SW7100907_CURRENT PERMIT_20210809 (2)

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO. SW 7_/0 ey2
DOC TYPE CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑. COMPLIANCE EVALUATION INSPECTION
DOC DATE ;m
YYYYMMDD

1n�aKc�
ROY COOPER
Oovemor
ELIZABETH S. BISER
Secretary
BRIAN WRENN
Director
NORTH CAROLINA
Environmental Quality
August 9, 2021
CarolinaEast Health System
Attention: Leslie Allen, VP Facilities & Safety
P.O. Box 12157
New Bern, NC 28561
Subject: Stormwater Permit No. SW7100907 Renewal/ Ownership Change
CarolinaEast Cardiac, Thoracic, Vascular Surgery
High Density Project
Craven County
Dear Leslie Allen:
The Washington Regional Office received Stormwater Management Permit Applications
for renewal and change of ownership of the subject permit on July 6, 2021. Staff review
of the applications have determined that the permit can be reissued. We are forwarding
Permit No. SV 7100907 dated August 9, 2021, for the continued operation of the
existing stormwater system.
This permit, upon its effective date, will replace all previous State Stormwater permits for
this project. This permit shall be effective from the date of issuance until August 8, 2029
and shall be subject to the conditions and limitations as specified therein and does not
supersede any other agency permit that may be required. 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 150B of the North Carolina General Statutes, and filed with the
Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714.
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 me at [phone].
Sincerely,
Roger K. Thorpe
Environmental Engineer
�C North Carolina Department of Environmental Quality 1 Division of Energy. Mineral and Land Resources
J% Washington Regional Office . 043 Washington Square Mall I Washington. No, th Carolina 27889
n+.uamna� 00 2.51946 6481

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
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
CarolinaEast Health System
CarolinaEast Cardiac, Thoracic, Vascular Surgery
Located at 960 Newman Road, New Bern, NC
Craven County
FOR THE
construction, operation and maintenance of a Wet Detention Pond in compliance with
the provisions of 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 Energy,
Mineral, and Land Resources (Division) and considered a part of this permit.
This permit shall be effective from the date of issuance until August 8, 2029, and
shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
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 20,000 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. The built -upon area for the future
development is limited to 33 square feet.
North Carolina Department of Environmental Quality I Dtvisbn of Energy. ytmeini and Land Resources
Washmgton Regional Office • 433 Washington Square Nall I Washington, North Carolina 27884
252.446.a481

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:
a. Drainage Area, acres: 1.06
b. Total Impervious Surfaces, ft2: 20,000
C. Design Storm, inches: 1.50
d. Pond Depth, feet: 3.0 average
e. TSS removal efficiency: 90%
f. Permanent Pool Elevation, FMSL: 22.00
g. Permanent Pool Surface Area, ft2: 2,379
h. Permitted Storage Volume, ft3: 5,420 at temporary pool elev
i. Temporary Storage Elevation, FMSL: 23.50
j. Predevelopment 1 year 24 hour: 1.27 cfs
k. Post development 1 year 24 hour: 0.03 cfs
I. Controlling Orifice: 0.75" 0 pipe .
M. Permitted Forebay Volume, ft3: 839
n. Fountain Horsepower, HP 0, no pump allowed, too small
o. Receiving Stream/River Basin: Lawson Creek / Neuse
P. Stream Index Number: 27 — 101 — 42
q. Classification of Water Body: "SC; Sw; NSW"
II. SCHEDULE OF COMPLIANCE
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 times 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.
North Carolina Department of Environmental Quality Drviswn of Energy. Mineral and Land Resources
_ Washington Regional office I q43 Washington SquareMall I Washington, North Carolina 2788q
252.946 o481

ri
11
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.
a. Access to the outlet structure must be available at all times.
Records of maintenance activities must be kept for each permitted SCM. 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 an annual summary report of the
maintenance inspection records for each SCM. 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 not be allowed in the stormwater treatment
system.
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.
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.
G. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
North Carolina Department of Envn onmental Quality I Division of `Energy. Mineral and Land Resources
_EQ 'Washington Regional Office 1433 Washington Square Hall I'Vashrrgton. Worth Carolina 27S8g
.gym � 25244t,o481 _

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.
Ill. 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, signed by
both parties, and accompanied by supporting documentation 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.
The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division, in accordance with
North Carolina General Statute 143-215.6A to 143-215.6C.
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 DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
North Carolina Department of Environmental Quality Division of Energy. Mmeml and Land Resources
Washington Regional Office � o 1,3 Washington Square Stall 1 Washington. North Carolina 27889

