SW4210703_Annual Certification Review (2024)_20240214

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 2/14/2024 9:24:25 AM (Annual Certification Submittal)
Approve by Kaitlin Peck 2/14/2024 9:27:24 AM (Annual Certification Submittal Review)
• The task was assigned to Kaitlin Peck 2/14/2024 9:24:29 AM

Post-
Construction StormwaterProgram
OVERVIEW
Please read the following as it contains useful information that will help you better understand and complete this form.
Before filling out this form:
• Go to our website and check the current information we have on file by running a State Stormwater Permit Summary Report.
• Get a copy of the most recently issued post-construction stormwater permit and plans for the project. Hard copies of these items should
have been sent to the Applicant once the permit was issued.The post-construction stormwater permit will have a permit number(on the
cover letter and at the top of each page of the permit)in the form"SW#######"(where the V"symbols are usually numbers but can
also be letters). If you do not have a copy of the permit or plans,they can either be found in our online repository or by contacting
the DEMLR office that issued the permit. For additional assistance,send an email to [e-mail]
• Ensure that the correct person is filling out this form.This certification form must be completed by the Permittee(listed on the permit)or
by a Designee of the Permittee.This form does not need to be completed by an engineer or other licensed professional.
• NOTE: For permits that have multiple Permittees,only one Annual Certification per permit needs to be submitted. Each separate
Permittee is not required to submit their own Annual Certification.
Why is an annual certification required?
• The annual permit certification on conformance with permitting conditions is required per G.S. 143-214.7(b4): "New stormwater permits
and stormwater permits that are reissued due to transfer, modification,or renewal shall require the permittee to submit an annual
certification on the project's conformance with permit conditions.The annual certification shall be completed by the permit holder or their
designee.The Department shall not require the annual certification to be completed by another party besides the permit holder or their
designee.The Department shall provide an electronic means of submittal for the permit holder or their designee to satisfy the annual
certification requirement.The addition of annual certification requirements to an existing permit or certification shall not be considered to
be a new or increased stormwater control."-G.S. 143-214.7(b4)
• The annual certification supports the Permittee by ensuring that they are aware of and are meeting all of the permitting conditions that
are required per the permit.
An annual certification must be completed each year on or before the day of the year on which the permit was issued.
For example, if a permit was issued on April 15,2022,the first annual certification for that permit would be due on or before April 15,2023;
the second annual certification would be due on or before April 15,2024;and each subsequent annual certification would be due on or
before April 15th of that year until the permit is reissued(at which point the day of the year that the permit was reissued would become the
new annual certification date).
About Saving Drafts of this Form:
If you are unable to complete the entire Annual Certification Form in one sitting,the form can be saved by clicking the"Save as Draft"
button at the bottom of any section and resuming at a later time.You will provide an email and password(set specifically for the current
project form)so you can access the form again when the link is sent to that email address. Do not upload any documents to the draft
until you are ready to submit the form,or you may encounter problems submitting it. If this happens, remove and re-upload
attachments to submit. IMPORTANT: pre-populated information that has been updated on our end since you started the draft may not
update in a saved draft. In those cases,we recommend starting a new form.

A. Permit and Project Information
Section A - Permit and Project Information:
Please enter the permit number associated with this property.
.........................................................................................................................................................................................................................................................................................................................................................................................................................
Permit Check: Reviewer must verify the permit number
The permit number entered is correct
Permit Number* Enter Permit number(in format SW#######).
SW4210703
Must begin with'SW'followed by 7 letters or numbers.ALL LETTERS MUST BE CAPITALIZED.
Project Name:* Information we have on file:
Tally Pointe
The project name can be found in the permit or in the cover letter sent out with the permit.
Project County:* Information we have on file:
Davidson
This is the county the project is located in. Projects that are located in multiple counties will only list
one county as the"Project County".
Project City/Town* Information we have on file:
Lexington
This is the town or city the project is located in.
Date of Permit Information we have on file:
Issuance* 12/6/2021
The date that the permit was issued can be found in the permit or in the cover letter sent out with the
permit.
Issuance Month and Day December 6
(Hidden field on submission and used on the Certificate)
Project Information* Is the project name and information that we have on file for this project,as listed above,current and
correct?
Yes
No
Project Status* Construction on the project has not yet started
Construction on the project is underway
Construction on the project is completed

