SW6130401_CURRENT PERMIT_20130418

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

�R
MCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Tim Register
Hart Redd, LLC
116 Wilson Pike circle, suite 103
Brentwood, TN 37027
Division of Water Quality
Charles Wakild, P.E.
Director
April 18, 2013
Subject: Stormwater Permit No. SW6130401
CVS Pharmacy Store #7500, Erwin, North Carolina
Dear Mr. Register:
®ENR-FRo
APR 2 3 200
ME
. E
John E. Skvarla, III
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for the
subject project on April 8, 2013. Staff review of the plans and specifications has determined that the project, as
proposed, will comply with the Stormwater Regulations set forth in Title 15A NCAC 2H.1000 and Session Law
2006-246. We are forwarding Permit No. SW6130401, dated April 18, 2013, for the construction, operation
and maintenance of the subject project and the stormwater Bli
This permit shall be effective from the date of issuance until April 17, 2021 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 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 follow the procedures for
transfer of 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. Per NCGS 143-
215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this permit. You should
contact the OAH with all questions regarding the filing fee (if a filing fee is required) and/or the details of the
filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via telephone at 919-431-3000, or visit
their website at www.NCOAH.com. Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Faytteville Regional Office. If you have any questions, please contact Mike
Randall at [phone]; or [e-mail].
Sincerely, �tZ �
for Charles Wakild,P•�E., ,Di�nr/eJetor
cc: SW6130401 File
ec: John Buffaloe - Buffaloe Bowling Partnership
Jason Meadows - Kimley-Horn and Associates
Chris Bostic - Kimley-Horn and Associates
Fayetteville Regional Office
Wetlands and Stormvrater Branch
1617 Mall Service Center, Raleigh, Nodh Carolina 27699-1617
Location: 512 N. Salisbury SI. Raleigh, Nodh Carolina 27604
Phone: [phone] FAX [phone]
Internet, v m,.ncvratarqualily.org
An Fq gal Opp^ham^; i Pcl ,n Eaq - -�ie-
NorthCarci ina
Naturally

State Stormwater Permit
Permit No. SW6130401'
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL_ RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
CVS Pharmacy
Store #7500
100 W. Jackson Blvd., Erwin, North Carolina
FOR THE
construction, operation and maintenance of one infiltration basin and one Bioretention
Cell in compliance with the provisions of Session Law 2006-246 and 15A NCAC 2H
.1000 (hereafter referred to as the "stormwater rules') and the approved stormwater
management plans and specifications and other supporting data as attached and on file
with and approved by the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until April 17, 2021and shall be
subject to the following specified conditions and limitations:
1. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application, supporting data and as shown on the approved
plans.
2. This stormwater system has been approved for the management of stormwater
runoff as described in the application, supporting data and as shown on the
approved plans.
3. The tract will be limited to the amount of built -upon area indicated in the
application and other supporting data, and as shown on the approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
Page 1 of 4

State Stormwater Permit
Permit No. SW6130401
6. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
II. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
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.
C. Mowing and revegetation 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 bypass structure, infiltration media, flow
spreader, catch basins, piping and vegetated filter.
g. A clear access path to the bypass structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
5. The permittee shall submit to the Division of Water Quality, Regional Office an
annual summary report of the maintenance and inspection records for each
BMP. The report shall summarize the inspection dates, results of the
inspections, and the maintenance work performed at each inspection.
6. The stormwater treatment system shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
supporting data.
7. 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.
8. 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.
9. Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
Page 2 of 4

State Stormwater Permit
Permit No. SW6130401
10. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
11. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of eight years from the date of the completion of
construction.
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.
III. GENERAL CONDITIONS
This permit is not transferable to any person or entity except after notice to and
approval by the Director. In the event of a change of ownership, or a name
change, the permittee must submit a completed Name/Ownership Change form
to the Division of Water Quality, signed by both parties, and accompanied by the
appropriate documentation as listed on page 2 of the form. The approval of this
request will be considered on its merits and may or may not be approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
Page 3 of 4

State Stormwater Permit
Permit No. SW6130401
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 reissuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
controls must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et. al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 18th day of April, 2013.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Jor Gnarles waked, F'.t., Uirector
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 4

