pt j )
,Total Drainage Area (sf)
On-site Drainage Area sf
Off-site Drainage Area (sf)
Prof� Area**Servious d is ��(total) (sf) C ( C)ZS
Impervious'' Surface Area Drainage Area__.. I)rainage Area Drainage Area_ Drainage Area
On-site Buildings/Lots(st)
On-site Streets (sf)
On-site Parking (st) ,3
On-site Sidewalks (sf) j co 3 _
Other on-site (sf) �/f
Future (sf) 77`
Off-site (sf) �,{ — —` — ---
Existing l3UA***(sf) d
Total (sf): Co�/ 02c6
• h•ealu Class(lilt!Index MOUNT can I'c'eleh'rruirtc'c(ul: _ .
• In1)k'17'ious area is ctefenect as Mc'('hilt 1114'11 area Inccluclirig, (gut nut Ii1llitrct to, roa.ls, luarklll ruYns,
sic 1I1'alks, prac'el areas, etc.
Form SWII-I01 Version Oct. 31, 2013 faze 3 o 6

***Report only that amount of existing RCA that coil! remain after rlez'elopment. De not report any existing BUA that
is to he rcnroz'e1t and which mill hc' replacel l'ii noto RCA.
11. 1 low was the off-site impervious area listed above determined?Provide documentation. T.--z/A
Projects in Union Counts.: Contact DF.tILR('errnal Olfirc staff ry,check if prnject is located within a lhrc'atenecl cti
Endangered Species watershed that mar hk'subject to more stringent storrmratcr requirements'as per 154 1.C'.•IC 0213.0600.
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. l'he latest versions of the forms can be downloaded
from hitp �, l
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
(1,Th . • . -. 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
Please indicate that the following required information have been Provided by initialit±ig in the space provided
for each item. All original documents L-IUSl be signed and initialed in blue ink. Download the latest versions
for each submitted application package from << ,
Initials
1. Original an,l one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions& Protective Covenants • - 7G
Form. (if required as per Part VIl below)
3. Original of the applicable Supplement Form(s) (sealed,signed and dated)and O&\l ' ?
agreement(s) for each BMP.0 s 1 _, 5.D r t✓ ��;L Zc? c
4. Permit application processing fee of S505 por/ahle to NCDF.N1l. (For an Express review, refer to _ 1L�
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.)
3. 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 >G:_
receiving stream drains to class SA waters within '2 mile of the site boundary, include the'
mile radius on the map. r�
7. Sealed,signed and dated calculations(one cops). (<-
8. Two sets of plans folded to 8.5" 14" (sealed,signed,& dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NC(...-AZ 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 111' or NHW line of tidal
waters,and any coastal wetlands landward of the MHW or \I IW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers,and the Nil 1W (or AH1V) of tidal waters,
i. Dimensioned property/project houndars with bearings& distances.
j. Site I.ayout with all RCA 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 identity 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 SW U-101 Version Oct. >I, 201.1 Page-I 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 DENILK Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DL\iLR immediately and
submit a completed \ame/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 1-3-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to S25,000 per day, pursuant to\CGS 143-215.6.
Signature: Date:
I, 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,
I
SI:AI.
Lly commission expires
X. APPLICANT'S CERTIFICATION ��}} !�� �__
I, (/ int or hype name or person li�1ctl in Contact Intaruiati�ur, item la) 1Z• 1n1 r",J01
certify that the information included on this permit application form is, to the est of my knowlet. ge,correct and
that the project will he 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 211 .1000 and any other applicable state stormwater requirements.
Signature: A llc c-1 _D( r%e Date: I.2/L-Y-•l I
I, s)n 1---)3art,s , a I ,otary Public for the State of MOT ( aunty of
, do hereby certify thatk W1L. 1 _- __-- personally appeared
before me this day of - , 207i3 an icknowledge the due etec7,ri in of the application for
a stormwater permit. Witness my hand and official seal, _
SEAL,
\.'
Q GOO\ c2i c�
' OX..e-OS- ZS
�� �1y commission expires
; IN
Form S\Ait -101 Version Oct. 31,2013 Page. 6 of 6