SW7090601_COMPLETE FILE - HISTORICAL_20090729

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

North Carolina
Beverly Eaves Perdue
Governor
Mr. Randell Woodruff
Camden County
PO Box 190
Camden, NC 27921
Dear Mr. Woodruff:
sac® NR
Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
July 29, 2009
County Manager
Dee Freeman
Subject: Stormwater Permit No. SW7090601
South Mills Fire Department
High Density Commercial Wet Pond Project
Camden County
The Washington Regional Office received a complete Stormwater Management Permit
Application for South Mills Fire Department on Jun 1, 2009. Staff review of the plans and
specifications has determined that the project, as proposed, will comply with the Stormwater
Regulations set forth in Session Law 2008-211 and Title 15A NCAC 2H.1000. We are
forwarding Permit No. SW7090601 dated July 29, 2009, for the construction of the subject
project.
f1%a b-I
This permit shall be effective from the date of issuance until July 29, 2019, and shall be subject
to the conditions and limitations as specified therein. Please pay special attention to the
Operation and Maintenance requirements in this permit. Failure to establish an adequate
system for operation and maintenance of the stormwater management system will result in
future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have
the right to request an adjudicatory hearing upon written request within thirty (30) days
following receipt of this permit. This request must be in the form of a written petition,
conforming to Chapter 150E of the North Carolina General Statutes, and filed with the Office of
Administrative Hearings, P.O. Drawer 27447, Raleigh, NC 27611-7447. Unless such demands
are made this permit shall be final and binding.
If you have any questions, or need additional information concerning this matter, please
contact Samir Dumpor, or me at [phone].
Si erely,
I 7 _
Al Hodge
Regional Supervisor
Surface Water Protection Section
AH/ so: S:\WQS\STORMWATER\PERMIT\SW7090601
cc: Derek Dail, PE, Hobbs, Upchurch & Associates, P.A. (PO Box 1929, Nags Head,
NC 27959)
Camden County Building Inspections
ashington Regional Office
Central Files
North Carolina Division of Water Qualm• Internet, w++w newalcr u_hlr mg
943 Washington Square Mall Phone [phone] One
Washington, NC 27889 FAX [phone] North Cauojtna
An Equal OpportundylAHumative Action Employer —50%Recycledll0% Post Consumer Paper ;Vats al4if

State Stormwater Management Systems
Permit No. SW7090601
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
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
Camden County
South Mills Fire Department
FOR THE
construction, operation and maintenance of a wet detention pond in compliance with
the provisions of Session Law 2008-211 and 15A NCAC 2H .1000 (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 Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until July 29, 2019, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 of this permit. The stormwater control has been
designed to handle the runoff from 68,285 square feet of impervious area.
3. The tract will be limited to the amount of built -upon area indicated in Section I. of
this permit, and per approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6. The built -upon areas associated with this project shall be located at least 50 feet
landward of all perennial and intermittent surface waters.
7. The following design criteria have been provided in the wet detention pond and
must be maintained at design condition:
Page 2 of.7

State Stormwater Management Systems
Permit No. SW7090601
a.
b.
G.
d.
e.
f.
h.
k.
I.
m
A
Drainage Area, acres:
Total Impervious Surfaces, ftz:
Design Storm, inches:
Pond Depth, feet:
TSS removal efficiency:
Permanent Pool Elevation, FMSI :
Permanent Pool Surface Area, ft
Permitted Storage Volume, ft :
Temporary Storage Elevation, FMSL:
Predevelopment 1 year 24 hour:
Post development 1 year 24 hour:
Controlling Orifice:
Permitted Forebay Volume, ft3:
Fountain Horsepower, HP
Receiving Stream/River Basin:
Stream Index Number:
Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
2.94
68,285
1.5"
4.50
90%
9.50
20,989
37,499 at temporary pool el.
11.00
5.76 ft
3is
0.00 ft3/s
1.0" 0 pipe
9,350
1/6 HP (optional)
UT to Joyce Creek / Pasquotank
River Basin
30-3-2-2
"C, Sw"
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the vegetated filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans and
specifications.
f. Debris removal and unclogging of outlet structure, orifice device, level
spreader, filter strip, catch basins and piping.
g. Access to the outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
records will indicate the date, activity, name of person performing the work and
what actions were taken.
The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance inspection records for each BMP. The report shall
summarize the inspection dates, results of the inspections, and the maintenance
work performed at each inspection.
Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
Decorative spray fountains will be allowed in the stormwater treatment system,
subject to the following criteria:
a. The fountain must draw its water from less than 2' below the permanent
pool surface.
b. Separated units, where the nozzle, pump and intake are connected by
Page 3 of 7

State Stormwater Management Systems
Permit No. SW7090601
tubing, may be used only if they draw water from the surface in the
deepest part of the pond.
c. The falling water from the fountain must be centered in the pond, away
from the shoreline.
d. The maximum horsepower for a fountain in this pond is 1/6 horsepower.
8. The facilities shall be constructed as shown on the approved plans. This permit
shall become void unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other
supporting data.
9. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
10. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
11. 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 any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
12. 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.
13. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
14. A copy of the approved plans and specifications shall be maintained on file by
the Permittee at all times.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form, to the Division of Water
Quality, signed by both parties, and accompanied by supporting documentation
Page 4 of 7

