SW8130113_CURRENT PERMIT_20211119

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO
SW8 kl W 13
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
Zo z l 1119
YYYYMMDD

ROY COOPER
Governor
ELIZABETH S BISER
secterory
BRIAN WRENN
Director
November 19, 2021
Autumn Corporation
Attn William I Weisberg, President
2700 Commerce Park
Beachwood, OH 44122
NORTH CAROLINA
Env4vnmentot QuaQty
Subject Permit Renewal
State Stormwater Management Permit No SW8 130113
Autumn Care Brunswick County
Brunswick County
Dear Mr Weisberg
Effective August 1, 2013 the State Stormwater program has been transferred from the Division of Water Quality
(DWQ) to the Division of Energy, Mineral and Land Resources (DEMLR) All previous references to DWQ will
remain in older stormwater permits issued prior to August 1, 2013 until they are modified Please note that this permit
will now reference DEMLR as the Division responsible for issuance of the permit
The Wilmington Regional Office received a complete 8 year Stormwater Management Permit Renewal Application for
the subject project on November 18, 2021 The Division is hereby notifying you that permit SW8 130113 has been
renewed on November 19, 2021, and shall be effective until April 5, 2029 For your records, please find enclosed a
renewed, updated, and re -issued permit and a copy of the renewal application As requested, a copy of the current
operation and maintenance agreement is enclosed Please keep this permit on file at all times Please note that the
renewed, updated, and re -issued permit does not impose new or different terms, it merely restates some of the previous
terms to provide you with a better understanding of your obligations under the permit
The renewal and reissuance of this stormwater permit does not imply that the site is currently m compliance with the
terms and conditions of this state stormwater permit The plans originally approved on April 5, 2013, will remain in
full force and effect in accordance with the regulations set forth in Title 15A NCAC 2H 1000
This permit is subject to the conditions and limitations as specified therein Please pay special attention to the
conditions listed in this permit regarding the Operation and Maintenance of the BMP(s), recordation of deed
restrictions, procedures for changes of ownership, transferring the permit, and renewing the permit Failure to establish
an adequate system for operation and maintenance of the stormwater management system, to record deed restrictions,
to transfer the permit, or to renew the permit, will result in future compliance problems
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the tight to request an
adjudicatory hearing by filing a written petition with the Office of Administrative Hearings (OAH) The written
petition must conform to Chapter 150B of the North Carolina General Statutes, and must be filed with the OAH within
thirty (30) days of receipt of this permit. You should contact the OAH with all questions regarding the filing fee (if a
filing fee is required) and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or
via telephone at 919-431-3000, or visit their website at www NCOAH com Unless such demands are made this permit
shall be final and binding
If you have any questions, need additional copies of the permit or approved plans, please contact Ashley Smith in the
Wilmington Regional Office, at [phone] or ashleym smith@ncdenr gov
Sincerely,
Gk v"� H j
5;; Brian Wrenn, Director
Division of Energy, Mineral and Land Resources
D_E QZ� North Carohna Department of Environmental Quality I Dninon of Energy Kneral and Land Resources
Wilmington Regional Office 1127 Cardmal Dyne Extension I wihmngton North Carohna 28405
w

State Stormwater Permit No SW8 130113
Page 2 of 2
Enclosures
DES/ams
cc
O & M Agreement
Attachment C — Permitting History
Renewal Application Documents
\\\Stormwater\Permlts & Projects\2013\130113 HD\2021 11 permrt 130113
NCDEQ-DEMLR Wilmington Regional Office
North Carolina Department of Environmental Quality I DWon of Energy Mineral and Land Resources
E ryr Wilmington Regional Office 1 127 Cardinal Drive Extension I Wilmington North Carolina 28405
��\ / 9107967215