State Stormwater Permit
Permit No. SW6130401
CVS Pharmacy
Store #7500
100 W. Jackson Blvd., Erwin, North Carolina
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
CVS Pharmacy Store #7500 at 100 W. Jackson Blvd., Erwin, North Carolina
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.
Noted deviations from approved plans and specification:
SEAL
Signature
Registration Number
Date

D W Q USE ONLY
Date Received
Fee Paid
Permit Number
13
Applicable Rules: ❑ Coastal SW —1995 Coastal SW — 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
'Phis farm may be photocopied for use as an original
1. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
CVS Pharmacy Store #7500
2. Location of Project (street address):
100 W. Jackson Blvd. Erwin NC
City: Erwin County: Harnett Zip: 28339
3. Directions to project (from nearest major intersection):
Northern Quadrant of the intersection of W. Jackson Blvd. and N. 13th Street
1 4. Latitude: 35° 20' 16.67" N /L�t • Longitude: 78° 40' 34.08" W `AW of the main entrance to the project.
77 ti
It. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major
®Sedimentation/Erosion Control: 3.37 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit: N/A
Form SWU-101 Version 07Jun2010 Page I of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who ownsthe ,_project):
Applicant/Organization: Hart Redd, LLC
Signing Official & Title:Tim Register, Registered Agent
b.Contact information for person listed in item la above:
Street Address:116 Wilson Pike Circle, Suite 103
City:Brentwood State:TN Zip:37027
Mailing Address (if applicable):N/A
City:
Phone: (910 ) 385-5194
Email: [e-mail]
State:
Fax: (615 ) 591-5868
c. Please check the appropriate box. The applicant listed above is:
❑ The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
® Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:Buffaloe Bowling Partnership
Signing Official & Title:lohn Buffaloe
b. Contact information for person listed in item 2a above:
Street Address:6701 Fayetteville Road
City:Raleigh State:NC Zip:27603
Mailing Address (if applicable):Same as above
Phone:
Fax: ( 1
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization: Ion Thomas
Signing Official & Title: Redd Realty Construction Manager
b.Contact information for person listed in item 3a above:
Mailing Address:116 Wilson Pike Circle, Suite 103
City:Brentwood State:TN Zip:37027
Phone: (615 ) 591-5525 x 230 Fax: (
Email: [e-mail]
4. Local jurisdiction for building permits: Town of Erwin
Point of Contact:Kathy Blake Phone #: (910 ) 897-5140
Form SWU-101 Version 07Jun2010 Page 2 of 6

IV. Y ROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The net increase in impervious area will be treated with a bioretention basin located on the site to the
Southeast of the CVS building and an infiltration basin located on the property adjacent to CVS.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUDApproval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW —1995 ❑ Ph lI — Post Construction
3. Stormwater runoff from this project drains to the
4. Total Property Area: 1.69 acres
River basin.
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) —Total Coastal Wetlands Area (5) —Total Surface Water Area (6) = Total Project Area':
1.69 acres
Total project area shall be calculated to exclude the following: the normal pool of imppounded structures, the area
between the banks of streams and rivers, the area below the } lorrnal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward front the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may be
included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 89.5 %
9. How many drainage areas does the project have?2 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
Receiving Stream Name
Unnamed
tributary
Unnamed
tributary
Stream Class
WS-IV
WS-IV
Stream Index Number *
Total Drainage Area (sf)
49,850
23,646
On -site Drainage Area (sf)
49,850
23,646
Off -site Drainage Area (sf)
Pro osed Impervious Area** (sf)
42,247
23,646
0% Impervious Area** (total)
84.7%
100%.
Impervious— Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area
On -site Buildings/Lots (sf)
11,945
0
On -site Streets (sf)
0
0
On -site Parking (sf)
28,513
0
On -site Sidewalks (sf)
1,695
0
Other on -site (sf)
1 94
1 0
Future (sf)
0
0
Off -site (sf)
0
23,646
Existing BUA*** (so
0
0
Total (sf):
42,247
23,646
* Stream Class and Index Number can be determined at: httu://nortalT ncdenr.org/zoeb/roq(ps/csu/classi ications
Form SWU-101 Version 07Jun2010 Page 3 of 6

