SW8951014_CURRENT PERMIT_20210721

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW8 cIE 10yq
DOC TYPE]
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
20 21 0"12\
YYYYMMDD

ROYCOOPER
Governor
DIONNE DELLI-GATTI
seamy
BRIAN WRENN
Diractor
July 21, 2021
NORTH CAROLINA
FnWonmentalQuaitty
Medsery Management Company, LLC
Wilmington Health, PLLC; Sole Manager
Attn: Chris Bunch, Chief Operations Officer
1202 Medical Center Drive
Wilmington, NC 28401
Subject: Permit Correction and Renewal
State Stormwater Management Permit No. SW8 951014
Wilmington Health Associates Clinic
New Hanover County
Dear Mr. Bunch:
The Wilmington Regional Office issued the subject project a permit on July 21, 2016 and recently discovered it
contained an error. This permit correction is to correct the entity which holds the permit from Wilmington Health,
PLLC to Medsery Management Company, LLC.This corrected permit does not impose new or different terms; it
merely restates some of the previous terms to provide you with a better understanding of your obligations under the
permit Please replace the previously issued permit with the enclosed corrected permit
The Wilmington Regional Office received a complete 8 year Stormwater Management Permit Renewal Application for
the subject project on June 30, 2021. The Division is hereby notifying you that permit SW8 951014 has been renewed
on July 21, 2021, and shall be effective until January 2, 2030. For your records, please find enclosed a renewed,
updated, and re -issued permit and a copy of the renewal application. As requested, a copy of the current operation and
maintenance agreement is enclosed. Please keep this permit on file at all times. Please note that the renewed, updated,
and re -issued permit does not impose new or different terms; it merely restates some of the previous terms to provide
you with a better understanding of your obligations under the permit.
The renewal and reissuance of this stormwater permit does not imply that the site is currently in compliance with the
terms and conditions of this state stormwater permit The plans originally approved on January 2, 1996 and most
recently modified on July 21, 2016, will remain in full force and effect in accordance with the regulations set forth in
Title 15A NCAC 2H.1000.
This permit is subject to the conditions and limitations as specified therein. Please pay special attention to the
conditions listed in this permit regarding the Operation and Maintenance of the BMP(s), recordation of deed
restrictions, procedures for changes of ownership, transferring the permit, and renewing the permit. Failure to establish
an adequate system for operation and maintenance of the stormwater management system, to record deed restrictions,
to transfer the permit, or to renew the permit, 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 by filing a written petition with the Office of Administrative Hearings (OAH). The written
petition must conform to Chapter 150B of the North Carolina General Statutes and must be filed with the OAH within
thirty (30) days of receipt of this permit. You should contact the OAH with all questions regarding the filing fee (if a
filing fee is required) and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or
via telephone at 919-431-3000, or visit their website at www.NCOAH.com. Unless such demands are made this permit
shall be final and binding.
If you have any questions, need additional copies of the permit or approved plans, please contact Ashley Smith in the
Wilmington Regional Office, at [phone] or [e-mail].
Sincerely, CAI /7 �%%
o
Brian Wrenn, Director
Division of Energy, Mineral and Land Resources
®� North Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
Wilmington Regional Office 1 127 Cardinal Drive Extension I Wilmington. North Carolina 28405

t
State Stormwater Permit No. SW8 951014
Page 2 of 2
Enclosures: Attachment A — Designer's Certification Form
Attachment C — Permitting History
Renewal Application Documents
DES/ams: \\\Stormwater\Permits & Projects\ 1 995\951014 HD\2021 07 permit 951014
cc: NCDEQ-DEWR Wilmington Regional Office
®� Z North Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
Wilmington Regional Office 1127 Cardinal Drive Extension I Wilmington. North Carolina 28405
910.796.7215

