SW6201102_Application_20210202

DEMLRUSE ONLY
Date Received Fee Paid Permit Number
Applicable Rules:Coastal SW –1995Coastal SW –2008Ph II -Post Construction
(select all that apply)Non-Coastal SW-HQW/ORW WatersUniversal 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 APPLICATIONFORM
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.):
Yarborough Express with Gas PX-0001-20
2.Location of Project (street address):
Tora Bora Blvd.
City:FortBraggCounty:CumberlandZip:28310
3.Directions to project (from nearest major intersection):
From intersection NC 401 and Wayside Road. Travel North on Wayside Road to Intersection of Plank Rd. Right onto
Plank Road. Travel approx. 5.5 miles on Plank road, Plank turns into Chicken Road. Turn
Rightonto Tora Bora Blvd. Site is approximately 0.45 miles South on Tora Bora on the Left.
4.Latitude:3505’11” NLongitude:791’32” Wof the main entrance to the project.
II.PERMIT INFORMATION:
†
1.a.Specify whether project is (check one):New ModificationRenewal w/ Modification
†
Renewals with modifications also requires SWU-102 – Renewal Application Form
b.If this application is being submitted as the result of a modificationto an existing permit, list the existing permit
Not Started
number, its issue date (if known), and the status of construction:
Partially Completed*Completed**provide a designer’s
certification
2.Specify the type of project (check one):
Low DensityHigh DensityDrains to an Offsite Stormwater SystemOther
3.If this application is being submitted as the result of a previously returned applicationor 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 1-877-623-6748):
CAMA MajorSedimentation/Erosion Control: 3.0ac of Disturbed Area
NPDES Industrial Stormwater404/401 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:

5. Is the project located within 5 miles of a public airport? No Yes
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013Page 1of 6

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:Fort Bragg Directorate of Public Works (DPW)
Signing Official& Title:David A. Heins, Chief, Environmental Division, Directorate of Public Works
b.Contact information for person listed in item 1a above:
Street Address:4300 Butner Road
City:Fort Bragg State:NCZip:28310
Mailing Address(if applicable):2175 ReillyRoad Stop A
City:Fort BraggState:NCZip:28310-5000
Phone: [phone]Fax: ()
Email:[e-mail]
c.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, item2a and 2b below)
Purchaser*(Attach a copy of the pending sales agreement and complete Contact Information, item2a and 2b below)
Developer*(Complete Contact Information, item2a and 2b below.)
2.a.Print Property Owner’s name and titlebelow, if you are the lessee, purchaser or developer. (This is the person who owns
the propertythat 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 nameand titleof another contact such as the project’s construction supervisor or other person who
can answer questions about the project:
Other Contact Person/Organization:Lee Ward
Signing Official& Title:Chief, Water Management Branch, Directorate of Public Works
b.Contact information for person listed in item 3a above:
Mailing Address:2175 Reilly Road Stop A
City:Fort BraggState:NCZip:28310
Phone: [phone]Fax: ()
Email:[e-mail]
4.Local jurisdiction for building permits: Federal
Point of Contact:Phone #:()
Form SWU-101Version Oct. 31, 2013Page 2of 6

IV.PROJECT INFORMATION
1.In the space provided below, brieflysummarize how the stormwater runoff will be treated.
Runoff will be directed into an open sand filter for treatment.
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 PUDApproval Date:
Valid Building PermitIssued Date:
Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
Coastal SW –1995Ph II –Post Construction
3.Stormwater runoff from this project drains to the Cape FearRiver basin.
4. Total Property Area:3.01acres5.Total Coastal Wetlands Area:acres
6.Total Surface Water Area:acres
+
7.Total Property Area (4) –Total Coastal Wetlands Area (5) –Total Surface Water Area (6) = Total Project Area:3.01acres
+
Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water(NHW)lineor Mean High Water
(MHW)line, and coastal wetlands landward from the NHW (or MHW)line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non-coastal wetlands landward of the NHW (or MHW) line may be
included in the total project area.
8.Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 52.4%
9.How many drainage areas does the project have?1(For high density, count 1 for each proposed engineered stormwater
BMP. For low density and other projects, use 1 for 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 InformationDrainage Area Drainage Area Drainage Area Drainage Area
Receiving Stream NameStewarts Creek
Stream Class *C
Stream Index Number *18-31-24-5-4
Total Drainage Area (sf)82,340
On-site Drainage Area (sf)82,340
Off-site Drainage Area (sf)
**68,682 sf
Proposed Impervious Area(sf)
**83.4
% Impervious Area(total)
**
Drainage Area Drainage Area Drainage Area Drainage Area
ImperviousSurface Area
On-site Buildings/Lots (sf)6,510 sf
On-site Streets (sf)
On-site Parking (sf)56,579 sf
On-site Sidewalks (sf)5,593 sf
Other on-site (sf)
Future (sf)
Off-site (sf)
Existing BUA*** (sf)
Total (sf):68,682 sf
*Stream Class and Index Number can be determined at: http://portal.ncdenr.org/web/wq/ps/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 remainafter development. Do
not report any existing BUA that is to be removed and which will be replaced by new BUA.
11.How was the off-site impervious area listed above determined?Provide documentation.
Form SWU-101Version Oct. 31, 2013Page 3of 6

su tin Firm: ineerin,
Mailing, Address:PO Box 4041
City:155injingign State:NC
Zip28406
Phone- Fax: ffig )__Z21:1EQ1
Email. howard@csd-enqinPPrh- - - - rn
VIA I
TJW 17 A %
1, (print or type name of person listed in Contact Infonnation, 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 Inforniation, itent 1a) with (print or type name of organization listed in
Contact Inforniation, itent 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 star aster system.
Form SWU- 10 1 Version Ou, 31, 2013 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 DEMLR Star cater 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.&
Signature: .................................................................................................................. .......... ......................................................................................................................................................................................................................................................................................................................................................................................... . .... ,,— Date:
L............................ County of
do hereby certify that . . . ....... personally appeared
before me this I'll, ............................. day of , and acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal,_ ................. .... ....
Mycommission expires ............................................................ ", ................................................................................................................................................................................................................................................................................................................
1, (print or type name o person i led in Contact h!f brination, it nt 1q),,Da2d.&Heins
Signature: ................................................................................. .... . ........... .w. Date:
Ig a Notary Public for the State of , County of
do hereby certify that - — ------- — personally appeared
before me this day of 0 and acknowledge the due execution of the application for a
stormwater permit. Witness my and and official seal,
My commission expires
Form SWU, 101 Version Oct, 11, 2013 Page 6 of 6