'11. How was the off -site impervious area listed above determined? Provide documentation. Survey
Proiects in Union County: Contact DWQ Central OfJice staff to check if the project is located within a Threatened &
Endangered ,Species watershed that may be subject to more stringent stormwater requirements as per NCAC 02B .0600,
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://portal.naienr.ore/web/raq/ws/su/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available fromlittp://Liortal.ncdenr.or«/web/wq/ws/su/Stlttesw/forms does. Thecomplete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map athttp://portal.ncdenr.org/web/wq/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. • Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms does.
InitiaJs
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII beloto)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.envhelp.org/pages/onestopexpress.htmI for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished Floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
O
ce'd
r
e08
Form SWU-101 Version 07Jun2010 Page 4 of 6

'9. Copy of any applicable soils report with the associated SHWT elevations (Please identify cm -
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to venifij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 02543 Page No: 619
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per NCAC 21-1.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hn: / /www.secretary.state.nc.us/Corporations/­`CSearch.aspx
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from
htt : ortaLncdenr.org/web/wy/ws/su/statesw/forms does. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
Vill. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer: Chris Bostic, PE
Consulting Firm: Kimley-Horn and Associates, Inc.
Mailing Address: 333 Fayetteville Street, Suite 600
Phone: (919 ) 835-1494
Email: chris.bostic®kimley-horn.com
State: NC Zip: 27601
Fax: (919 ) 653-5847
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) John Bu,ffaloe , certify that I
own the property identified in this permit application, and thus give permission to (print or hjpe name of person
listed in Contact Information, itenn la) Tim Register with (print or hype name of organization listed in
Contact Information, item la) Hart -Redd, LLC to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 07Jun2010 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Date: Al- q- / 3
1, L. W<-Ik�'
. a Notary Public for the State of County of
W"'k_fdo hereby certify that J 0 6 Sk ffe-) 0 e- personally appeared
before me this 5�day of QOci_ � 2-013 and acknowledge the
dueexecutionof the application for
a stormwater permit. Witness my hand and official seal, j.,S L• L 1 L-
MELISSA L WAU(ER
NOTARY PUBLIC
my
COUNTY, JZ 17
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires Z/5 / j �'
1, (print or type narne of person Listed in Contact Information, itern la) Tine Register
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants be recorded, and that the proposed project complies with the requirementq of the
applicable stormwat ides nder 15 NCAC 2H .1000, SL 2006-246 (Ph. II -Post Construction) r SL 08-211.
Signature: Date:
1e a Notary Public for the State of Nenril J1„„/.•.no- , County of
J�a.•�s ...1 , do hereby certify that /�.' �•r /�rsakt personally appeared
before me this 2t day of--' + ti4- ?vis , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal '-D. / J� .•�
SEAL
My commission expires_ 3- 3/• o?cl3
Form SWU-101 Version 07Jun2010 Page 6 of

Kimley-Horn
IIIIIIIIIIIIIIIIIIIN and Associates, Inc.
Transmittal
RECEIVED
OCT 0.3 2014
DENR-LAND QUALITY
STORMWATER PERMITTING
Date: 9/30/2014
Project Name: CVSPharmacy-Erwin
To: NCDENR-Division of Water Ouality
ATTN: Mike Randall
Stormwater Permitting Unit
512 N Salisbury St., Suite 942
Raleigh, North Carolina 27604
333 Fayetteville Street,
Suite 600
Raleigh, North Carolina
27601
TEL [phone]
FAX [phone]
Job Number: 012426063
We are sending these by
❑ U.S. Mail ® FedEx
❑ Other
We are sending you
®
Attached
❑
Under separate cover via
❑
Shop drawings
❑
Prints/Plans ❑ Samples
®
Other State Stormwater Permit
('nniac
/)nln
Nn
ne¢criniinn
❑ Hand Delivery
the following items:
❑ Specifications ❑ Change Orders
I original
CVS Pharmacy Store #7500 State Stormwater Permit
T 8 2014
I .
These are transmitted as checked below:
®
For your use ❑ Approved as submitted
❑ Resubmit
❑ Copies for approval
❑
As requested ❑ Approved as noted
® Submit
® Copies for distribution
®
For review and comment ❑ Returned for corrections
❑ Return
❑ Corrected prints
Remarks: If you have any questions or comments, please feel free to contact me directly at
[phone].
Copy to: File
Signed: Chris Bostic, P.E.

