SW3190201_Application O'Reilly Auto Parts_20190211

DEMLR USE ONLY
Date Received Fee Paid
Permit Number
52 1 () r-;, ) 0, t-A ' I c46- 2-4 T121
5W :bks 020 1
Applicable Rdles: 0 Coastal SW - 1995 0 Coastal SW - 2008 0 Ph 11 - Post Constructs
(select all that apply) C3 Non -Coastal SW- I IQW/ORW Waters 0 Universal Stormwater Management Plan
0 Other WO Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORR
This form may be photocopied for use as an original
I. GENERAL INFORMATION
FEB 0 5 2019
Project Name (subdivision, facility, or establishment name - should be consistent with project name RJJWND QUALITY
specifications, letters, operation and maintenance agreements, etc.): STOR WATER PERMITTING
O"Reillv Auto Part-,. Wingate NC
2. Location of Project (street address):
3628 US Highway 74
City: Wingate County:Union Zip:28174
3. Directions to project (from nearest major intersection):
Heading northwest on US-601 North, right onto US-74 EIE Roosevelt Blvd. Continue east for 3.5 miles, and the proLect
property will be on the left at the intersection of Chaney Street.
4. Latitude:34' 58' 56.0316" N Longitude:80' 27' 23.472" W of the main entrance to the project.
IL PERMIT INFORMATION:
1. a. Specify whether project is (check one): (New ElModification F1 Renewal w/ Modificationt
tKenewals with niodifications also requires SKU-102 - Renewal Application Form
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: CNot Started
[31'artially Completed* EJ Completed* *provide a designer's
certification
2. Specify the type of project (check one):
MI -ow Density ®High Density FlDrains to an Offsite Stormwater System FlOther
3. If this application is being submitted as the result of a previously returned application or a letter from D EMIR
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
[]NPDES Industrial Stormwater
E]Sedimentation/Erosion Control: 1.3 ac of Disturbed Area
❑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:
5. Is the project located within 5 miles of a public airport? Inj"7"No Flyes
If yes, see S.L. 2012-200, Part VI: htti2:/1.12ortal.ncdenr.orgZweb`/ir/rules-and-regulations
FormSWU-101 Version Oct. 31,2013 Page 1 of 6

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/Organizafion:O'Reilly AutoParts
Signing Official & Title:Scott Kraus -
b. Contact information for person listed in item I a above:
Street Address:233 S. Patterson
City: Springfield State:MO Zip:65802
Mailing Address (if applicable): Same as contact information -
an
State: Zip -
Phone: (417 ) 829-2967 Fax:
Email:
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:Samle., as applicant
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City:,
Mailing Address (if applicable):
am
State:NC -- — Zip:28174 - - -
State: - Zip:
Phone: ( Fax: (
Email:
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:
ME
Phone: ( ) . Fax: (
Email:
0-3
4, Local jurisdiction for building permits: Town of Wingate
Point of Cont-act:Adreinne Rorie Phone#: [phone]
Form SVrU- 10 1 Version Oct. 31, 2013 Page 2 of 6

1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater quality and quantity will be handled by a bioretention cell.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
[I Approval of a Site Specific Development Plan or PUD Approval Date:
F-1 Valid Building Permit Issued Date:
F-1 Other: Date:
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
F1 Coastal SW — 1995 El Ph 11 — Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee Dee River basin.
4. Total Property Area: 1.03 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': 1.03acres
Total project area shall be calculated to exclude the followt following: the normal pool of impounded structures, the area
between the banks ofstreams and rivers, the area below the Normal High Water (N1-5V) line or Mean High Water
(MHIV) line, and coastal wetlands landward from the NI -RV (&rMHJV) line. The resultant project area is used to
calculate overall percent built upon area (BUR). Non -coastal wetlands landward of the NHJV(or MHTV) line maybe
included in the total project area.
8. Project percent of impervious area: (Total Impervious Area I Total Project Area) X 100 = 73 %
9. How many drainage areas does the project have? I (For high density, count I for each ,proposed engineered stormwater
BUP. For low density and other projects, use I 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
Drainage Area _
Drainage Area
Drains e Area
Drainage Area
Receiving Stream Name
Meadow Branch
Stream Class *
C
Stream Index Number
13-17-36-11
Total Drainage Area (sf)
87556
On -site Drainage Area (so
60548
Off -site Drainage Area (sf)
27007
Pro2osed Impervious Area ** (sf)
30492
% Im2ervious Area** (total)
81
1
Impervious" Surface Area
Drainage Area
Drainage Area
Drainage Area
Drainage Area
On -site Buildings/Lots (sf)
7,395
On -site Streets (so
On -site Parking (sf)
20,004
On -site Sidewalks (sf)
3,093
Other on -site (so
Future (so
Off -site (sf)
Existing BUA*** (so
40,511
Total (so:
71,003
Stream Class and Index Number can be determined at:
Imyervi . ous area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
e e
Walks, gravel areas, etc.
Report only that amount ofexistingRUA that will remain after development. Do
not report any existing RUA that is to be removed and which will be replaced by new BUA,
Porm SWU-101 Version Oct. 31, 2013 Page 3 of 6

