SW6230103_Application Form_20230131

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
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 Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. 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.):
Carter Farms Subdivision - Phase 1
2. Location of Project (street address):
190 Carter Road
City:Lumber Bridge County:Hoke County Zip:28357
3. Directions to project (from nearest major intersection):
550 It south of the interesecton of Carter Road and Chason Road on Carter Road
4. Latitude:34° 56' 04.2" N Longitude:790 04' 46.1" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SWU-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 ❑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
DEMLR 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: 8.9 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 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 ❑Yes
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 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 owns the project):
Applicant/ Organization: Rheibeck Investements, LLC.
Signing Official & Title:Geoff Becker - Owner/Manager
b. Contact information for person listed in item 1a above:
Street Address:3727 Legion Road
City:Hope Mills
State:NC
Zip:28348
Mailing Address (if applicable):same as above
City: State: Zip:
Phone: (910 ) 426-7575 Fax: ( )
Email: [e-mail]
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:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City:
State:
Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
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:
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: Hoke County
Point of Contact:Andy Conner Phone #: (910 ) 878-1266
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff will be discharged through brass swales that have been design to be a minimum of 100 ft
in length and to flow a 10-vr storm event.
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 II - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 18.4 acres
5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:18.4 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHV9 line, and coastal wetlands landward from the NHW (or MHVO line. The resultant project area is used to
calculate overall percent built upon area (B UA). Non -coastal wetlands landward of the NHW (or MHM line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =13.0
9. How many drainage areas does the project have?1 (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 _
Draina e Area _
Drainage Area _
Receiving Stream Name
Mill Creek
Stream Class *
B
Stream Index Number *
18-31-20
Total Drainage Area (sf)
801504
On -site Drainage Area (sf)
711282
Off -site Drainage Area (so
89012
Proposed Impervious Area** (sf)
104108
% Impervious Area** (total)
13.0
Impervious' Surface Area
Drainage Area _
Drainage Area —
Drainage Area —
Drainage Area —
On -site Buildings/Lots (sf)
71071
On -site Streets (sf)
28622
On -site Parking (sf)
On -site Sidewalks (sf)
4415
Other on -site (sf)
Future (sf)
Off -site (sf)
Existing BUA*** (sf)
Total (sf):
104108
* Stream Class and Index Number can be determined at: http.- portal.ncdenr.orglwehLzt?a ps/csu/classi 'cations
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

'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 B UA.
11. How was the off -site impervious area listed above determined? Provide documentation. NA for Low Density
Projects in Union County: Contact DEMLR Central Office 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 15A 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
fromh!!p://portal.ncdenr.org/web/wq/ws/`suZbmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application 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
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map athW2://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 htt2://portal.ncdenr.org/web/wq/ws/suLstatesw/`forms_docs.
Initials
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 below)
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.html 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/management
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 (one copy).
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).
V
ford f� AAT
A �
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify zm
11.
A copy of the most current property deed. Deed book: 1315 Page No: 0981
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 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.
http: / /www.secretaKy.state.ric.us/­`Corporations/­CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
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"x11" 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 verify the SHWT prior
to submittal, [phone].)
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 http:J/portal.ncdenr.org/web/lr/state_
stormwater-forms docs. 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 any lot.
VIII. 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:Michael D. Averette
Consulting Firm: Averette Engineering Co., P.A.
Mailing Address:712 E. Lake Ridge Road
City:Raeford
Phone: (910 ) 488-5656
Email:[e-mail]
State:NC Zip:28376
Fax: (910 ) 488-0181
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) , 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 1a) with (print or type name of organization listed in
Contact Information, item 1a) 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 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 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 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.
Signature: Date:
a Notary Public for the State of
do hereby certify that
before me this _ day of
County of
personally appeared
, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 1a) Rheibeck Investments, LLC. - Geoff Becker ,
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 pr.aective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable or at �der.15VkNCAC 2H .1000 and any other applicable state stormwater requirements.
Signature: Date:
I, g v e (,e f f e' a Nii ootary Public for the State of 'A101 � `'1- �_f1e0 County of
0 "!�-e- do hereby certify that VCAV "J 6'efos�( Oe ke_ ✓° personally appeared
before me this Lday of i,kO -C 4 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, �'� 4;;q
NOTARY
PUBLIC
SEAL
My commission expires 'Z5�- t k 1 P, a 4;2 3
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