State Stormwater Management Systems
Permit No SW8 130113
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Autumn Corporation
Autumn Care Brunswick County
9646 No 5 School Rd, Shallotte, Brunswick County
FOR THE
construction, operation and maintenance of 1 (one) constructed wetland in compliance with Session
Law 2008-211 and the provisions of 15A NCAC 2H 1000 (hereafter collectively referred to as the
"stormwater rules') and as outlined in the application, approved stormwater management plans,
supplement, calculations, operation and maintenance agreement, recorded documents,
specifications, and other supporting data (the "approved plans and specifications") as attached and/or
on file with and approved by the Division of Energy, Mineral and Land Resources (the "Division" or
"DEMLR") The project shall be constructed, operated and maintained in accordance with these
approved plans and specifications The approved plans and specifications are incorporated by
reference and are enforceable part of this permit
This permit shall be effective from the date of issuance until April 5, 2029 and shall be subject to the
following specified conditions and limitations The permit issued shall continue in force and effect until
the permittee files a request with the Division for a permit modification, transfer, renewal, or
rescission, however, these actions do not stay any condition The issuance of this permit does not
prohibit the Director from reopening and modifying the permit, revoking and reissuing the permit, or
terminating the permit for cause as allowed by the laws, rules, and regulations contained in Title 15A
NCAC 2H 1000 and NCGS 143-215 1 et al
I DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater described in
the application and other supporting data
2 This stormwater system has been approved for the management of stormwater runoff as
described in Section 17 of this permit
3 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 project shall maintain a 50' wide vegetated buffer adjacent all surface waters, measured
horizontally from and perpendicular to the normal pool of impounded structures the top of
bank of each side of rivers and streams and the mean high water line of tidal waters
Page 1 of 5

State Stormwater Management Systems
Permit No SW8 130113
5 All runoff being directed into wetlands shall flow into and through those wetlands at a non -
erosive velocity of 2 fps or less
6 The following design elements have been approved for this constructed wetlands stormwater
facility, and must be provided in the system at all times
a
Drainage Area, acres
830
Onsite, ft2
361,589
Offsite, ft2
0
b
Total Impervious Surfaces, ft2
202,092
Onsite, ft2
202,092
Offsite, ft2
0
c
Design Storm
1 5
d
Permitted Storage Volume, ft3
25,600
e
Planting/Ponding Depth, in
1200
f
Temporary Storage Elevation, fmsl
2950
(top of shallow land)
g
Temporary Storage Surface Area, ft2
10,210
(shallow land surface area at top)
h
Permanent Pool Elevation, fmsl
2850
(top of shallow water)
i
Permanent Pool Surface Area, ft2
10,250
(shallow water surface area at top)
j
Deep Pool Bottom Elevation, Forebay, fmsl
265
k
Deep Pool Surface Area, Forebay, fmsl
2,580
(Deep Pool Surface Area at Top, Forebay)
I
Deep Pool Bottom Elevation, Non-Forebay, fmsl
265
m
Deep Pool Surface Area, Non-Forebay, fmsl
2,560
(Deep Pool Surface Area at Top, Non-Forebay)
n
Controlling Orifice 0 Pipe, in
200
o
Pre -development 1 yr 24 hr peak flow, cfs
11 02
p
Post -development 1 yr 24 hr peak flow, cfs
81
(onfirce flowrate)
q
Number Herbaceous Plants Provided
4,680
r
Number Shrubs & Small Trees Provided
416
s
Number 2 5" cal Trees Provided
0
t
Seasonal High Water Table, FMSL
N/A Liner is
provided
u
Time to Draw Down Storage Volume, day
477
v
Receiving Stream/River Basin
Earnest Branch
w
Stream Index Number
15-(1)
x
Classification of Water Body
C, Sw
II SCHEDULE OF COMPLIANCE
The permittee is responsible for verifying that the proposed built -upon area for the entire
project does not exceed the allowable built -upon area
Page 2 of 5