State Stormwater Management Systems
Permit No. SW7090601
as listed on page 2 of the form. The project must be in good standing with the
Division. 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 such
time as the Division approves the transfer request.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. 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) having jurisdiction.
5. 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 this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
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
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. 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 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 NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division of any name, ownership or mailing
address changes at least 30 days prior to making such changes.
12. This permit shall be effective from the date of issuance until July 29, 2019.
Application for permit renewal shall be submitted 180 days prior to the expiration
date of this permit and must be accompanied by the processing fee.
Permit issued this the 29th day of July, 2009.
N RTH C ROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
�- for
Coleen H. Su i , Direc or
Division of Water Quality
By Authority of the Environmental Management Commission
Stormwater Permit No. SW7090601
Page 5 of 7

State Stormwater Management Systems
Permit No. SW7090601
South Mills Fire Department
Stormwater Permit No. SW7090601
Camden County
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/ full
time) the construction of the project,
(Project)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 6 of 7

State Stormwater Management Systems
Permit No. SW7090601
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
7. Trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation.
9. Vegetated slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and/or volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13. All required design depths are provided.
14. All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
15. The required system dimensions are provided per the approved plans.
cc: NCDENR-DWQ Washington Regional Office
Camden County Building Inspections
Page 7 of 7

•nnr,1�F1' S / 7/2—y lam/..
DWQ USE ONLY
Date Received
Fee Paid
Permit Number
JUN - 1 2009
p
State of North Carolina 6WAC-K Coll �49
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied far use as an original
1. GENERAL INFORMATION
1. Applicants name (specify the name of the corporation, individual, etc. who owns the project):
2. Print Owner/Signing Official's name and title (person legally responsible for facility and compliance):
Randell Woodruff. Camden County Manager
3. Mailing Address for person listed in item 2 above:
City:Camden State:NC Zip:27921
Phone: (252 ) 338-1919 ext. 222 Fax: [phone]
Email: [e-mail]
4. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
South Mills Fire Department - Keeter Barn Road
5. Location of Project (street address):
Keeter Barn Road
City:South Mills County:Camden Zip:27976
6. Directions to project (from nearest major intersection):
Leaving Elizabeth City proceed north on Route 17 to Keeter Barn Road and take a right then proceed to the
first gravel road and take a right
7. Latitude:36° 28' 21" N Longitude:76° 19' 58" W of project
8. Contact person who can answer questions about the project:
Name:Derek Dail. P.E. Telephone Number: (252 1 441-3913
Email: [e-mail]
II. PERMIT INFORMATION:
I. Specify whether project is (check one): ®New Renewal ElModification
Form SWU-101 Version 09.2.5.08 Page I of 4

2. If this application is being submitted as the result of a renewal or modification to an existing permit, list the
existing permit numberN/A and its issue date (if known)
3. Specify the type of project (check one):
❑Low Density ®High Density ❑Redevelop []General Permit []Universal SMP [-]Other
4. 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 ❑404/401 Permit ❑NPDES Industrial Storm water
III. PROJECT INFORMATION
1. In the space provided below, summarize how stormwater will be treated. Also attach a detailed narrative
(one to two pages) describing stormwater management for the project.
Stormwater will be directed to vegetated swales and conveyed the a single Wet Detention Basin located toward
the rear of the subject parcel.
2. Stormwater runoff from this project drains to the Pasquotank River basin.
3. Total Property Area: 3.0 acres 4. Total Coastal Wetlands Area: 0 acres
5. Total Property Area (3) - Total Coastal Wetlands Area (4) = Total Project Area**:3.0 acres
6. (Total Impervious Area / Total Project Area) X 100 = Project Built Upon Area (BUA):50 %
7. How many drainage areas does the project have?I
8. Complete the following information for each drainage area. If there are more than two drainage areas in the
project, attach an additional sheet with the information for each area provided in the same format as below.
For high density ro ects, com lete the table with one drainage area for each engineered stormwater device.
Basin Information
Drainage Area 1
Drainage Area 2
Receiving Stream Name
TRIB TO JOYCE CREEK
Stream Class & Index No.
C , SW
Total Drainage Area (so
127,985
On -site Drainage Area (so
125,040
Off -site Drainage Area (so
2,945
Existing Impervious* Area (so
0
Proposed Impervious*Area (so
68,285
% Impervious* Area (total)
53.4
Impervious* Surface Area
Drainage Area 1
Drainage Area 2
On -site Buildings (so
11,700
On -site Streets (so
19,795
On -site Parking (sf)
On -site Sidewalks (sf)
Other on -site (sf)
33,945
Off -site (so
2,945
Total (so:
68,285
' Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
**Total project area shall be calculated to exclude Coastal Wetlands from use when calculating the built upon area
percentage calculation. This is the area used to calculate overall percent project built upon area (BUA).
Form SWU-101 Version 09.25.08 Page 2 of 4

