Mitchell Community College - REVISED-SSW-SWU-101-Application-DEMLR-SPU Oct 2013

DEMLR USE ONLY
Date Received Fee Paid Permit Number

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 Mgmt Plan:

Form SWU-101 Version Oct. 31, 2013 Page 1 of 6
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, letters, operation and maintenance agreements, etc.):
Mitchell Community College - Health Sciences Building
2. Location of Project (street address):
706 Cherry Street
City: Statesville County:Iredell Zip:28677
3. Directions to project (from nearest major intersection):
From the intersection of U.S. Hwy 64 (W. Front St.) and NC-115 (S. Center St.), head west on U.S. Hwy 64
until you reach S. Oak St. Go north on S. Oak St. towards Cherry St. and arrive at project site.

4. Latitude:35° 46’ 55.00” N Longitude:80° 53’ 53.35” W of the main entrance to the project.

II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): New Modification Renewal w/ Modification†
†Renewals with modifications also requires SWU-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 SW3180305 , its issue date (if known) , and the status of
construction: Not Started Partially Completed* Completed* *provide 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 letter from
DEMLR 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/Erosion Control: 3.27 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:Mitchell Community College - Health Sciences Building
IREDE-2018-010, Issued January 19,2018
5. Is the project located within 5 miles of a public airport? No Yes
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7
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:Mitchell Community College
Signing Official & Title:James T. Brewer, President
b. Contact information for person listed in item 1a above:
Street Address:500 West Broad Street
City:Statesville State:NC Zip:28677
Mailing Address (if applicable):Same as above
City: State: Zip:
Phone: (704 ) 878-3200 Fax: ( )
Email: [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)
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:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City: State: Zip:
Mailing Address (if applicable):
City: 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:
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
4. Local jurisdiction for building permits: Iredell County, NC
Point of Contact:Bruce Kuete Phone #: (704 ) 928-2021

Form SWU-101 Version Oct. 31, 2013 Page 3 of 7
IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff (drainage area of 2.00 ac) will be treated by an above ground sand filter located west of the
building and will discharge into exisitng stormwater system - refer to plans.

2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
Approval of a Site Specific Development 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 Yadkin River basin.
4. Total Property Area: 3.27 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+: 3.27 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non-coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 37.13 %
9. How many drainage areas does the project have? 1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 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 Drainage Area 1 Drainage Area Drainage Area Drainage Area
Receiving Stream Name Fourth Creek
Stream Class * C
Stream Index Number * 12-108-20
Total Drainage Area (sf) 2.00
On-site Drainage Area (sf) 2.00
Off-site Drainage Area (sf) -
Proposed Impervious Area** (sf) 32,344
% Impervious Area** (total) 37.13

Impervious** Surface Area Drainage Area 1 Drainage Area Drainage Area Drainage Area
On-site Buildings/Lots (sf) 20,095
On-site Streets (sf)
On-site Parking (sf) 8,067
On-site Sidewalks (sf) 4,182
Other on-site (sf)
Future (sf)
Off-site (sf)
Existing BUA*** (sf)
Total (sf): 32,344
* Stream Class and Index Number can be determined at: http://portal.ncdenr.org/web/wq/ps/csu/classifications
** Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7
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 including the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.

Signature: Date:

I, _____________________________________, a Notary Public for the State of ____________________, County of
____________________, do hereby certify that ______________________________________ personally appeared
before me this day of _________________, _______, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, _________________________________________________

SEAL

My commission expires