Prgiects in Union County: Contact DEMLRCentral Office staffto check ifthe project is located within a Threatened&
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per 15A NC,4C 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 can be downloaded
from l)ttp:/./por.tal.n,cd.enr.o e4h6LqhYs1-su-Zh—mp.-manual.
VI. SUBMITTAL REt~UIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
btLtp-L/porta1.ncdenr,org/web/wq/ws/su/statesw/forrns�-docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at http-1/p n eb wq/ws/­,;u/"­maps.)
.-qrtal,ncde nor /YY g _ --J -
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
I
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"xl1" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMFs, 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 DEMLR to verify the SHWT prior
to submittal [phone] )
A copy of the most current property deed. Deed book: - Page No: _
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.secretary.state.nc.us/CorporationsZCSearch.gVx
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 htf -Iportal.ncdenr.or web/Ir/state-stormwiter-
Pi
forms does. 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.
I ais f.M14.
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:Daniel Renckens
Consulting Finn: Bohler Engineering
Mailing Address:1927 S. Tryon Street, Suite 310
City:Charlotte State:NC Zip:28203
Phone: [phone] Fax:
Email:[e-mail]
IX PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (print or type name of person listed in Contact Information, item 2a) certify that I
own the roper identified in this pen -nit a tic a tion, and thus give permission to (print or type nante of person
listed i . n &ontact Ynjbrwation, item 1a) witr(urint or type name o organization listed in
Contact Information, item 1a) to develop the project -a's 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 Oct. 31, 2013 Page 5 of 6

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 enfi meqt action including the assessment of civil penalties of up to $25,000 per day, pursuant to
NCGS 143-215.(L-
Date:
1, VIJ 41 A rlesA tL4 a Notary Public for the State of #7;5,souj-1 County of
do hereby certify that S C04 k personally appeared before
me this 4-7 4�- day of Lcl n ".CL a0l and knowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal,
WEDNESDAY PAGE
SEAL Nota'rX Public - NotaZ Seal
ST TE OF MISSO Rl
Christian County
My Commission Expires Apt. 4, 2021
Commission 13405367
My commission expires ECE R - Iv
F-
X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item ]a) C AA± K
FEB 0 5 2M
DENR-LAND QUALITY
STORMWATER PERW-fTING
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 stormwater rules
under 15A NCAC 2H A QMAOany other applicable state stormwater requirements.
Signature: I- -/--v Date:
1, _
!Ah -2 � 0(4- 1 PCC a Notary Public for the State of Z-415sbit- rt , County of
ni I
L�-A �H!�, �r . do hereby certify that personally appeared before
me this -.7 4 - day of I . 6z C) I d acknowledge the execution of the application for a
e d
stormwater permit. Witness my hand and official seal,
WEDNESDAY PAGE
SEAL Notary Public - Notaz seat
STATE OF MISS©Rl
Christian County
My Commission Expires Apr, 4. 2021
Commmsion 13405367 —
My commission expires -//- Z/- d- / -
FormSWU-101 Version Oct. 31, 2013 Page 6 of 6