SW3190803_SSW-NOI-SWG03-20100217-DWQ-SPU_8/22/2019

N.C. DIVISION OF WATER QUALITY
SURFACE WATER PROTECTION SECTION
STATE STORMWATER NOTICE OF INTENT (NOI)
SWG030000 - GENERAL PERMIT TO CLEAR AND GRADE A PROPOSED
DEVELOPMENT SITE
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Certificate of Coverage
3
Check #
Amount
Permit Assi g n e d to
State Stormwater Management Application Notice of Intent for coverage under the General Stormwater
Management Permit to Clear and Grade a proposed development site.
For the clearing and grading only of a proposed development site where the final design is not known.
(Please print or type)
1. Mailing address of owner/developer: (The address to which all permit correspondence will be mailed.)
Owner/Developer Name Salem Leasing Corporation
Street Address 175 Charlois Boulevard
City
Telephone No.
Winston-Salem State NC ZIP Code 27103
(336 ) 768-6896 Fax [phone]
2. Proposed Project Information:
Project Name Salem Leasing Corporation
Street Address
of the Project
City
220 Delray Street
Statesville State NC ZIP Code 28677
County Iredell
Contact Person Steve Teague
Mailing Address P. O. Box 24788
City
Telephone No.
Winston-Salem
State NC ZIP Code 27114
036 ) 768-6896 Fax [phone]
3. Physical Location Information:
Please provide the street address of the project and describe how to get to the project, using street names,
state road numbers, and the distance and direction from the nearest major intersection: From the intersection of
Interstate 40 and U.S. Highway 64 at Exit 148 proceed east on U.S. Highway 64 864 feet to W. Front St. turn left on W. Front St. proceed east on
W. Front St. 0.5 mile to Delray St.; turn right onto Delray St. proceed south 1,000 feet, the site will be on the right.
4. What is the name of the receiving stream?
5. River Basin South Yadkin
Third Creek
Receiving Stream Classification C
6. This Certificate of Coverage is being submitted as a result of:
New or proposed project ❑ Modification to an existing project
Existing COC or Permit Number:
Date project is scheduled to begin construction January 1, 2019
7. What is the total project area above mean high water? 467,167.79 ft2
8. Will wet detention basins or other ponds be constructed at this site?
N(YES ❑ NO
SWU-1 15-17FEB201 0 Page 1 of 3

9. Please list all proposed piping, ditches, and drainage alterations to be constructed as part of this project:
(attach an additional sheet if needed)
Seven existing drop inlets collect stormwater runoff from the site and transport through existing HDPE pipe to a proposed wet detention basin.
10. Is the project within 575' of the Mean High Water line of class ORW waters?
❑ YES (Please show the 575' AEC line on plans) ® NO
(If yes, total built -upon area must be less than or equal to 25% of the total project area within the AEC above mean high water.)
11. Are there any wetlands on the site? ❑ YES (please delineate on the plans) ® NO
Name and affiliation of person making this determination:
12. Please list all Best Management Practices employed at this site:
Wet detention basin.
13. Certification:
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan,
or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly
makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies,
tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or
maintained under this Article or rules of the Commission implementing this Article shall be guilty of a Class 2 misdemeanor
which may include a fine not to exceed $10,000. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both, for a similar offense.)
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit will
constitute the permit requirement for the project and is enforceable in the same manner as an individual permit.
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed name of person signing
Title: Registered Agent
(Signature of Applicant)
C. Stephen Dula
(Date signed)
A check or money order must accompany this Notice of Intent for $505.00, made payable to: NCDENR.
Your application will be returned unprocessed unless all of the following items are submitted:
® This completed form
® Two sets of grading plans
® A check for $505.00
® A USGS map with the project clearly located on it.
Mail the entire package to: NCDENR Division of Water Quality
Surface Water Protection Section — Stormwater
at the Appropriate Contact Address (see the following page)
Note:
The submission of this document does not guarantee the issuance of a Certificate of Coverage under the General
Permit.
SWU-1 15-17FEB201 0 Page 2 of 3

For questions, please contact the DWQ Central Office or Regional Office for your area.
DWQ Regional Office Contact Information:
ASHEVILLE REGIONAL OFFICE
2090 US Highway 70
Swannanoa, NC 28778
[phone]
HQW & ORW Projects in Counties Above
RALEIGH REGIONAL OFFICE
3800 Barrett Drive
Raleigh, NC 27609
[phone]
HQW & ORW Projects in Counties Above
WINSTON-SALEM REGIONAL
OFFICE
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
HQW & ORW Projects in Counties Above
FAYETTEVILLE REGIONAL OFFICE
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
[phone]
HQW & ORW Projects in Counties Above
WASHINGTON REGIONAL OFFICE
943 Washington Square Mall
Washington, NC 27889
[phone]
Coastal Stormwater, HQW & ORW Projects in Counties
Above
CENTRAL OgQQ
1617 Mail Service Center
Raleigh, NC 27699-1617
[phone]
Phase 2 Post -Construction Projects not covered
by local government
MOORESVILLE REGIONAL OFFICE
610 East Center Avenue/Suite 301
Mooresville, NC 28115
[phone]
HQW & ORW Projects in Counties Above
WILMINGTON REGIONAL OFFICE
127 Cardinal Drive Extension
Wilmington, NC 28405-2845
[phone]
Coastal Stormwater, HQW & ORW Projects in
Counties Above
"To preserve, protect
and enhance
Ab h Camlina's water.-."
SWU-115-17FEB2010 Page 3 of 3