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 Title 15A NCAC
21-1.1000, 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 August 8, 2029.
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 9 th day of August 2021.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
For
Brian Wrenn, Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Permit Number SW7100907
�R North Carolina Depat unent or Envn ornnental Quality I Divisiun or Energy. Mimi at and Land Resources
_ J! Washington Regional Office I Q43 Washington Square Mall I 'wash,ngton, North Carolina 27384
n.«.m anbm,..moia.� 252.946 o481

Wet Detention Basin
Permit Number: S Iv% /O 07a %
(to be provided by DWQ)
Drainage Area Number:
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, J �/ I�7E pretreatment including forebays and the vegetated filter if one is provq
This system (check one): SEP 2 4 2010
❑ does ® does not incorporate a vegetated filter at the outlet. DWQ
This system (check one): Pxoa # _
❑ 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 time 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 I 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

Permit Number:
(to be provided by DWQ)
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 the
Water Quality Regional Office, or
outlet.
the 401 Oversight Unit at 919-733-
1786.
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 4.5 feet in the main pond, the sediment
shall be removed.
When the permanent pool depth reads 4.5 feet in the forebay, the sediment
shall be removed.
Sediment Removal
Bottom
BASIN DIAGRAM
ill in the blanks)
Permanent Pool Elevation 22.0
17.5 1 Pe anen Pool
Volume Sediment Removal Elevation 17.5 Volume
66.5 -ft Min.
Sediment Bottom Elevation 16.5 1-ft r
Storage Sedimei
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:Cardiac, Thoracic, & Vascular Associates, PLLC
BMP drainage area number:
Print name:Dr. Michael E. Halligan
Title:Managing Member - CTVAEC Properties, LLC
Address:2111 Neuse Boulevard, Suite H, New Bern, NC 28560
Date: 9-211-ZO10
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, Jo5h.cia P pa_oI'M, a Notary Public for the State of
J ��"I t`no�, County of �,�ys do hereby certify that
am rc.J personally appeared before me this
day of Sin 2d 10 ,and acknowledge the due execution of the
forgoing wet detention basin maintenance requirements. Witness my hand and official
seal, I,-')
Notary PubliC
Jones County
My Commission ex
02/07/2012
"/,// �"N C AVk�;,•
SEAL
My commission expires Q-00 7 ZO/Z
Form SW401-Wet Detention Basin O&M-Rev.4
Page 4 of 4

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Date Received
Fee Paid
Permit Number
7 1S121
1
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NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT TRANSFER APPLICATION FORM
Pursuant to 15A NCAC 02H.1045 and other applicable statues as reference within
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at., http://deg.nc.gov/contact/regional-offices.
After this application is accepted, DEMLR will conduct a compliance inspection and report any deficiencies to the
current permittee and/or the proposed permittee. Per the state stormwater rules and the state stormwater permit
conditions, the permit shall not be transferred until:
1. the current permittee resolves all non-compliance issues identified in the inspection report;
2. the current permittee negotiates a resolution with the proposed permittee (in writing and signed by both
entities. The negotiated resolution must identify the necessary actions, the responsible party(ies), and the
timelines to correct the deficiencies. The site must either be found in compliance or a copy of the
negotiated resolution must be submitted prior to the transfer of the permit.); or
3. in the case where a transfer falls under G.S. 143-214.7(c2) (see also SL 2011-256), the proposed
permittee resolves all non-compliance issues upon acquiring the permit.
Signature requirements for the named signing official (for current and proposed permittee) must meet the following:
• Corporation - a principal executive officer of at least the level of vice-president;
• Limited Liability Company (LLC) - the designated manager,, (Documentation from the NC Secretary of
State or other official documentation must be provided that states the titles and positions held by the
person who signed the application (pursuant to 02H.1040) that shows they have legal authority to sign for
the LLC)
• Municipality - a ranking official or duly authorized employee;
• Partnership or limited partnership - the general partner,
• Sole proprietor;
• The signature of the consultant or other agent shall be accepted on this permit transfer application only if
accompanied by a letter of authorization signed by one of the signatories noted in a-e above, as
applicable.
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW7100907
2. Project name: CarolinaEast Cardiac Thoracic Vascular Surgery
Is this an updated project name from the current permit? X Yes ❑ No
3. Reason for the permit transfer request:
Purchase of property.
Stormwater Permit Transfer Application Form Page 1 of 7 April 27, 2018