State Stormwater Management Systems
Permit No SW8 130113
2 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
3 The stormwater management system shall be constructed in its entirety, vegetated and
operational for its intended use prior to the construction of any built -upon surface
No person or entity, including the permittee, shall alter any component shown in the approved
plans and specifications Prior to the construction of any modification to the approved plans,
the permittee shall submit to the Director, and shall have received approval for modified plans,
specifications, and calculations including, but not limited to, those listed below For changes to
the protect or SCM that impact the certifications, a new or updated certification(s), as
applicable, will be required and a copy must be submitted to the appropriate DEQ regional
office upon completion of the modification
a Any modification to the approved plans and specifications, regardless of size including
the SCM(s), BUA, details, etc
b Redesign or addition to the approved amount of BUA or to the drainage area
c Further development, subdivision, acquisition, lease or sale of any, all or part of the
project and/or property area as reported in the approved plans and specifications
d Altering, modifying, removing, relocating, redirecting, regrading, or resizing of any
component of the approved SCM(s), the stormwater collection system and/or
vegetative conveyance shown on the approved plan
e The construction of any allocated future BUA
f The construction of any permeable pavement, #57 stone area, public trails, or
landscaping material to be considered a permeable surface that were not included in
the approved plans and specifications
g Other modifications as determined by the Director
During construction, erosion shall be kept to a minimum and any eroded areas of the system
will be repaired immediately Infiltration systems should not be used as erosion control
devices, due to the potential clogging 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
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
The permittee shall at all times provide the operation and maintenance necessary to assure
that all components of the permitted stormwater system function at the design condition The
approved Operation and Maintenance Plan must be followed in its entirety and maintenance
must occur at the scheduled intervals including, but not limited to
Semiannual scheduled inspections (every 6 months)
Sediment removal
Mowing and revegetation of side slopes
Maintenance of the wetlands plants and replacement of dead plants
Immediate repair of eroded areas
Maintenance of side slopes in accordance with approved plans and specifications
Trash and debris removal and unclogging of the wetlands, outlet structure, orifice,
catch basins and piping
Access to all components of the system must be available at all times
Page 3 of 5

State Stormwater Management Systems
Permit No SW8 130113
8 Records of maintenance activities must be kept and made available upon request to
authorized personnel of DEMLR The records will indicate the date, activity, name of person
performing the work and what actions were taken
9 The facilities shall be constructed, operated and maintained in accordance with the provisions
of this permit, the approved plans and specifications, and the supporting documents attached
to this permit and on file with the Division
10 Built upon area includes, but is not limited to, structures, asphalt, concrete, gravel, brick,
stone, slate, coquina and parking areas, but does not include raised, open wood decking, or
the water surface of swimming pools
11 ANNUAL CERTIFICATION The permittee shall electronically submit to the Division an annual
certification completed by either the permittee or their designee confirming the protects
conformance with permit conditions
III GENERAL CONDITIONS
CORRECTIVE ACTIONS REQUIRED If the facilities fail to perform satisfactorily, the
permittee shall take immediate corrective actions This includes actions required by this
Division and the stormwater rules such as the construction of additional or replacement on -site
stormwater systems These additional or replacement measures shall receive a permit from
the Division prior to construction
PERMIT RENEWAL A permit renewal request must be submitted at least 180 days prior to
the expiration date of this permit The renewal request must include the appropriate
application, documentation and the processing fee as outlined in Title 15A NCAC
02H 1045(3)
CURRENT PERMITTEE NAME OR ADDRESS CHANGES The permittee shall submit a
completed Permit Information Update Application Form to the Division within 30 days to
making any one or more of the following changes
A name change of the current permittee,
A name change of the protect,
A mailing address change of the permittee,
TRANSFER This permit is not transferable to any person or entity except after notice to and
approval by the Director Neither the sale of the protect and/or property, in whole or in part, nor
the conveyance of common area to a third party constitutes an approved transfer of the permit
TRANSFER REQUEST The transfer request must include the appropriate application,
documentation and the processing fee as outlined in 15A NCAC 02H 1045(2) This
request must be submitted within 90 days of the permit holder meeting one or more of
the following
i A natural person who is deceased,
u A partnership, limited liability corporation, corporation, or any other business
association that has been dissolved,
ui A person or entity who has been lawfully and finally divested of title to the property
on which the permitted activity is occurring or will occur through foreclosure,
bankruptcy, or other legal proceeding
IV A person or entity who has sold the property, in whole or in part, on which the
permitted activity is occurring or will occur,
TRANSFER INSPECTION Prior to transfer of the permit, a file review and site
inspection will be conducted by Division personnel to ensure the permit conditions
have been met and that the protect and the on -site stormwater system complies with
the permit conditions Records of maintenance activities performed to date may be
requested Protects not in compliance with the permit will not be transferred until all
permit and/or general statute conditions are met
Page 4 of 5