State Stormwater Management Systems
Permit No. SW8 951014
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY COMMERCIAL 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
Medsery Management Company, LLC
Wilmington Health Associates Clinic
1202 Medical Center Drive, Wilmington, New Hanover County
FOR THE
construction, operation and maintenance of one (1) 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 (the "Division" or
"DEMLR") and considered an enforceable part of this permit.
This permit shall be effective from the date of issuance until January 2, 2030, 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.
This stormwater system has been approved for the' management of stormwater runoff as
described in Section 1.5 on page 2 of this permit and per the approved plans. The stormwater
control has been designed to handle the runoff from a maximum built -upon area of 75,000
square feet of impervious area. The built -upon area reserved for future development is limited
to 2,800 square feet and is included in the total amount listed above.
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.
4. The runoff from all built -upon area within the permitted drainage area(s) of this project must be
directed into the permitted stormwater control system.
Page 1 of 6

State Stormwater Management Systems
Permit No. SW8 951014
The following design criteria have been provided in the wet detention pond and must be
maintained at design condition:
a. Drainage Area, acres:
Onsite, ft2:
Offsite, ft2:
b. Total Impervious Surfaces, ft2:
Existing + permeable pavement, ft2:
Future, ft2:
C. Design Storm, inches:
d. Average Pond Design Depth, feet:
e. TSS removal efficiency:
f. Permanent Pool Elevation, FMSL:
g. Permanent Pool Surface Area, ft2:
h. Permitted Storage Volume, ft3:
i. Temporary Storage Elevation, FMSL:
J. Controlling Orifice:
k. Fountain Horsepower, HP
I. Receiving Stream/River Basin-
M. Stream Index Number:
n. Classification of Water Body:
It. SCHEDULE OF COMPLIANCE
3.
4.
a
2.37
103,300
0
75,000
72,200
2,800
1.0
7.5
90%
11.5
3,099
7,587 at temporary pool elev.
13.5
1.25"0 pipe
N/A
Greenfield Lake / Cape Fear
18-76-1
"C. Sw"
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.
The permittee shall at all time provide the operation and maintenance necessary to assure the
permitted stormwater system functions at the design condition. 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.
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, flow spreader, catch
basins and piping.
g. Access to the outlet structure must be available at all times.
Records of maintenance activities must be kept and made available upon request to
authorized personnel of DEMLR. The records will indicate the date, activity, name of person
performing the work and what actions were taken.
The facilities shall be constructed, operated and maintained in accordance with the provisions
of this permit, the approved plans and specifications, and the supporting documents attached
to this permit and on file with the Division.
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.
6. 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.
Page 2 of 6

State Stormwater Management Systems
Permit No. SW8 951014
7. Access to the stormwater facilities for inspection and maintenance shall be maintained via
appropriate recorded easements at all times.
8. Decorative spray fountains will not be allowed in the stormwater treatment system, as the
permanent pool volume is less than 30,000 cubic feet.
9. No person or entity, including the permittee, shall alter any component shown in the approved
plans and specifications. Prior to the construction of any modification to the approved plans,
the permittee shall submit to the Director, and shall have received approval for modified plans,
specifications, and calculations including, but not limited to, those listed below. For changes to
the project or SCM that impact the certifications, a new or updated certification(s), as
applicable, will be required and a copy must be submitted to the appropriate DEQ regional
office upon completion of the modification.
a. Any modification to the approved plans and specifications, regardless of size including
the SCM(s), BUA, details, etc.
b. Redesign or addition to the approved amount of BUA or to the drainage area.
C. Further development, subdivision, acquisition, lease or sale of any, all or part of the
project and/or property area as reported in the approved plans and specifications.
d. Altering, modifying, removing, relocating, redirecting, regrading, or resizing of any
component of the approved SCM(s), the stormwater collection system and/or
vegetative conveyance shown on the approved plan.
e. The construction of any allocated future BUA.
f. The construction of any permeable pavement, #57 stone area, public trails, or
landscaping material to be considered a permeable surface that were not included in
the approved plans and specifications.
g. Other modifications as determined by the Director.
10. 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.
11. Prior to transfer of the permit, a file review and site inspection will be conducted by Division
personnel to ensure the permit conditions have been met and that the project and the on -site
stormwater system complies with the permit conditions. Any items not in compliance must be
repaired, replaced restored, or resolved prior to the transfer. Records of maintenance activities
performed to date may be requested.
III. GENERAL CONDITIONS
1. Any individual or entity found to be in noncompliance with the provisions of a stormwater
management permit or the requirements of the stormwater rules is subject to enforcement
procedures as set forth in NCGS 143 Article 21.
2. The issuance of this permit does not preclude the permittee from complying with and obtaining
any other permits or approvals that are required for this development to take place, as
required by any statutes, rules, regulations, or ordinances, which may be imposed by any
other Local, State or Federal government agency having jurisdiction. Any activities undertaken
at this site that cause a water quality violation or undertaken prior to receipt of the necessary
permits or approvals to do so are considered violations of NCGS 143-215.1, and subject to
enforcement procedures pursuant to NCGS 143-215.6.
3. If the facilities fail to perform satisfactorily, the permittee shall take immediate corrective
actions. This includes actions required by this Division and the stormwater rules such as the
construction of additional or replacement on -site stormwater systems. These additional or
replacement measures shall receive a permit from the Division prior to construction.
Page 3 of 6