B. Permittee Information
Section B - Permittee Information:
......................................................................................................................................................
Permittee Name* Information we have on file:
Sagamore Homes NC Inc
This is the organization,government entity, individual,etc.that is currently responsible for maintaining
conformance with the permit conditions. Some permits are issued to multiple Permittees,there will be
an option to include these additional Permittees later in the form.
Current Permittee Signing Official
This is a person who represents and can sign for the permittee(for corporations,this person must be the at the level of Vice President or
higher).This person may be the same person as the permittee if the permittee is an individual.
Permittee Signing Information we have on file:
Official Kenneth Anson
As of: 2/12/2024
Permittee Signing Official contact information we have as of 2/12/2024:
Sagamore Homes NC Inc
Kenneth Anson(Signing Official)
1348 Westgate Center Dr Ste 100
Winston Salem, NC 27103
Phone: [phone] Ext.
Email:[e-mail]
First Name* Kenneth
Last Name* Anson
Title* President
Current Permittee Street Address
Mailing Address* 1348 Westgate Center Dr Ste 100
Address Line 2
City State/Province/Region
Winston Salem NC
Postal/Zip Code Country
27103 USA
Check here if the mailing address is the same as the street address.
Current Permittee Street Street Address
Address* 1348 Westgate Center Dr Ste 100
Address Line 2
City State/Province/Region
Winston Salem NC
Postal/Zip Code Country
27103 USA

Permittee Signing Please enter a telephone number that we can use to reach the Permittee Signing Official during
Official Telephone normal business hours.
Number* 336-687-1117
Permittee Signing Please enter an email address that we can use to reach the Permittee Signing Official.
Official Email Address* [e-mail]
Permittee Information* Is the Permittee information that we have on file for this project,as listed above, current and correct?
Yes
No
Additional Permittees?* Are there additional Permittees associated with this permit?
Yes
- No
Any additional Permittees associated with the permit can be found in the permit or in the cover letter
sent out with the permit.Typical additional Permittees include Developers, Property Owners,
Purchasers,and Lessees.
Additional Permittee Has any of the Additional Permittee(s)information changed since this permit was last issued or since
Information* the last Annual Certification was submitted(whichever occurred most recently)?
No
Yes

C. Property Owner Information
Section C - Property Owner Information
..................................................................................................................................................................................
These property owners may or may not be listed as the Permittee and/or Co-permittees above.
Check here if the current Property Owner is the same as the Permittee listed in Part B.
Do not select this item if the current Property Owner is the same as one of the Additional Permittees
listed in Part B.
Check here if the project is a subdivision with each of the individual lots owned by separate
individual entities.
It is not necessary to add each individual lot owner into this form unless that is how the permit is explicitly written(very rare).
Please enter the Homeowners Association(HOA)information for the Property Owner information.
Property Owner Please enter the name of the Property Owner that owns the property covered under the permit.
(Primary)Name* Tally Pointe HOA, LLC
This is the organization,government entity, individual,etc.that is currently owns the property covered
under the permit.Some permits cover property owned by multiple entities,there will be an option to
include these additional Property Owners later in the form.
Property Owner Signing Official
This is a person who represents and can sign for the current Property Owner(for corporations,this person must be the at the level of Vice
President or higher).This person may be the same person as the current Property Owner if the current Property Owner is an individual.
First Name* Jordan
Last Name* Drake
Title* President
Property Owner Signing Street Address
Official Mailing PO Box 38843
Address
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code Country
27438 USA
Check here if the mailing address is the same as the street address.
Property Owner Signing Street Address
Official Street Address* 109 Muirs Chapel Road
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code Country
27410 USA
Property Owner Signing Please enter a telephone number that we can use to reach the Property Owner Signing Official during
Official Telephone normal business hours.
Number* 336-564-6384

Property Owner Signing Please enter an email address that we can use to reach the Property Owner Signing Official.
Official Email* [e-mail]
Property Owner Has the Property Owner information changed since this permit was last issued or since the last Annual
Information* Certification was submitted(whichever occurred most recently)?
- No
Yes
Additional Property Does this permit have additional Property Owners associated with it?
Owners?* Yes
No
Any additional Property Owners associated with the permit can be found in the permit or in the cover
letter sent out with the permit. Individual lot owners in a subdivision should not be included here unless
it is specifically written into the permit.
Additional Property Has any of the Additional Property Owner(s)information changed since this permit was last issued or
Owner Information* since the last Annual Certification was submitted(whichever occurred most recently)?
- No
Yes

