SW4140401_CURRENT PERMIT_20140506

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW �e�
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE���%J(Q
YYYYMMDD

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
May 6, 2014
Mr. Courtney Driver
Deputy Director on Utilities
Suite 357, City Hall
101 N. Main Street
Winston-Salem, North Carolina 27101
Subject: Stormwater Permit No. SW4140401
Muddy Creek Wastewater Treatment Plant
Dear Mr. Driver:
John E. Skvarla, III
Secretary
N.C.Deot. of ENR
JUN 11 2011
Winston-Salem
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on April 14, 2014. Staff review of the plans and
specifications has determined that the project, as proposed, will comply with the Stormwater Regulations set
forth in Title 15A NCAC 2H.1000 and Session Law 2006-246. We are forwarding Permit No. SW4140401,
dated April 14, 2008, for the construction, operation and,maintenance of the subject project. This permit shall
be effective from the date of issuance and shall be subject to the conditions and limitations as specified
therein, and does not supersede any other agency permit that may be required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing by filing a written petition with the Office of Administrative Hearings
(OAH). The written petition must conform to Chapter 150B of the North Carolina General Statutes. Per
NCGS 143-215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this permit.
You should contact the OAH with all questions regarding the filing fee (if a filing fee is required) and/or the
details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via telephone at 919-
431-3000, or visit their website at www.NCOAH.com. Unless such demands are made this permit shall be
final and binding.
This project will be kept on file at the Winston-Salem Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely,
/�
for Tracy E. Davis, PE, CPM, Director
cc:
ec
SW4140401 File, Winston-Salem Regional Office
Randy Ashburn, black & Veatch International Co.
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-9200 / FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: http://portal.ncdenr.org/web/Ir/
An Equal Opportunity 1 Affirmative Action Employer - 50% Recycled 110% Post Consumer Paper

State Stormwater Permit
Permit No.SW4140401
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Muddy Creek Wastewater Treatment Plant
4561 Copper Road
Winston-Salem, Forsyth County, NC
FOR THE
construction, operation and maintenance of a low density development in compliance
with the provisions of 15A NCAC 2H .1000 and S.L. 2006-246 (hereafter referred to as
the "stormwater rules') and the approved stormwater management plans and
specifications, and other supporting data as attached and on file with and approved by
the State and considered a part of this permit.
The Permit shall be effective from the date of issuance until rescinded and shall be
subject to the following specific conditions and limitations:
I. DESIGN STANDARDS
The overall tract built -upon area percentage for the project must be maintained
below 24%, as required by Session Law 2006-246 of the stormwater rules.
3. Approved plans and specifications for projects covered by this permit are
incorporated by reference and are enforceable parts of the permit.
4. The only runoff conveyance systems allowed will be vegetated conveyances
such as swales with minimum side slopes of 3:1 (H:V) as defined in the
stormwater rules and approved by the Division.
5. No piping is allowed except that minimum amount necessary to direct runoff
beneath an impervious surface such as a road or to provide access.
6. All roof drains must terminate at least 30 foot from the mean high water mark.
The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent streams.
All swales shall that discharge into a wetland shall do so at a non -erosive velocity
for the 10 year storm.
II. SCHEDULE OF COMPLIANCE
The permittee is responsible for verifying that the proposed built -upon area does
not exceed the allowable built -upon area.
Page 1 of 4

State Stormwater Permit
Permit No.SW4140401
The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
This project may not be sold or subdivided in whole or in part without first
receiving a permit modification.
4. The following deed restrictions must be recorded with the Office of the Register
of Deeds:
a. The following covenants are intended to ensure ongoing compliance with
State Stormwater Management Permit Number SW4140401.
b. The State of North Carolina is made a beneficiary of these covenants to
the extent necessary to maintain compliance with the Stormwater,
Management Permit.
C. These covenants are to run with the land and be binding on all persons
and parties claiming under them.
d. The covenants pertaining to stormwater may not be altered or rescinded
without the express written consent of the State.
e. Alteration of the drainage as shown on the approved plans may not take
place without the concurrence of the State.
f. This project may not be sold or subdivided, in whole or in part, without first
receiving a permit modification from the Division.
h. Construction of additional impervious areas such that low -density
requirements are no longer met will require a permit modification prior to
construction. An engineered system will be required to collect and treat
the runoff from all built -upon area associated with the project, including
that area permitted under the low density option.
i. Filling in or piping of any vegetative conveyances (ditches, swales, etc.)
associated with this development, except for average driveway crossings,
is strictly prohibited by any persons.
j. The built -upon areas shall be located a minimum of 30 feet landward of all
perennial and intermittent surface waters.
A copy of the recorded restrictions must be received in this Office within 30 days
of the date of sale.
Filling in or piping of any vegetative conveyances (ditches, swales, etc.)
associated with the permitted development, except for average driveway
crossings, is strictly prohibited by any persons.
The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to the approved plans, regardless of size.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area.
e. Further subdivision, acquisition, or sale of the project area in whole or in
part. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval was sought.
f. Filling in, altering or piping any vegetative conveyance shown on the
approved plan.
Page 2 of 4

