SW3201202_Certifications_20240305

State Stormwater Management
Permit No. SW3201202
Attachment A
Certification Forms
The following blank Designer Certification forms are included and specific for this project:
• As-Built Permittee Certification
• As-Built Designer's Certification General MDC
• As-Built Designer's Certification for Low Density Projects
A separate certification is required for each SCM. These blank certification forms may be copied and
used, as needed, for each SCM and/or as a partial certification to address a section or phase of the
project.
Page 1 of 1

State Stormwater Management
Permit No. SW3201202
AS-BUILT PERMITTEE CERTIFICATION
I hereby state that I am the current permittee for the project named above, and I certify by my signature below,
that the project meets the below listed Final Submittal Requirements found in NCAC 02H.1042(4) and the terms,
conditions and provisions listed in the permit documents, plans and specifications on file with or provided to the
Division. ----
❑ Check here if this is a partial certification. Section/phase/SCM#?
❑ Check here if this is part of a Fast Track As-built Package Submittal.
Printed Name John Shutak Signature
1, Cynthia Fisher a Notary Public in4hCState of North Carolina
County of Union do hereby certify that John Shutak
/ T�qx N8Qk4B.BfF
personally appeared before me this day of February �� > 0. '';2� 24
and acknowledge the due execution of this as-built certification. ff
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Wi ss my hand and off is seal d '
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My commission expires ' go-, 5 ',ly,/„�uN1k111ilk%,,`.�`'`
Permittee's Certification NCAC .1042(4) Completed/ N/A
Provided
A. DEED RESTRICTIONS/ BUA RECORDS
1. The deed restrictions and protective covenants have been recorded Y or N X
and contain the necessary language to ensure that the project is
maintained consistent with the stormwater regulations and with the
permit conditions.
2. A copy of the recorded deed restrictions and protective covenants Y or N X
has been provided to the Division.
3. Records which track the BUA on each lot are being kept. (See Note Y or N
1
B. MAINTENANCE ACCESS
1. The SCMs are accessible for inspection, maintenance and repair. Y or N
2. The access is a minimum of 10 feet wide. Y or N
3. The access extends to the nearest public right-of-way. (Y)or N
C. EASEMENTS
1. The SCMs and the components of the runoff collection/conveyance Y or N X
system are located in recorded drainage easements.
2. A copy of the recorded plat(s) is provided. Y or N X
D. SINGLE FAMILY RESIDENTIAL LOTS- Plats for residential lots that Y or N
have an SCM include the following:
1. The specific location of the SCM on the lot. Y or N X
2. A typical detail for the SCM. Y or N X
3. A note that the SCM is required to meet stormwater regulations and
that the lot owner is subject to enforcement action as set forth in Y or N X
NCGS 143 Article 21 if the SCM is removed, relocated or altered
without prior approval.
E. OPERATION AND MAINTENANCE AGREEMENT Y or N
1. The O&M Agreement is referenced on the final recorded plat. Y or N X
2. The O&M Agreement is recorded with the Register of Deeds and Y or N X
appears in the chain of title.
F. OPERATION AND MAINTENANCE PLAN — maintenance records are
being kept in a known set location for each SCM and are available for Y or N X
review.
G. DESIGNER'S CERTIFICATION FORM— has been provided to the Clor N
Division.
Page 1 of 7

State Stormwater Management
Permit No. SW3201202
Note 1- Acceptable records include ARC approvals, as-built surveys, and county tax records.
Provide an explanation for every requirement that was not met, and for every "N/A" below. Attach
additional sheets as needed.
Description of Not Applicable Items
Item A.1. and A.2 - This Stormwater Permit is on a Union County owned parcel for a municipal
Water Treatment Plant and therefore did not require any formal easements or deeds and there
are no single family residential lots on the property. The County owns the property entirely.
Item CA and C.2 - This Stormwater Permit is on a Union County owned parcel for a municipal
Water Treatment Plant and therefore did not require any formal easements.
Item D.1, D.2. and D.3 — This property/project does not include any single family residential lots.
Item E.1, E.2 and F — Union County/Union County Water will maintain full responsibility for the
operation and maintenance of the stormwater systems so there are not maintenance
agreements. Additionally because there are no formal SCMs, there is no need for a specific
operation and maintenance plan for the stormwater systems.
Item G - Designer's Certification form is enclosd with this permittee certification.
Page 2of7