B. PERSON(S) WHO HAVE SIGNED THIS FORM (select only one response below)
❑ 1. Both the current and proposed permittees
❑ 2. Only the current permittee of a condominium or planned community (skip PartF & G).
In accordance with G.S. 143-214.7(c2) (see also SL 2011-256), this type of transfer is allowed only
when all of the following items can be truthfully checked.,
❑ Any common areas related to the operation and maintenance of the stormwater management
system have been conveyed to the unit owners' association or owners' association in
accordance with the declaration,
❑ The declarant has conveyed at least fifty percent (50%) of the units or lots to owners other than
a declarant (provide documentation per submittal requirements below);
❑ The stormwater management system is in compliance with the stormwater permit.
NOTE: If subdivision was built prior to 1999, the Declarant's Attorney can make a determination that
the elements of the Planned Community Act (see §47F) have been met by the Declarant for the
subdivision. If the Declarant chooses to use this type of transfer, the determination must be in
writing, signed by the attorney, and submitted to DEMLR with this form.
X 3. Only the proposed permittee (skip Part D below).
In accordance with G. S. 143-214.7(c5) (see also SL 2013-121), this type of transfer is allowed only
when all of the following items can be truthfully checked:
❑ a. The proposed permittee is either (select one of the following):
X The successor -owner who holds title to the property on which the permitted activity is
occurring or will occur;
❑ The successor -owner who is the sole claimant of the right to engage in the permitted
activity.
❑ b. The current permittee is (select at least one of the following, but all that apply):
❑ A natural person who is deceased.
❑ A partnership, Limited Liability Corporation, corporation, or any other business
association that has been dissolved
❑ A person who has been lawfully and finally divested of title to the property on which the
permitted activity is occurring or will occur.
X A person who has sold the property on which the permitted activity is occurring or will
occur.
❑ Other (please explain):
❑ c. The proposed permittee agrees to the following requirements (all must be selected):
X There will be no substantial change in the permitted activity.
X The permit holder shall comply with all terms and conditions of the permit until such
time as the permit is transferred.
X The successor -owner shall comply with all terms and conditions of the permit once the
permit has been transferred.
Stormwater Permit Transfer Application Form Page 2 of 7 April 27, 2018

C. SUBMITTAL REQUIREMENTS
Please mark "Y" to confirm the items are included with this form. Please mark "X" if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. A processing fee of five hundred and five dollars ($505.00) per G.S. 143-215 3D(e)(2).
Y 2. Two hard copies (with original signatures) and one electronic copy of this completed form and the
required items.
NA 3. For proposed permittees that are corporations or LLC's, documentation from the NC Secretary of
State demonstrating that the proposed permittee is a legal and viable entity able to conduct
business in North Carolina.
NA 4. If Part B, Items 1 or 3 of this form is selected, the signed and notarized
applicable O&M agreement(s) from the proposed permittee, as required by the permit.
NA 5. Legal documentation that the property has transferred to the proposed permittee (such as a
recorded deed for the property, uncompleted development and/or common areas) or legal
documentation demonstrating that the proposed permittee is the sole claimant of the right to
engage in the permitted activity.
NA 6. If required by the permit and if the project has been built, a signed, sealed and dated certification
document from a licensed professional stating that the stormwater management system has been
inspected and that it has been built and maintained in accordance with the approved plans.
NA 7. A copy of the recorded covenants and deed restrictions, if required by the permit. If the project has
been built, documentation that the maximum allowed per lot built -upon area or the maximum
allowed total built -upon area has not been exceeded. If the project has not been built, the new
owner shall provide a signed agreement to submit final recorded deed restrictions and protective
covenants.
NA 8. If transferring under G.S. 143-214.7(c2) (i.e., Part B, Item 2 of this form is selected),
documentation verifying that 50% or more of the lots have been conveyed to individuals (not
builders). Copies of the deeds of conveyance or a chart listing the lot number, lot address,
owner's name, conveyance date and deed book and page number are acceptable.
NA 9. If transferring under G.S. 143-214.7(c5) (i.e., Part B, Item 3 of this form is selected), provide legal
documentation supporting the dissolution of the corporation or documentation supporting the
current permittee was lawfully and finally divested of title of the property.
NA 10. A copy of the lease agreement if the proposed permittee is the lessee.
NA 11. A copy of the pending sales agreement if the proposed permittee is the purchaser.
N 12. A copy of the development agreement if the proposed permittee is the developer.
Stormwater Permit Transfer Application Form Page 3 of 7 April 27, 2018