State Stormwater Management Systems
Permit No SW8 130113
COMPLIANCE The permittee is responsible for compliance with the terms and conditions of
this permit until the Division approves the transfer request
APPROVED PLANS AND SPECIFICATIONS A copy of this permit, approved plans,
application, supplement, operation and maintenance agreement, all applicable
recorded documents, and specifications shall be maintained on file by the permittee at
all times
DIVISION ACCESS The permittee grants Division Staff permission to enter the
property during normal business hours to inspect all components of the permitted
protect
c ENFORCEMENT Any individual or entity found to be in noncompliance with the
provisions of a stormwater management permit or the requirements of the stormwater
rules is subject to enforcement procedures as set forth in NCGS 143 Article 21
d OBTAINING COMPLIANCE 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 modified plans and certification in writing to the Director that the
changes have been made
e OTHER PERMITS The issuance of this permit does not preclude the permittee from
complying with and obtaining any other permits or approvals that are required for this
development to take place, as required by any statutes, rules, regulations, or
ordinances, which may be imposed by any other Local, State or Federal government
agency having jurisdiction Any activities undertaken at this site that cause a water
quality violation or undertaken prior to receipt of the necessary permits or approvals to
do so are considered violations of NCGS 143-215 1, and subject to enforcement
procedures pursuant to NCGS 143-215 6
6 Unless specified elsewhere, permanent seeding requirements for the on -site stormwater
system must follow the guidelines established in the North Carolina Erosion and Sediment
Control Planning and Design Manual
Permit renewed, updated and reissued this the 19th day of November 2021
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
a '914
Brian ren Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Page 5 of 5

Attachment C - Permitting History
Autumn Care Brunswick County
Permit No SW8 130113
Approval
Date
permit
Action
BIMS
Version
Desc nphon of the Changes
4/5/2013
Original
Approval
10
11/19/2021
Renewal
20

c
Permit Number (nl 6 13 0113,
(to be pnn ,dcd bl DWQ)
Drainage Area Number
Stormwater Wetland Operation and Maintenance Agreement
1 ,
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
— Immediately following construction of the stormwater wetland, bi-weekly inspections will be
conducted and wetland plants will be watered bi-weekly until vegetation becomes established
(commonly six weeks)
— No portion of the stormwater wetland will be fertilized after the first initial fertihzation that is
required to establish the wetland plants
— Stable groundcover will be maintained in the drainage area to reduce the sediment load to the
wetland
— Once a year, a dam safety expert should inspect the embankment
After the stormwater wetland is established, I will inspect it monthly and within 24 hours after every
storm event greater than 10 inches (or 15 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 '
I
BMP element
Potential problem.
How I will remediate the problem
Entire BMP
Trash/debris is present
Remove the trash/debris
Perimeter of wetland
Areas of bare sod 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
i
and a one-time fertilizer application
Vegetation is too short or too long
Maintain vegetation at an appropriate
height
Inlet device pipe or
The pipe is clogged (if applicable)
Unclog the pipe Dispose of the sediment
swale
offsite
The pipe is cracked or otherwise
Replace the pipe
if applicable)
-damaged
Erosion is occurring in the swale (if
Regrade the swale if necessary to smooth
applicable)
it over and provide erosion control f '
devices such as reinforced turf matting or
riprap to avoid future problems with,
erosion
APR 0 5 2013 ,
Form SW401-Wetland O&M -Rev 4
BV Page 1 of 3
,
,, Ii,

