WQ0041259_Application (FTSE)_20191011

State of North Carolina
Department of Environmental Qudlity
DWR Division of Water Resources
15A NCAC 02T .0300 -- FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: WU OO K 12-11 (to be completed by DWR)
All items must be completed or the application will be returned
I. APPLICANT INFORMATION:
Applicant's name: Scout Development. LLC (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual
® Corporation ❑ General Partnership
❑ Federal
❑ State/County ❑ Municipal
3. Signature authority's name: Mr. Andrew Greene per 15A NCAC 02T .0106(b)
Title: Member -Manager
4. Applicant's mailing address: 103 Unwin Place
City: Chanel Hill State: NC
Zip: 27516-
5. Applicant's contact information:
Phone number: 919) 265-7595
Email Address: andy(@scoutdevelopment.com
11. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ Other
I. Project name: Daphine Drive Subdivision
2. Application/Project status: ® Proposed (New Permit) ❑ Existing PermittProject
If modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Orange
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.0819" Longitude:-79.115"
5. Parcel ID (if applicable): 9864588647
(or Parcel ID to closest downstream sewer)
I11. CONSULTANT INFORMATION:
1. Professional Engineer: William Z. Shipman License Number: 035027
Firm: Shipman Engineering, PLLC
Mailing address: 137 Middlegreen Place
City: Holly Springs State: NC Zip: 27540-
Phone number: [phone] Email Address: zakashipmanen ink eering.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
I. Facility Name: Town of Hillsborough WWTP Permit Number: NCO026433
Owner Name: Town ofHillsborouuh
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ^ Downstream (Receiving) Sewer Size: 8 inch
System Wide Collection System PermitNumber(s) (if applicable): WQCS00077
Owner Name(s): Town of Hillsborough
R
M
w
c�
O
0
.to
G
oA
'-1
FORM: FTA 04-16 Page 1 of 5

VI.' GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a De_veloper's_Oncrational.Agreeme+it (.E0 _XM•. DEV been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Wome?fMm Owners' Assoeiation,.has,an t)p€rationall Agreemcnt ( FORM: HOA! been attached?
❑ Yes ❑No ®N.'A
4. Origin of wastewater: (check all that apply):
® Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial 0 % Commercial
0 % Industrial Uwe 15A NCAC 02T .0103(201)
4-Is there a Pretreatment Program in effect? ❑ Yes [:]No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ®No
i If yes. provide a cony of flow reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.01 It I
Daily Design Flow'.e
No. of Units
Flaw
Residential Dwelling Unit4 Bedroom
480 gallday
9
4,320 GPD
gaV
GPD
gaV
GPD
gaV
GPD
gall
GPD
gal/
GPD
Total
4,320 GPD
a See 15A NCAC 02T .01 141b),_(d), (e)f 1) and (e}(21 for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A4).
b Per 15A NCAC 02T .01 14(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01 141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 4,320 GPD (per 15A NCAC 02T .0114)
Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why:
❑ Pump Station or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
FORM: FTA 04-16 Page 2 of

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MIX (Graihv Scorer+):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
8 199 PVC
Section [I & I[[ ofthe NIDC for Permitting of Gravity Sewers contains information related to design criteria
> Section [If contains information related to minimum slopes for gravity sewer(s)
> Oversizing lines to meet minimum slope requirement is not allowed and a violation of the hIDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MW I Pumn titatinnsrl'nrcc �lainsl:
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: _
?. Approximate Coordinates (Decimal Degrees): Latitude: Longitude:
3. Design flow of the pump station: _ __ millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): gallons per minute at feet total dynamic head (TDFI)
5_ Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 03'f .03D�ili)f ! 1:
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(13);
i Required for a[] pump stations with an average daily flow greater than or equal to 15,000 gallons per day
i Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quid; -connection receptacle and telemetry - 15A NCAC 02T
,0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - I SA NCAC 02T _0305(h)(I)(C):
i It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station_
> If the portable power source or pump is dedicated to multiple pump stations, an evaluation ofall the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