State Stormwater Permit
Permit No.SW4140401
8. During construction, erosion shall be kept to a minimum and any eroded areas of
the swales or other vegetated conveyances will be repaired immediately.
9. The permittee shall at all times provide the operation and maintenance
necessary to operate the permitted stormwater management systems at
optimum efficiency to include:
a. Inspections
b. Sediment removal.
c. Mowing, and re -vegetating of the side slopes.
d. Immediate repair of eroded areas.
e. Maintenance of side slopes in accordance with approved plans and
specifications.
10. Within 30 days of completion of the project, the permittee shall certify in writing
that the project has been constructed in accordance with the approved plans.
11. The permittee shall submit all information requested by the Director or his
representative within the time frame specified in the written information request..
III. GENERAL CONDITIONS
This permit is not transferable to any person or entity except after notice to and
approval by the Director. The Director may require modification or revocation and
re -issuance of the permit to change the name and incorporate such other
requirements as may be necessary. In the event of a name or ownership
change, a completed Name/Ownership Change form, signed by both parties,
must be submitted to the State accompanied by the supporting documentation
as listed on page 2 of the form. The approval of this request will be considered
on its merits, and may or may not be approved.
2. The permittee is responsible for compliance with all permit conditions until the ,
Director approves a transfer of ownership. Neither the sale of the project nor the
transfer of common areas to a third party, such as a homeowner's association,
constitutes an approved transfer of the stormwater permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to an enforcement action in accordance with North
Carolina General Statutes 143-215.6A to 143-215.6C.
The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws,. rules, and regulations contained in Session Law 2006-
246, Title 15A of the North Carolina Administrative Code, Subchapter 2H.1000;
and North Carolina General Statute 143-215.1 et. al.
In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by the State, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants permission to DENR Staff to enter the property during
normal business hours, for the purpose of inspecting all components of the
stormwater management. facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
Page 3 of 4

State Stormwater Permit
Permit No.SW4140401
filing of a request for a permit modification, revocation and re -issuance, or
termination does not stay any permit condition.
Unless specified elsewhere, permanent seeding requirements for the swales
must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state and federal), which have jurisdiction.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
Permit issued this the 6th day of May, 2014.
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
r
.->-
SW IUDyOI
ApplicableRules': ❑ Coastal SW —1995 ❑ Coastal SW —2008
VPh 11 - Post Construction
(sdmtd/th&qqp/y) ❑ Non -Coastal SW- HOW/ ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt Plan: .x
(to a
Stateof North Carolina / RECEIVED
Department of Environment and Natural ReSouroes [7N.C.DePt. of ENR
Division of Energy, Mineral and Land Resouroes ►(jN f �t71�a
STORMWATER MANAGEMENT PERMIT APPLICATION FORM Winston-salem
Th/sfcrmmay be#xYo g91aYforuseasa7 crig/na' L__Re. Tonal Offce
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name- should beconsistent with project nameon plans,
specifications, letters, operation and maintenance agreements, etc.):
Muddy Creek Wastewater Treatment Plant Consolidated Influent Pumping Improvements
2. Location of Project (street address):
City:W i n ston-Salem County: Forsyth Zi p:27127
3. Directionsto project (from nearest major intersection):
At theintersection of US-1581 SStratford Road and State Road 29901 Fraternity Church Road head south on
Fraternity Church Road. go 423 feet.
At the traffic circle, continue straight to stay on State Road 2990/ Fraternity Church Road go 1.7 miles.
Turn right onto State Road 2995✓ Cooper Road. go 0.7 miles.
Turn left ontothe access road for the Muddy Creek W WTP go 0.3 miles
Arrive at main entrance for Muddy Creek WWTP.
4. Latitude:350 59' 49.70" N Longitude:80° 20' 6.41" W of the main entranceto the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is(check one): ❑New ®Modification ❑ Renewal w/ Modificationt
t Renewals with modifications also requires SWU-102 - Renewal Application Form
b.If this application is being submitted as the result of a modif !cation to an existing permit, list the existing
permit numberNCG110133 ,itsissuedate(ifknown).Ame1. 0013 and the status of
construction: ®Not Started ❑Partially Completed' ❑ Completed` provideadesgna'scetifrra'icn
2. Specify the type of project (check one):
®Low Density ❑High Density ❑Drainstoan Off site Stormwater System ❑Other
3. If thisapplication isbeing submitted asthe result of a previously returned application or aletterfrom
DEM LR requesting a state stormwater management permit application, list thestormwater 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 statepermitscan be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major
❑NPDESIndustrial Stormwater
®Sedimentation/ Erosion Control: 25 acof Disturbed Area
❑404/ 401 Permit: Proposed Impacts
b.lf 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
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