D. Site Conformance with Permit
Section D - Site Conformance with Permit
.................................................................................................................................................................................................
The following statements of project conformance for this project are in roughly the same order as they appear in the permit. Certain
sections below may not be included in your permit(especially for permits that were originally issued prior to 2017), in which case, please
answer"N/A"and indicate that these conditions are not included in the permit in the provided text box. Please answer the following
statements about the current project conformance with the permitting conditions(Any answers of"N/A"will require an explanation in the
provided text box,and any answers of"No"will require an explanation and a corrective action plan in Section E):
NOTE: Unless a specific statute is cited,the provided definitions below are not technical definitions(and should not be used as such), but
rather are approximate definitions that should allow the layperson to reasonably understand and certify their conformance with permitting
conditions.
Built-Upon Area(BUA)
BUA generally refers to impervious surfaces(impervious surfaces are surfaces that do not allow stormwater to infiltrate through them,
such as roofs, roadways,sidewalks,etc.)BUA is defined in G.S. 143-214.7(b2).
1. Maximum BUA not The maximum allowable BUA for the entire project has NOT been exceeded.
exceeded?* Yes
No
N/A
The amount of BUA allocated to the project should be included in the permit and/or the permitting
documents.
2.SCM BUA not HIGH DENSITY PROJECTS ONLY:The maximum allowable BUA within the drainage area(s)to the
exceeded?* Stormwater Control Measures(SCMs)has(have)NOT been exceeded.
Yes
No
N/A
The amount of BUA allocated to the SCM should be included in the permit and/or the permitting
documents.
The project density should be indicated on the permit.As a general rule of thumb, high-density projects include an SCM (such as a pond)
to treat stormwater runoff,while low-density projects are not required to include an SCM and rely on vegetated areas to provide treatment.
Projects that are entirely low-density should answer"N/A". SCM is defined in 15A NCAC 02H .1002(49)
Explain:* Provide a detailed explanation about why this item is not applicable for this project.
The project is low-density
3.Individual lot BUA not SUBDIVISIONS ONLY:The maximum allowable BUA for the individual lots has NOT been exceeded.
exceeded?* Yes
No
N/A
If a project is a subdivision, it should be indicated on the permit.A subdivision project can be a
residential subdivision,a commercial subdivision,or a mixture of the two.

4. BUA as shown on The BUA is as shown on the approved permit documents.
plans?* Yes
No
N/A
The BUA footprints for individual lots of a subdivision are not typically shown on the plans since the
exact layouts of the houses/driveways/etc.on the lots is not known at the time of permitting. Instead,
each lot is typically allocated an amount of BUA that they can use which should be indicated in the
permitting documents.
Stormwater Control Measures(SCMs)and/or Low-Density Areas
There are SCM Inspection Forms and videos available on our website that can help you determine if the SCM(s)is(are)in conformance.
(NOTE: Not all SCMs currently have an inspection form or video on that website.)
5.SCM(s)and/or low- The SCM(s)and/or low-density area(s)are in accordance with the approved permit documents.
density area(s)per Yes
plans?
No
N/A
Low-density projects typically do not have SCM(s),and high-density projects typically do not have low-
density areas.This should be indicated in the permitting documents.
6.SCM(s)and/or low- The SCM(s)and/or low-density area(s)is(are)accessible for access and maintenance(as
density area(s)are applicable).
accessible?* Yes
No
N/A
Generally speaking,you should be able to drive a maintenance vehicle,such as a pickup truck,to the SCM(s)and/or low-density area(s)
to perform required maintenance tasks.Current specific maintenance access requirements are outlined in 15A NCAC 02H .1050(8).
Stormwater Outlets
A stormwater outlet is any location that stormwater runoff(water,from rain or snow,that flows across the ground)leaves a pipe or a ditch.
7.Stormwater outlets The stormwater outlets are free of erosion.
are stable?* Yes
No
N/A
Erosion occurs when material,such as soil, is worn away from where it should be.The presence of
bare soil without vegetation indicates that erosion is occurring.Typically,the area immediately
downstream of a pipe(and sometimes a ditch)is covered in rocks(called riprap)that help prevent
erosion. It is important for the riprap to be free of debris and sediment to function properly.
Vegetative Setbacks
Vegetated setbacks(which may also be referred to as"vegetated buffers"in certain permits)refer to vegetated areas directly adjacent to
surface waters(such as lakes, rivers,streams,etc.)These vegetated areas are required to help protect the surface waters from
stormwater runoff,are typically required to be free of BUA",and the widths of these vegetated areas are measured perpendicularly from
the bank or normal water surface elevation of the surface water(it should also be clearly indicated on the approved plans).A surface water
may not be readily visible when inspecting the project;some surface waters are ephemeral (meaning that they are dry for part of the year),
but the surface waters should be indicated on the approved plans and/or USGS topographic map in the permitting documents.
There are certain types of BUA that may be allowable within this vegetated area, but they should be clearly indicated on the approved
plans.

