Permit Application Form.pdf

NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to Application Instructions
A. ELIGIBILITY FOR FAST-TRACK PERMITTING
To be considered for a Fast Track ATC Permit, ail of the items below must be checked. If any item cannot
be checked, then the project must apply under the Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project) will meet all applicable
requirements of 15A NCAC 02H .1000 -.1062, including the Minimum Design Criteria (MDC), upon project
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Director's
Certification.
® The project is not out of compliance with an existing stormwater permit or any other environmental permit.
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined in 15A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seal of a professional licensed pursuant to either Chapter 89A
or 89C of the NC General Statutes.
® 1 understand that at project completion, an application with the as -built stormwater plans (as described in 15A
NCAC 02H .1044 must be submitted, and DEQ will review the as -built stormwater plans to confirm compliance
with the MDC. Approval of the as -built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1 Project Name: Aubert Landing Subdivision
2. Previous Project Name (if applicable): N/A
3. Location of Project (street address): McWhorter Road
City: NIA County: Un ion Zip:28110
4. Directions to project (from nearest major intersection):
From intersection of Potters Road and McWhorter Road proceed West for approximately 3900 linear feet or
0.75 Miles. Site will be on South side of McWhorter Road
5. Latitude:340 88' 79" N Longitude:800 69' 30" W of the main entrance to the project.
C. PERMIT INFORMATION
1. Specify whether project is (check one):
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: SWA
Stormwater Fast Track ATC Application Form Page 1 of 10 Feb. 10. 2018
DEMLR USE ONLY
Date Received
Fee Paid Permit Number
SW Program(s): 0 Coastal SA -HOW
0 Non -coastal HOW
0 Coastal SA-ORW 0 Coastal FW-ORW 0 Coastal Other
0 Non -coastal ORW 0 Urbanizing Areas 0 USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to Application Instructions
A. ELIGIBILITY FOR FAST-TRACK PERMITTING
To be considered for a Fast Track ATC Permit, ail of the items below must be checked. If any item cannot
be checked, then the project must apply under the Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project) will meet all applicable
requirements of 15A NCAC 02H .1000 -.1062, including the Minimum Design Criteria (MDC), upon project
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Director's
Certification.
® The project is not out of compliance with an existing stormwater permit or any other environmental permit.
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined in 15A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seal of a professional licensed pursuant to either Chapter 89A
or 89C of the NC General Statutes.
® 1 understand that at project completion, an application with the as -built stormwater plans (as described in 15A
NCAC 02H .1044 must be submitted, and DEQ will review the as -built stormwater plans to confirm compliance
with the MDC. Approval of the as -built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1 Project Name: Aubert Landing Subdivision
2. Previous Project Name (if applicable): N/A
3. Location of Project (street address): McWhorter Road
City: NIA County: Un ion Zip:28110
4. Directions to project (from nearest major intersection):
From intersection of Potters Road and McWhorter Road proceed West for approximately 3900 linear feet or
0.75 Miles. Site will be on South side of McWhorter Road
5. Latitude:340 88' 79" N Longitude:800 69' 30" W of the main entrance to the project.
C. PERMIT INFORMATION
1. Specify whether project is (check one):
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: SWA
Stormwater Fast Track ATC Application Form Page 1 of 10 Feb. 10. 2018

By choosing this option, you are also requesting that DEQ rescind the previous Fast Track ATC Permit
upon issuance of the new Fast Track ATC Permit.
Stormwater Fast Track ATC Application Form Page 2 of 10 Feb. 10, 2018