If yes, see S.L. 2012-200, Part VI: httl2://12ortal.ncdenr.org/web/Ir/rules-and-regulations
III. CONTACT INFORMATION
1.a.PrintApplicant / 9gning Official's name and title (specifically thedeveloper, property owner, lessee,
designated government official, individual, etc. who owns theproiect):
Applicant/ Organ ization:City of Winston-Salem
Signing Official & Title:Courtney Driver, Deputy Director of Utilities
b.Contact information for person listed in item la above:
Street Address:Suite357, City Hall, 101 N. Main St.
City:Winston-Salem State:NC Zip:27101
Mailing Address (if agdicatY4:P. O. Box 2511
City:Winston-Salem State:NC Zip:27102-2511
Phone: (336 ) 747-7315 Fax: [phone]
Em ai I:Cou rtnev D ft tvofw s.org
c. Pleasecheck the appropriate box. Theapplicant 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 salesagreement and complete Contact Information, item 2a and
2b below)
❑ Developer' (Complete Contact Information, item 2aand 2b below.)
2.a.Print Property Owner'snameand titlebelow, if you arethelessee, purchaser or developer. (Thisisthe
person who owns the property that the project is located on): - Not Applicable
Property Owner/ Organization:
Sgning Official & Title:
b.Contact information for person listed in item 2a above:
Street Address:
City: State: Zip:
M aiIing Address (ifTplicW6):
City: State: Zip:
Phone: ( ) Fax: ( 1
Email:
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/ Organ ization: Marcus Kiser/City of Winston-Salem
Signing Official & Title:Courtngy Driver, Deputy Director of Utilities
b.Contact information for person listed in item 3aabove:
Mailing Address:P.0. Box 2511
City: W i n ston-Salem
Phone: (336 ) 747-7306
Em ai I: M arcu sK a(JJ tyofw s.org
State:NC Zip:27102-2511
Fax: (336 ) 727-8432
4. Local jurisdiction for building permits: City of Winston-Salem. Inspections Department
Point of Contact:Buckv Frye Phone#: (336 ) 727-2497
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarizehow thestormwater runoff will betreated.
This Project will utilize vegetatedconvevancetothe maximum extent possible. However, there area several
short sectionsof storm water oonvevancenecessary which arenot vegetative. A short storm drain will be
installed in thenortheast section of thenew paved area surrounding the Headworks& Influent Pumping
Station (H W& IPS). This will collect runoff from the paved areaand a portion of the H W& IPS and disperse the
flow into the property'svegetated floodplain.
Oncetheflow isdispersed into thevegetated floodplain property areait will travel a minimum of 200' across
avegetated surfaceprior to reaching South Fork Muddy Creek. Additionally, storm drainswill beinstalled in
the new paved road southwest of the H W& I PSand one near the base of the road up to the Storm Flow and
Centrate_Egualization Basins. Thesestorm drainswill collect storm water from thepaved roadsand discharge
it to an existing vegetated storm water channel that runswest along the existing plant drive. Thisvegetated
channel dispersesstorm water into the property's floodplain wheretheflow will travel a minimum of 450'
across a vegetative surface prior to reaching Muddy Creek
There are no storm water systems being added under this Proiect which discharge directly into the receiving
stream without vegetated conveyance as noted above.
2. a. If daimi ng 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 claim! ng vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW —1995 ❑ Ph I I —Post Construction
3. Stormwater runoff f rom this project d rains to the Yad ki n River basin.
4. Total Property Area: 142.3 acres 5. Total Coastal WetlandsArea:0 acres
6. Total Surface Water Area: 2.6 acres
7. Total Property Area (4)—Total Coastal Wetlands Area (5) —Total SurfaceWater Area (6) = Total Project Area:
139.7 acres
TctdprgeLtaeg&Wlbecdallct67toerdudethefdiaving: thenon&pr LYimpainOW5trudure�theae6
t'dwe ? theta7ks d`stra nsa7drivee,S theaegLdav theNvmat High Wate- (NHW) tines Mess High Wate-
(MHW) tine and aa3std w6tta7dsla7dwad fran theNHW (cr MHW) tine Theresuttar7t prged a®isusaYto
cdaildeova,dl pe ant built upcn am (BUA). Nm-c-,t9af wdlaidsta7ofvad aflheNHW (c MHW) tinemv be
indudeiin thetdat prq'et aea
8. Project percent of i m pervious area: (Total ImperviousArea/ Total Project Area) X 100 = 8.5 %
9. How many drainage areas does the project have?l(Fcrhighdaisty,aamtIfor esetrprgxzssia7ginestel
stcrmwde- BMP. For law density aid dhe-prge7s use t for the whdeprgae-ty a®)
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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 7

Basin Information
Drainage Areal
Drainage Area_
Drainage Area_
Drainage Area_
Receiving Stream Name
Muddy Creek/
South Fork
Muddy
Creek
Stream Class '
C/ C
Stream Index Number'
12-94-(0.5)/
12-94-13
Total Drainage Area (sf)
6,090,000
On -site DrainageArea(sf)
6,090,000
Off -site DrainageArea(sf)
0
Proposed Impervious Are** (sf)
519,000
% Impervious Arce"(total)
8.5
Impervioue'SurfaceArea
Drainage Areal
DrainageArce_
Drainage Area_
Drainage Area_
On -site Buildings/Lots(sf)
38,800
On -site Streets (sf)
21,200
On -site Parking (sf)
30,700
On-siteSdewalks (sf)
900
Other on -site (sf)
0
Future (sf)
2,500
Off -site (sf)
N/A
Existing BUA"" (sf)
427,000
Total (sf):
519,000
StravnClassand lnderNumber ra7beddemineta<: httoj/cata'.nwlair.adwWwdas/csu/dassficatims
lmperviousarea isderIneofas, the will upnarea induding, but not limitetY to wilding$ rows pa -king aras
sdewa 4 gravd ae-,tg etc
Rcpa7 cay tha wwrit cf twisting BUA that will ranan tea devdgarr7e7t. Do not rqua-t any twisting BUA that is
toterarnweia7d which will teroaed by nav BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
No off -site storm impervious areas drain to the stormwater system for this project.
Proieets in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A NCAC 02B .0600
V. SUPPLEMENTAND O&M FORMS -Not Applicable
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must besubmitted foreach BMPspecified forthisproject. The latest versions oftheformscanbedownloaded
from htto:/ / oortal.nodenr.ora/ web/ wa/ ws/ su/ bmD-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete appl!cation packages wlII be accepted and reviewed by the Division of Energy, Mineral and
Land Resouraes(DEMLR). A oompletepadcageindudesall of theitemslisted below. A detailed application
Instruction shestand BM P checklists are avallablefrom
http:/ / portal.ncdenr.ora/ web/ wa/ ws/ su/ statesw/ forms docs. Theeomplete application padcageshould be
submitted totheappropriateDEMLROffice. (The appropriate office may befound by locating project on the
interactive online map at http:/ / portal.ncdenr.ora/ web/ wa/ ws/ su/ maps.)
Pleaseindicatethat thefollowing required information have been provided by initialing in the space provided
for each item. All original documents M UST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from hthn / / portal. nodenr.org/ web/ wa/ ws/ su/ statesw/ forms docs.
niti s
1. Originaatdmeapyof the Stormwater Management Permit Application Form.
2. Origindasndcneapyof the signed and notarized Deed Restrictions& Protective Covenants Not ADDI rabie
Form. (ifre7uireiaspe, Part Vll bdav)
3. Originaof the applicable Supplement Form(s)(sealed, signed and dated) and O&M Not Applicable
agreement(s) for each BM P.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 7

