SW4231203_Application Form_20240214

DEMLR USE ONLY
Date Received I Fee Paid Permit Number
Applicable Rules: El Coastal SW-1995 ❑Coastal SW-2008 ❑ Ph II-Post Construction
(select all that apply) 0 Non-Coastal SW-HQW/ORW Waters C Universal Stormwater Management Plan
❑Other WQ vlgmt 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,Ietters,operation and maintenance agreements,etc.):
Noland Farm
2. Location of Project(street address):
off Tussev Road
City:
County:Davidson Zip:272%
3. Directions to project(from nearest major intersection):
0.4 mile south of Helmstetler Road
4. Latitude:35'49'04"N Longitude:-80' 18'30" 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 SWLI 102-Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit,list the existing
, its issue date(if known)5/26/22 ,and the status of
permit numberSWA00010�
construction: ❑Not Started ❑Partially Completed* ®Complete& "provide a designer's certification
tion
2. Specify the type of project(check one): y Other
® ❑
Low Density Hi h Density ❑Drains to art Offsite Stormwater System ❑
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,N/A 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):
[LAMA Major ®Sedimentation/Erosion Control:6.63 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 permitNoland Farm, david 2021-050 06/17/21
5. Is the project located within 5 miles of a public airport? I INo , Yes
If yes,see S.L. 2012-200, Part VI:http://portal.ncdenr.org/web/lr/rules-and-regulations
Pt}'1/1DS4ti1 GeI./NT"Y 4 ?PbRT
,i 71 gxy/ARD 0440
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•
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:Sagamore Homes NC Inc A North Carolina Corporation.Developer/CurrentProperty
Owner
Signing Official&Title:Kenneth L Anson Tr.
b.Contact information for person listed in item la above:
Street Address:1348 Westgate Center Drive,Suite 100
City:Winston-Salem
State:NC Zip:27103
Mailing Address(if applicable):
City: State: Zip:
Phone: (336 1 687-1117 Fax:
[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)
El 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): %faj I/S�c
Property Owner/Organization: �l D LA NDF' R rh m o oi,NER gSSOCi
Signing Official&Title: Alm) ZAI"NN/of I f PH Es iDEN`T
b.Contact information for person listed in item 2a above:
Street Address: 12 8 PIG, G i 4 C T
City: —
cid 4-- 04 State: Zip: 2 728 5-
Mailing Address(if applicable):
City: State: Zip:
Phone: (2 ) /7'- 790.' Fax: (
Email: VI Ft)pet-10 r e i j.God►'!..
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: Dn-V I P50 4 (i0u-1 1.11 ��2._-2$G 7
Point of Contact: 1 o D A M�b C k
Phone#: f 3 3 6 )
,,..,,, in 1 Page 2 of

IV. PROJECT INFORMATION
1. In the space provided below,briefly summarize how the stormwater runoff will be treated.
The runoff is being treated in zrassed swales on the rear of the lots and also in grassed swales at the roadside
channels.
2.a.If claiming vested rights,identify the supporting documents provided and the Date:—date they were pproved:
I)J0 ❑ Approval of a Site Specific Development Plan or PUD AIssue oval
Date:
❑Valid Building Permit Date.
❑Other:
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 Yadkin Pee Dee
River basin.
5. Total Coastal Wetlands Area:0 fairer
4. Total Property Area: 14.55 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':14.55 acres
- Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
betweenWHIN the and coal al etlandstvers,landward froe aream he Nlow ,e Normal HW(r MHW)tli e.ter TheNHW)resultante or project area is usedan High to
WHIN)line,overall overall percent built upon area(BIM). Non-coastttl wetlands landward of the N (or MHUV)line may
be included in the total project area. %
8. Project percent of impervious area:(Total Impervious Area/Total Project Area)X 100 =16.18
9. How many drainage areas does the project have?Z(For high density,count 1 for each proposed engineered
stormwater 8NI1'. For low densihij and other projects, use 1 for the whole property area)
10. Complete the followinge a n o drainage identifieditem in Project Information
e
ar more than four drauageaithepe �can additia sheet with the information for each area
provided in the same format as below.
Basin Information �a
Drain e Area 1 Drainage Area 2 Drainage Area— Drainage Area_
Receiving Stream Name Swearing Creek ''a 1Gro-14:n e.rt4
Stream Class C -
_Stream Index Number* 12-113 112.-113-'1"
Total Drainage Area(sf) 419 3,171(0`/� 22 ND;333,'7
93; `�6
On site Drainage Area(sf) , `� 22- /40, 333.19
D
Off-site Drainage Area(sf) 0
Proposed Impervious Area'*(sf) I 82;r'19,Se:, /9,622,e"f9B�o
Impervious Area(total) /6 g/ To 0,
t'
Impervious''Surface Area Drainage Area 1 .Drainage Area 2 Drainage Area—_Drainage Area
On-site Buildings/Lots(sf) 6 4 sew I 6,ovel,
On-site Streets (sf) 2.1,74/1.5 22,a6 3, 1L
On-site Parking (sf) N/A /U/A
On-site Sidewalks (sf) N/A Iv/4 _
Other on-site (sf) 1 0 - .0
Future(sf) 0 0
Off-site (sf) 0 0
Existing BUA***(sf) 0 0
Total (sf): �g2,`/`f g�s4 I 6 2-2.‘��
Stream Class and Index Number can be 'eter un y tt: 1: ortalawder r.or_ vcb riff s csu/classi cations
7o1 L. -"P /0 2, S?/. 6 O 'S F
v.,...., cixTT 1_1 n i V rcinn Oct.31.2013 Page 3 of 6