Low Density Residential Subdivisions
Deed Restrictions & Protective Covenances
In accordance with Title 15 NCAC 2H.1(o;;jtd S.L. 2006-246, the Stormwater Management
Regulations, deed restrictions and prot ` Covenants are required for Low Density Residential
Subdivisions where lots will be subdividg and sold. Deed restrictions and protective covenants are
necessary to ensure that the development maintains a "built -upon" area consistent with the applicable
regulation governing the density level.
I, Rheibeck Investments. LLC. — Geoff Becker acknowledge and affirm by my signature below, that I
will cause the following deed restrictions and protective covenants to be recorded for
Carter Farms Subdivision - Phase 1 prior to the sale of any lot:
1. The following covenants are intended to ensure ongoing compliance with State Stormwater
Management Permit Number , as issued by the Division of Energy, Mineral and
Land Resources under the Stormwater Management Regulations.
2. The State of North Carolina is made a beneficiary of these covenants to the extent necessary to
maintain compliance with the stormwater management permit.
3. These covenants are to run with the land and be binding on all persons and parties claiming
under them.
4. The covenants pertaining to stormwater may not be altered or rescinded without the express
written consent of the State of North Carolina, Division of Energy, Mineral and Land Resources.
5. Alteration of the drainage as shown on the approved plan may not take place without the
concurrence of the Division of Energy, Mineral and Land Resources.
6. The maximum allowable built -upon area per lot is _4738 square feet. This allotted
amount includes any built -upon area constructed within the lot property boundaries, and that
portion of the right-of-way between the front lot line and the edge of the pavement. Built upon
area includes, but is not limited to, structures, asphalt, concrete, gravel, brick, stone, slate, and
coquina, but does not include raised, open wood decking, or the water surface of swimming
pools.
7. In the case of a lot within CAMA's regulated AEC, where the Division of Coastal Management
calculates a different maximum allowable built -upon area for that lot than is shown herein, the
governing maximum built -upon area for that lot shall be the most restrictive of the two.
8. Filling in or piping of any vegetative conveyances (ditches, swa/es, etc.) associated with the
development except for average driveway crossings is strictly prohibited by any persons.
9. Each lot will maintain a 30* foot wide vegetated buffer between all impervious areas and surface
waters.
10. All roof drains shall terminate at least 30* foot from the mean high water mark of surface waters.
*50 foot for ects loc to a 20 coastal counties.
Signature: Date: 2 I � ,
I, Akt,4 J � � �� a Notary Public in the
State of �" i`�, fir, I j , County of
do hereby certify that PCt4_1✓r12_ 6,- � eC/f' personally appeared
before me this the" day of _� r��-f' 20-23, and acknowledge
the due execution of the foregoing instrument. Witness my hand and official seal,
tltttlttttyp1i�
SEA
Signature ' "O TA 13 y o
My Commission expires _J;
Form DRPC-5 Rev.2 05Nov2009 Page 1 of 1

