SW6140801_CURRENT PERMIT_20140903 (2)

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATEy��D
ZO3
YYYYMMDD

e�®
NC®ENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
September 3, 2014
Mr. Guy Lampe, Managing Partner
Lampe Management Company
PO Box 608
Smithfield, North Carolina 27577
Subject: Stormwater Permit No. SW6140801
Ample Storage Lake Worth
Dear Mr.Lampe:
John E. Skvarla, III
Secretary
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on August 7, 2014. Staff review of the plans
and specifications has determined that the project, as proposed, will comply with the Stormwater
Regulations set forth in Title 15A NCAC 2H.1000 and Session Law 2006-246. We are forwarding
Permit No. SW6140801, dated September 3, 2014, for the construction, operation and maintenance of
the subject project and the stormwater system, This permit shall be effective from the date of issuance
until September 2, 2022 and shall be subject to the conditions and limitations as specified therein, and
does not supersede any other agency permit that may be required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right
to request an adjudicatory hearing by filing a written petition!with the Office of Administrative
Hearings (OAH). The written petition must conform to Chapter 1508 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 Fayetteville Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely,
for rac vis, PE PM, i'ectof SEP 2 6 2014.
i
cc: SW6140801 File, Fayetteville Regional Office _ _
--
cc: Brian Kraynak, Bateman Civil Surveying
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-9200 / FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: htto://portal.ncdenr.orohveb/lr/
An Equal Opportunity 1 Affirmative Action Employer- 50% Recycled 110% Post Consumer Paper

State Stormwater Permit
Permit No. SW6140801
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Ample Storage Lake Worth, LLC
in Hoke County
FOR THE
construction, operation and maintenance of a sand filter 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 State and considered a part of this permit.
This permit shall be effective from the date of issuance until September 2, 2022 and
shall be subject to the following specified conditions and limitations:
DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
The sand filter is approved for the management of stormwater runoff as
described in the application documents and as shown on the approved plans.
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 of this
project must be directed into the permitted stormwater control system.
5. The built -upon areas associated with this project shall be located at least 30 feet
. landward of all perennial and intermittent surface waters.
Page 1 of 4

State Stormwater Permit
Permit No. SW6140801
II. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
2. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted sand filter functions at optimum efficiency. The approved
Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
3. 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.
4. The permittee shall submit an annual summary report of the maintenance and ..
inspection records for the sand filter. The report shall summarize the inspection
dates, results of the inspections, and the maintenance work performed at each
inspection.
5. The sand filter shall be constructed in accordance with the approved plans and
specifications, the conditions of this permit, and with other supporting data.
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 sand filter 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.
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. 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 was sought.
f. Filling in,.altering, or piping of any vegetative conveyance shown on the
approved plan.
Page 2 of 4

State Stormwater Permit
Permit No. SW6140801
9. 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.
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.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, to the
State, accompanied by the supporting documentation. 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 a request to transfer the permit.
Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the State, in accordance with.
North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 21-1.1000, and NCGS 143-215.1 et.al.
Page 3 of 4

State Stormwater Permit
Permit No. SW6140801
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 shalt 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 3`d day of September, 2014.
/i
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW6140801
Ample Storage Lake Worth, LLC
Hoke County
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
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:
Signature
Registration Number
Date
SEAL
cc: NCDENR-DEMLR Regional Office
Page 1 of 1

r
`DEMLR'USE,ONLY_
Date Received
Fee. aid
Permit Number
Applicable,Rules; ❑ Coastal SW -1995 Coastal SW - 2008 ❑ Ph 11- PostConstructlon
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑Universal Stormwater Management Plan
❑ Other WQ MgmtPlan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM .
Tlris form ruay 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.):
kyv (e Skoce.da Leese Wor'Ak. LLC
2. Location of Project (street address):
US
City: County: \fie�9e_ _.Zip:R36.
3. Directions to project (from nearest major intersection);
(oOD :eek Lt�ef(sst 'caw. �^
4. Latitude: 35 ° D \ 5" ° N Longitude: -44z b 6 S D " W of the main entrance to
H. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ONew ❑Modification ❑ Renewal w/ Modificationt
tRen-ioals with modifications also requires SVVU-102 - Renewal Application Form
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 ❑I artially Completed' []Completed* 'provide adesigner'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 .
DEMLR requesting a state stormwater management permit application, list the stormwaterproject 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 at1=877-623-6748):
❑LAMA Major ❑Sedimentation/Erosion Control: 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
5. Is the project located within 5 miles of a public airport? ❑No 50Yes
If yes, see S.L. 2072-200, Part VI. httl2://portal.ncdenr.org/web/ir/rules=and-regulations
Form SWU-101 Version Oct. 31, 2013 Page i of 6