B.Vegetated setbacks The vegetated setbacks are in accordance with the approved permit documents.
per plans?* Yes
No
N/A
These requirements vary depending on a number of factors so you will need to refer to the permit for
the project-specific requirements.
Recorded Documents
Recorded documents help ensure that the site is accessible for State inspections and that the permitting conditions will be met in
perpetuity.
9. Easements recorded? The easements have been recorded with the Register of Deeds.
*
Yes
No
N/A
10.O&M Agreement The O&M Agreement has been recorded with the Register of Deeds.
recorded?* Yes
No
N/A
11.O&M Agreement The O&M Agreement has been referenced on the final plat(if applicable).
referenced on plat?* Yes
No
N/A
12. Deed restrictions Deed restrictions/protective covenances have been recorded.
recorded?* Yes
No
N/A
Example deed restriction forms can be found on our website.
Construction
During construction,vegetated ground cover is often removed from the project area.Without the vegetation to hold the soil in place,
controlling erosion and sediment on-site is critically important,especially since fine sediment particles can clog certain SCMs and prevent
them from functioning properly. In addition,certain SCMs may be used during project construction to provide E&SC protection but must be
cleaned out and converted to the approved SCM configuration before the construction can be considered"finished."If you are not sure if
the Erosion&Sediment Control(E&SC)Plan for the project is being/was followed,the developer or contractor that is performing the
construction should be able to inform you.Generally speaking, projects that require a post-construction stormwater permit will also require
an E&SC plan that outlines the E&SC practices that are being provided for this project during the different phases of construction.
13.O&M being Operation and maintenance are being performed in accordance with the approved Erosion and
performed per E&SC Sediment Control(E&SC)Plan.
plan?* Yes
No
N/A
If construction for the site has finished,this item should be answered as"N/A"and it should be
explained that construction for the site has finished in the text box
Explain:* Provide a detailed explanation about why this item is not applicable for this project.
The construction at the site is finished.

14.SCMs returned to SCMs that are were used as E&SC devices, removed,and/or destroyed during construction have
approved conditions?* been returned to approved conditions.
Yes
No
N/A
Modifications
If the project was modified from what was permitted,you will either need to apply for a Major or Minor Modification(depending on the
nature of the changes)prior to completing this form. More information can be found on our website.
15. Project site is as Yes
shown on plans?* No
N/A
Designer's Certification
16. Designer's The Designer's Certification Forms have been completed and returned to the Regional Office.
Certification submitted? Yes
No
N/A
If you are unsure if these forms have already been submitted, please check the electronic permit file
for this project or reach out to the appropriate Regional Office.
Operation&Maintenance
The required operation and maintenance procedures that need to be provided in order for your project to function properly vary depending
on the specifics of your project. Please refer to the Operation&Maintenance(O&M)Agreement Form as this document outlines the
required operation and maintenance procedures that need to be provided for your project and the regularity with which these procedures
need to be provided.
17.Operation& Operation and maintenance are being performed regularly per the O&M Agreement.
Maintenance performed Yes
regularly?
No
N/A
18. No maintenance There are no outstanding maintenance issues.
issues?* Yes
No
N/A
19. Maintenance records Maintenance records are being kept and are available upon request.
being kept?* Yes
No
N/A
You may be asked to provide these maintenance records during a site inspection.
Permit Renewal
Permit Expiration Date: Permit Status
as of 2/12/2024 ACTIVE
as of 2/12/2024
Please note that permit renewals must be submitted to the Division at least 180 days prior to the permit expiration date. If the permit will
expire within 180 days prior to the expiration date,a Renewal Application can be found on our website and should be submitted to the
appropriate DEMLR Office. Low-density permits do not have an expiration date and do not need to be renewed.