D. CURRENT PERMITTEE INFORMATION AND CERTIFICATION Please be sure to provide Email.
1. Current Permit Holder's Company Name/Organization:
2. Signing Official's Name:
3. Signing Official's Title:
4. Mailing Address:
City:
5. Street Address:
City: State: ZIP:
6. Phone: (_)
I, , the current permittee, am submitting this application for a
transfer of ownership for the above listed stormwater permit under the General Statute and Session Law identified
on Page 1 of this application. I hereby notify DEMLR of the sale or other legal transfer of the property/project
and/or the stormwater system associated with this permit. I have provided a copy of the following documents to
the proposed permittee named in this application form: (select all that apply)
❑ the most recent permit;
❑ the designer's certification for each SCM;
❑ any recorded deed restrictions, covenants, common areas, drainage easements or plats;
❑ the approved plans and/or approved as -built plans;
❑ the approved operation and maintenance agreement;
❑ past maintenance records from the previous permittee (where required);
❑ a copy of the most recent inspection report,
I further attest that this application and request for a permit transfer is accurate and complete to the best of my
knowledge. I attest that I have provided all of the required items per the law to transfer this permit. I understand
that if all required parts of this request are not completed or if all required supporting information and attachments
listed above are not included, this request package will be returned as incomplete I assign all rights and
obligations as permittee to the proposed permittee named below. I understand that this request to transfer the
permit may not be approved by the DEMLR unless and until the facility is in compliance with the permit.
Signature:
that
this the
day of
County of
execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature:
My commission expires
Stormwater Permit Transfer Application Form
Page 4 of 7
Date:
a Notary Public for the State of
do hereby certify
personally appeared before me
20 , and acknowledge the due
April 27, 2018

E. PROPOSED PERMITTEE INFORMATION
1. The proposed permittee is the:
X Property owner (Also complete Part F.)
❑ Home Owners Association (HOA), Property Owners Association (POA), or Unit Owner Association
(UOA) (Also complete Part F.)
❑ Lessee - Attach a copy of the lease agreement. Both the lessee and the property owner will appear on
the permit as co-permittees. If the lease is terminated, responsibility for the permit reverts to the property
owner. (Also complete Parts F & G.)
❑ Purchaser - Attach a copy of the pending sales agreement. The permit will require submission of a copy
of the recorded deed after the purchase has taken place. If the purchase agreement is cancelled the
permit reverts to the property owner. (Also complete Parts F & G.)
❑ Developer - Attach a copy of the development agreement. Both the developer and the property owner
will appear on the permit as co-permittees. If the development agreement is terminated, responsibility for
the permit reverts to the property owner. (Also complete Parts F & G.)
2. Proposed permittee name (check one of the following and provide the name):
X Corporation, LLC, Partnership, Municipality name: CarolinaEast Health System
❑ HOA IPOA IUOA name:
❑ Sole Proprietor
3. Proposed permittee contact information:
Please be sure to provide Email.
a. Signing Official's Name: Leslie Allen
b. Signing Official's Title: Vice President Facilities & Safety
c. Mailing Address: P.O. Box 12157
City:
d. Street Address: 2000 Neuse Blvd
City:
e. Phone: [phone] Email: LAllen(dCarolinaeasthealth.com
NC ZIP: 28561
NC —ZIP: 28561
4. If there is a Management Entity that manages the property for an HOA, POA or UOA, please provide:
Please be sure to provide Email.
a. Management Company or Business name:
b. Contact Name: Title:
c. Mailing Address:
d. City:
e. Phone: (_) Email:
ZIP:
Stormwater Permit Transfer Application Form Page 5 of 7 April 27. 2018

F. PROPOSED PERMITTEE CERTIFICATION
I, CarolinaEast Health Systems , hereby notify the DEMLR that I have acquired through sale, lease,
development agreement, or other legal transfer, the project/property covered by the stormwater management
permit and/or the responsibility for constructing and/or operating and maintaining the permitted stormwater
management system. I acknowledge and attest that I have received a copy of: (select all that apply):
❑ the most recent permit;
❑ the designer's certification for each SCM;
❑ any recorded deed restrictions, covenants, common areas, drainage easements or plats;
X the approved plans and/or approved as -built plans;
❑ the approved operation and maintenance agreement,
❑ past maintenance records from the previous permittee (where required),
❑ a copy of the most recent inspection report;
❑ Check here if the proposed permittee agrees to be the entity responsible for addressing any compliance
issues outlined in the Compliance Inspection Report. If checked, the proposed permittee must provide a
written document statement, with a plan of action and schedule" addressed to this office stating that they will
bring the project into compliance upon receipt of the transferred permit. This written plan of action and
schedule" must be received by the Division before the Division will transfer the permit.
I have reviewed the permit, approved plans and other documents listed above, and I acknowledge that I will
comply with the terms and conditions of the permit. I will construct the project's built -upon area as shown on the
approved plans; and I will (construct), operate and maintain the approved stormwater management system
pursuant to the requir ents list i the permit and in the operation and maintenance agreement.
Signature: Date: Lp�IZ�
I, P el in�a is • /3a.4e19-- a Notary Public for the State of f na—
County of Paden , do hereby certify that
personally appeared before me this the 3044) day of 20 al, and
ackngvyjedge the due execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
�tMr
u ==
Notgnat
4v ei@�pn-'expires o2O oZ
Stormwater Permit Transfer Application Form Page 6 of 7 April 27, 2018