i
Permit Number 1
(v, he provided by DWQ)
BMP element
Potential problem.
How I will remediate the problem
Forebay
Sediment has accumulated in the
Search for the source of the sediment and
forebay to a depth that inhibits the
remedy the problem if possible Remove
forebay from functioning well
the sediment and dispose of it in a location
where it will not cause impacts toPstreams'
or the BMP I P
Erosion has occurred
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
problems 'I
Weeds are present
Remove the weeds, preferably by hand If
a pesticide is used, wipe it on the plants
rather than spraying
Deep pool, shallow water
Algal growth covers over 50% of the
Consult a professional to remove and i
and shallow land areas
deep pool and shallow water areas
control the algal growth
Cattails, phragmites or other invasive
Remove mvasives by physical removal or
plants cover 50% of the deep pool and
by wiping them with pesticide (do not
shallow water areas
spray) - consult a professional
Shallow land remains flooded more
Unclog the outlet device immediately
than 5 days after a storm event
'
device
Receiving water
Plants are dead, diseased or dying
Determine the source of the problem
soils, hydrology, disease, etc Remedy the
problem and replace plants Provide a
one-time fertilizer application to establish
the ground cover if necessary
Best professional practices show that
Prune according to best professional
pruning is needed to maintain ophmal
practices
Plant health
Sediment has accumulated and
Search for the source of the sediment and
reduced the depth to 75% of the
remedy the problem if possible Remove
original design depth of the deep
the sediment and dispose of it in a location
pools
where it will not cause impacts to streams
or the BMP
A tree has started to grow on the
Consult a dam safety specialist to remove
embankment
the tree
An annual inspection by appropriate
Make all needed repairs
professional shows that the
embankment needs repair
Evidence of muskrat or beaver activity
Consult a professional to remove muskrats
is present
or beavers
Sediment has accumulated and
Search for the source of the sediment and
reduced the depth to 75% of the
remedy the problem if possible Remove
original design depth
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP P
Clogging has occurred
Clean out the outlet device Dispose of the
sediment off -site I
The outlet device is damaged
Repair or replace the outlet device "
Erosion or other signs of damage have
Contact the NC Division of Water Quality
occurred at the outlet
401 Oversight Unit at 919-733-1786
Form SW401-Weiland O&M -Rev 4
I
I
i t
c
APR 0 3 2013' a
e2'of3
1'' 01;ldo':A, iMh, t. lit l l t III

i
Permit Number ^
I acknowledge and agree by my signature below that I am responsible for the performance of the ,
maintenance procedures listed above 1 agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party
Project name Autumn Care - Brunswick Co , NC
BMP drainage area number 1
Print
Title Vile V2e5 ttVA
Address 451 N Winstead Ave
Phone [phone]
Signature r ,
Date 31!t / a�
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
f otary Public for the State of ,
rL,Countp of Q do hereby certify that
Q personally appeared before me this day of
and acknowledge the due execution of the forgoing stormwater'wetland
maintenance requirements Witness my hand and official seal,
SEAL
DECEIVE
My commission expires ate APR 0 5' 2013�
I,
Form SW401-Wetland O&M -Rev 4 Page'3 of 3 I
� , ,i'! ,�� ,I I ;? ,I �I' i`: , I,, .I II I UI I l,Ili;,,, IEII, hJ„gel„i„b!II�,1J•4a��1', .I ,,I:.t�

NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER.
PERMIT RENEWAL APPLICATION FORM
In accordance with 15A NCAC 2H 1045(3); the crment permit holder shaft renew their high density permit 180 days
prcr to ds exp6ahon Renewed permits are veld for a period of 8 years per Session Law 2011-398 (SB 781)
Section 60 (o) This application form Is for permit renewals only
A PROJECT INFORMATION
1 State Stormwater Permit Number SW8130113
2 Pro)ect name Autumn Care of Brunswick County
3 Prgect street address 9600 No 5 School Read NW
City Ash _ _ (;pub Brunswick ZIP 29420
4 What. If any, changes have been made to the project as pernntedo? None
/f the
nos cnangeo tram me ongrnal approved plans, please complete SAV- 101 for a Major
or Minor Modlflcahon Application form avadabie at httoslldeo no eov/about/dwtisionsfe
B PERMITTEE INFORMATION
if changes to the permdtee or project name have been made, please complete either the Permit Update form
or the Permit Transfer firm available at https //deg nc aovlabout/divisions/energy-mineral-land-
resources/energy-mineral-land-rulesistormwater-program/post-construction State StormweterPermks do not
automatically transfer with the sale of the property
1 Current Permit Holders Company Name/Organization Autumn Corporation
2 Signing Official's Name Witham I Weisberg
3 Signing Official's Title President
4 Mailing Address 23700 Commerce Park
Cny —Beachwood - _ State OH ZIP 44122
5 Street Address 23700 Commerce Park
City Beachwood _ - State OH ZIP-44122
6 Phone f 216 I 292_5706 Email _ peter.holmes@�saberhealth com
EcovE
NOV 19 2021
BY —�
Stormwater Perrot Renewal Form Page 1 of 3 May 11 2018

C SUBMITTAL REQUIREMENTS
Submrt the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQW/ORW) Only applications packages that
include all required items listed below will be accepted and reviewed
Initial each Item below to indicate that the required information is provided In the application package
X 1 A permit application processing fee of $505 00 payable to NCDEQ
X 2 One original signed hard copy and one electronic copy of this completed form The signing official
named on this application to represent the current permittee must meet one of the following
a Corporation — a principle executive officer of at least the level of vice-president,
b Limited Liability Company (LLC) — a manager or company official as those terms are defined
in G S 57D'North Carolina Limited Liability Company Act;
c Public Entity— a principal executive officer, ranking official or other duly authorized employee,
d Partnership or limited partnership — the general partner,
e Sole proprietor, or
f Letter of authorization signed by one of the signatories noted in a — e above authorizing the
signature of another entity
3 One hard copy and one electronic copy of recorded documents required by the original permit that
have not yet been received by DEMLR, including deed restrictions protective covenants,
condominium/planned community declaration and easements If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has not been exceeded If
the project has not been built, include a signed agreement that the final recorded deed restrictions
and protective covenants will be submitted at a later date
X 4 O&M Agreements, Please select one
❑ I have a copy of the current recorded O&M Agreement for all SCMs and I will continue to
keep this on file with the permit, or
® I do not have a copy of the current recorded O&M Agreement for all SCMs and am
requesting a copy be sent tome I agree to keep this on file with the permit
X 5 Designer Certifications, Please select one
® A copy of the certification(s) confirming that the project was built in accordance with the
approved plans have been previously provided to the Division, or
❑ A copy of the certfication(s) confirming that the project was built in accordance with the
approved plans are enclosed, or
❑ The project has not yet been built
6 [IF APPLICABLE] If the project has been built, one original hard copy and one electronic copy of a
signed, sealed, and dated letter from a licensed professional stating that the SCMs have been
inspected, and that they have been built and maintained in accordance with the permit
_ CX 7 [IF APPLICABLE] When the permittee is a corporation or a limited liability corporation (LLC)
Provide one hard copy and one electronic copy of documentation from the NC Secretary of State
or other official documentation, which supports the titles and positions held by the persons listed in
Section C 2 per 15A NCAC 2H 1043(3)(b)
NOV 12 2021 �)
Br
Stormwater Permit Renewal Application Form Page 2 of 3 May 11 2018