Ill. CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee;
designated government official, individual, etc. who owns the oroiect):
Applicant/Organization: Aw%pkP. SFord 1_a1.cd Wsrl4.� i t t.
Signing Official & Title: G UA Laj AW j . 1K[uAn %,:s Pdekvcpo-
b.Contact information for person listed in item 1a above:
Street Address: -A�15 E. Nae rL� RcmA
city: SV t 41n. A -%A State: x1C Zip: d1534
Mailing Address (if applicable): PDi 'Box (60A
City: Swy-Aftt'c &%6 State: Al Zip: 3-4571
Phone: (9\9 1 lt%4-'SO41 Fax: ( )
Email: 0.i.�eNnn v�o �e hn
c. Please check the appropriate box. The applicant listed above is:
Q The.property.owner (Skip to Contact Information, item 3a)
I essee' (Attach a copy of the lease agreement and complete Contact Information, item 2a and2b below)
0 Purchaser` (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer' (Complete Contact Information, item 2a and2b 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:
Signing Official & Title:
b.Contact information for Person listed in item 2a above:
Street Address:
City: State: Zip:
Mailing. Address (if opplicable):
City: State: Zip:
Phone: d ) Fax: ( )
Email: .
3. a. (Optional) Printthe 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:
Signing Official & Title:
b.Contact information for person listed: in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
4. Local jurisdiction for building permits: N a4tr of rwi��
Point of Contact pt., Oor k F2cc e 0 Phone #: ( 910 -) . R-+5
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6 .

141. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the storm%vater runoff will be treated.
Vde C"_-1';ov% i 0c 6 4•\tree,'
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 PUD Approval 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 11- Post Construction
3. Storm%vater runoff from this project drains to the C Ftae River basin.
4. Total Property Area: 7D. %'& acres 5. Total Coastal Wetlands Area: o acres
- -6. TotalSurface%VaterArea: rn acres
7. Total Prorty Area (4)-Total Coastal Wetlands Area (5) -Total Surface Water Area (6) -Total Project
Area': r ?;_X acres
Total project area shall be calculated to exclude the folloroin : the noruuat pool of inn ounded structures, the area
behraeu the banks ofstreamns and rivers, the area below the Normal High Water (NM tine or Mean High Water
(h1HYV).line, and coastal wetlands landward from the NHl V (or A4MV) line. The resultant project area is used to
ealadate overall percent built ruponrareir (BUA). Nor -coastal wetlands landward of the NMV (or &fMV) line ntay
he included in the total project area..
B. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 _ -4 a %
y g project (For high densih�, count 1 for each proposed engineered
9. How man drainage areas does the roject have?
storumuater BIVIP. For ton, 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 " .,"
Drains a Area
Drainage Area
Drains' eArea''"'.
Drama &Area''
Receiving Stream Name
SitW l` re
Stream Class
Stream Index Number'
\ _ I_:
Total Drainage Area.(sf)
-'
On -site Drainage Area (sf)
VIS. 4SLA
Off -site Drainage Area (sf)
p
Proposed Impervious Area" s
l 5
% Impervious Area" ((total)
-4Q ch,
.,
Im' &&ions-Suiface Area ' ,:"
Draina`eArea' i
Drains eArea'='
Drains a Area' = :
Drain a Acea ..
On -site Buildin s/Lots'(sf)
LA 6 16clo
On -site Streets. (so
O
On -site Parkin (so
-4
On -site Sidewalks (sf)
O
Other on -site (so
Future (so.
9, 050
Off -site (sE)
Existing BUA'•• (sf)
Q
Total (so:
Strearn Class and Index Number can be determined at: lam✓/portal:ncdear.org/ruebAm/ps/csru/clossificatioas
" imppervious area is defined as the built upon area including; but not limited to, buildings, roads, parking areas,
siXelwatks, gravel areas, etc.
Report only that amount of existing B UA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new $UA.
Form SWU-101 Version Oct. 31, 2013 Page of 6