G. PROPERTY OWNER INFORMATION AND CERTIFICATION
Fill out this section only if the property owner is different from the proposed permittee. The permit will revert to
the property owner if the purchase agreement, development agreement or lease expires or is terminated.
Company Name/Organization:
Signing Official's Printed Name:
Signing Official's Title:
Mailing Address:
City:
Phone: (_) Email:
ZIP:
I, , hereby certify that I currently own the property identified in
this permit transfer document and acknowledge that the Proposed Permittee listed in Part F will be purchasing the
property, developing the property on my behalf, and/or leasing the property from me. A copy of the purchase
agreement, development agreement or the lease agreement, which names the party responsible for the
construction and/or operation and maintenance of the stormwater system, has been provided with the permit
transfer request.
I agree to notify DEMLR within 30 days if there are any changes to the purchase, developer or lease agreements
and will submit the applicable completed and signed Permit Information Update Form, or Permit Transfer
Application Form to address these changes. As the legal property owner, I acknowledge, understand, and agree
by my signature below, that the permit will revert to me and I will be responsible for complying with the DEMLR
Stormwater permit if the property purchase, lease or developer agreement/contract is cancelled or defaults. I
understand that any individual or entity found to be in noncompliance with the provisions of the stormwater
management permit or the stormwater rules, is subject to enforcement action as set forth in NC General Statute
(NCGS) 143, Article 21. -0
�//f
Signature of the property owner � vn Date: �f 2
I, C&:J I /1 /fin f l . %J%�X"& a Notary Public for the State of
Wr4—h i.Q.�ohno� , County of l/ira VPirl , do hereby certify that
1_e6 l f e A i I &Y) personally appeared before me this the D day of
,J VnG , 20 a I and acknowledge the due execution of the forgoing instrument. Witness
official seal,
M,M} , M �n expires o2 02
Stormwater Permit Transfer Application Form Page 7 of 7 April 27, 2018

Permit No
Im W P.md dby DWO)
T
NCDENR
Contact person
Phone number
Date
Drainage area number
020E vN ATF9OG
h
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 111) must be printed, filled out and submitted along with all of the required information.
II?rDESIGNIINEORMATION's,�
Site Characteristics
Drainage area 46,173 ft?
Impervious area, post -development 20,000 e
%impervious 43.32 %
Design rainfall depth 1.5 in
Storage Volume: Non -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
1.5' runoff volume
Pre -development 1-yr, 24-hr runoff
Post -development 1-yr, 24-hr runoff
Minimum volume required
Volume provided
Peak Flow Calculations
Is the pre/post control of the lyr 24hr storm peak flow required?
1-yr, 24-hr rainfall depth
Rational C, pre -development
Rational C, post -development
Rainfall intensity: 1-yr, 24-hr storm
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
PrelPost 1-yr, 24-hr peak flow control
Elevations
Temporary pool elevation
Permanent pool elevation
SHWT elevation (appmx. at the perm. pool elevation)
Top of 1 Oft vegetated shelf elevation
Bottom of 10ft vegetated shelf elevation
Sediment cleanoul, top elevation (bottom of pond)
Sediment deanout, bottom elevation
Sediment storage provided
Is there additional volume stored above the state -required temp. pool?
Elevabon of the top of the additional volume
2,539 ft3
5,420 ft3
ft3
ft3
ft3
ft3
ft3
Thoracic & Vascular Associates, PLLC
OK
OK, volume provided is equal to or in excess of volume required.
Y (Y or N)
3.7 in
0.20 (umbels)
0.55 (unidess)
6.00 irdhr OK
l.Lr fir/sec
0.03 fl3/sec
-1.24 fl3/can
23.50 fmsl
2200 frost
21.5 d- fmsl
22.50 fmsl
21.50 fmsl
17.50 fmsl
16.50 fmsl
100 it
N (Y or N)
fmsl
RECEIVED
cc, oiZO
D`AQ
YROJ #
Forth SW401-Wet Detention Basin-Rev.8_9117109 Parts I. & 11 Design Summary, Page 1 of 2