D PERMITTEE'S CERTIFICATION
1, William I Weisberg , the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on site (or I will obtain a copy and it will be kept on site), that I am
responsible for the performance of the maintenance procedures, and the site has been and will be maintained
according to the O&M Agreement and approved plans I agree to notify DEMLR of any problems with the SCMs
or built -upon area and to submit the proper forms to modify or transfer the permit prior to any changes to the
project, SCMs, or ownership All information provided on this permit renewal application is, to the best of my
knowledge, correct and cJ
Signature Date 11 / 08/ Zc72(
NOTARIZATION
I, Stephanie Szymanski a Notary Public for the State of
Ohio County of Cuyahoga , do hereby certify
that William I Weisberg personally appeared before me
this the !E�� day of November 20 21 , and acknowledge the due
execution of the forgoing instrument Witness my hand and official seal,
(Notary Seal)
Notary Signature
My commission
innnnnh
2�
a+ _
ey NOV 12 2021 !
Stormwater Permit Renewal Application Form Page 3 of 3 May 11 2018

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NCDENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WETLAND SUPPLEMENT
This form must be filled out, printed and submitted
The Required Items Checklist (Part 1/1) must be pnnted, filled out and submitted along with all the required information
I' PR09ECTONFORMATIOW
33 3J
Project name
Autumn Care Brunswick Co , NC
Contact name
Mat Trowbridge, El
Phone number
919 552 0849
Date
March 15, 2013
Drainage area number
1
II DESIGNINF,ORMATIONk
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Site Characteristics
Drainage area
361,895 00 fe
Impervious area
202,092 00 fe
Percent Impervious
55 8% %
Design rainfall depth
150 Inch
Peak Flow Calculations
1 yr 24 hr rainfall depth
370 In
1 yr 24 hr intensity
015 In/hr
Pre -development 1 yr, 24 hr runoff
1102 ft'/sec
Post -development 1 yr, 24 hr runoff
1912 ft3/sec
PrelPost 1 yr, 24 hr peak control
810 ft3/sec
Storage Volume Non SA Waters
Minimum required volume
24,98800 ft'
Volume provided (temporary pool volume)
25 600 00 ft' OK
Storage Volume SA Waters Parameters
1 5" runoff volume
000 It,
Pre development 1 yr, 24 hr runoff volume
000 ft3
Post development 1 yr, 24 hr runoff volume
000 ft3
Minimum volume required
000 fe
Volume provided
000 fe
OK
Outlet Design
Depth of temporary pool/ponding depth (DPI i,)
1200 In
OK
Drawdown time
4 77 days
OK
Diameter ofonfice
200in
OK
Coefficient of discharge (Co) used in onfice diameter
calculation
060 (unlfiess)
Driving head (Ho) used In the orifice diameter calculation
100 It
OK
BY
- CEIVED
Form SW401 Wetland Rev 6 11/16/09 Parts I and 11 Protect Design Summary Page 1 of 3

Surface Areas of Welland Zones
Surface Area of Enbre Wetland
25 600 00 fe
OK
Shallow Land
10 210 00 ftz ✓
OK
The shallow land percentage is
40% %
Shallow Water
10,250 00 h2 V
OK
The shallow water percentage is
40% %
Deep Pool
Forebay portion of deep pool (pretreatment)
2,580 00 h2
OK
The forebay surface area percentage is
10% %
Non forebay portion of deep pool
2 560 00 It"
OK
The non forebay deep pool surface area percentage is
10% %
Total of wetland zone areas
25,600 00 ft'
OK
Add or subtract the following area from the zones
000 ft2
Topographic Zone Elevations
Temporary Pool Elevation (TPE)
Shallow Land (top)
29 50 It amsl
Permanent Pool Elevation (PPE)
Shallow Water/Deep Pool (top)
28 50 It amsl
Shallow Water bottom
28 00 It amsl
Most shallow point of deep pool s bottom
26 50 It amsl
Deepest point of deep pool's bottom
26 50 It amsl
Design must meet one of the following two options
This design meets Option #1
n (Y or N)
Top of PPE is within 6" of SHWT If yes
SHWT (Seasonally High Water Table)
0 00 It amsl
OK
This design meets Option #2,
y (Y or N)
Wetland has liner with permeability < 0 01 in/hr If yes
Depth of topsoil above impermeable liner
4 00 in
OK
Topographic Zone Depths
Temporary Pool
Shallow Land
12 00 in
OK
Permanent Pool
Shallow Water
6 00 in
OK
Deep Pool (shallowest)
2400 in
OK
Deep Pool (deepest)
24 00 in
OK
Planting Plan
Are cattails included in the planting plan
n (Y or N)
OK
Number of Plants recommended in Shallow Water Area
Herbaceous (4'cubic inch container)
2,600
Number of Plants recommended in Shallow Land Area
Herbaceous (4'cubic inch container) OR
2,600
Shrubs (1 gallon or larger), OR
416
Trees (3 gallon or larger) and Herbaceous (4+cubic inch)
52 and
2080
Number of Plants Provided in Shallow Water Area
Herbaceous (4'cubic inch container)
2,600
OK
Number of Plants Provided in Shallow Land Area
Herbaceous (4'cubic inch container)
0
More required if not planting shrubs or trees
Shrubs (1 gallon or larger)
416
OK
Trees (3 gallon or larger) and
0
More required d not planting herb and/or shrubs
Grass like Herbaceous (4+ cubic inch)
2,080
OK
MAR 18 2013
Form SW401 Weiland Rev 6 f 1/16r09 Parts I and 11 Protect Design Summary Page 2 of 3