r -
11. How was rth�-e off -site impervious area listed
NOnt1' cete ;w,crrAaus arcs
Prolects in Union County: Contact DEMLR Central Office staff to.check iifthe project is located within a 77treatened &
Endangered Species watershed that maybe subject to more stringent siormwater requirements as per I5A NCAC 0?B .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 htto://vortal.ncdeni.ore/web/wq/ws/su/bmp'manual.
Vl. SUBMITTAL REQUIREMENTS
Only:completeapplication packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
htto://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms dots. The complete application package should be
submitted to the appropriate DEMLR Office., (The appropriate office maybe found by locating project on the
interactive online map ath_pt ://portal.ncdenr.org/web/wo/ws/su/maps.)
Please indicate that the following required information have been provided by initialin¢ 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 fromIttto://portal.ncdencorg/web/wq/ws/su/statesw/forms dots.
In' i
1. Original and one ropy 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 par! VII below) /Jv
3. Original of the applicable Stipple mentForm(s)'(sealed, signed and dated) and O&M
a reement(s) for ach BMP
4.
g
Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
hft://www.envhe[R.org/pay-es/onestopgxpress.htriii 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.
Adetailed 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.
R j�
D
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.l i mile of the site boundary, include the th
7.
mile radius on the map.
Sealed, signed and dated calculations (one copy).
'
8.
Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
_ U
a. Development/Project name.
b. Engineer and, firm:._
c. Location map with named streets and NCSR numbers:.
d.c Legend.:
e. North arrow.
f. Scale.
g. Revision numberand 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.
f. Dimensioned, property/ project boundary with bearings& distances.
j. Site Layout with all BUA identified and dimensioned.
it. 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).
FormSWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required). I
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"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 DEMLR to veriftj the SHWP prior
to submittal, [phone].)
10. A copy of the most current proper tyldeed. Deed book: /A Page No: q_
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other officialdocumentation, which supports the.tides and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hn://www.5ecretary.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 httt ://12ortal.ncdenr.org/web/Ir/state-stormwater-
forms dots. 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 DEMLR, and that they will be recorded prior to the sale of anylot.
VIII. CONSULTANTINFORMATION AND AUTHORIZATION
Applicant:. Complete this section if you wish to designate authority So 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 Firm: %a:ba y%^,a.Lm U A\ Sew a
Mailing Address: '3M 0 :A1ew-4�, Mo .,n G3, ce e k
City: "'0A TFae : ykc c State: Al n. Zip: 1A 5 40
Phone:{ 91q 1 '5-7- \09sb Fax:'( RkCk t Ski-�etl\
Email:lnn,� im&v%c'.,.(s�sarc..cnw�
IX. PROPERTY OWNER AUTHORIZATION (if Contacthifonnah'on, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed,in Contact htforvration, item 2a) certify that I
own the, property identified in this permit application, and thus give permission to (print or hjpe name of person.
listed in Contacthtfonnation, item 1n) with (print or type nante of organization listed in
Contact htfonnation, item la) to develop the project as currently proposed. A copy of
the lease agreement or.pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form'SWU-101 Version Oct. 31,2013 Page 5of6