❑ Major Modification, replacing an existing stormwater permit — provide existing permit number: SW
Status of construction? ❑ Not Started ❑ Partially Completed ❑ Completed
Major modifications must be submitted by the original permittee and are allowed only if the SW permit is
not expired. Minor modifications must use Standard Permitting Process. By choosing this option, you
are also requesting that DEQ rescind the previous SW Permit upon issuance of the new Fast
Track ATC Permit.
❑ Transfer of existing Fast Track ATC Permit — provide existing ATC permit number: SWA
2. Applicable state stormwater program(s) (check all that apply):
❑ Coastal SA-HQW ❑ Urbanizing Areas (Phase 2)
❑ Coastal SA-ORW ❑ Non -Coastal HQW
Is any portion of the project within 575 feet
of SA-ORW waters? ❑ Yes ❑ No ❑ Non -Coastal ORW
❑ Coastal Freshwater ORW ❑ USMP
❑ Coastal — Other
3. Other Permits (as applicable, write "NA" for those permit types that are not annlirahla)
4. Local jurisdiction for building permits: Union County Building Department
Point of Contact:Terry Griffin Phone #: [phone] )
D. CONTACT INFORMATION
Applicant/Financially Responsible Party (may be an Organization): Mr. Tim Richardson
Signing Official Name & Title:Mr. Tim Richardson -Owner
Street Address:2524 Parkwood School Road
City:Monroe State:N.C. Zip:28112
Mailing Address (if different): NA
City:
State:
Phone: [phone] Fax: ( )
Email: timrgolow&gmail.com
2. If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the Secretary of
State):
Name of Registered
Mailing Address:_
City:
Phone: ( )
State:
Fax: ( )
Stormwater Fast Track ATC Application Form Page 3 of 10 Feb. 10, 2018
Project Name
Permit/Appl
Issue Date
Other Information
No.
CAMA Major
NA
NA
Erosion &
Sedimentation Control
Aubert Landinq
Union 2018-
02/15/2018
Disturbed Area 2_54
030
acre
NPDES Industrial
NA
-
Stormwater
NA
404/401 Permit
NA
Proposed Impacts
If/ac
4. Local jurisdiction for building permits: Union County Building Department
Point of Contact:Terry Griffin Phone #: [phone] )
D. CONTACT INFORMATION
Applicant/Financially Responsible Party (may be an Organization): Mr. Tim Richardson
Signing Official Name & Title:Mr. Tim Richardson -Owner
Street Address:2524 Parkwood School Road
City:Monroe State:N.C. Zip:28112
Mailing Address (if different): NA
City:
State:
Phone: [phone] Fax: ( )
Email: timrgolow&gmail.com
2. If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the Secretary of
State):
Name of Registered
Mailing Address:_
City:
Phone: ( )
State:
Fax: ( )
Stormwater Fast Track ATC Application Form Page 3 of 10 Feb. 10, 2018

3. The Applicant is the (check all that apply):
® Property Owner
❑ Lessee (Attach a copy of the lease agreement & complete Item 4.)
❑ Purchaser (Attach a copy of the pending sales agreement & complete Item 4.)
❑ Developer (Attach a copy of the development agreement & complete Item 4.)
4. If the Applicant is NOT the Property Owner (skip to Item 5 if the Applicant IS the Property Owner):
Property Owner Name/Organization:NA
Signing Official &
Street
Mailing Address (if applicable):
Phone:
State:
Fax: ( )
5. The licensed Design Professional that will be retained for the duration of the project, who may provide
information on the Applicant's behalf, and who will prepare and certify the as -built package:
Consulting Engineer/Landscape Architect:G. Carter Moore III P.E.
Consulting Firm: GCM3 Engineering PLLC
Mailing Address:3031 Spring Fancy Lane
City:lndian Trail State:N.C. Zip:28079
Phone: (704 ) 821-4205 Fax: [phone]
Email:gcm3awindstream. net
6. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:NA
Organization:
Mailing Addre
Phone:
Email:
E. PROJECT INFORMATION
1. Specify the type of project (check one): ® Low Density
Fax: ( )
❑ High Density
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
Overland flow from the North side of the property to the South
3. Stormwater runoff from this project drains to the Catawba River basin(s).
4. Receiving water information (if more than 3 receiving waters, provide additional information on an attached sheet):
Receiving Receiving Receiving
Water 1 Water 2 Water 3
Receiving Stream Name Waxhaw Creek NA NA
Stream Classification
Stream Index Number
Stormwater Fast Track ATC Application Form Page 4 of 10 Feb. 10, 2018