I
Additional Information
Can the design volume be contained?
Does project drain to SA watersv If yes,
What Is the length of the vegetated filter?
Are calculations for supporting the design volume provided In the
application?
Is BMP sized to handle all runoff from ultimate build -out?
Is the BMP located in a recorded drainage easement with a
recorded access easement to a public Right of Way (ROW)?
The length to width ratio is
Approximate wetland length
Approximate wetland width
Approximate surface area using length and width provided
y (Y or N)
n (Y or N)
000 It
y (Y or N)
y (Y or N)
y (Y or N)
200 1
230 00 It
115 00 ft
26 450 00 ft'
Will the wetland be stabilized within 14 days of construction9 y (Y or N)
OK
Excess volume must pass through filter
n
OK
OK
OK
This approx surface area Is within this number of square feet
of the entire welland surface area reported above
OK
MAR 19 2013
Fomi SW401 Wetland Rev 6 11/16/09 Parts I and 11 Proieoi Design Summary Page 3 of 3

Autumn Care Brunswick County
Stormwater Permit No SW8130113
Brunswick County
Designer's Certification
r1 S State Stormwater Management Systems
i Permit No SW8 130113
Page 1 of 2
I, Donald L Curry Jr , PE, as a du registered Professional Engineer inthe State of North Carolina,
having been authorized to observeQenodicall ekiylfuli time) the construction of the project,
Autumn Care - Brunswick Co, NC
(Protect)
for Saber Healthcare Group (Project Owner) hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the project construction such that the construction was observed to be
built within substantial compliance and intent of the approved plans and specifications
The checklist of items on page 2 of this form are a part of this Certification
Noted deviations from approved plans and specifications
Signatur
Registratwn Number 026970
Date
BY
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Certification Requirements
State Stormwater Management Systems
Permit No SW8 130113
Page 2 of 2
1 The drainage area to the system contains approximately the permitted acreage
*v/2 The drainage area to the system contains no more than the permitted amount of built -upon area
V3 All the built upon area associated with the project is graded such that the runoff drains to the
system
�4 All roof drains are located such that the runoff is directed into the system
%/5 The wetland zone elevations are per the approved plan
%/6 The wetland is located per the approved plans
V-7 A trash rack is provided on the outlet structure
!t/8 All slopes are grassed with permanent vegetation
!�/9 Vegetated slopes are no steeper than 31
% 10 The inlets are located per the approved plans and do not cause short-circwbng of the system
�11 The permitted amounts of wetland zone surface area and volume have been provided
!t/12 Required drawdown devices are correctly sized and located per the approved plans
3 All required design depths are provided
�14 All required parts of the system are provided
V15 The required number of wetlands plantings have been provided
cc NCDENR DWQ Regional Office
Inspector, Brunswick County Building Inspections
EGEIV�
APR, 1 7 20"3