9. How was the off -site impervious area listed above derived?AutoCADD area routine
Projects in Union County: Contact the DWQ Central Office staff to check to see dfyou project is located
within a Threatened & Endangered Species watershed that may be subject to more stringent stormwater
requirements.
IV. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
One of the following property restrictions and protective covenants are required to be recorded for all
subdivisions, outparcels and future development prior to the sale of any lot. If lot sizes vary significantly, a table
listing each lot number, size and the allowable built -upon area for each lot must be provided as an attachment.
Forms can be downloaded from http://h2o.enr.state.nc.us/su/bml2 forms.htm - deed restrictions.
Form DRPC-1
High Density Commercial Subdivisions
Form DRPC-2
High Density Developments with Outparcels
Form DRPC-3
High Density Residential Subdivisions
Form DRPC-4
Low Density Commercial Subdivisions
Form DRPC-5
Low Density Residential Subdivisions
Form DRPC-6
Low Density Residential Subdivisions with Curb Outlets
By your signature below, you certify that the recorded property restrictions and protective covenants for this
project shall include all the applicable items required in the above form, 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 NC DWQ, and that they will be recorded prior to
the sale of any lot.
V. SUPPLEMENT FORMS
The applicable state stormwater management permit supplement form(s) listed below must be submitted for each
BMP specified for this project. Contact the Stormwater Permitting Unit at [phone] for the status and
availability of these forms. Forms can be downloaded from http://h2o.enr.state.nc.us/su/bml2 forms.htm.
Form SW401-Low Density
Form SW401-Curb Outlet System
Form SW401-Off-Site System
Form SW401-Wet Detention Basin
Form SW401-Infiltration Basin
Form SW401-Infiltration Trench
Form SW401-Bioretention Cell
Form SW401-1-evel Spreader
Form SW401-Wetland
Form SW401-Grassed Swale
Form SW401-Sand Filter
Form SW401-Permeable Pavement
Form SW401-Cistem
Low Density Supplement
Curb Outlet System Supplement
Off -Site System Supplement
Wet Detention Basin Supplement
Infiltration Basin Supplement
Underground Infiltration Trench Supplement
Bioretention Cell Supplement
Level Spreader/Filter Strip/Restored Riparian Buffer Supplement
Constructed Wetland Supplement
Grassed Swale Supplement
Sand Filter Supplement
Permeable Pavement Supplement
Cistern Supplement
Form SWU-101 Version 09.25.08 Page 3 of

VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. The complete application package should be
submitted to the appropriate DWQ Office. (Appropriate office may be found by locating project on the
interactive online map at httt)://h2o.enr.state.nc.us/su/msi mans htm)
Please indicate that you have provided the following required information by initialing in the space provided
next to each item.
Initials
• Original and one copy of the Stormwater Management Permit Application Form
A
• Original and one copy of the Deed Restrictions & Protective Covenants Form (if
A D
required as per Part IV above)
• Original of the applicable Supplement Form(s) and O&M agreement(s) for each BMP
A6
• Permit application processing fee of $505 (Express: 54,000 for HD, $2,000 for LD)
payable to NCDENR
1) ks
• Calculations & detailed narrative description of stormwater treatment/management
D A_D
• Copy of any applicable soils report
A l)
• Two copies of plans and specifications (sealed, signed & dated), including:
a'
- Development/Project name
- Engineer and firm
-Legend
- North arrow
- Scale
- Revision number & date
- Mean high water line
- Dimensioned property/project boundary
- Location map with named streets or NCSR numbers
- Original contours, proposed contours, spot elevations, finished floor elevations
- Details of roads, drainage features, collection systems, and stormwater control measures
- Wetlands delineated, or a note on plans that none exist
- Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations
- Drainage areas delineated
- Vegetated buffers (where required)
VIL AGENT AUTHORIZATION
If you wish to designate authority to another individual or firm so that they may provide information on your
behalf (such as additional information requests), please complete this section. (ex. designing engineer or firm)
Designated agent (individual or firm):Hobbs, Upchurch & Associates. P.A.
Mailing Address:PO Box 1929, Nags Head. NC 27959
City:Nags Head State:NC Zip:27959
Phone: (252 ) 441-3913 Fax: [phone]
Email:ddail®hobbupchurch.com
VIII. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in General Information, item 2) Randell Woodruff Camden County Manager
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 15A
NCAC 2H .1000. �/ q
Signature: N�'
Form SWU-101 Version 09.25.08 Page 4 of 4