i
State Stormwater Permit
Permit No. SW6130401
CVS Pharmacy
Store #7500
100 W.Jackson
Designer's Certification
North Carolina
I, U:$+6P )4V 0 • 84JS7• t , as a duly registered C" r r ,kqr in the
State of Norlh Carolina, having been authorized to obse (periodically/ weekly/ full
time) the construction of the
CVS Pharmacy Store #7500 at 100 W. Jackson Blvd., Erwin, North Carolina
for Ndr + 40U r etc (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.
Noted deviations from approved plans and specification:
Tus Gu4;1Fcarto'vN 'S -or 4Lt. n6
,,%n
Qr�IY, lr4
Signature /
Registration umber 03 Z 5TZ p
Date 1.27- )e%
OCT 8 2014 I
cE
SEAL
6�\ t C ARG�i
a SEAL
032582
;0• —

..�. i$f}L. '1 �ryrr ."�)•;�:
..}'"� iV +...
t'.i 1, iJ' i
; :�_. .h 1.
J:
�1 i ,
1 ''�. ��J1
,_•�11 1gi�114L.
:•�1 1�,�I1{,1

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x1l" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 02543 Page No: 619
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per NCAC 2H.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hqp://www.secretary.state.nc.us/Corporations/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from
h1tp://portaLnalcnr.ors/«eb/��q/��s/su/stntes�/forms does. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
Vill. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer: Chris Bostic, PE
Consulting Firm: Kimley-Horn and Associates, Inc.
Mailing Address: 333 Fayetteville Street, Suite 600
City: Raleigh State: NC Zip: 27601
Phone: [phone] Fax: [phone]
Emad:[e-mail] Ja. 6oq, nea,de ws (�-
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) John Buffaloe certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item la) Tim Register with (print or type name of organization listed in
Contact Information, item la) Hart -Redd, LLC to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 071un2010 Page 5 of 6

Permit
AA
NCDENR
(to be provided by DWO)
or0p WATfgO
N y
� r
5
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
BIORETENTION CELL SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part III) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name
CVS Store #7500
Contact name
Chris Bostic
Phone number
919-653-2927
Date
April 4, 2013
Drainage area number
I
II. DESIGN INFORMATION
Site Characteristics
Drainage area
49,850 ft2
Impervious area
42,247 f12
Percent impervious
94.7% %
Design rainfall depth
1.0 inch
Peak Flow Calculations
Is pre/post control of the 1-yr, 24-hr peak flow required?
1-yr, 24-hr runoff depth
1-yr, 24-hr intensity
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
Pre/Post 1-yr, 24-hr peak control
Storage Volume: Non -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
HMV;
3.05 in
0.127 in/hr
0.010 ft/sec
0.000 ft3/sec
-0.010 ft'/sec
3,520.0 ft3
5,389.0 rya
1.5" runoff volume rya
Pre -development 1-yr, 24-hr runoff ft 3
Post -development 1-yr, 24-hr runoff -it
Minimum volume required 0 ft 3
Volume provided ft 3
Cell Dimensions
M
Pending depth of water
9.36 inches
OK
Pending depth of water
0.78 ft
Surface area of the top of the bioretention cell
5,154.0 ft2
OK
Length:
149 ft
OK
Width:
57 If
OK
-or- Radius
ft
Media and Soils Summary
Drawdown time, ponded volume
6 hr
OK
Drawdown time, to 24 inches below surface
18 hr
OK
Drawdown time, total:
24 hr
In -situ soil:
Soil permeability
0.02 in/hr
Insufficient. Increase infiltration rate or include underdrains.
Planting media soil:
Soil permeability
2.00 in/hr
OK
Soil composition
• Sand (by volume)
85-88%
Sand should be-85-88%
• Fines (by volume)
8-12/,
Fines should be -8-12%
Form SW401-Bioretention-Rev.9
June 25, 2010
Parts I and II. Design Summary, Page 1 of 3