State Stormwater Management
Permit No. SW3201202
AS-BUILT DESIGNER'S CERTIFICATION GENERAL MDC
I hereby state that I am a licensed professional and I certify by my signature and seal below, that I
have observed the construction of the project named above to the best of my abilities with all due care
and diligence, and that the project meets the below listed General MDC found in NCAC 02H.1050 in
accordance with the permit documents, plans and specifications on file with or provided to the
Division, except as noted on the "AS-BUILT" drawings, such that the intent of the stormwater rules
and statutes has been preserved.
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this is a part of a Fast-Track As-Built Package Submittal per .1044(3).
Check here if the designer did not observe the construction, but is certifying the project.
Check here if pictures of the SCM are provided.
Printed Name Jonathan S. Lapsley Signature
NC Registration Number 032668 Date February XX, 2024
SEAL: ��� N t iiiOZ 0 �, Consultant's Mailing Address:
CAR �?ii
�•.••••••••.•••/',%, 4600 Park Road, Suite 240
�•..��FESS/0% -y
Q 9
City/State/ZIP Charlotte/NC/28209
8 Phone Number 704-342-4546
c
ysee
S..�PQS``�.
Consultant's Email address:
111111111% , 2/26/24 [e-mail]
O Circle N if the as-built value differs from the Plan. If N is circled, provide an explanation on Page 2.
ON/E = not evaluated (provide explanation on page 2) ON/A = not applicable to this SCM or project.
Consultant's Certification NCAC .1003((3) & General MDC OAs-built ON/E ON/A
.1050
A. TREATMENT REQUIREMENTS
1. The SCM achieves runoff treatment. Y or N X
2. The SCM achieves runoff volume match. Y or N X
3. Runoff from offsite areas and/or existing BUA is Y or N X
bypassed.
4. Runoff from offsite areas and/or existing BUA is directed Y or N
into the permitted SCM and is accounted for at the full X
build-out potential.
5. The project controls runoff through an offsite permitted Y or N X
SCM that meets the requirements of the MDC.
6. The net area of new BUA increase for an existing project Y or N
has been accounted for at the appropriate design storm X
level.
7. The SCM(s) meets all the specific minimum design Y or N X
criteria.
B. VEGETATED SETBACKS / BUA
1. The width of the vegetated setback has been measured Y or N
from the normal pool of impounded waters, the MHW
line of tidal waters, or the top of bank of each side of
rivers or streams.
2. The vegetated setback is maintained in grass or other Y or N
vegetation.
3. BUA that meets the requirements of NCGS 143-214.7 Y or N
b2 2 is located in the setback.
4. BUA that does not meet the requirements of NCGS 143- Y or N
214.7 (b2)(2) is located within the setback and is limited
to:
Page 3of7

State Stormwater Management
Permit No. SW3201202
a. Publicly funded linear projects (road, greenway
sidewalk) X
b. Water-dependent structures
c. Minimal footprint uses (utility poles, signs, security
lighting and appurtenances)
5. Stormwater that is not treated in an SCM is released at Y or N X
the edge of the setback and allowed to flow through the
setback as dispersed flow.
OAs-built ON/E ON/A
C. STORMWATER OUTLETS—the outlet handles the peak O or N
flow from the 10 year storm with no downslo a erosion.
D. VARIATIONS
1. A variation (alternative) from the stormwater rule Y or N X
provisions has been implemented.
2. The variation provides equal or better stormwater control Y or N X
and equal or better protection of surface waters.
E. COMPLIANCE WITH OTHER REGULATORY PROGRAMS O or N
has been met.
F. SIZING -the volume of the SCM takes the runoff from all
surfaces into account and is sufficient to handle the required Y or N X
storm depth.
G. CONTAMINATED SOILS— infiltrating SCM's are not Y or N X
located in or on areas with contaminated soils.
H. SIDE SLOPES
1. Vegetated side slopes are no steeper than 3H:1 V. Y or N
2. Side slopes include retaining walls, gabion walls, or or N X
other surfaces that are steeper than 3H:1 V.
3. Vegetated side slopes are steeper than 3H:1 V (provide Y or N
supporting documents for soils and vegetation).
I. EROSION PROTECTION
1. The inlets do not cause erosion in the SCM. Y or N X
2. The outlet does not cause erosion downslope of the Y or N
discharge point during the peak flow from the 10 year X
storm.
J. EXCESS FLOWS—An overflow/ bypass has been Y or N X
provided.
K. DEWATERING —A method to drawdown standing water has Y or N X
been provided to facilitate maintenance and inspection.
L. CLEANOUT AFTER CONSTRUCTION —the SCM has been Y or N X
cleaned out and converted to its approved design state.
M. MAINTENANCE ACCESS
1. The SCM is accessible for maintenance and repair. Y or N X
2. The access does not include lateral or incline slopes Y or N X
>3:1.
N. DESIGNER QUALIFICATIONS (FAST-TRACK PERMIT)—
The designer is licensed under Chapters 89A, 89C, 89E, or Y or N X
89F of the General Statutes.
Provide an explanation for every MDC that was not met, and for every item marked "N/A" or "WE",
below. Attach additional pages as needed:
Page 4of7

