SW4130801_Application_20130905

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DW.Q USE.QNLY .
Date Received Fee Paid Permit Number
w I3 0
Applicable Rules:
❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply)
❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This forin niay he yhotocoyied for rise as air 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 agreernents, etc.):
Dollar General -Snow Camp r
2. Location of Project (street address):
West Greensboro Chavel Hill
City:Snow Camp County:Alamance Zip:27349
3. Directions to project (from nearest major intersection):
roximately 450ft west of the intersection of Snow Can1U Road and W. Greensboro Chaoel Hill Road
Latitude:35° 53' 39" N Longitude:79° 25' 51" W
II. PERMIT INFORMATION:
of the main entrance to the project.
].a. Specify whether project is (check one): NNew ❑Modification
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *yrovide 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 Ietter from DWQ
requesting a state Stormwater management permit application, list the Stormwater project number, if
assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ❑Sedimentation/Erosiorn Control: "1.7 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:
Form SWU-101 Version 07Juu2010 Page l of6

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:Glandon 1,orest Equity, LLC
Signing Official & Title:George T. Barnes, Jr. Member/Manager
b.Contact information for person listed in item la above:
Street Address:3900 Merton Drive, Suite 210
City:Raleigh
Mailing Address (if applicable):
City:
State:NC
State:
Phone: (919 ) 459-2601 Pax: (919
Email:gbarnes« vanguardpg.com
Zip:27609
— Zip:-
459-2604
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:Caroline A. Hinshaw
Signing Official & `I'ide:Owner
b.Contact information for person listed in item 2a above:
Street Address:781 Clark Road
City5now Camp
Mailing Address (if applicable):
City:
State:NC
State:
Phone: ( ) Pax:
Email:
Zip:27349
Zip:
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:George Venters - Glandon Forest Equity, LLC
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:3900 Merton Drive, Suite 210
City:Raleigh State:NC Zip:27609
Phone: (919 ) 459-2602
l,nmail:gventers aOvarlgiaa rd pg.com
4. Local jurisdiction for building permits: Ala mance Coun
Point of Contact:lason Martin
Fax: (919 ) 459-2604
Phone #: (336 ) 570-4052
Form SWU-101 Version 07Jun2010 Page 2 of6

IV. PROJECT INFORMATION
1. In the space provided below, briefly, summarize how the stormwater runoff will be treated.
Stormwater runoff from the proposed building and parking spaces will be collected and treated in a
stormwater bio-retention basin. The pond is designed to treat a 1.0" storm & 85% TSS
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Developrnent 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: 3.16 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. 'Total Property Area (4) -Total Coastal Wetlands Area (5) -Total Surface Water Area (6) = "Total Project
Area,:3.16 acres
Total project area shrill be calculated to exclude llte follozoing: the nortual pool of impounded structures, lire area
betwecrr lire banks of streams and rivers, the area below the �qortnal High Water (NHW) line or Meati High Water
(MHW) line, and coastal wetlands landzoard from the NHW (or MHW) litre. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal zvellarrds landward of the NNW (or MHW) line tray
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 20.6 %
9. How many drainage areas does the project have?7 (For high density, count I for each proposed engineered
stortawater BMP. For lout density and other projects, ruse 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
Draina =e Area 1
Draina re Area
Drainage Area _
Draina' e Area _
Receiving Stream Name
Cane Creek
Stream Class *
WS-V,NSW
Stream Index Number *
16-28
Total Drainage Area (so
52,275
On -site Drainage Area (so
52,275
Off -site Drainage Area (so
0
Proposed Im ervious Area** s
28,415—,{�
% hu ervious Area** total
( 54.4
Im ervious- Surface. Area,
Draina 7e Area 1
Draina Te Area -
Draina e Area
Draina Ye.Area _
On -site Buildings/Lots (so
9,100
On -site Streets (so
0
On -site Parking (so
-17,487
On -site Sidewalks (so
1,828
Other on -site (so
0
Future (sf)
0
Off -site (so
0
Existing BUA*** (so
0
Total (so:
28,415 i✓
* Stream Class and Index Ntrrrrber can be deterntined at: http://portal.ucderrr.a`�zcleb/zurlj)s/csrr/classifications
" Inr peroious area is defined as the built upon area including, but not linrited to, buildings, roads, parking areas,
sidezvolks, gravel areas, etc.
Form SWU-101 Version 07Jun2010 Page 3 of 6