IX.' SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in I5A NCAC 02T .0305[f) & (y ® Yes ❑ No
> 15A NCAC 02T.0305(n contains minimum separations that shall be provided for sewer systems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer including in benched trenches
18 inches
Water mains horizontal
10 feet
Reclaimed water lines vertical - reclaimed over sewer
18 inches
Reclaimed water lines horizontal - reclaimed over sewer
2 feet
"Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water
100 feet
"Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water or tide elevation and wetlands see item IX.2
50 feet
"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
Top slo a of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade vertical
36 inches
> 15A NCAC 02'r,0305fy) contains alternatives where separations in 02T.0305(f) cannot be achieved.
`r "Stream classifications can be identified using the Division's NC.Surface Water Classifications webp-age
> If noncompliance with 02T.0305(n or_(4), see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ❑ Yes ❑ No ® NIA
See the Division's draft separation requirements for situations where separation cannot be meet
> No variance is required if the alternative design criteria specified is utilized in design and construction
> As built documents should reference the location of areas of%cted
3. Does the project comply with setbacks found in the river basin rules per I5A NCAC 02B .0200? [:]Yes ❑ No ® NIA
> This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project require coveragetauthorization under a 404 Nationwide or [-]Yes ® No
individual permits or 401 Water Quality Certifications?
> Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 156 NCAC- 02T.01.05(cl(6] (additional permitslcertifications)? ® Yes [:]No
Per 15A NCAC 02T.011D5(t3(6), directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc_).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ®No ❑ NIA
If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTTIFICATTOIVS:
1. Does the submitted system comply %kith 15A NCAC 02T, the Minimum Design Criteria_for_the PtrmittinU of Pump Stations
and_Forec Uams (latest version). and the Gravity Sew r Minimum Design Criteria (latest version) as applicable?
ED Yes ❑ No
if No, complete and submitthe VariancelAlternative Design Request application (VADC 10-14) and supponingdocurneats for
review. Approval of the rettuest Kreguired prior to submittal of the Fast 'track Application and supn2rtinv document
2. Professional Engineer's Certification.
name from Application Item 111.1.)
attest dust this application for
has been reviewed by me and is accurate, complete and consistent with Elie information supplied in tic plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledgc. i further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable: regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Forte plains (latest version). Although other professionals may have developed certain portions of this
subtittal package, inclusion of these materials under my signature and sett( signifies that 1 have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE -- In accordance with General Statutes 143-215.6A and 1_ R3-213.6A, any person who knowingly makes any false
statement, representation, or c:rttlication to any application package shall be guilty of a CI.ass 2 misdemeanor, which may
include a fine not to L-xcce:d SMOG(), as well as civil penaltics up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date: ���\��,� CkRQ(�ffii
.SS�Qy�
03 7_ -
73- FNGlNE� ip
3. Applicam's Certification per 15A NCAC 02T _0106(b):
1, w Andrew Greene, Member -Manager _ attest that this application for
(Signature Authority's name & title from Application Item 1.3.)
has been reviewed by me and is accuraw and complete to the best of arty knowledge. 1 unde:rstand 11ml if all required parts of
this application arc not completed and that if all required supporting documentation and attachments are not included, this
application package is subject in being returned as incomplete. I understand that am discharge of u:xstmrater frrom this non -
discharge system to surlace waters or the land will result in an immediate entbrcement action that may include civil penalties,
injunctive relief; and/or criminal prosecution. i will make no claim against the Division of Water Resources should a condition
of this permit he violated. i also understand that if all required parts of this application package are not completed and that if
all required supporting inrormation and attachments are not included, this application package will he returned to me as
incomplete.
[VOTE — In accordance with General Statutes Ids',-,215 G, and 143-21 i.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 miadcmeanor. which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature; _ 9�
Date: 7*
FORM: FTA 04-16 Page 5 ors

