SWA000065_FilledandsigneSSWFTATCForm_1/27/2020

DEMLR USE ONLY
Date Received
Pee Paid
Permit Number
SW Program(s): ❑ Coastal SA-HQW C] Coastal SA-ORW ❑ Coastal FW-ORW ❑ Coastal Other
❑ Non -coastal HQW ❑ Non -coastal ORW ❑ Urbanizing Areas ❑ USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FO
Link to Application Instructions
A. ELIGIBILITY FOR FAST -TRACK PERMITTING
To be considered for a Fast Track ATC Permit, all of the items below must be checked. If any
be checked, then the project must apply under The Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project) will meet all appli
requirements of 15A NCAC 02H .1000 - .1062, including the Minimum Design Criteria (MDC), up
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Dir.
Certification.
cannot
project
® The project is not out of compliance with an existing stormwater permit or any other environmental ermi
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined i 15A
NCAC 02H .1002(25)) to an existing state stormwater permit_
® The project application bears the signature and seal of a professional licensed pursuant to either
or 89C of the NC General Statutes.
® 1 understand that at project completion, an application with the as -built stormwater plans (as descril
NCAC 02H .1044 must be submitted, and DEQ will review the as -built stormwater plans to confirm
with the MDC. Approval of the as -built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1
2.
3.
4.
Project Name: My Storage Unit, LLC T
Previous Project Name (if applicable): NA
Location of Project (street address): 3740 NC 210 N.
City:Lillington County:Harnett
Directions to project (from nearest major intersection):
Zip:27
69A
in 15A
1pliance
5. Latitude:350 26' 40" N Longitude:-780 47' 34" W of the main entrance tot the project.
C. PERMIT INFORMATION
1. Specify whether project is (check one):
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: 5WA
By choosing this option, you are also requesting that DEG? rescind the previous Fast Track AT Permit
upon issuance of the new Fast Track ATC Permit.
Stormwater Fast Track RTC Application Form Page 1 of 9 Feb. h0. 2018

❑ Major Modification, replacing an existing stormwater permit — provide existing permit number: SW
Status of construction? ® Not Started ❑ Partially Completed ❑ Completed
Major modifications must be submitted by the original permittee and are allowed only if the S permit is
not expired. Minor modifications must use Standard Permitting Process. By choosing this option, you
are also requesting that DEQ rescind the previous SW Permit upon issuance of the new Fast
Track RTC Permit.
❑ Transfer of existing Fast Track ATC Permit — provide existing ATC permit number:
2. Applicable state stormwater program(s) (check all that apply):
❑ Coastal SA-HQW ® Urbanizing Areas (Phase 2)
❑ Coastal SA-ORW ❑ Non -Coastal HQW
Is any portion of the project within 575 feet
of SA-ORW waters? ❑ Yes ❑ No ❑ Non -Coastal ORW
❑ Coastal Freshwater ORW ❑ USMP
❑ Coastal — Other
3. Other Permits (as applicable; write "NA" for those permit types that are not applicable):
Project Name
Permit/Appl
Issue Date
Other Information
No.
LAMA Major
NA
Erosion &
Sedimentation Control
My Storage Unit LLC
Harne-2020-
10/31/2019
Distu
bed Area
013
acre
NPDES Industrial
NA
Stormwater
404/401 Permit
Proposed
Impacts
iflac
4. Local jurisdiction for building permits: Harnett County
Point of Contact:Planning Department
D. CONTACT INFORMATION
1.
2.
Phone #:
Applicant/Financially Responsible Party (may be an Organization):My Storage Un
Signing Official Name & Title:Joseph Gardner, Manager
Street Address:1116 Tysinger Road
City:Lillin ton State:NC
Mailing Address (if different):Same as above
City: State:
Phone: ( ) _ _ Fax:
Email:
If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the
State):
Name of Registered Agent:
Mailinq Address:
City: State: Zip:
Phone: Fax:
Email.
of
Stormwater Fast Track ATC Application Form Page 2 of 9 Feb. 110, 2018

3. The Applicant is the (check all that apply):
® Property Owner
❑ Lessee (Attach a copy of the lease agreement & complete Item 4.)
❑ Purchaser (Attach a copy of the pending sales agreement & complete Item 4.)
❑ Developer (Attach a copy of the development agreement & complete Item 4.)
4.
5.
If the Applicant is NOT the Property Owner (skip to Item 5 if the Applicant IS the Property Owner):
Property Owner Name/Organization:Joe Gardner
Signing Official & Title:Manager
Street Address:1116 Tysinger Road
City:Lillington --
Mailing Address (if applicable). -Same as above
City:
Phone:
Email:
State:NC
State:
Fax: ( )
The licensed Design Professional that will be retained for the duration of the project, who may
information on the Applicant's behalf, and who will prepare and certify the as -built package:
Consulting Engineer/Landscape Architect:Samir W. Bahho, PE
Consulting Firm: Civil and Structural EngifleerincL Services PLLC
Mailing Address:4612 Kaplan Drive
City -.Raleigh State:NC Zip:27606
Phone: [phone] Fax:
Email:ba.casesollcOomail. com
6. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization:
Mailing Address:
City: State: Zip:
Phone: Fax:.( )
Email:
E. PROJECT INFORMATION
1. Specify the type of project (check one): ❑ Low Density ® High Density
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
3. Stormwater runoff from this project drains to the Cape Fear
4. Receiving Water information (if more than 3 rereivina wafers_ nrnvidfa arfrfitinnai infnrmafinn nn an
basin(s).
ChA,] A -
Receiving
Water 1
Receiving
Water
Receiving
Water
Receiving Stream Name
Dry Creek
Stream Classification
WS-IV
Stream Index Number
18-17--(2)
Stormwater Fast Track ATC Application Forin Page 3 of 9 Feb. 110, 2018

5_ Project area and density information:
Total Property Area
217800 sf
Total Surface Water Area
255700 sf
Considered to include:
• the normal pool of impounded structures;
• the area between the banks of streams and rivers; and
• the area below the Normal High Water (NHW) line or Mean High Water (MHW) line.
Total Coastal Wetlands Area
sf
Considered to include: coastal wetlands landward from the NHW (or MHW) line.
Total Project Area
217800 sf
Excludes the surface water area and coastal wetland area identified above.
May or may not be the same as Property Area.
Built -Upon Area (BUA) associated with Existing Development
108900 sf
"Existing development" means those projects that are built or those projects that have established a
vested right under North Carolina taw as of the effective date of the state stormwater program or
applicable local government ordinance to which the project is subject.
Proposed New BUA
sf
Includes proposed new BUA that is not associated with existing development
"BUA" is defined in N. C. G. S. 143-214.7(b2). It includes, but is not limited to: buildings, roads, parking
areas, sidewalks, and some gravel areas. The design volume of SCMs must take into account the
runoff from build out from all surfaces draining to the SCM in accordance with 15A NCAC 02H .1050(1).
Project Density
w/Existing Development: Project Density = (New BUA]/[Total Project Area — Existing BUA] x 100 or
50 %
wio Existing Development. Project Density = [New BUA]/Total Project Area] x 100
6. Anticipated construction start date January
7. Is the project located within 5 miles of a public airport? ® No ❑ Yes
if `Yes,' see S.L. 2012-200, Part VI: gp:l/www.ncleg.ni
DEQ Stormwater Design Manual Chapter E-4 Airports.
and
8. For projects in Union County: Contact DEMLR Central Office Stormwater staff at 919-707-9200 to termine if
the project is located within a Threatened & Endangered Species watershed that may be subject to ore
stringent stormwater requirements per 15A NCAC 028 .0600.
Stormwater Fast Track ATC Application Form Page 4 of 9 Feb. t, 2018

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or D MLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQW/ORW). Only application packages t at include
all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application
initials
yes d 1. Two original signed hard copies and one electronic copy of this State Stormwater Fast Tr ck
Process "Authorization to Construct" (ATC) Permit Application Form.
yes ✓ 2. Permit application processing fee of $505 payable to NCDEQ.
Y.es— 3. Two hard copies and one electronic copy of a USGS map identifying the project location
and GPS coordinates for the project. If the receiving water is Class SA or the receiving v
drains to Class SA waters within'/z mile of the project boundary, include the % mile radiu
on the map. If the project is within 575 feet of Class SA-ORW waters, include the 575-fc
radius on the map.
yes ✓ 4. Two original signed hard copies and one electronic copy of a site plan depicting the boun ary
of the project or project phase currently being permitted, including the locations of SCMs,
streams, wetlands, and buffers.
yes 5. Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased. r� [�f� (� Q7
yes _ 6. A copy of the most current property deed. Deed book: ! Page No: ' " l f i
yes 7. [IF APPLICABLE] When the applicant is a corporation or a limited liability corporation (LL ): Provide
two hard copies and one electronic copy of documentation from the NC Secretary of State, or other
official documentation, which supports the titles and positions held by the persons listed
in Section C.2 per 15A NCAC 2H. 1043(3)(b). The corporation or LLC must be listed as an active
corporation in good standing with the NC Department of the Secretary of State, otherwise the
application will be returned. hftr)s-://www.sosnc.gov/search/index/corp
NA 8. [IF APPLICABLE1 When the applicant is a Partnership or other person engaging in businss under
an assumed name, attach a copy of the Certificate of Assumed Name.
NA 9. [IF APPLICABLE] When the applicant is not the property owner: Provide two hard copies and one
electronic copy of lease agreements, affidavits, pending sales agreement, development a reemer
or other documents showing that the applicant has obtained legal rights to submit a storm ater
permit application within the proposed project area.
NA 10. [IF APPLICABLE] If modifying an existing permit for completed or partially completed
of the designer's certification.
a copy
Stormwater Fast Track ATC Application Form Page 5 of 9 Fe'c 162018