Permit Number:
(to be provided by DWQ)
Drainage Area Number:
Wet Detention Basin Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
The wet detention basin system is defined as the wet detention basin, E"
pretreatment including forebays and the vegetated filter if one is provided.
JUN - 12009
This system (check one):
❑ does ® does not incorporate a vegetated filter at the outlet.
This system (check one):
® does ❑ does not . incorporate pretreatment other than a forebay.
Important maintenance procedures:
— Immediately after the wet detention basin is established, the plants on the
vegetated shelf and perimeter of the basin should be watered twice weekly if
needed, until the plants become established (commonly six weeks).
— No portion of the wet detention pond should be fertilized after the first initial
fertilization that is required to establish the plants on the vegetated shelf.
— Stable groundcover should be maintained in the drainage area to reduce the
sediment load to the wet detention basin.
— If the basin must be drained for an emergency or to perform maintenance, the
flushing of sediment through the emergency drain should be minimized to the
maximum extent practical.
— Once a year, a dam safety expert should inspect the embankment.
After the wet detention pond is established, it should be inspected once a month and
within 24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in a
Coastal County). Records of operation and maintenance should be kept in a known set
location and must be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash debris.
The perimeter of the wet
Areas of bare soil and/or
Regrade the soil if necessary to
detention basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
Vegetation is too short or too
Maintain vegetation at a height of,
long.
approximately six inches.
Form SW401-Wet Detention Basin O&M-Rev.4
Page 1 of 4

Permit Number:
(to be provided by DWQ)
Drainage Area Number:
BMP element:
Potentialproblem:
How I will remediate theproblem:
The inlet device: pipe or
The pipe is clogged.
Unclog the pipe. Dispose of the
swale
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the swale if necessary to
swale.
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design depth for
possible. Remove the sediment and
sediment storage.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
The vegetated shelf
Best professional practices
Prune according to best professional
show that pruning is needed
practices
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the
dying.
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
The main treatment area
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design sediment
possible. Remove the sediment and
storage depth.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Algal growth covers over
Consult a professional to remove
50% of the area.
and control the algal growth.
Cattails, phragmites or other
Remove the plants by wiping them
invasive plants cover 50% of
with pesticide (do not spray).
the basin surface.
Form SW401-Wet Detention Basin O&M-Rev.4 Page 2 of 4

r
Permit Number:
(to be provided by D
Drainage Area Number:
BMP element:
Potentialproblem:
How I will remediate theproblem:
The embankment
Shrubs have started to grow
Remove shrubs immediately.
on the embankment.
Evidence of muskrat or
Use traps to remove muskrats and
beaver activity is present.
consult a professional to remove
beavers.
A tree has started to grow on
Consult a dam safety specialist to
the embankment.
remove the tree.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair. if applicable)
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose
of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the local NC Division of
damage have occurred at thet1786.
Water Quality Regional Office, or
outlet.
the 401 Oversight Unit at 919-733-
The measuring device used to determine the sediment elevation shall be such
that it will give an accurate depth reading and not readily penetrate into
accumulated sediments.
When the permanent pool depth reads 3.5' feet in the main pond, the sediment
shall be removed.
When the permanent pool depth reads 3.5' feet in the forebay, the sediment
shall be removed.
BASIN DIAGRAM
(fill in the blanks)
Permanent Pool Elevation 9.5'
Sediment Removal . 6_0' Pe anen Pool
--------- Volume Sediment Removal Elevation 6.0' Volume
Bottom Elevatio 5_0' ft Min.
----------------------------- ------------ ------
Sediment Bottom Elevation 5.0' 1-ft r
Storage Sedimet
Storage
FOREBAY MAIN POND
Form SW401-Wet Detention Basin O&M-Rev.4
Page 3 of 4

Permit Number:
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name:South Mills Fire Department - Keeler Bam Road
BMP drainage area number:
Print name:Randell Woodruff
Title: Camden County Manager
Address:P.O. Box 190, Camden, NC 27921
Phone:[phone] ext. 222
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
1, Jbo W 1. W . hW r q a Notary Public for the State of
n(OM) &ro I i t1A , County of ,it-(✓ , do hereby certify that
kar) el I Wc)odru-ff personally appeared before me this 27
day of _r)-" y—, and acknowledge the due execution of the
forgoing wet detention basin maintenance requirements. Witness my hand and official
seal, `T U/1L W L A)7C1�—
No rg
DAWN W LOWRY
NOTARY PUBLIC
PASQUOTANK COUNTY
STATE OF NORTH CAROLI
SEAL
My commission expires 1 1- q-,Q n o
Form SW401-Wet Detention Basin O&M-Rev.4 Page 4 of 4

