NCS000518_Navassa SWM Permit Application Form_20191209

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Undated 11/1/2011
OFFICE USE ONLY
Date Received
Fee Paid
Pennit Number
Town of Navassa
Planning and Zoning
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may fie photocopied_for use as an original
I. GENERAL INFORMATION
1. Applicants Name (specify the name of the corporation, individual, etc. who owns the project):
2. Print Owner/Signing Official's name and title (person legally responsible for the facility and compliance):
3. Mailing Address for person listed in item 2 above:
Phone:(_) Fax:
Email:
4. Project Name (subdivision, facility, or establishment name- should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
5. Location of Project (street address):
City: Zip:
6. Directions to project (from nearest major intersection):
7. Latitude: " N Longitude:
8. Contact person who can answer questions about the project:
Name: Telephone Number:
II. PERMIT INFORMATION:
„W
1. Specify whether the project is (check one): [-]New ❑Renewal ❑Modification
2. If this application is being submitted as the result of a renewal or modification to an existing permit, list the
existing permit number and its issue date (if known)
3. Specify the type of project (check all that apply):
Flow Density ❑High Density ❑Redevelopment ❑Residential ❑Commercial
4. Additional Project Requirements (check the applicable blanks; information on required state permits can be
obtained by contacting the customer service center at 1-877-623-6748):
❑CAMA Major ❑CAMA Minor ❑Sediment/Fxosion Control ❑404/401 Permit
❑404 Certification ❑ NPDES Industrial Stormwater Permit

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III. PROJECT INFORMATION
Application print
1. In the space below, summarize how stormwater will be treated. Also attach a detailed narrative (one to two pages)
describing the stormwater management for this project.
2. Stormwater runoff from this project drains to the
River Basin.
3. Total Property Area: acres 4. Total Coastal Wetlands Area: acres
5. Total Property Area (3) — Total Coastal Wetlands Area (4) = Total Project Area**: acres
6. (Total Impervious Surface Area / Total Project) x 100 = Project Built Upon Area (BUA): %
7. How many drainage areas does the project have?
8. Complete the following information for each drainage area. If there are more than two drainage areas in the
project, attach an additional sheet with the information for each area provided in the same format below. For High
Density Projects, complete the table with one drainage area for each engineered stormwater device.
Basin Information
Drainage Area 1
Drainage Area 2
Receiving Stream Name
Stream Class and Index Number
Total Drainage Area (sf)
On -site Drainage Area (s
Off -site Drainage Area (s
Existing Impervious* Area s
Proposed Imervious* Area (sf)
% Impervious* Area (total)
Impervious* Surface Area
Drainage Area 1
Draina a Area 2
On -site Buildings s
On -site Streets (s
On -site Parkin (sf)
On -site Sidewalks (sf)
Other On -site s
Off -site s
Total (sf):
*Impervious area is defined as the built upon area including but not limited to buildings, roads, parking areas,
Sidewalks, gravel areas, etc.
**Total Project Area shall be calculated to exclude Coastal Wetlands from use when calculating the built upon area
percentage calculation. This is the area to calculate overall percent project built upon area (BUA).
9. How was the off -site impervious are listed above derived?

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IV. DEED RESTRICTIONS AND PROTECTIVE COVENTANTS
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 htW:i/l)ortal.ncdenr.org/web/wq/ws/su/statesw/forms docs. 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 signing this application, you certify that the recorded property restrictions and protective covenants for this project
shall include all applicable items required in the above form, 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 Town of Navassa Stormwater Management Division, and that they will be
recorded prior to the sale of any lot.
V. SUPPLEMENT FORMS
The applicable stormwater management permit supplemental form(s) listed below must be submitted for each BMP
specified for this project. Contact the Town of Navassa Stormwater Management Division at [phone] for the
status and availability of these forms. Forms can be downloaded from h!tp://h2o.enr.state.nc.us/su/bmp forms htm
Form SW401-Low Density
Form SW401-Curb Outlet System
Form SW401-Off-Site System
Form SW401-Wet Detention Basin
Form SW401-Infiltration Basin
Form SW401-Infiltration Trench
Form SW401-Bioretention Cell
Form SW401-Level Spreader
Form SW401-Wetland
Form SW401-Grassed Swale
Form SW401-Sand Filter
Form SW401-Permeable Pavement
Form SW401-Cistern
Low Density Supplement
Curb Outlet System Supplement
Off -Site System Supplement
Wet Detention Basin Supplement
Infiltration Basin Supplement
Underground Infiltration Trench Supplement
Bioretention Cell Supplement
Level Spreader/Filter Strip/Restored Riparian Buffer Supplement
Constructed Wetland Supplement
Grassed Swale Supplement
Sand Filter Supplement
Permeable Pavement Supplement
Cistern Supplement

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VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Stormwater Management Division. A complete
package includes all of the items listed below. The complete application package should be submitted to the Stormwater
Management Division.
1. Please indicate that you have provided the following required information by initialing in the space provided next
to each item.
Initials
• Original and one copy of the Stormwater Management Permit Application Form
Original and one copy of the Deed Restrictions & Protective Covenants
Form (if required as per Part IV above)
• Original of the applicable Supplement Form(s) and O&M agreement(s) for each BMP
• Permit application processing fee (see Fee Schedule) Payable to the Town of Navassa
• Calculations & detailed narrative description of stormwater treatment/management
• Copy of any applicable soils report
• Two copies of plans and specifications (sealed, signed & dated), including:
- Development/Project name
- Engineer and firm
-Legend
- North arrow
- Scale
- Revision number & date
- Mean high water line
- Dimensioned property/project boundary
- Location map with named streets or NCSR numbers
- Original contours, proposed contours, spot elevations, finished floor elevations
- Details of roads, drainage features, collection systems, and stormwater control measures
- Wetlands delineated, or a note on plans that none exist
- Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations
- Drainage areas delineated
- Vegetated buffers (where required)
• An electronic copy of all above mentioned forms, documents and plans
VII. AGENT AUTHORIZATION
If you wish to designate authority to another individual or firm so that they may provide information on your behalf
(such as additional information requests), please complete this section. (ex. designing engineer or firm)
Designated agent (individual or firm):
Mailing Address:
City: State:
Phone:
Email:
VIII. APPLICANT'S CERTIFICATION
Fax:
I, (print or type name ofperson listed in General Information, item 2),
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 15A NCAC
211.1000.
Signature: Date: