SW6210906_Application Form_20211014

DEMLR USE ONLY
Date Received Fee Paid Permit Number

Applicable Rules: Coastal SW – 1995 Coastal SW – 2008 Ph II - Post Construction
(select all that apply) Non-Coastal SW- HQW/ORW Waters Universal 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 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.):
Brooke Valley Subdivision
2. Location of Project (street address):
Mumford Road, 926' north of intersection with Pittman Grove Church Road
City:Raeford County:Hoke Zip:28376
3. Directions to project (from nearest major intersection):
north along Mumford Road from the interction with Pittman Grove Church Road. Project will be ~926 ft
north on the east side of Mumford Road

4. Latitude:34 57’ 26.09” N Longitude:-79 3’ 54.81” W of the main entrance to the project.

II. PERMIT INFORMATION:
†
1. a. Specify whether project is (check one): New Modification Renewal w/ Modification
†
Renewals with modifications also requires SWU-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
2. 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 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 Major Sedimentation/Erosion Control: 4.9 ac of Disturbed Area
NPDES Industrial Stormwater 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:

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:Tupvu!Mboe!Efwfmpqnfou-!MMD
Signing Official & Title:Ben Stout - Managing Member
b. Contact information for person listed in item 1a above:
Street Address:1786 Metromedical Drive
City:Fayetteville State:NC Zip:28304
Mailing Address (if applicable):1786 Metromedical Drive
City:Fayetteville State:NC Zip:28304
Phone: (910) 779-0019 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, 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 propertythat the project is located on):
Property Owner/Organization:!CTOK!Mboe-!MMD
Signing Official & Title: Ben Stout - Manager
b. Contact information for person listed in item 2a above:
Street Address: 1786 Metromedical Drive
City: FayettevilleState:NC Zip: 28304
Mailing Address (if applicable):
City: State:NC Zip:28348
Phone: ( 910 ) 779-00179 Fax: ( )
Email: [e-mail]

3. a. (Optional) Print the name and titleof 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:
4. Local jurisdiction for building permits:
Point of Contact: Phone #: ( )

Form SWU-101Version Oct. 31, 2013Page 2of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff will sheet flow across lots and collect into underground storm drainage system within
roadways. Collected stormwater will be discharged from the system into grassed swales.

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 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 Cape Fear River basin.
4. Total Property Area: 50.2 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: 50.2 acres
+
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) line or 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 = 7.4 %
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 1Drainage Area Drainage Area Drainage Area
Receiving Stream Name Big Branch
Stream Class * B
Stream Index Number * 18-31-20.7
Total Drainage Area (sf)2,186,570
On-site Drainage Area (sf) 2,186,570
Off-site Drainage Area (sf) 0
**162,433
Proposed Impervious Area (sf)
** 7.4
% Impervious Area(total)

**
Impervious Surface Area Drainage Area 1Drainage Area Drainage Area Drainage Area
On-site Buildings/Lots (sf) 108,000
On-site Streets (sf) 54,433
On-site Parking (sf) 0
On-site Sidewalks (sf) 0
Other on-site (sf)0
Future (sf) 0
Off-site (sf) 0
Existing BUA*** (sf) 0
Total (sf): 162,433
* 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 remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
Form SWU-101Version Oct. 31, 2013Page 3of 6