pp�� Permit No.
4fE rt�,�''_��pY Ir (to be provtled by DWO)
JUN - 12009
®TA Op W A TF9
O� �G
NCDENR o
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WET DETENTION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist )Part III) must be printed, filled out and submitted along with all of the required information.
Contact person
Phone number
Date
Drainage area number
1252441-3913
5R712009
1
Road
I1ADESIGN INFORMATION
She Characteristics
Drainage area r
ti7,985e ✓
Impervious area, post -development
68,285 ft
%impervious
53.35 %
Design rainfall depth
1.5in
Storage Volume: Non -SA Waters
Minimum volume required
12,958 ft3 OK
Volume provided
37,499'ft3
OK, volume provided is equal to or In excess of volume required.
Storage Volume: SA Waters
1.5' runoff volume
0
Pre -development 1-yr, 24-hr runoff
ft3
Post -development 1-yr, 24-hr runoff
ft3
Minimum volume required
0 0
Volume provided i ft3
Peak Flow Calculations
Is the pre/post control of the lyr 24hr storm peak flow required?
n (Y or N)
1-yr, 24-hr rainfall depth I
in
Rational C, pre -development
(unitless)
Rational C, post -development
(unNess)
Rainfall intensity: l-yr, 24-hr strum
• in/hr
Pre -development 1-yr. 24-hr peak flow
5.76 ft3/sec
Post -development 1-yr, 24-hr peak flow
0.00 ft3lsec
PmFost 1-yr, 24-hr peak flow control
-5.76 ft3lsec
Elevations
Temporary pool elevation
11.00 fmsl
Permanent pool elevation i
9.50 fmsl
SHWT elevation (approx. at the perm. pool elevation)
9.50 fmsl
Top of 1 Dft vegetated shelf elevation
10.00 fmsl
Bottom of 10ft vegetated shelf elevation I
9.00fmsl
Sediment cleanout, top elevation (bottom of pond) I
6.00r Imsl
Sediment deanout, bottom elevation I
5.00; fmsl
Sediment storage provided
1.00 ft
Is there additional volume stored above the state -required temp. pool?
y 1 (Y or N)
Elevation of the top of the additional volume
11.0 Imsl
OK
Form SW401-Wet Detention Besui-Rw 6.2/20/09 Parts I a 11 Design Summery, Page 1 of 2

Permit No.
(to be rrovded by D6YT])
Area, temporary pool
Area REQUIRED, permanent pool
SAIDA ratio
Area PROVIDED, permanent pool, %b._nm
Area, bottom of 10ft vegetated shelf, A,,_.
Area, sediment deanoul, top elevation (bottom of pond), A,.
Volumes
Volume, temporary pool
Volume, permanent pod, Vpe,rym
Volume, forebay (sum of forebays it more than one forebay)
Forebay %of permanent pool volume
SAIDA Table Data
Design TSS removal
Coastal SAIDA Table Used?
MountainlPiedmont SAIDA Table Used?
SAIDA ratio
Average depth (used in SAIDA table):
Calculation option 1 used? (See Figure 10-2b)
Volume, permanent pod, Vp _Pw
Area provided, permanent pool, A,
Average depth calculated
Average depth used in SAIDA, dN, (Round to nearest 0.5ft)
Calculation option 2 used? (See Figure 10-2b)
Area provided, permanent pool, yba�,_oon
Area, bottom of 1011 vegetated shelf, A�mw
Area, sediment deanout, top elevation (bottom of pond), Ab
'Depth' (distance b/w bottom of 10ft shelf and top of sediment;
Average depth calculated
Average depth used in SAIDA, d., (Round to nearest 0.5ft)
Drawdown Calculations
Drawdown through orifice?
Diameter of orifice (it circular)
Area of orifice (if-rioncucular)
Coefficient of discharge (Cm)
Driving head (It)
Drawdown through weir?
Weir type
Coefficient of discharge IQ
Length of weir (L)
Driving head (H)
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
Storage volume discharge rate (through discharge orifice or weir)
Storage volume drawdown time
Additional Information
Vegetated side slopes
Vegetated shelf slope
Vegetated shelf width
Length of flowpath to width ratio
Length to width ratio
Trash rack for overflow & orifice?
Freeboard provided
Vegetated filter provided?
Recorded drainage easement provided?
Capures all runoff at ultimate build -out?
Drain mechanism for maintenance or emergencies
29,51—1 12
8,063 It'
1 6.30, limitless)
20,989if?✓ OK
15,106'ft
12,385!ft
37,499'ft3
55,4881 ft3
9,3501ft3
16.9% %
so'%
I y (Y or N)
I n (Y or N)
6.30 (unitless)
N (Y or N)
I ft3
fl
I fl
Y (YorN)
20,989,ft
15,106 It'
12.385 ft2
3.00 ft
3.00, ft
3.0 If
Y (Y or N)
100 in
in
0.60 limitless)
0.03It
N (Y or N)
(unitless)
(unitless)
If
It
5 76' ft3lsec
0.00 ft3/sec
I 0.07' ft3/sec
3 37j days
or N)
or N)
or N)
or N)
OK
Insufficient forebay volume. MAIN SAy S5 5"'56 LhRGE
iU ACcolImowf T4E - 9
y, 3 " STo17M ; kEr�eE E
FORS 13AY TS'SIZFO 5t 'f P�aYL
SHALL trt T14AN 1dajad
OK
OK
OK
OK
OK
OK
OK
OK
OK, draws down in 2-5 days.
Drawdown time varying from expected value by more than a half day.
t SE E I)12AWDOWI•I ( At -es
OK
OK
OK
OK
OK
OK
OK
OK e�RIVATi SYSTEM ON A j)rtIVA1E Ld
Insufficient. Recorded drainage easement required.
OK
Form SW401-Wet Detention BasirvRev 6-2r20/09 Parts 1. a 11 Design Summary, Page 2 of 2