G. CERTIFICATION OF APPLICANT/ FINANCIALLY RESPONSIBLE PARTY
The Applicant, who is also the Financially Responsible Party, identified in Section D of this form must
notarized the following guaranty:
and have
1, (print or type name of Applicant/Financially Responsible Party) Joe Gardner
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that:
1. the design has been or will be completed in accordance 'th th UDC fi
2
3.
o
wl a t
02H .1050 through .1062, to the best of my knowledge; as seit" in Rules 15A NCAC
the completed design meets or will meet the MDC and that the percentage BUA that is the basi for the
design shall not be exceeded, to the best of my knowledge; and
As the applicant, 1 shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as -built package. If I retain another licensed
professional before the project is complete, then I shall provide an updated
guaranty with the current licensed professional's seal. A licensed professional shall inform
the Division if he is no longer associated with this project.
The above information is true and correct to the best of my knowledge and belief and was provided by
agree to provide corrected information should there be any change in the information provided herein.
Type„or print name
Title or Authority A1�//q
nature -, - Date
a N ry Public for the St a of J
of l �� do hereby ce tha#
appeared before me this /OA-day of and acknowledge the due
the application fora stormwatear permit.. Witness my hand and official seal,
SEAL
My commission expires��
under oath I
County
Ily
►n of
Starmwater Fast Track ATC Applications Form Page 6 of 9 Feb. 4 201 S

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be completed by the Design Professional identified in Section D.5.
Samir W. Bahho PE , attest to the following:
1. This application has been reviewed by me and is accurate and complete, to the best of my
2. The design has been completed in accordance with the MDC as set forth in Rules 15A NC
.1050 through .1062, as applicable;
3. The percentage built -upon area that is the basis for the design will not be exceeded; and
4. 1 have the expertise, education, and experience required to design the SCMs proposed in
application in accordance with the MDC as set forth in Rules 15A NCAC 02H .1050 throug
5. 1 will provide all documents and certified as -built plans in hard copy and electronic format r
permit to a new Applicant/Property Owner and to DEMLR upon transfer of this permit to a 1
Appiicant/Property Owner.
Note: In accordance with N.C.G.S. 143-215.6A and 143-215.613, any person who knowingly makes ai
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. In addition,
who Knowingly makes any false statement, representation, or certification in any application may be r
the appropriate NC professional licensing board.
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Signature Date:
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Storrnwater Fast Track ATC Application Form Page 7 of 9 Feb. 4 2018

I. PROPERTY OWNER'S AUTHORIZATION (IF APPLICANT IS NOT THE PROPERTY OVItNER)
, (print or type name of the Property Owner) , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of Applicant)
with (print or type name of Applica is
organization) 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 s stem_
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 o i 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 NamelOwnership Change Form within 30 days; otherwise I will be operating a stormwater tepatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without b valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action 'ncluding
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.8.
Signature: Date:
of
appeared before me this
a Notary Public for the State of _ _,. -`, County
do hereby certify that
day of
, and acknowledge the due
the application for a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
of
Stormwater Fast Track ATC Application Form Page 8 of 9 Fel_i. 4 2p1g

J. CERTIFICATION OF CURRENT PERMITTEE (COMPLETE ONLYIF PERMIT
REQUESTED)
I, (print or type name of the Current Permittee) a
this request for a transfer of Fast Track ATC permit # SWA V
submission of this transfer request I am providing a copy of the most recent permit, all related docum
built plans certified by my design professional in hard copy and electronic format to the Proposed
Permittee/Applicant identified in Section G of this application and to DEMLR . I further attest that this
permit transfer is accurate and complete to the best of my knowledge. I assign all rights and obligatio
permittee to the proposed permittee named in Section G of this form.
Signature -
I, , a Notary Public for the State of
of do hereby certify that
appeared before me this day of and acknowledge the due
the application for a stormwater permit. Witness my hand and official seal,
SEAL
My commission expi
R IS
submitting
i the
is and as -
quest fora
as
County
Of
Stormwater Fast Track ATC Application Form Page 9 of 9 Feb. 16, 2018