State Stormwater Management Systems
Permit No. SW8 951014
Permit Transfer: This permit is not transferable to any person or entity except after notice to
and approval by the Director. The permittee shall submit a completed and signed "Permit
Transfer Application Form" (available on the Division website) accompanied by the required
fee and supporting documentation as listed on the form, to the Division at least 60 days prior
to any one or more of the following events:
a. The sale or conveyance of the project area in whole or in part, except in the case of an
individual lot sale that is made subject to the recorded deed restrictions and protective
covenants;
b. Dissolution of the partnership, corporate, or LLC entity, subject to NCGS 55-14-05 or
NCGS 57D-6-07 and 08;
C. Bankruptcy;
d. Foreclosure, subject to the requirements of Session Law 2013-121,
5. Current Permittee Name or Address Changes: The permittee shall submit a completed
"Permit Information Update Application Form" (available on the Division website) to the
Division within 30 days to making any one or more of the following changes:
a. A name change of the current permittee;
b. A name change of the project;
C. A mailing address change of the permittee;
6. The permittee is responsible for compliance with all terms and conditions of this permit until
the Division approves the transfer request. Neither the sale of the project, in whole or in part,
nor the conveyance of common area to a third party constitutes an approved transfer of the
permit.
7. The permittee grants Division Staff permission to enter the property during normal business
hours to inspect all components of the permitted project.
8. The permit issued shall continue in force and effect until the permittee files a request with the
Division for a permit modification, transfer, renewal, or rescission, however, these actions do
not stay any permit conditions.
9. Approved plans, application documents, supplements, calculations, operation and
maintenance agreement, and specifications for this project are incorporated by reference and
are enforceable parts of the permit. A copy of this permit, application, supplements, operation
and maintenance agreement, and approved plans and specifications shall be maintained on
file by the permittee.
10. Unless specified elsewhere, permanent seeding requirements for the on -site stormwater
system must follow the guidelines established in the North Carolina Erosion and Sediment
Control Planning and Design Manual.
11. 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 for cause as allowed by the
laws, rules, and regulations contained in Title 15A NCAC 2H.1000 and NCGS 143-215.1 et.al.
12. A permit renewal request must be submitted at least 180 days prior to the expiration date of
this permit. The renewal request must include the appropriate application, documentation and
the processing fee as outlined in Title 15A NCAC 02H.1045(3).
Permit renewed, updated and reissued this the 21 st day of July 2021.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Brian
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Management Systems
Permit No: SW8 951014
Wilmington Health Associates Clinic
Stormwater Permit No. SW8 951014
New Hanover County
Attachment A
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 specifications:
Signature
Registration Number
Date
SEAL
Page 5 of 6

State Stormwater Management Systems
Permit No. SW8 951014
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 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 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 and located 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.
-16. All components of the stormwater BMP are located in either recorded common
areas, or recorded easements.
cc: NCDEQ-DEMLR Wilmington Regional Office
Page 6 of 6

Attachment C - Permitting History
Wilmington Health Associates Clinic
Permit No. SW8 951014
Approval
Date
Permit Action
BIMS
Version
Description of the Changes
1/2/1996
Original
Approval
1.0
8/19/2013
Renewal
2.0
9/13/2013
Renewal
3.0
Double Renewal to get back to active status
7/21/2016
Modificaition
3.1
Permeable pavement has been added in the parking
lot in drainage area of existing wet pond in order to
offset new built -upon area (MRI Suite Addition) on
the site. A permeable pavement Supplement and
O&M Agreement have been provided. Impervious
allocations have changed and overall impervious
area for the site has been reduced.
7/21/2021
Renewal
4.0
and correction back to the correct entity, Medsery
Management Company, LLC. Wilmington Health,
PLLC is the sole manager of Medserv.

Permit Number.v Z
(to be provided by D1VQ)
Drainage Area / Lot Number:
Permeable Pavement 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.
At all times, the pavement shall be kept free of:
— Debris and particulate matter through frequent blowing that removes such
debris, particularly during the fall and spring.
— Piles of soil, sand, mulch, building materials or other materials that could deposit
particulates on the pavement.
— Piles of snow and ice.
— Chemicals of all kinds, including deicers.
The permeable pavement will be inspected once a quarter. Records of operation and
maintenance will be kept in a known set location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
i Potenti al, problem:
How to remediate the problem:
The ern of the
P
i / -
Areas of bare soil and or
_7-R g necessary to
le pa
permeable pavement
erosive gullies
remove the gully, then plant ground I�
e the gully,
re
per untl established.
A vegetated area drains
Regrade the area so that it drains
toward the pavement.
away from the pavement, then plant
ground cover and water until
( established.
_
The surface of the
Trash/debris present
I Remove the trash/debris.
permeable pavement
_
___ ___
Weeds
I Do not pull the weeds (may pull out
jmedia as well). Spray them with a
i
(systemic herbicide such as
glyphosate and then return within
by hand.
the week to remove them
(Another option is to pour boiling
water on them or steam them.)_
Sedin
\ acuum sweep the pavement
11 Rutting, cracking or slumping
i Consult an appropriate professional.
_!
or damaged structure
Observation well
! Water present more than five
days after a storm event
I Clean out clogged underdrain pipes.
Consult an appropriate professional
Educational sign
_�-a _ soil subgrade.
Missing or is da� R—C E, W a lgn.
MAY 2 6 2016
Form SW401-Permeable Pavement O&M-Rev.4 10/03/2012— Page 1 of 2

Permit
(to he provided by LnVQ)
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:Wilmington Health a�Elinic t
BMP drainage area or lot number: I
Print name:MedSery Management Company. LLC; . JowAa- Spa
Title:MemberManager, Wiltvi.h, on WCRllA,PLLCt ancari
Address:1202 Medical Center Drive, Wilmington, NC 28401
Phone: [phone]
Date:
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.
I, Jk1 'PI-7- r- , a Notary Public for the State of
Mnj,kI (2Zjt)(lPla CouCounty of 93mlt Ce, , do hereby certify that
� )= o&h\L lib personally appeared before me this
day ofgj and acknowledge the due execution of the
forgoing permeable pavement maintenance requirements. Witness my hand and official
seal,
\J PN&6 EB(c t /
i
Noto(V Public
Pamlico Count
MV Commission %PI�`;
/tiOn),H CA�D�.�`.
III I1111
My commission expires
Form SW401-Permeable Pavement O&M-Rev.4 10/03/2012
JMAY 262016
Page 2 of 2