Permit
(to be provided by DWO)
% Organic (by volume) 3-5% Organic should be -3-5%
Total: 0%
Phosphorus Index (P-Index) of media 10-- 30 (unitless) Insufficient P-Index.
Form SW401-Bioretention-Rev.8
June 25, 2010 Parts I and If. Design Summary, Page 2 of 3

Permit
(to be provided by DWO)
Basin Elevations
Temporary pool elevation
Type of bioretention cell (answer "Y' to only one of the two following
questions):
Is this a grassed cell?
Is this a cell with trees/shrubs?
Planting elevation (top of the mulch or grass sod layer)
Depth of mulch
Bottom of the planting media soil
Planting media depth
Depth of washed sand below planting media soil
Are underdrains being installed?
How many clean out pipes are being installed?
What factor of safety is used for sizing the underdrains? (See
BMP Manual Section 12.3.6)
Additional distance between the bottom of the planting media and
the bottom of the cell to account for underdrains
Bottom of the cell required
SHWT elevation
Distance from bottom to SHWT
Internal Water Storage Zone (IWS)
Does the design include IWS
Elevation of the top of the upturned elbow
Separation of IWS and Surface
Planting Plan
Number of tree species
Number of shrub species
Number of herbaceous groundcover species
Additional Information
Does volume in excess of the design volume bypass the
bioretention cell?
Does volume in excess of the design volume flow evenly distributed
through a vegetated filter?
What is the length of the vegetated filter
Does the design use a level spreader to evenly distribute flow?
Is the BMP located at least 30 feet from surface waters (50 feet if
SA waters)?
Is the BMP located at least 100 feet from water supply wells?
Are the vegetated side slopes equal to or less than 3:1?
Is the BMP located in a proposed drainage easement with access
to a public Right of Way (ROW)?
Inlet velocity (from treatment system)
Is the area surrounding the cell likely to undergo development in the
future?
Are the slopes draining to the bioretention cell greater than 20%?
Is the drainage area permanently stabilized?
Pretreatment Used
(Indicate Type Used with an "X' in the shaded cell)
Gravel and grass
(8'inches gravel followed by 3-5 ft of grass)
Grassed swale
Forebay
Other
191.00 fmsl
Y (Y or N) OK
N (Y or N)
190 fmsl
0 inches Insufficient mulch depth, unless installing grassed cell.
188 fmsl
2 ft
0.5 ft
Y (Y or N)
2 Insufficient number of clean out pipes provided.
10 OK
1 ft
186.5 fmsl
185.5 fmsl
1 If Insufficient distance to SHWT.
N (Y or N)
fmsl
190 ft
0
0
0 Recommend more species.
Y (Y or N) OK
N (Y or N) Excess volume must pass through filter.
N/A I
N/A
(Y or N)
Enter Data
Y
(YorN)
OK
Y
(YorN)
OK
Y
(YorN)
OK
N
(Y or N)
Insufficient ROW location.
3.82 ft/sec Insufficient inlet velocity unless energy dissipating devices are being
used.
N (Y or N) OK
N (Y or N) OK
Y (Y or N) OK
X
Rip Rap Apron
#VALUE!
Form SW401-Bioretention-Rev.8
June 25, 2010
Parts I and II. Design Summary, Page 3 of 3

Permit Number:
(to be Inov' ed by DWQ)
Drainage Area Number:
Bioretention 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.
Important operation and maintenance procedures:
— Immediately after the bioretention cell is established, the plants will be watered
twice weekly if needed until the plants become established (commonly six
weeks)-
- Snow, mulch or any other material will NEVER be piled on the surface of the
bioretention cell.
— Heavy equipment will NEVER be driven over the bioretention cell.
— Special care will be taken to prevent sediment from entering the bioretention cell.
— Once a year, a soil test of the soil media will be conducted.
After the bioretention cell is established, I will inspect it 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 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:
Potentialproblems:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
bioretention cell
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
'one-time fertilizer application.
The inlet device: pipe,
The pipe is clogged (if
Unclog the pipe. Dispose of the
stone verge or swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
Stone verge is clogged or
Remove sediment and clogged
covered in sediment (if
stone and replace with clean stone.
applicable).
Form SW401-Bioretention O&M-Rev3 Page I of 4