Pennit No
m, be pro11ded by DWO)
Surface Areas
Area, temporary pool
Area REQUIRED, permanent pool
SAIDA ratio
Area PROVIDED, permanent pool, A...
Area, bottom of 1 Oft vegetated shelf, A. y
Area, sediment deanout, top elevation (bottom of pond), A,.
4,326 ft'
2,216 f?
480 (unidess)
2,379 ft? OK
1,336 ft
352 ft
Volumes
Volume, temporary pool 5,420 ft'
Volume, permanent pool, V._po, 4,305 ft'
Volume, forebay (sum of forebays if more than one forebay) 839 W
Forebay % of permanent pool volume 19.5% %
SAIDA Table Data
Design TSS removal
Coastal SAIDA Table Used?
Mountain/Piedmont SAIDA Table Used?
SAIDA ratio
Average depth (used in SAIDA table):
Calculation option 1 used? (See Figure 10-2b)
Volume, permanent pool, V� _pw
Area provided, permanent pool, A.yoy
Average depth calculated
Average depth used in SAIDA, d„, (Round to nearest 0 5ft)
Calculation option 2 used? (See Figure 10-2b)
Area provided, permanent pool, Ate,„.
Area, bottom of 10ft vegetated shelf, A,,�
Area, sediment deanout, top elevation (bottom of pond), A,,,�
90 %
Y (Y or N)
N (Y or N)
4.80 (unifless)
N (Y or N)
4,305 ft'
2,379 ft'
It
ft
Y (Y or N)
2,379 ft
1,336 ft
352 ft
'Depth' (distance b/w bottom of 1 Oft shelf and lop of sediment) 4.00 ft
Average depth calculated 2.98 ft
Average depth used in SAIDA, d„, (Round to nearest 0.5ft) 3 0 ft
Onawdown Calculations
Drawdown through orifice?
Diameter of office (if circular)
Area of orifice (if-mmcimular)
Coefficient of discharge (Cc)
Ddving head (Ha)
Drawdown through weir?
Weir type
Coefficient of discharge (C.)
Length of weir (L)
Driving head (H)
Pre -development 1-yr, 24-hr peak now
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 & onfce?
Freeboard provided
Vegetated filter provided?
Recorded drainage easement provided?
Capures all runoff at ultimate buildcut?
Drain mechanism for maintenance or emergencies is.
Y (Y or N)
0.75 in
in'
0.60 (unitless)
1.50 ft
(Y or N)
(unWess)
(unitless)
ft
ft
1.27 a/sec
0.03 ft'/sec
0.03 ft'/sec
200 days
OK
OK
Need 3 ft min. l �X\ ► � Y
��
QCj .0 I 2010
Dim Q
Need 3 ft min. #
OK Yg03
OK, draws down in 2-5 days.
3 1
OK
10 :1
OK
10.0 ft
OK
3 :1
OK
3.0 :1
OK
Y (Y or N)
OK
2.5ft
OK
N (Y or N)
OK
Y (Y or N)
OK
Y (Y or N)
OK
Mechanical Pumps
Form SW401-Wet Detention Basin -Rev 8-9/17/09 Pans I a 11 Design Summary, Page 2 of 2

EXPRESS
Permit
SEP 2 2 2010 (to be provided by DLVD)
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 fie space provided to
indicate the following design requirements have been met. If the applicant has designated an agent, the agent may initial below. If a
requirement has not been met, attach justification.
Pagel Plan
Initials Sheet No.
/L OL f 1. Plans (1' - 50' or larger) of the entire site shoving:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Basin dimensions.
Pretreatment system,
High flow bypass system,
Maintenance access.
Proposed drainage easement and public right of way (ROW),
Overflow device, and
Boundaries of drainage easement.
11 L10 n 1' 2. Partial plan (1' = 39 or larger) and details for the Bret detention basin shoving
- Outlet structure with trash rack or similar,
Maintenance access,
Permanent pool dimensions,
Forebay and main pond with hardened emergency spillway,
Basin rross-section,
- Vegetation specification for planting shelf, and
- Filler strip.
�(Q
of
3. Section view of the wet detention basin (1' = 20' or larger) showing:
- Side slopes, 3:1 or lower,
Pretreatment and treatment areas, and
Inlet and outlet structures.
,??
/vL�
6 ua 6
4. If the basin is used for sediment and erosion control during construction, clean out of the basin is specified
on the plans prior to use as a wet detention basin.
b o+�
5. A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for Forebay,
to verify volume provided.
DD
_rvvv�
`f OF
6, A construction sequence that shows how the wet detention basin will be protected from sediment until the
entire drainage area is stabilized.
d
7. The supporting calculations.
. a
B. A copy of the signed and notarized operation and maintenance (0&M) agreement.
/Z
� A
9. A copy of the deed restrictions (if required).
2 L to 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.6-9117109 Part In. Required Items Checklist. Page 1 of t

