SW3191101_Application_20191108

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
it-os-?0q
M 26ZO 4 e0 5
s:N 19 If D
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 M mt Plan: 11
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 r 3
I. GENERAL INFORMATION
Nov o 8 NVI
1. Project Name (subdivision, facility, or establishment name - should be consisteok. tfipr
.q�RMw on plans,
specifications, letters, operation and maintenance agreements, etc.): STORMVUNI ER E'-RM�Y f�NG
Cambridge Village Multifamily
2. Location of Project (street address):
307 N Pilot Knob Road
City:DENVER County:LINCOLN Zip:28037
3. Directions to project (from nearest major intersection):
:2,200 LF North of N Pilot Knob Road and Hwy 73 intersection and front N Pilot Knob Road for _
500 LF.
4. Latitude:35° 26' 58.6" N Longitude:80° 59' 40.6" W
II. PERMIT INFORMATION:
of the main entrance to the project.
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals 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 , 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):
El 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:12.85 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:
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/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

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:NORTH PILOT KNOB ROAD, LLC
Signing Official & Title:TACOB TACOBSON SENIOR PARTNER
b. Contact information for person listed in item 1a above:
Street Address:176 MINE LAKE COURT, SUITE 100
City:RALEIGH
Mailing Address (if
State:
Zip:27615
City: State: Zip:
Phone: (571 ) 220-4829 Fax: ( )
Email:TTACOBSONQARCHCORESIDENTIAL. COM
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: BBC CAMBRIDGE LLC
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:21000 TORRENCE CHAPEL RD #100
City:CORNELIUS State:NC Zip:28031
Mailing Address (if applicable):
City:
Phone: )
Email:
State: Zip:
Fax: ( )
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:
Phone: ( ) Fax:
4. Local jurisdiction for building permits: LINCOLN COUNTY
Point of Contact:BEN HOLDEN Phone #: (704 ) 736-8723
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stor nwater runoff will be treated.
(2) WET DETENTION BASINS WITH FOREBAYS
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 Catawba River basin.
4. Total Property Area:11.50 acres 5. Total Coastal Wetlands Area: 0.00 acres
6. Total Surface Water Area: 0.84 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area-,:10.66 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 (NW line or Mean High Water
W) (MHline, and coastal wetlands landward from the NHW (or MHIline. The resultant project area is used to
calculate overall percent built upon area (BUTA). 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 = 74.4 %
9. How many drainage areas does the project have? 2 (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 2
Drainage Area 3
Drainage Area 4
Receiving Stream Name
Forney Creek
Mountain Island
Lake
Stream Class *
C
WS-IV, CA
Stream Index Number *
11-119-2-3
11-(112)
Total Drainage Area (sf)
3.13
11.55
On -site Drainage Area (so
3.13
7.96
Off -site Drainage Area (so
0.00
0.00
Proposed Impervious Area** (Sol
2.29
5.24
% Impervious Area** total
73%
66.5%
Impervious- Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
34,523
68,727
On -site Streets (SO
0.00
0.00
On -site Parkin (sf)
49,276
104,554
On -site Sidewalks s
5,923
16,196
Other on -site s
10,000 and
30,000 (Pond)
Future (sf)
0.00
0.00
Off -site (so
0.00
0.00
Existing BUA*** (s
0.00
8,910
Total (so:
99,722
1 228,387
Stream Class and Index Number can be determined at: httpaortal.ncdenr.org/webAvq&s/csu/classifications
Im ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidpewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