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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and
submit a completed Name/Ownership Change Form within 30 days; otherwise I will be operating 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 Vf ivil penatties`of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: v Date:
g-s-- z-►y
I; _ Q go 8a / d o. a Notary Public for the State of A%e , f i Ga.o Jr..* County of
Jo l.a S4.. do hereby certify, that ly d.a . Pt personally appeared
before me this day of A. jy 1 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,_�%Z _-
```p�Ulu
Q•BARe
NOTARY
oy; PUBLIC Z;
- TON COv
!I•/lllllll 11 l l ll•`
SEAL
My commission expires�'�S ' /9
X. APPLICANTS CERTIFICATION,
I, (print or type name ofperson listed in Contact Injonnatfon, item In)y y ,9L
r p e
t
certify that the information included on this permit application form is, to the tgst of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deedrestrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater riles under 15A CAC 2H .1000 and any other applicable state stormwaterrequirements.
Signature: Date: 9-5 /H
I, & •• I P. i3 + a Notary Public for the State of %r ro /,',.o, County of
wi.... do hereby certify that 7� Q personally appeared
before me thi4 11 day of A`J9`q'JQW' and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, -P�17 r .
,�°'PJv�;BARBp
°Q G,
O J• NOTA0.
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SEAL
My commission expires d - of S- 11
FornSWU-101 Version Oct.31,2013
Page 6 of 6

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Permit Number:
(to be provided by DWQ)
'� OF WA T(:'?
NCDENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
SAND FILTER SUPPLEMENT
This form must be filled out on line, printed and submitted with all of the required information.
Make sure to also fill out and submit the Required Items Checklist (Section III) and the I&M Agreement (Section IV)
Project name
Contact name
Phone number
Date
Drainage area number
Brian Kraynak
919-577-1080
August 5, 2014
Entire Site
II. DESIGN,INFORMATION
Site Characteristics
Drainage area (AD)
126,581.00 ft2 OK
Impervious area
97,627.00 ft2
% Impervious (IA)
77.1% %
Design rainfall depth (Rp)
_
3.20 in --
Peak Flow Calculations
1-yr, 24-hr runoff depth
3.20 in
1-yr, 24-hr intensity
0.13 in/hr
Ii
2014
Pre -development 1-yr, 24-hr runoff
0.08 ft3/sec
SEP 26
Post-development 1-yr, 24-hr runoff
0.33 ft3/sec
Pre/Post 1-yr, 24-hr peak control
0.25 ft3/sec
_I
L
Storage Volume
I-
Design volume (WQV)
7,849.00 ft3
Adjusted water quality volume (WQVAej)
5,886.75 ft3
Insufficient. The adjusted water quality volume can not
Volume contained in the sedimentation basin and on top of the sand filter
945.00 ft3
be contained. Increase area of filter and/or sed. Basin.
Top of sand filter/grate elevation
254 it amsl
Weir elevation (between chambers)
255.5 ftamsl
Maximum head on the sedimentation basin and sand filter (hMVFlller)
1.50 it
Insufficient depth.
Average head on the sedimentation basin and sand filter (hA)
0.75 it
OK
Runoff Coefficient (Rv)
0.74 (unitless)
Type of Sand Filter
Open sand filter? y
Y or N
SHWT elevation
250.00 ft amsl
Bottom of the sand filter elevation
252.17 ft amsl
Clearance (dSHWT)
2.17
Closed/pre-cast sand filter? n
Y or N
SHWT elevation
It amsl
Bottom of the sand filter elevation
it amsl
Clearance (dshwT)
If this is a closed, underground closed sand filter: The clearance between
the surface of the sand filter and the bottom of the roof of the underground
1t
structure (ds.)
Form SW401-Sand Filler-Rev.5 2009Sept17 Parts I and H. Project Design Summary, Page 1 of 2

Permit
(to be provided by DWQ)
Nedim;gation Basin
Surface area of sedimentation basin (As)
Sedimentation basin/chamber depth
Sand Filter
Surface area of sand filter (Ar)
Top of sand media filter bed elevation
Bottom of sand media filter bed/drain elevation
Depth of the sand media filter bed (d,)
Coefficient of permeability for the sand filter (k)
Outlet diameter
Outlet discharge/flowrate
Time to drain the sand filter (t)
Time to drain the sand filler (t)
Additional Information
Does volume in excess of the design volume bypass the sand filter?
Is an off-line Flow -splitting device used?
If draining to SA waters: 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 30ft from surface waters (50ft if SA waters)?
If not a closed bottom, is BMP located at least 100ft from water supply wells?
Are the vegetated side slopes equal to or less than 3:1
Is the BMP located in a recorded drainage easement with a recorded access
easement to a public Right of Way (ROW)?
What is the width of the sedimentation chamber/forebay (Wsty)?
What is the depth of sand over the outlet pipe (dpipe)?
5,089.00 ftz
vn. tun uu iuA i, uuuuay uadu IVuc ^: icdbcu to
J
3.00 ft
^rviuew
630.00 ft2
muuabe buuduc died. i uw Will dibu inuudbc me
254.00 it artist
252.17 It amsl
1.83 It
3.50 (ft/day)
4.00 in
0.41 ft'/sec
5.32hours
OK. Submit drainage calculations.
0.22 days
y YorN OK
y YorN OK
n Y or N Excess volume must pass through filter.
0.00 It
n Y or N Show how flow is evenly distributed.
y Y or N OK
y Y or N OK
y Y or N Insufficient vegetated side slopes.