BMP element:
Potentialproblems;
How I will remediate theproblem:
The pretreatment area
Plow is bypassing
Regrade if necessary to route all
pretreatment area and/or
flow to the pretreatment area.
gullies have formed.
Restabilize the area after grading.
Sediment has accumulated to
Search for the source of the
a depth greater than three
sediment and remedy the problem if
inches.
possible. Remove the sediment and
restabilize the pretreatment area.
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.
The bioretention cell:
Best professional practices
Prune according to best professional
vegetation
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.
Tree stakes/wires are present
Remove tree stake/wires (which
six months after planting.
can kill the tree if not removed).
The bioretention cell:
Mulch is breaking down or
Spot mulch if there are only random
soils and mulch
has floated away.
void areas. Replace whole mulch
layer if necessary. Remove the
remaining much and replace with
triple shredded hard wood mulch at
a maximum depth of three inches.
Soils and/or mulch are
Determine the extent of the clogging
clogged with sediment.
- remove and replace either just the
top layers or the entire media as
needed. Dispose of the spoil in an
appropriate off -site location. Use
triple shredded hard wood mulch at
a maximum depth of three inches.
Search for the source of the
sediment and remedy the problem if
possible.
An annual soil test shows that
Dolomitic lime shall be applied as
pH has dropped or heavy
recommended per the soil test and
metals have accumulated in
toxic soils shall be removed,
the soil media.
disposed of properly and replaced
with new planting media.
Form SW401-Bioretemion O&M-Rev.3 Page 2 of 4

BMP element:
Potentialproblems:
How I will remediate theproblem:
The underdrain system
Clogging has occurred.
Wash out the underdrain system.
(if applicable)
The drop inlet
Clogging has occurred.
Clean out the drop inlet. Dispose of
the sediment off -site.
The drop inlet is damaged
Repair or replace the drop inlet.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW401-Bioretention O&M-Rev3 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:CVS Pharmacy Store #7500
BMP drainage area number:
Print name:Tim Register - Hart -Redd, LLC
Title: Registered Agent
Address:116 Wilson Pike Circle, Suite 103, Brentwood, TN 37027
Phone: [phone]
Signature:
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.
a Notary Public for the State of
County of , do hereby certify that
personally appeared before me this
day of , and acknowledge the due execution of the
forgoing bioretention maintenance requirements. Witness my hand and official seal,
SEAL
My commission
Form SW401-Bioretention I&M-Rev. 2 Page 4 Of 4

Permit No.
(to be provided by DWO)
°F WAiFH
e
STORMWATER MANAGEMENT PERMIT APPLICATION FORM s -
NCDENR 401 CERTIFICATION APPLICATION FORM
INFILTRATION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 1/1) must be printed, filled out and submitted along with all of the required information.
I. PROJECT INFORMATION
Project Name
CVS Store #7500
Contact Person
Chris Bostic
Phone Number
919-653-2927
Date
414/2013
Drainage Area Number
2
II. DESIGN INFORMATION
Site Characteristics
Drainage area
23,646.00
ft2
Impervious area
23,646.00
h2
Percent impervious
100.00
%
Design rainfall depth
1.00
in
Peak Flow Calculations
1-yr, 24-hr rainfall depth
3.05
in
1-yr, 24-hr intensity
0.13
inmr
Pre -development 1-yr, 24-hr discharge
0.01
ft3/sec
Post -development 1-yr, 24-hr discharge
0.00
ft3/sec
Pre/Post 1-yr, 24-hr peak flow control
-0.01
ft3/sec
Storage Volume: Non -SA Waters
Minimum design volume required
1,872.00
rya
Design volume provided
9,025.00
h3 OK for non -SA waters
Storage Volume: SA Waters
1.5' runoff volume
rya
Pre -development 1-yr, 24-hr runoff volume
ft 3
Post -development 1-yr, 24-hr runoff volume
rya
Minimum required volume
ft 3
Volume provided
rya
Soils Report Summary
Soil type
Loamy Sand
Infiltration rate
0.54
inlhr
SHWT elevation
175.00
fmsl
Basin Design Parameters
Drawdown time
5.00
days OK
Basin side slopes
3.00
:1 OK
Basin bottom elevation
181.55
fmsl OK
Storage elevation
184.90
fmsl
Storage Surface Area
3,940.00
ftz
Top elevation
186.00
fmsl
Basin Bottom Dimensions
Basin length
54.00
it
Basin width
34.00
ft
Bottom Surface Area
1,815.00
it
Form SW401-Infiltration Basin-Rev.5 11Ap2011 Paris 1.811. Design Summary, Page 1 of 2