Deck, Erin M
From: Marie Strandwitz <[e-mail]>
Sent: Wednesday, November 20, 2019 4:21 PM
To: Zak Shipman; Robinson, Jason
Cc: Cashion, Ted; Deck, Erin M
Subject: [External] RE: RE: Daphine Drive Subdivision -Hillsborough NC
• External emafl.7Do n&i'@ck.lRi s or open attachments Unlessybu+ ef#I Send- suspiaious email as an atia mere to
Hi Jason,
Just for background info for developer donated projects, I do not want the town to be the applicant even if we intend to
take it over for several reasons -- the main reason being we are on the hook in the state's eyes as being the responsible
party for the project. We have no ownership the project at this stage. We provide initial approvals, periodic observation
that it is being constructed to our standards, and then final walk through before considering acceptance.
We have no contractual agreement with a contractor or the design engineer to ensure the construction is appropriate
and final certifications are completed and sent to the state. Should a project go awry and either not get completed, or
was completed in such a way that we choose not to accept it (and I'm thinking worse case scenarios here in a general
sense), I don't want the permits hanging out there in our name. And we should not be certifying the construction as well
as we are not in control of it nor do we have the resources to be the full time inspector of it. In my opinion, we should
not be the permittee until we take ownership which occurs after several pieces of information are provided to the
town. And we just don't have the resources to follow up on all these various permits that are in our name, but we really
are not the owner of until after they are completed.
may be over thinking this, but I used to be in your shoes issuing Fast -Tracks and full review sewer extension permits
long ago — ask Ted 11 would rather do a name change when we accept the system if that is ok by you all. Maybe one
more check box could be added to the FTA and BIMS to say "transfer to public upon completion and acceptance" and
have the utility sign it?
Sorry for the long message with explanation. It is what I've been having all our developments do lately. But yes, for
Daphine Drive, if all is well at the end of the project as I expect it to be as Zak has been really good, and we receive all
required documents — as builts, warranty bond, request to take system, certifications and affidavits of proper
construction and payment, GPS points, etc., we will bring acceptance of the system to our Board and will submit the
change of ownership form to the state at that time.
Thank you,
Marie
From: Zak Shipman <[e-mail]>
Sent: Wednesday, November 20, 2019 3:29 PM
To: Robinson, Jason <[e-mail]>
Cc: Cashion, Ted <[e-mail]>; Deck, Erin M <[e-mail]>; Marie Strandwitz
<[e-mail]>
Subject: RE: RE: Daphine Drive Subdivision -Hillsborough NC
Hey Jason,

Thanks for the email. Marie Strandwitz is the Town Engineer for Hillsborough and has been our POC through the design
process. I have CC'd her here for communication purposes.
Marie -just an FYI below.. We are working through the Fast Track sewer process with Jason re: Daphine Drive
subdivision. We listed Scout Development as the applicant per our prior dialogue with the understanding the Town
would take over the mains once constructed to TOH specifications. As such, we did not execute an operational
agreement such that we would normally do with a private line. Can you confirm that the Town still intends to accept the
lines into the public system?
Thanks!
Zak Shipman, PE
Shipman Engineering, PLLC
137 Middlegreen Place
Holly Springs, NC 27540
[phone]
zak shipmanengineering.com
From: Robinson, Jason <'ason.t.robinson ncdenr, ov>
Sent: Wednesday, November 20, 2019 3:24 PM
To: Zak Shipman <zak shi manen ineerin .com>
Cc: Cashign, Ted <ted.cashion ncdenr. ov>; Deck, Erin M <[e-mail]>
Subject: RE: RE: Daphine Drive Subdivision -Hillsborough NC
Zak,
We'd like confirmation from Hillsborough that they plan to take this over after its constructed/certified, since currently
the applicant is an LLC, and I assume the lots will be sold, so typically an Operational Agreement is required with the
application.
Do you know a good contact at Hillsborough that could verify that they will take over the permit after its
constructed/certified?
Thanks,
Jason
------------
Jason T. Robinson, P.E.
Raleigh Regional Office
Water Quality Regional Operations
NC Division of Water Resources, DEQ
919-791-4200
"Subscribe to Collection Svstern & Sewer Permitting UAdates**
E-mail correspondence to and from thl;s address may be subject to the North Carolina Public Records Low and may be disclosed to
third parties.
From: Robinson, Jason
Sent: Tuesday, November 19, 2019 3:44 PM