I IFMI N 11NF (INI V
n
Date Re ived
Fee Paid
Permit Number
W. 6 Z
t/
1 5rv-7 /ci o cl7
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT RENEWAL APPLICATION FORM
In accordance with 15A NCAC 2H.1045(3). the current permit holder shall renew their high density permit 180 days
prior to its expiration. Renewed permits are valid for a period of 8 years per Session Law 2011-398 (SB 781)
Section 60. (c). This application form is for permit renewals only.
A. PROJECT INFORMATION
1. State Stornwater Permit Number: SW100907
2. Project name: CaroiinaEast Cardiac Thoracic, Vasular Surgery
3. Project street address: 960 Newman Road
City: 1
28561
County: Craven —ZIP:
4. What, if any, changes have been made to the project as permitted? None
If the project has changed from the original approved plans, please complete SWU-101 for a Major
Modification or Minor Modification Application form available at. https://deg.nc.gov/abouUdivisions/e
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either the Permit Update form
or the Permit Transferform available at https://deg nc gov/abouUdivisions/energy-mineral-land-
Stormwater Permits do not
1. Current Permit Holder's Company Name/Organization: CarolinaFast Health Systems
2. Signing Official's Name: Leslie Allen
3. Signing Official's Title: Vice Presidient Facilities & Safety
4. Mailing Address: PO Box 12157
City: New Bern State: NC ZIP: 28561
5. Street Address: 2000 Neuse Blvd
City: New Bern State: NC ZIP: 28561
6. Phone: [phone] Email: LAIIenCgZcarolinaeasthealth.com
Stormwater Permit Renewal Form Page 1 of 3 May 11, 2018

C. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQ W/ORtM. Only applications packages that
include all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required Information is provided in the application package:
LA 1. A permit application processing fee of $505.00 payable to NCDEQ.
LA 2. One original signed hard copy and one electronic copy of this completed form. The signing official
named on this application to represent the current permittee must meet one of the following:
a. Corporation — a principle executive officer of at least the level of vice-president;
b. Limited Liability Company (LLC) — a manager or company official as those terms are defined
in G.S. 57D'North Carolina Limited Liability Company Act;"
c. Public Entity — a principal executive officer, ranking official, or other duly authorized employee;
d. Partnership or limited partnership— the general partner;
e. Sole proprietor; or
I. Letter of authorization signed by one of the signatories noted in a — e above authorizing the
signature of another entity.
LA 3. One hard copy and one electronic copy of recorded documents required by the original permit that have
not yet been received by DEMLR, including: deed restrictions, protective covenants,
condominium/planned community declaration and easements. If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has not been exceeded. If
the project has not been built, include a signed agreement that the final recorded deed restrictions
and protective covenants will be submitted at a later date.
LA 4. O&M Agreements, Please select one:
❑ I have a copy of the current recorded O&M Agreement for all SCMs, and I will continue to
keep this on file with the permit; or
® 1 do not have a copy of the current recorded O&M Agreement for all SCMs and am
requesting a copy be sent to me. I agree to keep this on file with the permit.
LA 5. Designer Certifications, Please select one:
® A copy of the certification(s) confirming that the project was built in accordance with the
approved plans have been previously provided to the Division; or
❑ A copy of the certification(s) confirming that the project was built in accordance with the
approved plans are enclosed; or
❑ The project has not yet been built.
6. [IF APPLICABLE] If the project has been built, one original hard copy and one electronic copy of a
signed, sealed, and dated letter from a licensed professional stating that the SCMs have been
inspected, and that they have been built and maintained in accordance with the permit.
7. [IF APPLICABLE] When the permittee is a corporation or a limited liability corporation (LLC):
Provide one hard copy and one electronic copy of documentation from the NC Secretary of State,
or other official documentation, which supports the titles and positions held by the persons listed in
Section C.2 per 15A NCAC 2H. 1043(3)(b).
https://www.sosnc.gov/online services/search/by title/ Business Registration
Stormwater Permit Renewal Application Form Page 2 of 3 May 11, 2018

D. PERMITTEE'S CERTIFICATION
t /
�'rS t;e 4UAW, JP YAe-'16 t165 r Si?Gt1 y the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on sitef (or I will obtain a copy and it will be kept on site), that I am
responsible for the performance of the maintenance procedures, and the site has been and will be maintained
according to the O&M Agreement and approved plans. I agree to notify DEMLR of any problems with the SCMs
or built -upon area and to submit the proper forms to modify or transfer the permit prior to any changes to the
project. SCMs, or ownership. All information provided on this permit renewal application is, to the best of my
knowledge, correct an complete.
Signature: Date: (zyl�
a Notary Public for the State of
County of 04Avz,, do hereby certify
that
this the ZS` day of
execution of the forgoing instrument Witness my hand and official seal,
(Notary Seal)
Notary Signature
My commission
personally appeared before me
20 2 I , and acknowledge the due
Stormwater Permit Renewal Application Form Page 3 of 3 May 11, 2018