Permit No.
(to be provided by DWQ)
III. REQUIRED ITEMS CHECKLIST. -
Please indicate the page or plan sheet numbers where the supporting documentation can be found.An incomplete submittal package will
result in a request for additional information. This will delay final review and approval of the project. Initial in the space provided to
indicate the following design requirements have been met. If the applicant has designated an agent, the agent may initial below.lf a
requirement has not been met, attach justification.
Page/ Plan
Initials
Sheet No.
D Pr
G 4
1. Plans (1" - 50' or larger) of the entire site showng:
D S
- Design at ultimate build -out,
- Off -site drainage (if applicable),
- Delineated drainage basins (include Rational C coefficient per basin),
- Basin dimensions,
- Pretreatment system,
-High Bow bypass system, Soa y��s� �CM!Rr,ENCY 5 ILLWA1'
m J/a.+ d✓<rehppr^�
- Maintenance access,
- Proposed drainage easement and public right of way (ROW),
- Overflow device, and
- Boundaries of drainage easement.
A I
2. Partial plan (1" = 30' or larger) and details for the wet detention basin showing:
S
- Outlet structure with trash rack or similar,
- Maintenance access,
- Permanent pool dimensions,
- Forebay and main pond with hardened emergency spillway,
- Basin cross-section,
- Vegetation specification for planting shelf, and
- Filter strip.
DN
3. Section view of the wet detention basin (1' = 20' or larger) showing:
J S
- Side slopes, 3:1 or lower,
- Pretreatment and treatment areas, and
- Inlet and outlet structures.
D A b
3
4. If the basin is used for sediment and erosion control during construction, dean out of the basin is specified
on the plans prior to use as a wet detention basin.
1) A,
CAL c S
5. A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for forebay,
to verify volume provided.
3
6. A construction sequence that shows how the wet detention basin will be protected from sediment until the
entire drainage area is stabilized.
DAt)
C ALCS
7. The supporting calculations.
A b 41A,kid 8. A copy of the signed and notarized operation and maintenance (08M) agreement
MIA IA 9. A copy of the deed restrictions (if required).
A (AL C S 10. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. County
soil maps are not an acceptable source of soils information.
Form SW401-Wet Detention Basin-Rev.6-2/20/09 Part III. Required Items Checklist, Page 1 of 1

%tA'h V%\\s f D
STORMWATER SUBMITTAL REQUIREMENTS
WET DETENTION POND
Objective
A. Collect all runoff from all BUA (proposed and/or existing and/or offsite) as the case may be,
by any means including piping or swales, and direct it to the pond.
B. Check the proposed pond design to make sure it meets or exceeds the minimum design
criteria for surface area, volume and drawdown.
II. What makes up a complete wet detention pond application package?
A. Two sets of sealed, signed & dated layout & grading plans with appropriate details.
(Additional sets of plans may be requested for projects in certain counties)
B. Completed application with supplement(s), SWU-101, SW401-Wet Pond, and inspection and
maintenance agreements.
C. Deed restriction document, if applicable (for subdivisions & projects with out parcels)
D. Sealed, signed & dated calculations.
E. Estimated seasonal high water table elevation at all pond locations.
F. Chlorides test results must be provided if the project is within ''/z mile of SR waters (Phase II).
(This is only required to test out of SR water treatment requirements)
III. BIMS entry (for DWQ use only)
Enter & track application acknowledged date, review date, add info requested/received dates, permit
issue dates, and drainage area info. Best done after the add info letter is written and before sending
permit up for signature.
IV. Shell documents (for DWQ use only) \ l
Permit shells: s:\wqs\stormwater\shells\highcompon,?-G;'
s:\wqs\stormwater\shells\highsubpond
s:\wqs\stormwater\shells\HDhybrid 3
Spreadsheet: s:\wqs\stormwater\excel spreadsheets\pond v " �I
VI. Review Procedure
A. APPLICATION
,/1. An original signature is required. Photocopied signatures cannot be accepted.
,/2. A completed wet detention pond supplement and a signed, dated and notarized wet
detention pond Inspection and Maintenance Agreement with an original signature.
-�j 3. The numbers on the supplement match up to the numbers used in the calculations and
shown on the plan details.
✓4. Built -upon areas are reported in square feet in Section 111.6.
,/5. Receiving stream name and classification. This is important because in the non -Phase
11 counties, a wet pond cannot,be used on a project that is within 'Y2 mile of and draining
to SA waters. For Phase 11, a wet pond is allowed within Yz mile'of SA waters.
„ . v/6. • ,Section 111.6 is ,filled, in -cannot be.left.blank. One column must be filled in for each
proposed wet'pond.
tkIN7. If the applicant is a corporation, partnership or LLC,, look it up on the Secretary of State
Corporations Database. Make sure corporation is spelled correctly (capitalization and
punctuation matter) and that the person signing the application is at least a vice-
president in the corporation, a General Partner in the partnership, a member in a
member -managed LLC, or the manager of a manager -managed LLC. Need
documentation to support if the Articles of Incorporation do not list the members or
managers of the LLC. If an agent signs, then a letter of authorization is needed from the
president, vice president, general partner, member or manager.
%JK 8. For subdivided projects, a signed and notarized deed restriction statement must be
provided.
lvnip S�atoo�¢. Va�oMe, &MLets = 40 J
%n Apt 68, LM 4r6p. \WV. i"AVNS (C-4) c05';b�
V