20. Permit is active?* The permit is active(it has not expired).
Yes
No
N/A
If the permit will expire within 180 days and a Renewal Application has not already been submitted to
the appropriate DEMLR Office,you must select"No"for this item.
Other Permit Conditions
21.Other permit Other permitting conditions not listed above are being followed per the permit language.
conditions being met?* Yes
No
N/A
The permit may contain other permitting conditions not specified above,either due to unique aspects
of the project or due to older permitting requirements(please refer to the permit). If that is the case,
please answer"No"if any of the unspecified permitting conditions are not being met and"Yes"if they
all are being met.
Is the project in No
conformance? (This field was used to select answer below on initial submission)
Is the project in conformance with ALL permit conditions?
* RECORDED ANSWER BASED ON PREVIOUS RESPONSES IN SUBMISSION
Yes
No

E. Plan to Bring the Project info Conformance
Section E - Plan to Bring the Project info Conformance
....................................................................................................................................................................................................................................................
Please provide a detailed plan explaining what actions and on what timeline these actions will be taken in order to bring the project into
conformance with ALL permit conditions. Please address ALL of the items from Section D that were answered"No". If a Conformance
Plan is not applicable,the submitter did not have the Plan upload option.
Note: If you save a draft of this form to work on before final submittal, do not save the draft form with anything uploaded below.Wait
to upload the attachment until just before submitting it.
Ensure that the permit number and project name are prominently included on the Conformance Plan:
SW4210703(Tally Pointe)
Conformance Plan Click the upload button or drag and drop files here to attach document.
Upload
ConformancePlan.pdf 77.21 KB
Only PDFs are accepted.

F. Project Certifier Information
Section F - Project Certifier Information
....................................................................................................................................................................................
Please enter the following information for the Project Certifier:
The Project Certifier is:* This is the individual that is certifying if the project is in conformance with all of the permit conditions.
This individual can be either the permittee or a designee of the permittee(an engineering license is not
required to certify that the project is in conformance with the permit conditions.
The Permittee(listed in Section B)
A designee of the Permittee
Project Certifier Name and Title
First Name* Kenneth
Last Name* Anson
Certifier's Title* President
Project Certifier Mailing Street Address
Address* 1348 Westgate Center Dr Ste 100
Address Line 2
City State/Province/Region
Winston Salem NC
Postal/Zip Code Country
27103 USA
Check here if the mailing address is the same as the street address.
Project Certifier Street Street Address
Address* 1348 Westgate Center Dr Ste 100
Address Line 2
City State/Province/Region
Winston Salem NC
Postal/Zip Code Country
27103 USA
Project Certifier 336-687-1117
Telephone Number*
Project Certifier Email* [e-mail]

G. Certification
Section G - Certification
...............................................................................................................
Certifier Full Name Kenneth Anson
(Hidden field on submission and used on the Certificate)
Signing Official Full Kenneth Anson
Name (Hidden field on submission and used on the Certification Summary)
As the current(permittee/designee of the permittee), I, Kenneth Anson,certify under penalty of law that,to the best of my knowledge,:
* the information in this form is true,accurate,and complete.
no, I cannot certify this.
* RECORDED ANSWER BASED ON SITE CONFORMANCE RESPONSES IN SUBMISSION
the project is currently in conformance with all of the permit conditions.
no, I cannot certify this(corrective actions required).
I, Kenneth Anson,also certify that,since the project is not currently in conformance with all of the permitting conditions,the permittee,
Kenneth Anson,will perform the corrective actions within the stipulated timeframes as outlined in Section E.
* Yes
No
* By checking this box and signing below:
o I agree that submission of this Annual Certification Form for the Post-Construction Stormwater Program is a"transaction"subject to
Chapter 66,Article 40 of the NC General Statutes(the"Uniform Electronic Transactions Act');
o I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the NC General Statutes(the"Uniform
Electronic Transactions Act');
o I understand that an electronic signature on this Annual Certification Form has the same legal effect and can be enforced in the same
way as a written signature;AND
o I intend to electronically sign and submit this Annual Certification Form.
Print Name:* Kenneth Anson
Name of person submitting this form(populated with Certifier Full Name)
Signature:
CXP;Irx 6r1few
Date:* 02/14/2024
Signed Month and Day Certification Year
February 14,2024 2024