** Imnpervious area is defined as the built upon area including, but not limited to, buildings,roads,parking areas,
sidewalks,gravel areas,etc.
'Report only that amount of existing BUA that will remain after development. Do not report any existing B LIA that
is to be removed and which will be replaced by neu'13 LTA.
11. How was the off-site impervious area listed above determined?Provide documentation.
N/A
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 I5A NCAC 02B.0600_
V. SUPPLEMENT AND O&M FORMS forms
The applicable state stormwater management permit supplement and operation and maintenance(O&M)
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http://portal•ncdenr.org[web/wq/ws/su/brnp-manual
VL SUBMITTAL REQUIREMENTS
d
Only complete application packaes �acka be accepted inc odes all of the items lishe Division of Energy,ted below. A detailed applieral cation
Land Resources (DEMLR). A completep g
instruction sheet and SNIP checklists are available from
t the apporpr ate DEMLR Office.
appropriate office may be fouete by application eating package
on the be
submitted to the appropriate (The
interactive online map at http://portaLncdenr.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 signedand
octal initialed
in or blue
a ink.
Download
the
wlatest versions
e sions.
for each submitted application package from http://p g Ini
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarize d 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
agreements) for each BMP.
4. Permit application 1p.or /pages/onest5o payablepess.html for information onress review, refer to
the Express program
http://www.envhelp.org/p � P p
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 liz mile of the site boundary,include the T/z
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: d--
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 or elev ltoin of tidal
impounded structures, the banks of streams and rivers,
the waters,and any coastal wetlands landward of the MHW or NFIW lines.
• Delineate the vegetated buffer landward from the normal pool elev o tidal on of
impouwaternded
structure,the banks of streams or rivers,and the IvIHW(or N-IW)
L 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.
Form SWU-101 Version Oct. 31,2013 Page 4 of 6

it. 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). /
9. Copy of any applicable soils report with the associated SHAN'T 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 8.5x11"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 visitor DEMLR to verify the SHWT prior
S7a
to submittal, [phone].) a S y 231(0 C731
10. A copy of the most current property deed. Deed book: A 5 3 3 PageNo: _
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.
http://www.secretarv.state.nc.us/Corporations/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
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://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 Iand,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:Paul A.Stimpson,PE
Consulting Firm:LaBella Associates,PC
Mailing Address:939 Burke Street,Suite H
City:Winston-Salem
State:NC Zip27101
) �
Phone: [phone] Fax: (
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been fitted out, complete this Tld� 1nC.
section) iy6GANo FARM ' HAS,€i JNEg M c/
I,(print or hype name of person listed in Contact Information, item 2a)
4-thy ,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, i,tern EclA/N fD ++/2A/A' � (print or hype name of organization listed in
Contact Information,item la) zaReu i_c�zaczsrrie,/ 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.

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 indudin assess t of civiLpenalties of up to$25,000 per day,pursuant to N GS 143-215 6.
,*rONLY Pt i'' o Coo ail A,eEs4 R S SHowAi oN-rilE JP�eo u a F4 TI
Signature: Date: /
I, pin h e}*tS)j p...c r- ,a Notary Public for the State of l\lD 0.-O`n`ma,County of
o.V1 d 5 b r l ,do hereby certify that A Fora\f 7 9 rtc 1 h 1 personally appeared
before me thisah lay of FPb_ M124 ,and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, aria.i`l t (USA
i t?
ANNETTE BARRY SEAL
Notary Public-North Carolina
Davidson County
My Commission Expires:August 8,2028
My commission expires A u c . 81 2.0 2 A
X. APPLICANT'S CERTIFICATION �^, �}
I, (print or type mumre of pet son listed in Contact Inform mration, item Lr) e., y,�',V1' L. r`n st n
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 th proposed project complies with the requirements of the
applicable stormwater rules and £ i . 000 and any other applicable state stormwater requirements.
Date: 2 lam— 2
Signature: •
` ,, ( 1I, \ Q) \ CtG)�L. + , a Notar Public for the State of 0rI 0.0d 0`l&cCounty of
10 04 I e. , do hereby certify that If Qnil 1_, fl-(Is b personally appeared
1
before me this 5 day of 1-r
C,rV a , aOa9.and ackn w e e th due executionff'' of the application for
a stormwater permit. my Witness hand nd official seal, „� &C A lam/
KELU CICH
��y�
SEAL MyComnioolo E>plm.October ,2020
KELLI RAJACICH
NOTARY PUBLIC
Davie County
North Carolina My commission expires \ 614 \4
My Commission Expires October 9,2028
Form SWU-10I Version Oct. 31,2013 Page 6 of 6