State Stormwater Management Systems
Permit No. SW7100907
Cardiac, Thoracic & Vascular Associates of Eastern Carolina, PLLC
Stormwater Permit No. SW7100907 REGEQVIED
Craven Countv
Designer's Certification JUL 257 2011
DWQVAR0
I, John G. Thomas as a duly registered Professional Engineer in the
State of North Carolina, having been authorized to observe (periodically/ weekly� fulI
time) the construction of the project,
Cardiac, Thoracic & Vascular Associates of Eastern Carolina, PLLC
(Project)
for CTVAEC Properties, LLC (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:
�2t1 C �i
Signature s/o
Registration Number 10 47 'a SEAL
Date 07 2 'toil ICq y;
SEAL
Page 6 of 7

�•
�. ��,�,C�r,�� �'ri:
,r �
_ a.
_ ,:�
.r r,�;:;

' State Stormwater Management Systems
Permit No. SV 7100907
Certification -Requirements:
x
9.
The drainage area to the system contains approximately the permitted
acreage.
x
2.
The drainage area to the system contains no more than the permitted
amount -of built -upon area.
x
3.
All the built -upon area associated with the project is graded such that the
runoff drains to the system. '
x
4.
All roof drains are located such that the runoff is directed into the system.
x
5.
The outlet/bypass structure elevations are per the approved plan.
x
6.
The outlet structure is located per the approved plans.
x
7.
"Trash rack is provided on the outlet/bypass structure.
x
8.
All'slopes.are grassed with permanent vegetatign.
(Slopes are seeded & mulched. Grow is sparse. Slopes not eroding)
x
9.
Vegetated slopes are no steeper than 3:1.
x
10:
The inlets are located per the approved plans and do not cause short-
circuiting of the system.
x
11.,
The permitted amounts of surface area and/or volume have been
provided.
x
.12.
Required drawdown devices are,correctly sized per the approved plans.
x
13.
All required design depths are provided.
x
14.
AIl'requiiFed parts of the system are provided, such as a vegetated shelf,
and a•forebay.
x
15.
The required system dimensions are provided_ per the approved plans.
cc: NCDENR-DWQ Washington Regional Office
City of New Bern Building Inspections
Page 7 of 7

,0 -- SW 710d i�J SEP 10 2010
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 and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name GA0?O1AG�7'f'oK /c d ✓ Sca4A2 4rsoc14rEs IELe c
2. Location of land -disturbing activity: County C e fv •/ City or Township 8 - NEw i36e.J
e i
Highway/Street 1JE!✓nrA.✓ RoAJ Latitude 3S6 31 /1n/ Longitude 7'7 , -78 h/
3. Approximate date land -disturbing activity will commence: z di o
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Caaim,5?2=14t-
5. Total acreage disturbed or uncovered (including off -site borrow and waste areaRW s�): A ' Ac 2 f; G
rs J`
6. Amount of fee enclosed: $ /30 The application fee of $SO-88 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is S450).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
& Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name % akldy 6,1&'W6rLe Y E-mail Address e THO�rNl
Fiv CV 1Aee'e1'" ?A. c d _
Telephone 252.637,2727 Cell #Zs2.67/.2-�f08 Fax# ZSZ.6S6,7-itV9
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C7VAEG PPoPEltTiEsl1G zrz.a33-&7rV
Name Telephone Fax Number
2 /ii r/EKrE 3�vv� � �.TE H 5AM5
Current Mailing Address Current Street Address
A1eja 941N A/ c, z8s6 D
City State Zip City
Zip
10. Deed Book No. 29 3 o Page No. / AZ Provide a copy of the most current deed.
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):
c fYAEC .v /1 01=^V Name E-mail Address
2n/ .YEu1E. ED
02<f14, S 41n'c A/ s4^-U�: SF e ; 7r7'o
Current Mailing Address Current Street Address
NEN 6,4W AI N 286,60 _<4 • E LAND QUALITY SECTIUN
City State Zip City State YVASHINGTOWGIONALOFFICE
Telephone Z s2. L33.67-?o Fax Number N,A

A

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:
Name
Mailing Address
City 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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State
Telephone Fax Number
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.
Dll. 1VA&Y4EG
or print name
Title or Authority
/0
Date
I, A, t C O`. F. l ;C))L , a Notary Public of the County of 0 YQVe AI
State of North Carolina, hereby certify that i G e\ E . F-liz11 'i 4Q N appeared
personally before me this day and being duly sworn acknowledged tha the above form was
executed by him.
Witness my hand
this i S+ day of 20�_
+pTAINP.
*VOLI0 ? i
rc� OOUN�����c
Notary f
My commission expires f' �- �' (�QQ 13