Wet Detention Pond, cont.
B. CALCULATIONS
11.
The orifice is sized based on drawing down the calculated minimum volume in 2-5
days. The average head to use in the orifice equation is approximately one-third of
the distance between the permanent pool elevation (PPE) and the elevation of the
next available outlet above the permanent pool. The elevation of the next available
outlet must be either the elevation where the minimum volume is provided, or it can
be higher. The temporary pool elevation (TPE) to report on the supplement will be
the elevation of the next available outlet above the PPE. The temporary pool volume
(TPV) to report on the supplement is the volume between the specified PPE and the
TPE.
"IA 2.
For Phase II projects that are within '/z mile of and draining to SR waters, the
difference in runoff from the predevelopment and post -development conditions for
the 1 year 24 hour storm must be controlled and treated.
%Ik 3.
For Phase II projects, the discharge rate leaving the pond can be no more than the
pre -development discharge rate for the 1 year 24 hour storm.
cvlA 4.
For Phase II projects draining to SA water, no discharge to surface waters may occur
/
from wet ponds. The discharge leaving the orifice must be effectively infiltrated prior to
surface waters.
5.
he average pond depth is the permanent pool volume divided by the permanent pool
freaching
surface area. The result must be between 3 ft. and 7.5 ft. Parts of the pond can be
deeper than 7.5 ft., but in no case can any part of the pond be less than 3 ft deep.
N/A 6.
If the 85% TSS chart is used a 30' vegetated filter must be provided at the outlet of the
pond. If the 90% TSS chart is used, no filter is required.
V 7.
Use the correct SA/DA TSS chart from the BMP Manual noting that there are different
charts for different areas of the State.
,/8.
Required surface area at permanent pool.
A.
Provided surface area at permanent pool (Based on pond dimensions)
cvjtA 0.
Required volume calculation based on 1.5" storm for Phase I I projects' and 1" storm for
all others projects. 'unless the project is Phase II and within '/z mile of and draining to
SR waters then the volume calculation must be based on difference between the pre
and post development conditions for the 1-yr 24-hr storm.
✓11. ,.
Table of elevations, areas, incremental volumes and accumulated volumes for overall
pond and for forebay, to verify volumes provided.
-MW2.
Forebay designed to hold 20% of the permanent pool volume. (Range of 18%-22%
OK.)
il,#K3.
Non -erosive flow for 10 yr. storm in the vegetated filter, if using 85% TSS.
/14.
The seasonal high water table must be at or below the proposed permanent pool
elevation to assure that the necessary volume will be available above the permanent
pool.
✓15.
Rounding numbers off during the calculation process can result in deficiencies. Do not
round the numbers until you get to the final result.
✓16.
An additional one foot must be excavated below the bottom elevation of the pond. The 1
foot sediment accumulation depth is not included in the average depth calculation.
Avec� �P
/. erwocvy 61' vetM Voo\ V*N/. l&je� ;o cNewut- A mare, pocva Soc Cwkuce 'buAl