II Z 2 " ULMLII UJt UNLY' - -'
Gate e,cerved
Fee Paid
Permit Number
a °0
W o
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 Stormwater Permit Number:
2. Project name:
3.
4.
Project street address: 120a llir;ju,
City: Q'Ily,t %4-0-
, County:
What, if any, changes have been made to the project as permitted?
ZIP : 28yD
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/about/divisions/energy-
min eral-la nd-resou rceslene rqy-mi nera I -la n d-rules/stormwate r-prop ram/post-construction.
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either the Permit Update form
or the Permit Transfer form available at: https://deg.nc gov/about/divisions/energy-mineral-land-
resources/energy-mineral-land-rules/stormwater-program/post-construction. State Stormwater Permits do not
automatically transfer with the sale of the property.
1. Current Permit Holder's Company Name/Organization: c
2. Signing Official's Name: Chris Bunch
3. Signing Official's Title: Chief Operations Officer
4. Mailing Address: 1202 Medical Center Dr
City: Wilmington State: NC ZIP
28401
5. Street Address: 1202 Medical Center Dr
City: Wilmington State: NC ZIP
28401
6. Phone: [phone] Email: cbunch(cDwilmingtonhealth cam
EEI YN' E
JUN 7 2021
BY:
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) orDEMLR
Central Office (Urbanizing Areas Ph Z USMP, Non -Coastal HQW/ORW). 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:
1. A permit application processing fee of $505.00 payable to NCDEQ.
-41 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
f. Letter of authorization signed by one of the signatories noted in a - e above authorizing the
signature of another entity.
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.
4. O&M Agreements, Please select one:
I ❑ 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
p I 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.
5. Desi er Certifications, Please select one:
t 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.goy/online services/search/bv title/ Business Registration
-` li�* .� ....
JUN 3 0 2021 J-
Stormwater Permit Renewal Application Form Page 2 of 3 May 11, 2018

D. PERMITTE/E'S CERTIFICATION
LZL , the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on site (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 and complet %
Signature:y.. Date: 2v�
NOTARIZATION:
a Notary Public for the State of
, do hereby certify
personally appeared before me
this the 22 day of Arne .2021 and acknowledge the due
1*0"t. Witness my hand and official seal,
7(NokBV-%%OVER
EBEKAH L SMRH
NOTARY PU9UC
COUNTYTE OF NORTH CAROLINA
Notary Signature: fUAVIG4110-f'l G, OrK /1-1
My commission expires OZ&'� ) Jzozz
JUN � U 2021 i
Stormwater Permit Renewal Application Form Page 3 of 3 May 11, 2018

{ }fjTi,C:i'0:

.i
Permit No.✓ l/ �` D/�
(to be provided by DWQ)
.f AINA o? pWATFqC
�c
STORMWATER MANAGEMENT PERMIT APPLICATION FORM o
NCDENR 401 CERTIFICATION APPLICATION FORM
PERMEABLE PAVEMENT SUPPLEMENT
This form must be completely 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.
Project Name
Contact Person
Phone Number
Date
Drainage Area
Wilmington Health Associates Clinic
Phillip G. Tripp, P.E.
910-763-5100
5/17/2016
1
II. DESIGN INFORMATION
Soils Report Summary
Hydrologic soil group (HSG) of subgrade
B
Infiltration rate
5.90
m/hr
Pavement Design Summary
BUA Credit for Permeable Pavement Footprint:
Permeable Pavement (PP) design type
Infiltration - HSG A/B
75% BUA Credit
SA of PP being proposed (A°)
2,667
ff'
Resulting BUA counted as impervious for main application form
667
ftz
Adjacent BUA directed to PP (Ac)
2,667
ftz
OK
Ratio of Ac to A.
1.00
(unitless)
Flow from pervious surfaces is directed away from PP?
yes
OK
Design rainfall depth
1.5"
in
Permeable pavement surface course type
PC
Layer 1- Washed aggregate size (ex. No. 57)
No. 57
Layer 1 - Aggregate porosity (n)
0.40
(unitless)
OK
Layer 2 - Washed aggregate size (ex. No. 57)
-
Layer 2 - Aggregate porosity (n)
-
(unitless)
Please verify; Must be between 0 & 1
Minimum total aggregate depth for design rainfall (D„,y)
7.5
in
Drawdown/infiltration time for D,
0.1
days
OK
How is 10-yr, 24-hr storm handled?
infiltrated
Aggregate depth to infiltrate 10-yr, 24-hr storm (Ds°)
-35.8
in
Drawdown/infiltration time of 10-yr, 24-hr storm
0.49
days
Actual provided total aggregate depth
9.0
in
OK
Top of aggregate base layer elevation
18.15-22.85
fmsl
Storage elevation of design rainfall depth
18.02-22.72
fmsl
Overflow elevation
-
fmsl
Bottom elevation at subgrade
17.4-22.1
fmsl
#REF!
SHWT elevation
16.33
fmsl
Underdrain diameter
-
in
ECEI b C
MAY 2 6 201n
BY:
Form SW401-Permeable Pavement-Rev.4-October 16. 2012 PP Supplement Form, Page 1 of 3