Description of Not Applicable Items
Items A.1 —A.7 - The project met all the requirements for Low Density and therefore does not
contain any formally required or approved Stormwater Conveyance Measures (SCMs)
Items B.4 and B.5 —All stormwater is contained within any required site setbacks and discharged
appropriately from the site.
Item D — There were not variations to the stormwater rule provisions therefore these are considered
Not Applicable.
Item F - The project met all the requirements for Low Density and therefore does not contain any
formally required or approved Stormwater Conveyance Measures (SCMs).
Item G — There are no contaminated soils at the project site.
Item H —All Side Slopes are 3:1 or if steeper are protected with additional protection and vegetation
as approved in the original design.
Item I - The project met all the requirements for Low Density and therefore does not contain any
formally required or approved Stormwater Conveyance Measures (SCMs) so there are no inlet
requirements for erosion protection.
Item J — There is no overflow or bypass associated with the system.
Item K— The project met all the requirements for Low Density and therefore does not contain any
formally required or approved Stormwater Conveyance Measures (SCMs) however any features
have the ability to draw down the water for maintenance.
Item L - The project met all the requirements for Low Density and therefore does not contain any
formally required or approved Stormwater Conveyance Measures (SCMs) however all features were
cleaned out post construction.
Item M - The project met all the requirements for Low Density and therefore does not contain any
formally required or approved Stormwater Conveyance Measures (SCMs) however all permanent
features are readily accessible.
Item N — This was not a fast-track permit.

State Stormwater Management
Permit No. SW3201202
AS-BUILT DESIGNER'S CERTIFICATION FOR LOW DENSITY PROJECTS
I hereby state that I am a licensed professional and I certify by my signature and seal below, that I have
observed the construction of the project named above to the best of my abilities with all due care and diligence,
and that the project meets all of the MDC found in 15A NCAC 02H.1003, in accordance with the permit
documents, plans and specifications on file with or provided to the Division, except as noted on the "AS-BUILT"
drawings, such that the intent of the stormwater rules and the general statutes has been preserved.
❑ Check here if this is a partial certification. Section or phase
❑ Check here if this is part of a Fast-Track As-Built Package Submittal per 15A NCAC 02H .1044(3).
❑ Check here if the Designer did not observe the construction but is certifying the project.
❑ Check here if pictures of the project are provided.
Printed Name Jonathan S. Lapsley Signature
NC Registration Number 032668 Date February XX, 2024
SEAL: ����xNttCAR�/ii/��Z� Consultant's Mailing Address:
..•••••••00�iij 4600 Park Road, Suite 240
0.�OFESS/0�;•• 9
'Q Charlotte
City: State: NC zip: 28209
�8
Phone:( 704-342-4546
�'•:�NGINE�-�`.' Consultant's Email address:
//A N S111`Pe�`` 2�26/24 la sle 's cdmsmith.com
i it p YJ @
O Circle N if the as-built value differs from the Plan/permit. If N is circled, provide an explanation on page 3.
O N/E = Not Evaluated (provide explanation on page 2). ON/A= Not Applicable to this project/plan.
Consultant's Certification (MDC 15A NCAC 02H .1003)
Project Density and Built-Upon Area OAs-built ON/E ON/A
1. The project has areas of high density based on natural drainage Y or N X
area boundaries, variations in land use or construction phasing.
2. The project's built-upon area does not exceed the maximum limit r N
specified in the permit. Oo
Dispersed Flow OAs-built ON/E ON/A
1. The project maximizes dispersed flow through vegetated areas �r N
and minimizes channelized flow.
Page 5of7

