NCS000515_Stormwater Permit_20200921

OFFICE USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Stormwater Management Plan
(select all that apply)
Town of China Grove, North Carolina
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.):
2. Location of Project (street address):
City: Zip:
3. Tax Map and Parcel ID:
II. PERMIT INFORMATION:
1. Specify whether project is (check one): ❑New ❑Modification
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:
Signing Official & Title:
b. Contact information for person listed in item 1a above:
Street Address:
City:
State:
Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone:
Email:
Fax:
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)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
Town of China Grove Stormwater Permit 01 /2015 Page 1 of 6

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: State: Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
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:
IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
2. Stormwater runoff from this project drains to the River basin.
3. Total Property Area: acres
4. Total Project Area:
T*OR]
5. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = %
6. How many drainage areas does the project have?
Town of China Grove Stormwater Permit 01/2015 Page 2 of 6

7. 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 *
Stream Index Number
Total Drainage Area (so
On -site Drainage Area (so
Off -site Drainage Area (so
Proposed Impervious Area** s
% Impervious Area** total
Impervious— Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
On -site Streets (sf)
On -site Parking (so
On -site Sidewalks (so
Other on -site (so
Future (sf)
Off -site (so
Existing BUA*** (so
Total (sf):
* Stream Class and Index Number can be determined at: http://portal.ncdenr.org web/wq&s/csu/classifications
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
***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.
8. How was the off -site impervious area listed above determined? Provide documentation.
V. SUPPLEMENT AND O&M FORMS
The applicable stormwater management permit supplement and operation and maintenance (O&M) forms must
be submitted for each BMP specified for this project.
Town of China Grove Stormwater Permit 01/2015 Page 3 of 6

VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Town of China Grove. A
complete package includes all of the items listed below.
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.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $400 plus $50 per acre disturbed payable to the Town of China
Grove.
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
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 (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 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).
Town of China Grove Stormwater Permit 01/2015 Page 4 of 6

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.
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 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.
ht!p://www.secretaLry.state.nc.us/Corporations/CSearch.as]2x
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.
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 Town of China Grove, 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:
Consulting Firm:
Mailing Address:
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
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 type name of person
listed in Contact Information, item 1a) with (print or type 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.
Town of China Grove Stormwater Permit 01/2015 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 Town of China Grove Stormwater
permit reverts back to me, the property owner. As the property owner, it is my responsibility to notify the Town
of China Grove 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.
Signature:
I,
a Notary Public for the State of
do hereby certify that
before me this _ day of
Date:
County of
personally appeared
, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 1a)
certify 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 stormwater requirements.
Signature:
I,
a Notary Public for the State of
do hereby certify that
Date:
County of
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 expires
Town of China Grove Stormwater Permit 01/2015 Page 6 of 6