Proieets in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per 15A NCAC 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
hgR://t)ortal.ncdenr.ora/web/��,4/ws/su/bmR-manual.
VI. SUBMITTAL REQUIREMENTS
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 http://Rortal.ncdenr.or /w¢ eb/wq/ws/su/statesw/forms 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://aortal.ncdenr.orL-' web/wo/ws/su/man .)
Please indicate that the following reauired information have been provided by initialing in the space provided for each
item. All original documents MUST be signed and initialed in blue ink. Download the latest versions for each submitted
application package from hM:HRortal.ncdenr,org/web/wg/ws/su/statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Fonn. 5�r-
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part V11 below)
3. Original of the applicable Supplement Form(s) (sealed. signed and dated) and O&M - —
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
hltp://www.envheIR.org/gages/onestopeggress.html for information on the Express program
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 for r<
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the F
receiving stream drains to class SA waters within''/I mile of the site boundary, include the''/s
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). S
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: 5 F
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 pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. 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.
I. 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.
n. 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).
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 SF
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"xI 1" 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 visit for DEMLR to verb the SHWT'prior
to submittal, [phone].) V7 6$ /d/ —p r
10. A copy of the most current property deed. Deed book: 2 Al I Page No: YI Y- 9? 1 - 5F
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.secretary.state.nc.tis/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 YU/lportal.ncdenr.org webAr/state-stormwater-forms dace. 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 land, 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 EngineenSteve Farmartino
Consulting Firm: Bohler Engineering, NC PLLC
Mailing Address:1927 S Tryon Street Suite 310
City:Charlotte State:NC Zip:28203
Phone: f980 ) 272-3400 Fax: (9B0 1 272-3401
Emaii:sfarmartinoC bohlereng.com
IX. PROPERTY OWNER AUTHORIZATION (f Contact Information, item 2 has been filled out, complete this section)
I, (print or type name of person listed in Contact Information, item 2a) Stevrn L BOda 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, item ]a) Tadd U Miller with (print or type name of organization listed in
Contact Information, item la) North Pilot Knob Road. LLC 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.
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 inappropriate enforcemePt' -'- - --tnetinv the a1A-sment of civil penalties of up to $25,000 per day, pursuant to
NCGS 143-215.6
�tgt 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
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item I a) -'V"66J M• fn t, (W ,
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 .I4P&J any other applicable smote-stomwater requirements.
Date: 10 /30I 15
I, j(�y�11 iYl�r a Notary Public for the State of ��b�J�� County of
fX-)01 do hereby certify that 1 m. ���Q�✓ personally appeared before
me this 3 d� day of C� U-C)b-P V , 610\ el , and,,acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal, A QUYIntt'n
LORI A GAHIMER
�..��'P?e'o;!.,�
Notary
Public, State of Indiana
Shelby County
SEAS
Commission M 649274
%.
M Commission Expires
y P
November 24, 2021
SEAL
My commission expires K)DJUY)ay ati . a0-1- 1
Form SWU-101 Version Oct. 31, 2013 Page 6 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 enforcement action including the assessment of civil penalties of up to $25,000 per day, pursuant to
NCGS 143-215.6.E
Date: 10 —31' / °I
I, Lam 1,1�'1 , a Notary Public for the State of County of
ftjklaftbf do hereby certify that �t ILA personally appeared before
me this y of ��� ,. nd acck_nowled ,h�e)duuee exxe'cut' n the application for a
stormwater permit. Witness my hand and official seal,,( �11�{
LEE-ANN RANDOLPH
Notary Public - North Carolina
Lincoln County
My Commission Expires Nov 18, 2023
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires NOV •
I, (print or type name of person listed in Contact Information, item ]a)
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 .1000 and any other applicable state stormwater requirements.
Date:
I, , a Notary Public for the State of
, do hereby certify that
County of
personally appeared before
me this day of 1 and acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

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Limited Liability Company
Legal Name
North Pilot Knob Road, LLC
Information
Sosld: 1889069
Status: Current -Active
Annual Report Status: Current
Citizenship: Foreign
Date Formed: 9/6/2019
State of Incorporation:
DE
Registered Agent: Registered Agent Solutions, Inc.
Addresses
Reg Office Reg Mailing Mailing
176 Mine Lake Court, Ste. 100 176 Mine Lake Court, Ste. 100 406 Virginia Ave
Raleigh, NC 27615 Raleigh, NC 27615 Indianapolis, IN 46203
Principal Office
406 Virginia Ave
Indianapolis, IN 46203
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
https://\vww.sosnc.gov/online_services/search/Business_Registration_Results 11 /15/2019