4. Permit application processing fee of M payabletoNCDENR. (For an Express review, refer to p
htto:/ / www.envhelo.org/ pages, onestopexpress.html 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 USGSmap identifying the sitelocation. If thereceiving stream isreported asclassS4 or the
receiving stream drainsto class SA waterswithin %mileof the site boundary, indudethe'/2
mile radiuson the map.
7. Sealed, signed and dated calculations(onecopy).
8. Two setsof plansfolded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/ Project name.
b. Engineer and firm.
c. Location map with named streetsand NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surfacewaterson theplansby delineating thenormal pool elevation of
impounded structures, the banks of streams and rivers, theMHW or NHW line of tidal
waters, and any coastal wetlands landward of theMHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and theMHW (or NHW) of tidal waters.
i. Dimensioned property/ project boundary with bearings & distances.
j. SlteLayout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
I. Detailsof roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must bedelineated 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. Copyof 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
elevationsand boring logs. Indudean 8.5"xll" copy of theNRCSCounty Soilsmap with the
project areadearly delineated. For projectswith infiltration BMPs, thereport should also
indudethesoil type, expected infiltration rate, and themethod of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Sctk-duleasitevistt fa DEMLRtoverifyth6SYtNTprig
tosubnitta (910)75Yr737B.) 1424 16151 1i
10. A copy of the most current property deed. Deed book: 1702 Page N o: Man j ✓Y
11. For corporations and limited liability corporations (L LC): Provid e docu mentation from the NC Not Applicable
Secretary of State or other off idat documentation, which su pports the titles and positions held
by the persons 1 isted in Contact Information, item la, 2a, and/ or 3aper 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.
htto:/ / www.secretarv.state.nc.us/ Corporations/ CSearch asox
Form SWU-101 Version Oct. 31, 2013 Page 5 of 7

VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS -Not Applicable
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. The appropriate deed restrictions and
protective covenants forms can be downloaded from ht_pt :Hl2ortal.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 rest ricti on s are recorded.
By the notarized signature(s) below, the permit hotder(s) certify that the recorded property restrictions and
protective covenants f or this proj ect, if required, shall IndudealI the items requi red in the permit and listed
on the f orms aval I able on the website, that the covenants wi I I bebinding on all parties and persons d ai mi ng
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence f rom the NC DEM LR, and that they will be recorded prior to the sale of any lot.
Vill. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/ or firm (such as
Consulting engineer and/ or firm) so that they may provide information on your behalf for this project (such as
addressing requestsfor additional information).
Consulting Engineer:Randy Ashburn
Consulting Firm: Black & Veatch International Co.
Mailing Address:10715 David Taylor Drive,SLite240
City:Charlotte State:NC Zip:28262
Phone: [phone] Fax: (704 ) 724-5901
Emai I:AshburnRDCabv.com
IX. PROPERTY OWNER AUTHORIZATION(if Contact 1nfamarim,itan2hastW7fitlaiad,canp✓etethis
s9560,7) - Not Applicable
1, (print o- typenarnec(pers ? listed in Ccntaf lnfcrrraim, it6n2a) , certify that I
own the property identified in this permit application, and thusgive permission to (pint crtypenanedpa-sn
tlstaiin Cmtxt tnfcrmation, itan fa) with (pint or typenanecf o-gaVza'icn listeiin
Cmtat 1nfrmatim, iten fa) 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 SWU-101 Version Oct. 31, 2013 Page 6 of 7

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 can celsor defaults on their
I ease agreement, or pending sale, responsibility for complianoewith theDEMLR Stormwater permit reverts back
tome, the property owner. As the property owner, it ism y responsibility to notify DEM LR immediately and
submit a completed Name/ Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without avalid permit. I understand that the operation of astormwater treatment fad Iity
without avalid permit is a violation of NC General Statue 143-215.1 and may result inappropriate enforcement
action indud ing the assessment of dviI penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Sgnatu
a Notary Public for the State of County of
do hereby certify that 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,
My commission exp
X. APPLICANT'SCERTIFICATION
1, (print ortypananea(persn listed in Contact tn/brmaticn, itan fa) CcvrtnawDriva
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 protect iv venantswinder
rded,andthattheproposed projedcumplieswiththe requirementsofthe
applicable st m rul A NCAC 2H .1000and any other applicable state stormwater requirements.
Sgnature: Date:
a Notary PublicfortheStateofNov+V- CIGl4'ol.Iho.-.County of
v�
do hereby certify that AUJfA-y !tA L.'OVly-an personally appeared
before me this -Ldayof karA adknowled��gethe
��due��execution ofthe applicationfor a
�
stormwater permit. Witness my hand and official seal, cA,r1�T ykoann'11'n
NOTARY PUBLIC
SEAL FORSYTH COUNTY
NORTH CAROLINA
A., r m ,n F.dme December 15. 2015
My commission expires 1:�4e _P Q rvujcu A 1 QM 5
Form SWU-101 Version Oct. 31, 2013 Page 7 of 7