S
Wet Detention Pond, cont.
C. PLANS- Due to storage space constraints, plan sheets should be kept to a minimum. For
small commercial single wet pond projects, the plan set could consist of only 2 or 3 sheets,
layout, grading and details. For larger projects, show as much information as possible on as
few sheets as possible, without cluttering them up.
✓1. Development/Project Name
V2. Engineer name and firm.
✓3. Legend
A. North Arrow
✓ 5. Location Map with nearest intersection of two major roads shown. Major road is any 1,
2, or 3 digit INC, US or interstate highway.
�0 Scale- standard engineering scale, no off-the-wall stuff.
�7 Date
N/08. Revision number and date, if applicable.
v19. Original contours, proposed contours, spot elevations, finished floor elevations, pipe
inverts, swale inverts, etc.
✓ 10. Existing drainage (piping, swales, ditches, ponds, etc.), including off -site. Include a map
delineating the offsite drainage areas.
✓11. Property/Project boundary lines, bearing & distances.
t4h12. Mean High Water Line or Normal High Water Line, if applicable.
✓13. The permanent pool elevation must be above the SHWT and above the lowest
elevation of adjacent wetlands. Evaluate the need for a liner and/or berm/slurry wall to
prevent dewatering the wetland.
141p,14. _ Drainage easement widths, pipe sizes and swale inverts are provided.
✓15. Wetlands delineated, or a note on the plans that none exist. Get a copy of the wetlands
delineation map signed by the Corps of Engineers, or have the applicant include a copy
of the unsigned delineation map submitted to the Corps. Wet ponds may not be located
in wetlands unless a permit to fill those wetlands has been obtained.
✓16. Details for the roads, parking, cul-de-sacs, including sidewalk width, radii, dimensions &
slopes.
NIN17. Apartment / Condo development- Provide a typical building footprint with dimensions
and note all concrete and wood deck areas.
/18. The drainage area for each wet pond is clearly delineated and numbered to match up to
the calculations and supplement. Drainage area delineation is best done as a separate
plan sheet.
V19. A pond section detail to include the forebay, a 10 foot wide vegetated shelf, pertinent
elevations for the bottom, permanent pool, temporary pool, and SHWT, 3:1 slopes
above the permanent pool, and the weir elevation between the main pond and the
forebay.
✓20, The 10 vegetated shelf extends 6" below and 6" above the permanent pool elevation.
✓21. An outlet structure detail showing a trash rack with 56" square openings, the necessary
orifice invert elevation (i.e., the permanent pool), orifice size and temporary pool
elevation.
22. Dimensions for each line and arc formed by the permanent pool contour.
Nip 23. Where the 85% TSS chart was used, a 30 ft. vegetated filter strip is required to be
shown on the plans & detailed (elevations, inverts, slopes, and flow spreader
mechanism). Please note that the filter strip is not a ditch.
✓24. A forebay is provided for each inlet and located so as to prevent short-circuiting.
,/25. The pond must have a minimum 1.5:1 length to width ratio and a minimum 3:1 flow path
length. Artificial "baffles" of timber, vinyl, or earth can be used to create a longer flow
path. The top elevation of the baffle should be set at the temporary pool elevation or
higher.
✓26. A Vegetation plan is specified for the pond, including slopes. Wetlands species are
listed for planting on the 10:1 shelf. Weeping Love Grass is not suitable as a permanent
vegetated cover for pond slopes.
✓27. All roof drainage must be directed to the pond. Show the roof drain collection lines on
the plan. This is necessary for projects where the buildings back up the property lines
where roof drainage may leave the site prior to going through the pond.

sw^yQ qo('7o 1 kan ,d-, 6 4-o4/,Gk0
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print apnd, if.'
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank?')t�. r ,w - a7
Part A.
1. Project
2. Location of land -disturbing activity: County CAMDEN City or
JUN - 2 2009
Highway/Street: Keeter Barn Road SR 1226 Latitude 360-28'-2" N Longitude 76°-19-58" W
3. Approximate date land -disturbing activity will commence: November 2008
4. Purpose of development (residential, commercial, industrial, institutional, etc.): MUNICIPAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.2 ac
6. Amount of fee enclosed: $ 260 . The application fee of $50.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $450).
7. Has an erosion and sediment control plan been filed? Yes No _ Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Randell Woodruff E-mail Address rwg!2druff@camdencouni�mc.gov
Telephone [phone] ext.222 Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Camden County 252-338-1919 252-333-1603
Name Telephone Fax Num ®����
PO Box 190 117 NORTH NC 3
Current Mailing Address Current Street Ad r "(�„� pp�`
CAMDEN NC 27921 CAMDEN AN 7 9of1g27921
City State Zip City L� A� I� Sgt to Zip
tA1VU�]UALITY SECTION
10. Deed Book No. 221 Page No. 8 ProviK-V0@ GiO${4 Lt YcrlC&eed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Randell Woodruff (County Manager)
Name
PO Box 190
Current Mailing Address
CAMDEN NC 27921
City State Zip
Telephone[phone] ext.222
rood ruff®camdencountync4ov
E-mail Address
117 NORTH NC 343
Current Street Address
CAMDEN NC 27921
City State Zip
Fax Number 252-333-1603

f . i J-_ i .1 1.
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Current Mailing Address
State Zip
Telephone
E-mail Address
Current Street Address
Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Randell Woodruff (County Manaoer
Name of Registered Agent
PO Box 190
Current Mailing Address
CAMDEN NC 27921
City State Zip
Telephone[phone] ext.222
rwoodruff@camdencoun!3mc.gov
E-mail Address
117 NORTH NC 343
Current Street Address
CAMDEN NC 27921
City State Zip
Fax Number 252-333-1603
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there by any change in the information provided herein.
Randell Woodruff
Type or print name
County Manager
Title or Authority
A7.�d q
Date
1, : D W K 'SOUyy ✓ I a Notary Public of the County of-q?64U_G+C� L
State of North Carolina, hereby certify that Ph nA F � ( I\ - Ve (1rYl ✓a appeared
personally before me this day and being duly sworn acknowledged that 4he above form was
executed by him.
Witness my hand and notarial seal, this day of 1. 20
DAWN W LOWRY Notary
AA,���yyOTARY PUBLIC
UOTANK COUNTY
STATE OF NORTH CAROLINA My commission expires