DEMLR USE ONLY permit Number
Fee Paid
Date Received
SW
❑ 2008 ❑ Ph II -Post Construction
-1995 Coastal SW -
able Rules: ❑ Coastal astal SW- HQW/ORW Waters []Universal Stormwat" Management Plan
select all that apply) ❑ Non -Co
❑ Other WQ Me! Plan:
State of North Carolina
Department of Enviromment and Natural neral and Land Resources Resources
Division of Energy, M
STORMWATER MANAGEMENT PERMITa Apps an LI IATION FORM
This form may he photocopied for u
I GENERAL INFORMATION
Name subdivision, facility, or establishment nament held be consistent with project name on Plans'
1. Project( )
specifications, letters, operation and maintenance agreements,
2. Location of Project (street address):
0 Carter Road County:u ke r ^""t" — Zip:28357
City -
.Lumber Brid e
3. Directions to project (from nearest major intersection): n -a -r t a, tPr Road
4. Latitude:350 56' 06.6" N Longitude:79° 04' 44.9" W of the main entrance to the project.
II. PERMIT INFORMATION: [] Renewal w% Modificationt
2. a. Specify whether project is (check one):
®New OModification
tRenezoals urifh modifications also requires S WI.I-1©2 —Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing�ptermid the status list the existing
permit number , its issue date (if known)
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
DEMLR 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):
F�CAMA Major ®Sedimentation/Erosion Control: 8.9 ac of Disturbed Area
ONPDES 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 UYes
rf yes, see S.L. 2012 200, Part vz- hW2.Y, f2ortalncdenr:0r&Web lrlrules-and-regulations
Form SWU-101 Version Oct. 31.2013 Pate l 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 owns the project):
Applicant/Organization:Rheibeck Investements LLC.
Signing Official & Title:Geoff Becker - Owner/Manager
b. Contact information for person listed in item 1a above:
Street Address:3727 Limon Road - - -
City:HUe Mills State:NC Zip:28348
Mailing Address (if applicable):same as above
City:
State:
Phone: (910 ) 426-7575 Fax:
Email:
Zip:
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:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):,
City:_
Phone:
Email:
State: Zip:
State: Zip:
Fax: ( _)
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:
Signing Official & Title:
b. Contact information for person listed in item 3a above:
Mailing Address:
City: State:
Phone: ( ) -_ Fax:
Email:
Zip:
4. Local jurisdiction for building permits: Hoke Count
Point of Contact:Andv Corner Phone #: [phone]
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, hjLefly summarize how the stormwater runoff will be treated.
Stormwater runoff will be discharged through grass swales that have been design to be a minimum of 100 ft
in leng1h and to flow a 10-3g storm event.
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 H - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area:18.4 acres 5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:18.4 acres
Total project area shalt be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (B LIA). 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 =13.0 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use I 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 _
Drainage Area _
Drainage Area _
Receiving Stream Name
Mill Creek
Stream Class *
B
Stream Index Number *
18-31-20
Total Drainage Area (sf)
801504
On -site Drainage Area (sf)
711282
Off -site Drainage Area (sf)
89012
Proposed Impervious Area** (s
% Impervious Area** (total)
104108
13.0
Impervious** Surface Area
Drainage Area —
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
71071
On -site Streets (sf)
28622
On -site Parking (sf)
On -site Sidewalks (sf)
4415
Other on -site (sf)
Future (sf)
Off -site (sf)
Existing BUA*** (sf)
Total (sf):
104108
Stream Class and Index Number can be determined at: u.»��
* Impervious area is defined as the built upon area including but not limited to, buildings, roads, parking areas,
sidawalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

***Report only that amount of existing BL1A that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new B LIA.
11. How was the off -site impervious area listed above determined? Provide documentation. NA for Low Density
Projects in Union County: Contact DEMLR Central Office 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 15A 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 httM-/ /Mortal ncdenr or /g_web/wq/ws/su/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application 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
http / /portal ncdetir org/web/wq/ws/su/statesw/forms flocs. 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 athM.//portal.iicdeiu.orgZweb/wq/ws/su/nial2s.)
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 ht ortai ncdenr or&Zweblwq/ws/su/statesw/forn�ti� s.
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 below)
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
ht42 / /www envhelp o /pages/a nestopexpress.html 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/ management
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 lh mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
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).
Farm SWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required).
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"xl1" 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 verify the SHVVT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1315 Page No: 0981
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 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.
hLt2://www.secretaly.state.nc.us/Corporations/CSearch.asox
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 http:Uportal.ncderr.org/web/lr/state-
stormwater-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 DEMLR, and that they will be recorded prior to the sale of any lot.
VIII. 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:Michael D. Averette
Consulting Firm: Averette Engineering Co., P.A.
Mailing Address:712 E. Lake Ridge Road
City:Raeford State:NC Zip:28376
Phone: (910 ) 488-5656
Email:[e-mail]
Fax: (910 ) 488-0181
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
(print or type name of person listed in Contact Information, item 2a)
own the property identified in this
listed in Contact Information, item 1a)
Contact Information, item 1a)
certify that I
permit application, and thus give permission to (print or h1pe name of person
with (print or type name of organization listed in
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-I01 Version Oct. 31, 2013 Page 5 of

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 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.
a Notary Public for the State of
, do hereby certify that
before me this _ day of
Date:
County of
personally appeared
, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 1a) Rheibeck Investments, LLC. -Geoff Becker
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 prcctive covenants will be recorded, and that the proposed project complies with the requirements of the
applicale orwat les de 1
5Vk NCAC 2H .1000 and any other applicable state stormwater requirements.
Signature: )ate:
I, / "CAf Ad�aa r3: Aye celte_ a Notary Public for the State of ��� � U-1 only of
do hereby certify that 0CAVJ taeoif I3e&/ice Y" personally appeared
Wz-
before me this E'" "day of"L`t i�kl`, , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,e-¢-
�QTARY�
PU 8 LIC
SEAL
My commission expires -emu` t `1 d . -1, -4 '�z 3
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6