n Y or N Insufficient ROW location.
63.00 It OK
2.00 It OK
Form SW401-Sand Filter-Rev.5 2009Sept17 Parts I and II. Project Design Summary, Page 2 of 2

Permit No.
(to be provided by DWO)
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.
Initials
Pagel Plan
Sheet No.
1. Plans (1" - 50' or larger) of the entire site with labeled drainage area boundaries
- System dimensions (length, width, and depth) for both the sedimentation chamber and the filter
chamber,
- Maintenance access,
- Flow splitting device,
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Off -site drainage (if applicable), and
2014
4J
Boundaries of drainage easement. I SEP 26
7L
2. Plan details (1" = 30' or larger) for the sand filter showing:
- System dimensions (length, width, and depth) for both the sedimentation chamber and,the filter
chamber,
- Maintenance access,
- Flow splitting device,
- Vegetative filter strip dimensions and slope (if SA waters),
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Off -site drainage (if applicable), and
- Boundaries of drainage easement.
3. Section view of the sand filter (1" = 20' or larger) showing:
- Depth(s) of the sedimentation chamber and sand filter chamber,
- Depth of sand filter media,
- Connection between the sedimentation chamber and the sand filter chamber and weir elevation,
- SHWT elevation,
- Outlet pipe, and
- Clearance from the surface of the sand filter to the bottom of the roof of the underground structure (if
(�
applicable).
4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
5. Supporting calculations (including drainage calculations)
6.
Signed and notarized operation and maintenance (0&M) agreement
4q
7. A copy of the deed restrictions (if required).
Form SW401-Sand Filter-Rev.5 2009Sept17 Part III, Page 1 of 1

p . -'.7
Permit Number.
(to be prortded by DIrL - -
Drainage Area Number:
Sand Filter Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in alog,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: SEP 2 6 2014 {
- The drainage area will be carefully managed to reduce the sediment load to the sand filter.
The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds'
six inches.
- Once a year, sand media will be skimmed.' -
- The sand filter media will be replaced whenever it fails to function properly after maintenance.
The sand filter will be inspected quarterly and within 24 hours after every storm event greater than
1.0 inches (or 1.5 inches if in aCoastal County). Records of operation and maintenance willbe 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'elementm, Paferttral "p`oble"m t)Fiow.=Itsvill;'ierriediate`.the roblem
^.
k=
Entire BMP
Trash debris is present.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as
applicable)
pavementsurface.
possible.
Perimeter of sand filter
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed. _;
gully, and then plant a ground cover and
water until it is established. Provide lime
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation' at an appropriate
height.
Flow diversion structure
The structure is clogged:
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too large for repair.
Forebay or pretreatment area
Sediment has accumulated to a
Search for the source of the sediment and
depth of greater than six inches.
remedy the problem if possible. Remove
the sediment and stabilize or 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
a pesticide is used, wipe it on the plants
rather than spraying.
Form SW401-Sand filter O&M-RevA 2009Septl7 Page l of 3

@BMPelement �_ ''� �'�;
"tPotenlial; iotileml .„...,' = i
GHowlI;will remediate.tha iolilein, ` "
Filter bed and underdrain
Water is ponding on the surface for
Check to see if the collector system is
collection system
more than 24 hours after a storm.
clogged and flush if necessary. if water
still ponds, remove the top few. inches of
filter bed media and replace. If water still
ponds, then consult an expert.
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the
sediment offsite.
The outlet device is dama ed
Re air or replace the outlet device.
Receiving water
Erosion or other signs of damage
I Contact the NC.Division of Water Quality
have occurred at the outlet.
1 401 Oversight Unit at 919-7331786.

Permit Number:
(to be pmtWed b DIVQ)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listedabove. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project name:Ample Storage Lake Worth, LLC
BMP drainage area number:Area l (entire site)
Print name:Guv Lampe
Title:Manaeing Partner
Address:225 E Peedin Road Smithfield NC 27577
Note:. The legally responsible party should not be a homeowners association unless more than 50% of the lots have been
soldand a resident of the subdivision has been named the president:
1, hA6,1 D. SaPbo.i a Notary Public for the State of
#-} k La rall .Q County of �'vk n 5 fo . do hereby certify that
� GO-1 14 personally appeared before me this S+t day of .
rQ tis� __, and acknowledge the due execution of the forgoing sand filter
maintenance' requirements. Witness my hand and official seal,
,..``WQp.UL D, 9"0,
Z• pUe�A :x
COUNT,;.,
SEAL.
My commission expires a = asjq
Form SW401-Sand Filter O&M-Rev.4 2009Septl7 Page 3 of 3