To: Zak Shipman <za WD shipmaneneinee ring. com>
Cc: Cashion, Ted <ted.cashion CaD ncdenr. ov>; Deck, Erin M <erin.deck ncdenr.sov>
Subject: RE: [External] RE: Daphine Drive Subdivision -Hillsborough NC
Thanks Zack. In the future, we'd like that to be explained in the narrative. I'm afraid that in the past, some of theirs
(and other's) permits we supposedly changed over to the town, but they never got the permit issued, so as far as we
know, the line is still owned and operated by the LLC.
We'll probably also put something in the permit in reference to this.
Thanks,
Jason
------------
Jason T. Robinson, P.E.
Raleigh Regional Office
Water Quality Regional Operations
NC Division of Water Resources, DEQ
919-791-4200
"Subscribe to Collection System & Sewer Permitting Updates"
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to
third parties.
From: Zak Shipman [mailto:zak shi maven ineerin .cam]
Sent: Tuesday, November 19, 2019 3:33 PM
To: Robinson, Jason <]ason.t.robinson ZDncdenr.eov>
Cc: Cashion, Ted <[e-mail]>; Deck, Erin M <[e-mail]_v>
Subject: [External] RE: Daphine Drive Subdivision -Hillsborough NC
• xt "atema E: Do not aiaR Ilriks or open attachments unless you venk. Send all suspicious einall-as an attachni- Ito
leport.s a
Thanks Jason. I appreciate the info.
The system will be turned over to the Town of Hillsborough at the completion of construction for public maintenance
and operation. The Town wanted us to submit the permit under the developer's name as the applicant for some reason,
but they have indicated they will accept it and submit the change of ownership form once accepted.
Thanks,
Zak Shipman, PE
Shipman Engineering, PLLC
137 Middlegreen Place
Holly Springs, NC 27540
[phone]
za�shipmanengineering_com

From: Robinson, Jason <iason.t_robinson@ncdenr_gov>
Sent: Tuesday, November 19, 2019 3:25 PM
To: Zak Shipman <zak shi manengineerine.com>
Cc: Cashion, Ted <[e-mail]>; Deck, Erin M <[e-mail]>
Subject: RE: Daphine Drive Subdivision -Hillsborough NC
Hi Zak,
We received it on October 11. Currently due to the volume of application we receive coupled with our other duties, it's
typically taking 6-8 weeks for us to review and issue permits.
Through a quick glance, we noticed that the permitee is an LLC. But "N/A" is checked on all items of Section VI of the
permit (Developer's Operational Agreement or HOA Operational Agreement). Does the LLC plan to own and operate the
sewerline line in perpetuity?
Thanks,
Jason
------------
Jason T. Robinson, P.E.
Raleigh Regional Office
Water Quality Regional Operations
NC Division of Water Resources, DEQ
919-791-4200
"Subscribe to Collection System & Sewer Permitting Updates"
E-mail corresp-�^dance to and from this address may be subject to the North Carolina Public Records Latin and may be disclosed to
third parties.
From: Zak Shipman[mailto:zak@shipmanengineerine,com]
Sent: Tuesday, November 19, 2019 2.38 PM
To: Robinson, Jason <'ason.t.robinson ncdenr. ov>
Subject: [External] Daphine Drive Subdivision -Hillsborough NC
s • e Me oli,lt !cs pt Fpen attachments unless you verify. Send all suspicious ern%1 as an attach nyent to 1
J
Hey Jason,
I submitted a sanitary sewer permit back in early October for the reference project but have yet to hear back on it. I'm
hoping it didn't fall through the cracks. Do you have any way to check the status on the submittal review?
Thanks,
Zak Shipman, PE
Shipman Engineering, PLLC
137 Middlegreen Place
Holly Springs, NC 27540
[phone]

zak _ shipmanengineering.com

Shipman Engineering, PLLC
137 Middlegreen Place --Holly Springs, NC
(919} 900-0006 NCBELS License P-1963
LETTER OF TRANSMITTAL
To: NCDEQ-Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Subject: Daphine Drive Subdivision -Hillsborough, NC
Date:10-07-19
Copies
2 Application Packages as follows:
2 Cover Letter
2 FTA 04-16 Applications
2 SOS LLC Documentation
2 USE 04-16 Forms
2 Site Maps -Street Level
2 USGS Quad Maps
1 Application Fee- $480
Transmitted:
❑ For your information
® For Approval
Comments:
NC n�pt of Environm�+�tal Quality
OCJ t 1201E
Description
® For Your Review/Comment
❑ Other:
�e1&F was o"'1e
❑ As Requested
Sincerely,
Zak Shipman, PE

