SWG040152_Application Form_20230605

FOR AGENCY USE ONLY
Date Received
DIVISION SURFACE WATER P OTECTION SECTION t_a23 MAR
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Certlitcate of STATE STORMWATER NOTICE OF INTENT(NOI) 4 Vr I Is Z
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SWG040000 - GENERAL PERMIT TO CONSTRUCT A LINEAR UTILITY LINE Permit Assigned to
AND ASSOCIATED INCIDENTAL BUILT-UPON AREA
State Stormwater Management Application Notice of Intent for coverage under the General Stormwater Management
Permit to construct a utility line and incidental built-upon area associated with a linear utility project including water,
sewer, gas, telephone, and electric.
For the construction, operation and maintenance of incidental impervious areas associated with the construction of a
linear utility line. Incidental built-upon area associated with the utility project includes small, single pump stations,
access roads which minimize their built-upon area, concrete pads, manhole covers, etc.
(Please print or type)
1. Mailing address of owner/developer: (The address to which all permit correspondence will be mailed.)
Owner/Developer Name Union County
Street Address 500 N Main St Ste 615
City Monroe State NC ZIP Code 28112
Telephone No. [phone] Fax ( )
2. Proposed Project Information:
Project Name NC 762 Pressure Zone Water Transmission Main and Finished Water Pump Station
Street Address
of the Project 3522 New Salem Rd
City Monroe State NC ZIP Code 28110
County Union
Contact Person Bob West, PE
Mailing Address 309 East Morehead Street,Suite 220
City Charlotte State NC ZIP Code 28202
Telephone No. ([phone] Fax { )
3. Physical Location Information:
Please provide the street address of the project and describe how to get to the project, using street names,
state road numbers, and the distance and direction from the nearest major intersection:
Located at 3522 New Salem Rd, Monroe, NC 28110. Head Northeast at the intersection of Morgan Mill Rd (SR-200)and
Andrew Jackson Hwy(US-74).Turn East onto New Salem Rd and the project will be on the right after 3.5 miles.
4. What is the name of the receiving stream? Richardson Creek, Bull Branch,Jacks Branch,Austin Branch
5. River Basin Yadkin-Pee Dee Receiving Stream Classification All streams are classified as C
6. This Certificate of Coverage is being submitted as a result of:
❑X New or proposed project ❑ Modification to an existing project
Existing COC or Permit Number:
Date project is scheduled to begin construction 2023
100% 23 ac 0.18 ac
7. What is the total project area above mean high water? 994,039 ftL =of project= LOD - Water
8. What is the total amount of built-upon area proposed at this site? 21,345 sqft ftz
(Please include all manhole covers,pump stations,concrete pads,and gravel access roads)
Pump Station Slab = 1,192 sqft
Valve Rings&Cover-38 @ 3.14 sqft= 119 sqft
ARV Assembly Vaults- 31 @ 49 sqft = 1,519 sqft
SWU-1 16-17FEB201 0 Page 1 of 3 Gravel Access Roads = 18,515 sqft

9. What type of utility project will be constructed?
❑X Water ❑ Sewer ❑ Gas ❑ Telephone ❑ Electric ❑ Other
10. Has the built-upon area been minimized to the extent practicable?
❑R YES ❑ NO
11. Is the runoff from the built-upon area outside the vegetative buffer directed away from surface waters,to the
extent practicable?
0 YES ❑ NO
12. Is the project within 575' of the Mean High Water line of class ORW waters?
❑ YES (Please show the 575' AEC line on plans) 0 NO
(If yes, total built-upon area must be less than or equal to 25%of the total project area within the AEC above mean high water.)
13. Are there any wetlands on the site? 0 YES(please delineate on the plans) ❑ NO
Name and affiliation of person making this determination: Brandon Phillips
Habitat Assessment& Restoration Professionals(HARP)
14. Please list all Best Management Practices employed at this site:
NIA,the project consists of buried water infrastructure with small concrete vaults,valve covers,and minimal gravel drive
entrances being the only impervious surface added and not requiring any water quality treatment. Land cleared and
disturbed for the project will be seeded and stabilized to prevent erosion.
15. Certification:
North Carolina General Statute 143-215.6B (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan,
or other document filed or required to be maintained under this Article or a rule implementing this Article;or who knowingly
makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,
tampers with,or knowingly renders inaccurate any recording or monitoring device or method required to be operated or
maintained under this Article or rules of the Commission implementing this Article shall be guilty of a Class 2 misdemeanor
which may include a fine not to exceed$10,000. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both,for a similar offense.)
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit wiil
constitute the permit requirement for the project and is enforceable in the same manner as an individual permit.
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed name of person signing: Thomas Mann, PE
Title:,{�C IP Program Manager
lk 3- 2-
(Signature of Applicant) (Date signed)
A check or money order must accompany this Notice of Intent for$505.00, made payable to:NCDENR.
Your application will be returned unprocessed unless all of the following items are submitted:
x❑ This completed form
0 Two sets of site and grading plans
❑X A check for$505.00
❑X A USGS map with the project clearly located on it.
Mail the entire package to: NCDENR Division of Water Quality
Surface Water Protection Section —Stormwater
at the Appropriate Contact Address (see the following page)
[Vote: The submission of this document does not guarantee the issuance of a Certificate of Coverage under the
General Permit.
SWU-1 16-17FEB201 0 Page 2 of 3