SW3180305 Original Signed Application

Stormwater Management Permitting
Mitchell Community College
Health Sciences Building
706 Cherry Street Statesville, NC, Iredell County
April 12, 2018
Laura Alexander
Stormwater Permitting Program
North Carolina Department of Environmental Quality
512 North Salisbury Street
Raleigh, North Carolina 27699
Re: MCC Stormwater Permitting Original Forms - Permit #SW3180305
Dear Laura,
Please find enclosed the original forms of the Stormwater Management Permit Application and Sand
Filter O&M Agreement for the Mitchell Community College Health Sciences Building.
Feel free to contact me if you have any questions.
Thank you,
GRISELDA RUAN, EI
Designer I Charlotte I (o) 704.333.0325
LandDesign.com
223 North Graham Street
Charlotte, NC 28202
• 1' •
w

Permit Number:
(to be provided by DPV(?
Drainage Area Number:
Sand Filter Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a log in a
known set location. Any deficient BMP elements noted in the inspection will be corrected, repaired or
replaced immediately. These deficiencies can affect the integrity of structures, safety of the public, and
the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area will be carefully managed to reduce the sediment load to the sand filter.
— The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds
six inches.
Once a year, sand media will be skimmed.
— The sand filter media will be replaced whenever it fails to function properly after maintenance.
The sand filter will be inspected quarterly and within 24 hours after every storm event greater than
1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance will be kept in
a known set location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired
immediately.
BMi';elernent
T'otentzal, roblem ';i
„How 7C will rernecllate,e r„ob„lem
Entire BMP
Trash debris is resent.
/
Remove the trash/debris.
Adjacent pavement (if
applicable)
Sediment is present on the
pavernent surface.
Sweep or vacuum the sediment as soon as
possible.
Perimeter of sand filter
Areas of bare soil and/or erosive
gullies have formed.
Regrade the soil if necessary to remove the
gully, and then plant a ground cover and
water until it is established. Provide lime
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height,
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too lar e for repair.
Forebay or pretreatment area
Sediment has accumulated to a
Search for the source of the sediment and
depth of greater than six inches.
remedy the problem if possible. Remove
the sediment and stabilize or dispose of it
in a location where it will not cause
impacts to streams or the BMP.
Erosion has occurred.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
roblems.
Weeds are present.
Remove the weeds, preferably by hand. If
a pesticide is used, wipe it on the plants
rather than spraying.
Form SW401-Sand Filter O&M-Rev.4 2009Septl7 Page 1 of 3

BMP element _'. ,.:.
1'otenhal xoblem, „" z All
HocgE 'will remeilzate„E,he x©,blem
Filter bed and underdrain
Water is ponding on the surface for
Check to see if the collector system is
collection system
more than 24 hours after a storm.
clogged and flush if necessary. If water
still ponds, remove the top few inches of
filter bed media and replace. if water still
ponds, then consult an expert.
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the
sediment offsite.
The outlet device is damaged
Re air or replace the outlet device.
Receiving water
Erosion or other signs of damage
Contact the NC Division of Water Quality
have occurred at the outlet.
401 Oversight Unit at 919-733-1786.
Form SW401-Sand Filter O&M-Rev.4 2009Septl7 Palle 2 of 3
I

Permit Number:
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project name:Mitchell Community College - Health Sciences Buildin
BMP drainage area number: 1
Print name: �S_arn'e5 T L�roxar
Title: YQSI d,e4a_
Address: Ki elf t'r"i jPge , SOc) Wast By o0j S-� 11 e A)(_ 96 77
-70�,1 9'79- 3x05'
Signature: �' i am - - �
Date: ; J 15 )' ZD 1 S'
Note: The legally responsible party should not be a homeowners association unless more than 50% of the lots have been
sold and a resident of the subdivision has been named the president.
I, �'-— TT �ial�_ ` r , a Notary Public for the State of
N CM &,"0 `A Q- , County of ( f , do hereby certify that
personally appeared before me this ( S
day of
Ik-� a rc.�, , cD�G i S , and acknowledge the due execution of the forgoing sand filter
maintenance requirements. Witness my hand and official seal,
SEAL
My commission expires 0 4 ` ( S _ f
Form SW401-Sand Filter O&M-Rev.4 2009Septl7 Page 3 of 3

DEMLR USE ONLY
Date Received
Fee Paid Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all Shat appy) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt 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 inn y 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.):
Mitchell Community College - Health Sciences Building
2. Location of Project (street address):
706 Cherry Street
City: Satesville County:IredeII Zip:28677
3. Directions to project (from nearest major intersection):
From the intersection of U.S. Hwy, 64 (W. Front St) and NC -115 (S. Center St.), head west on U.S. Hw Ty64
until you reach S. Oak St. Go north on S. Oak St„ towards Cherry St. and arrive at project site.
4. Latitude:35' 46' 55.00" N Longitude:80° 53' 53.35" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ RenewaI w/ Modificationt
tRenezoals zoith modifications also requires SWLI-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
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 Ietter 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
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 1.97 ac of Disturbed Area
❑404/401 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:MitcheR Community College - Health Sciences Building
IREDE-2018-.0..10, Issued Tanuary 19.2018
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part V2: httl2:Hl2ortal.ncdenr.or Ig web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