Permit
(to be provided by DWO)
Additional Information
Maximum runoff to each inlet to the basin?
0.54
ac-in
OK
Length of vegetative filter for overflow
N/A
ft
OK
Distance to structure
N/A
ft
OK
Distance from surface waters
>30
ft
OK
Distance from water supply well(s)
>100
It
OK
Separation from impervious soil layer
2.00
it
OK
Naturally occuring soil above shwl
2.00
ft
OK
Bottom covered with 4-in of clean sand?
Y
(Y or N)
OK
Proposed drainage easement provided?
Y
(Y or N)
OK
Capures all runoff at ultimate build -out?
Y
(Y or N)
OK
Bypass provided for larger storms?
Y
(Y or N)
OK
Pretreatment device provided
Rip Rap Apron
Form SW401-Infiltration Basin-Rev.5 11Ap2011
Parts I. 8 If. Design Summary, Page 2 of 2

7
Permit Number:
(to be provided t' DWQ)
Drainage Area Number:
Infiltration Basin Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area will be carefully managed to reduce the sediment load to the
infiltration basin.
— Immediately after the infiltration basin is established, the vegetation will be
watered twice weekly if needed undI the plants become established (commonly
six weeks).
— No portion of the infiltration basin will be fertilized after the initial fertilization
that is required to establish the vegetation.
— The vegetation in and around the basin will be maintained at a height of
approximately six inches.
After the infiltration basin is established, it will be inspected once a quarter 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 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:
Potentialproblem:
How l will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
infiltration basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer ap2lication.
The inlet device: pipe or
The pipe is clogged (if
Unclog the pipe. Dispose of the
Swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the Swale if necessary to
Swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
Form SW401-Infiltration Basin O&M-Rev3
Page 1 of 3

BMP element:
Potentialproblem:
How I will remediate theproblem:
The forebay
Sediment has accumulated
Search for the source of the
and reduced the depth to 75%
sediment and remedy the problem if
of the original design depth.
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred or
Provide additional erosion
riprap is displaced.
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 pesticides are used, wipe
them on the plants rather than
spray mg.
The main treatment area
A visible layer of sediment
Search for the source of the
has accumulated.
sediment and remedy the problem if
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP. Replace any media that
was removed in the process.
Revegetate disturbed areas
immediately.
Water is standing more than
Replace the top few inches of filter
5 days after a storm event.
media and see if this corrects the
standing water problem. If so,
revegetate immediately. If not,
consult an appropriate professional
for a more extensive repair.
Weeds and noxious plants are
Remove the plants by hand or by
growing in the main
wiping them with pesticide (do not
treatment area.
spray).
The embankment
Shrubs or trees have started
Remove shrubs or trees
to grow on the embankment.
immediately.
An amoral inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair.
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 NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW401-Infiltration Basin O&M-Rev.3 Page 2 of 3

Permit Number:
(to be provided bY DWQ)
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: G
BMP drainage area number:
f 6411M i_+/
Print name: -Xk. nA,
Title: 4 r
Address: 12 F /011.c 0111 . 0
Phor
Sign
Note: The legally responsible party should not he 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, Mtl;_, L • W-Ike-r , a Notary Public for the State of
0, C , County of
Johrn
�Jdkt do hereby certify that
personally appeared before me this yl_
day of 4prt , Zo 13 , and acknowledge the due execution of the
forgoing infiltration basin maintenance requirements. Witness my hand and official seal,
M N A4 UB�R
WAKE COUNTY, N.C.
by o aft" Boa Z 5 t
SEAL
My commission expires y/.S 117
y}-.te ) Mtrss, L. W-Acr-
Form SW401-Infiltration Basin O&M-Rev3 Page of 3