Permit No.
(to be provided by DWQ)
.Detention Systems (skip for infiltration systems)
Diameter of orifice
in
Coefficient of discharge (Co)
(unitless)
Driving head (Ho)
ft
Storage volume discharge rate (through discharge orifice)
ft'/sec
Storage volume drawdown time
days
Pre -development 1-yr, 24-hr peak flow
ft'/sec
Post -development 1-yr, 24-hr peak flow
ft'/sec
Additional Information
Slope of soil subgrade at bottom of permeable pavement
0.00
%
OK
Slope of the permeable pavement surface
4.00
%
OK
Construction sequence minimizes compaction to soils?
Yes
OK
Subsoil preparation specified (must select one)
scarified
Meets industry standards for structural requirements?
Yes
OK
Washed stone is specified for the aggregate?
Yes
OK
Required signage specified on plans?
Yes
OK
Number of observation wells provided
1
OK
Distance to structure
243.00
ft
Distance to surface waters
30+
ft
OK
Distance to water supply well(s)
100+
ft
OK
ECEI N C
MAY 2 6 ZOto
Form SW401-Permeable Pavement-Rev.4-October 16, 2012 PP Supplement Form, Page 2 of 3

Permit
(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. If a requirement has not been met, attach justification.
1. Plans (V = 50' or larger) of the entire site showing:
- Design at ultimate build -out,
- Off -site drainage (if applicable),
- Delineated drainage basins (include Rational C coefficient per
basin),
- Location of permeable pavement,
- Roof and other surface flow directed away from permeable
pavement,
- Location of the permeable pavement sign(s).
2. Section view of the permeable pavement (1" = 20' or larger)
showing:
- All layers (including details about the surface course), and
-SHWT
3. A detail of what the permeable pavement sign.
4. A site specific soils report that is based upon an actual field
investigation, soil borings, and infiltration tests within the
footprint of the proposed permeable pavement. The soils
investigation shall state the infiltation rate, SHWT elevation, and
information about any confining layers. County soil maps are not
an acceptable source of soils information.
(Projects in the WiRO - The results of the soils report must be
verified in the field by DWO, by completing & submitting the soils
investigation request form.)
5. A construction sequence that shows how the permeable
pavement will be protected from sediment until the entire
drainage area is stabilized.
fi. The supporting calculations.
7. A copy of the signed and notarized operation and maintenance
(O&M) agreement.
8. A copy of the deed restrictions (if required).
Initials
M1
C1, DI
_Ml
C2
ee-H-V-- C2
ATTACHED
C2
ATTACHED
ATTACHED
J--t/4 N/A
Pagel Plan Sheet No.
ECEIVE
MAY 2 6 2016
BY:
Form SW401-Permeable Pavement-Rev.4-October 16, 2012 PP Supplement Form, Page 3 of 3

B7bu/6
ante sormualer Nlanaeeme,.11 Svste:ns
Permit N. SW8 95101=
Wilmington Health Associates Clinic
Stormwater Project No. 951014
New Hanover County
Engineer's Certification
I, John Phillip Norris , as a duly registered Professional Engineer in the State of
North Carolina, having been authorized to observe (periodically/weekly/full time) the construction of the
project,
Wilmington Health Associates Clinic (Project)
for Wilmington Health Associates (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.
Lare January 13, 199 /
�Gil—`11�
lUL 2 9 2013
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