11. I -low was the off -site impervious area listed above determined? Provide documentation. N/A
Proieets in Union County: Contact 061'Q Cetural Office stuff to check if the project is located ts4ihin a Threatened &
E ndangered Species ii,atershed that !nary be subject to snore stringent slornnwder requirements as per NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms earl be downloaded
from httV//portal.ncdenr.org/web/wq/ws/su/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from littp://port-,ii.ticlenr.org/web/wq/ws/su/statesw/fornis docs. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating projector the interactive online map at http://L)ortal.iictienr.org/webbKcIZ%vsZstlznlaps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http_/Zportal.n_cdennorg/web/wg/ws/su/statcsw/forms does.
Initials
J. Original anif one copy of the Stormwater Management Permit Application Form. /!Pie-
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part V11 below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M iK 4.
agreenient(s) for each BMP.
4. Permit application processing fee of $505 parable to NCDENR. (For an Express review, refer to _ M0G-
lhttp://tvww-.enviielp.org/pages/onestopexpress,litml for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor AV14
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the A11-
receiving stream drains to class SA waters within '/s mile of the site boundary, include the'/z
mile radius on the map.
7. Sealed, signed and dated calculations. Jf+�d4
8. Two sets of plans folded to 8.5" x "14" (sealed, signed, & dated), including: AV PC
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 an), 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 13UA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
Form S WU-101 Version 07Jun2010 Page 4 of 6

Copy of any applicable soils report with the associated SHWT elevations (Please identify )RiL
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 DINQ to verifij the SHWI' prior
to submittal, [phone])
10. A copy of the most current property deed. Deed book: ?1 Page No: 3540
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC IMt�
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1 a, 2a, and/or 3a per NCAC 21-1.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
littp://www.secretary.state.iic,us/Coi-poratiotis/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
13UA 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://portal.ncdenr.org/web/wr1/ws/su/statesw/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 DWQ, and that they will be recorded prior to the sale of any lot.
Vill. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your Behalf for this project (such as
addressing requests for additional information).
Consulting Engineer:Mattliew Lowder, PE
Consulting Firm: Triangle Site Design, PLLC
Mailing Address:4006 Barrett Drive Suite 203
City:Raleigh State:NC Cip:27609
Phone: (919 ) 553-6570 _
Email:mlowder@trian Tlesitedesi n.coni
Fax: (919 ) 459-2604
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled ont, complete this
section)
I, (print or type name of person listed in Con fact Information, item 2a) Caroline A. Hiushavy , certify that I
own the property identified in this permit application, and thus give permission to (print or (/pe name of person
listed in Contact Information, item 1a) George T. Barnes, jr. with (print or type name of organization listed in
Confact Informatioti, item 1a) Glandon Forest Lquity, LLC to develop the project as currently proposed. A copy of
the lease agreement or pending; property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 07.iun20E0 Page 5 of6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $2r-,�00 per day, pursuant to NCGS 143-215.6.
Signature:
Date: -7 /i'r' 13
a N tary Public for the S r
of � C County of
do hereby certify that (I - 1`��rsonally appeared
before me this j&ay of ti3, and ac < wledge the due executi of the application for
a stormwater permit. Witness my hand and official seal,
SISAL
My commission expires 0 C4O� 1 ,- a )
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listen in Contact Information, item 1a) George Barnes
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable storm ate r es der 15A N C 21-1 .1000, SL 2006-246 (Ph. 1I - Post Construction) or St.2008-211.
Signature: Date: 1Z�
1, a Notary Public for the State of A/C County of
�/ , do hereby certify that !'U�� /12J1/�,S personally appeared
before me this � ,,,clay of aa-y .. and ac now edge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
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SISAL
My commission expires % zj ��
Form SWU-101 Version 07Jun2010
Page 6 of 6