Shipman Engineering, PLLC
October 7, 2019
Division of Water Resources
Raleigh Regional Office Water Quality Section
1628 Mail Service Center
Raleigh, NC 27699-1628
Re: Fast Track Sewer Extension Application FTA 04-16
Daphine Drive Subdivision -Hillsborough, NC
Dear Sir,
NC Dept of Environmental Quality
OCT 11 2019
Raleigh Regional Office
Enclosed please find Fast Track Sewer Permitting materials, documents, and other information for the Daphine
Drive Subdivision located in Hillsborough, NC. The project contains 9 single family detached residential lots located
near the intersection of Daphine Drive and Terrell Road. The lots were platted years ago but never built upon.
Currently, an existing gravity sanitary sewer traverses the project site in the north/south direction. Our plan is to
connect several sanitary sewer services to this existing sewer line, and additionally to construct a new gravity
sewer line to serve 6 of the existing lots. This development will generate an anticipated 480 gallons per day per lot
(4 bedroom units) of new sewer flow, for a combined total of 4,320 gallons per day.
We have included the required documents to enable permitting in this submittal package. If you have any
additional questions or comments, please don't hesitate to let me know.
Best Regards,
0�1r�
Zak Shipman, PE
Shipman Engineering, PLLC
Shipman Engineering, PLLC 919.900.0006
137 Middlegreen Place zak@shipmanengineering-com
Holly Springs, NC 27540 NCBELS License P-1963

5'

Comellus St Cometrus Sr
r,etRss Project 5 Q
cT � Hillstmrougln Q A M la
Heights Park
1
^w F 4
may
Calvary Baptist Church
5 j
h A t Fldlstiorrwgti
y Eleaicnl.1ry School
Central
Burwell School
u ntstanc5nc
Elementary School r ,
Orange County Central
Recreation Center (.S Orange County
Y Historical Museum
Carnarnn Park tj
�!y Wooden nickel Put) Vemerilary School T
Turnip e
Nkxrg S1 - Patch Park ty Ku St
N' Kmq S7 W
WEST r:eso;z 1 Urange Lcurity Public Oran<ijc County
H I L L S 6 0 R 0 U G H „�•• .... Library(tdani Library) Courthouse
Hiltsborough Peitecostal r �y^ a We Yes SYect Ma ket
Holiness Church
Eno
River Park
oaMrr.si - - n
Intlsbarounh BSO ,
s
l N N
The Cloih*A If
al Eno River r6
r Ca,eh«a Gym
D I M M O C K S Supply Corpuratioh hnon Srlio6l (7
MILL 0 Go do

13� LIMITED LIABILITY COMPANY ANNUAL REPORT
10/2017�
NAME OF LIMITED LIABILITY COMPANY: Scout Development, LLC
SECRETARY OF STATE ID NUMBER: 0739969 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2019
SECTION A: REGISTERED AGENTS INFORMATION
1. NAME OF REGISTERED AGENT: Greene, Susan P.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
3. REGISTERED OFFICE STREET ADDRESS & COUNTY
103 Unwin Place
,y affm Jim Orty
E- Ft,ed Annual Report
0739969
CA201907814868
3119/2019 04:12
❑Changes j
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
4. REGISTERED OFFICE MAILING ADDRESS
103 Unwin Place
Chapel Hill, NC 27516-4453 Orange County Chapel Hill, NC 27516-4453
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Real Estate Development
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS & COUNTY 5. PRINCIPAL OFFICE MAILING ADDRESS
103 Unwin Place 103 Unwin Place
Chapel Hill, NC 27516-4453 Chapel Hill, NC 27516-4453
6. Select one of the following If applicable. (Optional see Instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Andrew J. Greene
TITLE: Manager
ADDRESS:
103 Unwin Place
Chapel Hill, NC 27516
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a personlbusiness entity.
Andrew I Greene
SIGNATURE
Form must be signed by a Company Official [Wed under Section C of This form
Andrew J. Greene
3/19/2019
Manaaer
DATE
Print or Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 2782M525