State Stormwater Management
Permit No. SW3201202
Vegetated Conveyances OAs-built ON/E ON/A
1. Stormwater that is not released as dispersed flow is transported O or N
by vegetated conveyances.
2. The project has a minimal amount of non-vegetated conveyances O or N
to reduce erosion.
3. Other than minimal piping under driveways and roads, no piping 6or N
has been added beyond what is shown on the approved plans.
4. Side slopes are no steeper than 3H:1 V. YO or N
5. The conveyance does not erode in response to the peak flow from 0 or N
the 10-year storm.
Curb outlet systems(if applicable) OAs-built ON/E ON/A
1. The swale or vegetated area can carry the peak flow from the Y or N X
10-year storm at a non-erosive velocity.
2. The longitudinal slope of the swale or vegetated areas does not Y or N X
exceed 5%.
3. The swale has a trapezoidal cross-section and a minimum bottom Y or N X
width of two feet.
4. The minimum length of the swale or vegetated area is 100 feet. Y or N X
5. Side slopes are no steeper than 3H:1 V. Y or N X
6. The project utilizes treatment swales designed per Section .1061 Y or N X
in lieu of the curb outlet system requirements.
Vegetated Setbacks (if applicable) OAs-built ON/E ON/A
1. The width of the vegetated setback is at least 50'. O or N
2. The width of the vegetated setback has been measured from the
normal pool of impounded waters, the MHW line of tidal waters, YO or N
or the top of bank of each side of rivers or streams.
3. The vegetated setback is maintained in grass or other vegetation. YO or N
4. BUA that meets the requirements of NCGS 143-214.7(b2)(2) is O or N
located in the setback.
5. BUA that does NOT meet the requirements of NCGS 143-
214.7(b2)(2) is located within the setback and is limited to:
• Publicly-funded linear projects (road, greenway, or sidewalk) 0 or N
• Water dependent structures
• Minimal footprint uses such as poles, signs, utility
appurtenances, and security lights.
6. The amount of BUA within the setback is minimized, and 0 or N
channeling of the runoff from the BUA has been avoided.
7. Stormwater is not discharged (via swale or pipe) through a
vegetated setback. Stormwater is released at the edge of the oY or N
setback and allowed to flow through the setback as dispersed flow.
Page 6of7

State Stormwater Management
Permit No. SW3201202
Outlets OAs-built ON/E ON/A
1. Stormwater outlets do not cause erosion downslope of the 0 or N
discharge point during the peak flow from the 10-year storm.
Variations OAs-built ON/E ON/A
1. The project has variations from the MDC that were not previously Y or N X
approved. (Modification may be required.)
Deed restrictions(if applicable) OAs-built ON/E ON/A
1. Deed restrictions are recorded and ensure that the project and
the BUA will be maintained in perpetuity consistent with the Y or N X
permit, approved plans, and specifications.
For Subdivisions Only(Residential or Commercial) OAs-built ON/E ON/A
1. The number of platted lots is consistent with the approved plans. Y or N X
2. The project area is consistent with the approved plans. Y or N X
3. The layout of the lots and streets is consistent with the approved Y or N X
plan.
4. The width/radius of streets, paved accesses, cul-de-sacs and Y or N X
sidewalks is consistent with the approved plan.
5. No piping, other than those minimum amounts needed under a Y or N X
driveway or under a road, has been added.
6. The lot grading, road grading, vegetated conveyances, piping, Y or N X
inverts, and elevations are consistent with the approved plans.
Provide an explanation below for every MDC that was not met, and for every item marked "N/A" or
"N/E." Attach additional pages as needed.
Page 7of7

Description of Not Applicable Items
Project Density and Built-Upon Area Item 1 — The Project is low density and had no variations
in land use or construction phasing.
Curb outlet systems (if Applicable) Items 1- 6 — The project has no curb outlet systems
therefore all of these items are not applicable.
Variations Item 1 — The project does not have variations from the MDC therefore this item is
marked not applicable.
Deed restrictions ( if applicable) — There are no deed restrictions on the project, the property
and facility is Water Treatment Plant owned and operated by Union County.
For Subdivisions Only (residential or commercial) — this is not a subdivision therefore all of
these items are not applicable.