5. Project area and density information:
Total Property Area
944.250 sf
Total Surface Water Area
-0- sf
Considered to include:
• the normal pool of impounded structures;
• the area between the banks of streams and rivers; and
• the area below the Normal High Water (NHW) line or Mean High Water (MHIM line.
Total Coastal Wetlands Area
-0- sf
Considered to include: coastal wetlands landward from the NHW (or MHW) line.
Total Project Area
944.250 sf
Excludes the surface water area and coastal wetland area identified above.
May or may not be the same as Property Area.
Built -Upon Area (BUA) associated with Existing Development
-0- sf
"Existing development" means those projects that are built or those projects that have established a
vested right under North Carolina law as of the effective date of the state stormwater program or
applicable local government ordinance to which the project is subject.
Proposed New BUA
142,000 sf
Includes proposed new BUA that is not associated with existing development.
°BUA"is defined in N. C. G. S. 143-214.7(b2). It includes, but is not limited to: buildings, roads, parking
areas, sidewalks, and some gravel areas. The design volume of SCMs must take into account the
runoff from build out from all surfaces draining to the SCM in accordance with 15A NCAC 02H. 1050(l).
Project Density
w/ Existing Development., Project Density = [New BUA]/(Total Project Area — Existing BUA] x 100 or
15.04%
w/o Existing Development., Project Density = (New BUA]/Total Project Area] x 100
6. Anticipated construction start date April 2018
7. Is the project located within 5 miles of a public airport? ® No ❑ Yes
If `Yes,'see S.L. 2012-200, Part VI: http://www.ncleg.net/Sessions/2011/Bills/Senate/PDF/S229v6.pdf and
DEQ Stormwater Design Manual Chapter E-4 Airports.
8. For projects in Union Countv:Contact DEMLR Central Office Stormwater staff at 919-707-9200 to determine if
the project is located within a Threatened & Endangered Species watershed that may be subject to more
stringent stormwater requirements per 15A NCAC 028.0600.
Stormwater Fast Track ATC Application Form Page 5 of 10 Feb. 10, 2018

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQW/ORW). Only application packages that include
all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
Initials
TR 1. Two original signed hard copies and one electronic copy of this State Stormwater Fast Track
Process "Authorization to Construct' (ATC) Permit Application Form.
TR 2. Permit application processing fee of $505 payable to NCDEQ
TR 3. Two hard copies and one electronic copy of a USGS map identifying the project location
and GPS coordinates for the project. If the receiving water is Class SA or the receiving water
drains to Class SA waters within % mile of the project boundary, include the''/: mile radius
on the map. If the project is within 575 feet of Class SA-ORW waters, include the 575 -foot
radius on the map.
TR 4. Two original signed hard copies and one electronic copy of a site plan depicting the boundary
of the project or project phase currently being permitted, including the locations of SCMs,
streams, wetlands, and buffers.
TR 5. Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased.
TR 6. A copy of the most current property deed. Deed book: '2 "r 4 $ Page No:
NA 7. [IF APPLICABLE] When the applicant is a corporation or a limited liability corporation (LLC): Provide
two hard copies and one electronic copy of documentation from the NC Secretary of State, or other
official documentation, which supports the titles and positions held by the persons listed
in Section C.2 per 15A NCAC 2H. 1043(3)(b). The corporation or LLC must be listed as an active
corporation in good standing with the NC Department of the Secretary of State; otherwise, the
application will be returned. https://www.sosnc.gov/search/index/corD
NA 8. [IF APPLICABLE] When the applicant is a Partnership or other person engaging in business under
an assumed name, attach a copy of the Certificate of Assumed Name.
NA 9. [IF APPLICABLE] When the applicant is not the property owner: Provide two hard copies and one
electronic copy of lease agreements, affidavits, pending sales agreement, development agreement,
or other documents showing that the applicant has obtained legal rights to submit a stormwater
permit application within the proposed project area.
NA 10. [IF APPLICABLE] If modifying an existing permit for completed or partially completed projects, a copy
of the designer's certification.
Stormwater Fast Track ATC Application Form Page 6 of 10 Feb. 10, 2018