111. ` 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: M i tchell Community College
Signing Official & Title: aures T. Brewer President
b. Contact information for person listed in item 1a above:
Street Address:500 West Broad Street
City:StatesviIIe State:NC Zip:28677
Mailing Address (if applicable):Same as above
City: State: Zip:
Phone: [phone] Fax: { �_
Email: [e-mail]
c. Please check the appropriate box. The applicant fisted 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)
❑ 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:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):
City:_
Phone:
Email:
State: Zip:
State: Zip:
Fax: l 1
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: Land Design
Signing Official & Title:Griselda Ruan, Civil Engineering„Designer
b. Contact information for person listed in item 3a above:
Mailing Address:223 N. Graham St.
City:Charlotte State:NC Zip:28202
Phone: [phone] Fax:
Email:[e-mail]
4. Local jurisdiction for building permits:
Point of Contact: Phone #:
Form SWU-101. Version Oct. 31, 2013 Page 2 of 7

IV. ' PROJECT INFORMATION
I. In the space provided below, br_ iefl summarize how the stormwater runoff will be treated.
Stormwater runoff (drainage area of 1.48 ac) will be treated by an above ground sand filter Iocated behind the
building_.
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 Yadkin River basin.
4. Total Property Area: 1.97 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 -,:1.97 acres
+ Total project area shall be calculated to exclude the follozvin the normal pool of impounded strucitrres, the area
between the banks of streams and rivers, the area belozv the Normal Higlx Water (NHW) line or Mean High Water
(MHM line, and coastal wetlands landzvard frown the NHW (or MHW) lune. The resultant project area is used to
calculate overall percent built upon area (B UA). Non -coastal wetlands landward of the NHW (or MHVIj line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 47.3 %
9. How many drainage areas does the project have? 1 (For high densihj, count l for each proposed engineered
stornavater BMP. For lozv densihj and other projects, use T for the zvlrole properhj 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
_
Fourth Creek
Stream Class *
C
Stream Index Number *
12-108-20
Total Drainage Area (so
1.48
On-site Drainage Area (so
1.48
Off-site Drainage Area (so
-
Proposed Impervious Area** so
30,275
% Impervious Area** (total)
47.3
Impervious Surface Area
Drainage Area 1 Drainage Area Drainage Area Drainage Area
On-site Buildings/Lots (sf)
_ _
20,095
On-site Streets (so
On-site Parking (so
7,347
On-site Sidewalks (so
2,833
Other on-site (sf)
Future (sf)
Off-site (so
Existing BUA*** (so
Total (sf):
30,275
Stream Class and Index Number can be determined at: http.aortal.ncdctir`org veb/zvcl[p,s/csu/classi 'cations
Itnt ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Versio» Oct. 31, 2013 Pagge 3 of 7

*Report only that amount of existing B UA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by nezo B UA.
11. How was the off-site impervious area listed above determined? Provide documentation.
Proiects in Union Countv: Contact DEMLR Central Office staff to check if the project is located tivithin a Threatened &
Endangered Species watershed that maybe subject to more stringent storintivater iregziirements as per 15,4 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 Iatest versions of the forms can be downloaded
from http://12ortal.ncdenr.org/webZwq/ws/su/bm]2-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
h ortal.ncdenr.or 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 ath=. /.Z.portal.ncdenr.orgweb/wqf ws/su/maps.)
Please indicate that the following required information have been Rrovided by initialin 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.or web/wq/ws/su/statesw/forms docs.
1. Original and one copy of the Stormwater Management Permit Application Form. Initials
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII belozo)
3. Original of the applicable Supplement Form(s) (sealed, signed and datedi and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
h www.envl-teli).org/ pages/ onestopexl2xess.hLml 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
the project. This is required in addition to
the brief summary provided in the Project Information,
item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
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).
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 any coastal wetlands Iandward of the MHW or NHW Iines.
• 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.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 7

ni. 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 buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
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 verifij the SHWI' prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: Page No:
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 214.1003(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.
htt.p://www.secretary.state.nc.us/Corporations/­CSearch.asRx
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 Iisting 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 blt�p:Hl2ortc-tl.ncdenr.org/web/Ir/state-
stormwater-forms docs. 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 Iot.
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:
Consulting Firm:
Mailing Address:_
City:
Phone:
State: Zip:
Fax: ( }
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) certify that I
own the property identified in this permit application, and thus give permission to (print or tfpe naine of person
listed in Contact Information, item 1a) with (print or hype name of organization listed in
Contact Information, item 1a) 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 SWI1-101 Version Oct. 31, 2013 Page 5 of

As the Iegal 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 NCGSf1443-}215.6.
Signature: - Date: 7 1 261
I, �✓ c—' '� �`� a Notary Public for the State of c'(� (�.rz5 �`ra County of
T� do hereby certify that �� VLC�.S {� f �,r�J��,� personally appeared
before me this 3 � of rV\ �G -�- -- a P(8 , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires -04—(,5--19
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7
s
SEAL
My commission expires -04—(,5--19
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7

A. `APPLICANT'S CERTIFICATION
I, (print or pipe name of person listed in Contact Information, item Ia) ' Z�'e S T BY -4w eX•
cert-ify that the information included 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 the
applicable stormwater rules under 15A NCAC 2H.1000 and any other applicable state stormw
later requirements.
Signature: CT�tntiQA Date: 3 y
I, ' �� `� I a Notary Public for the State of Aj(dM C �� County of
moi,, do hereby certify that J I =� u�c/t'^ personally appeared
before me this 3 day of ,VA a(c – a 6 , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,_C
SEAL
My commission expires o q — (S` l
Form S WU-101 Version Oct. 31, 2013 Page 7 of 7