G. CERTIFICATION OF APPLICANT/ FINANCIALLY RESPONSIBLE PARTY
The Applicant, who is also the Financially Responsible Party, identified in Section D of this form must sign and have
notarized the following guaranty:
I, (print or type name of Applicant/Financially Responsible Party) Mr. Tim Richardson
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that:
1. the design has been or will be completed in accordance with the MDC as set forth in Rules 15A NCAC
02H .1050 through .1062, to the best of my knowledge,
2. the completed design meets or will meet the MDC and that the percentage BUA that is the basis for the
design shall not be exceeded, to the best of my knowledge; and
3. As the applicant, I shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as -built package. If I retain another licensed
professional before the project is complete, then I shall provide an updated
guaranty with the current licensed professional's seal. A licensed professional shall inform
the Division if he is no longer associated with this project.
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath I
agree to provide corrected information should there be any change in the information provided herein.
Mr. Tim Richardson
Type or print Wme- , Title or Authority
re
Date
I, dwa ?• & a Notary Public for the State of County
of do hereby certify that IZI dGi0 &or personally
appeared before me this 1-11r.- day of W* , Z01 9 , and acknowledge the due execution of
the application for a stormwater permit. Witness my hand and official seal,
w
JAIMEE R SHAFFER
Notary Public
Union County
North Carolina
Commission Expires May 20, 2019
SEAL
My commission expires N(&4 Zp, 2®
Stormwater Fast Track ATC Application Form Page 7 of 10 Feb. 10, 2018

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be completed by the Design Professional identified in Section D.5.
I, G. Carter Moore ///. P.E. attest to the following:
1. This application has been reviewed by me and is accurate and complete, to the best of my knowledge;
2. The design has been completed in accordance with the MDC as set forth in Rules 15A NCAC 02H
.1050 through .1062, as applicable;
3. The percentage built -upon area that is the basis for the design will not be exceeded; and
4. 1 have the expertise, education, and experience required to design the SCMs proposed in this
application in accordance with the MDC as set forth in Rules 15A NCAC 02H .1050 through .1062.
5. 1 will provide all documents and certified as -built plans in hard copy and electronic format related to this
permit to a new Applicant/Property Owner and to DEMLR upon transfer of this permit to a new
Applicant/Property Owner.
Note: In accordance with N.C.G.S. 143-215.6A and 143-215.66, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. In addition, any person
who knowingly makes any false statement, representation, or certification in any application may be reported to
the appropriate NC professional licensing board.
'V 0 kn ED,,,0�
SEAL
Date:
0-116 4-110
Stormwater Fast Track ATC Application Form Page 8 of 10 Feb. 10, 2018

I. PROPERTY OWNER'S AUTHORIZATION (IF APPLICANT IS NOT THE PROPERTY OWNER)
I, (print or type name of the Property Owner) , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of Applicant)
with (print or type name of Applicant's
organization) 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.
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.
a Notary Public for the State of , County
of , do hereby certify that
personally
appeared before me this day of I , and acknowledge the due execution of
the application for a stormwater permit. Witness my hand and official seal,
61All I
My commission expires
Stormwater Fast Track ATC Application Form Page 9 of 10 Feb. 10, 2018

J. CERTIFICATION OF CURRENT PERMITTEE (COMPLETE ONLYIF PERMIT TRANSFER IS
REQUESTED)
I, (print or type name of the Current Permittee) am submitting
this request for a transfer of Fast Track ATC permit # SWA With the
submission of this transfer request I am providing a copy of the most recent permit, all related documents and as -
built plans certified by my design professional in hard copy and electronic format to the Proposed
Permittee/Applicant identified in Section G of this application and to DEMLR . I further attest that this request for a
permit transfer is accurate and complete to the best of my knowledge. I assign all rights and obligations as
permittee to the proposed permittee named in Section G of this form.
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,
SEAL
My commission
Stormwater Fast Track ATC Application Form Page 10 of 10 Feb. 10, 2018

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