SW3200201_Application_20200212

D.EMLR 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 PIan
❑ Other WQ M&mt Plan:
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.):
Dollar General - Newton, NC
2. Location of Project (street address):
Providence Mill Road
City:Newton County: Catawba Zip:28658
3. Directions to project (from nearest major intersection):
Take Hwv 16 South from Newton for approx. 5 miles and at the intersection of Hwy 16 and Providence Mill
Road the site will be located at the northwestern 2.uadrant.
4. Latitude:35* 37 33.83" N Longitude:-810 8' 58,46" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with modifications Also requires SVM-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 numberN/ A , 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
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, Iist the stormwater project number,
if assigned, N/A 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: 2.20 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 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:Erosion Control applied for with Catawba County.
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: htt ortal.ncdenr.or. web lr rules -and -re gglations
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:Teramore Construction LLC
Signing Official & Titlejeffrey Lan
b. Contact information for person listed in item 1a above:
Street Address:214 Klumac Street - Suite 101
City:Salisbury State:NC Zip:28144
Mailing Address (if applicable):
city: State: Zip:
Phone: [phone] Fax: [phone]
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)
® DeveIoper* (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:Michael Monaco
Signing Official & Title:MichaeI Monaco
b. Contact information for person listed in item 2a above:
Street Address: 2164 Genova Drive
City: Oveido State:FL Zip: 32765
Mailing Address (if applicable):
City:
Phone: {_ ) N/A
Email:N/ A
State:_ Zip:
Fax: (N/A }
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:BREC PA
Signing Official & Title:Justin C. Church - Principal Engineer
b. Contact information for person listed in item 3a above:
Mailing Address:1520 Meadowview Drive
City: Wilkesboro State:NC Zip:28697
Phone: [phone] Fax: [phone]
Email:'[e-mail]
4. Local jurisdiction for building permits: Catawba Count
Point of Contact:Reid Goforth Phone #: [phone]
Form SWU-101 Version Oct. 3I, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated,
An above ground sand filter will be used to treat runoff from all impervious surfaces of a l2roposed
9100 sg ft Dollar General store.
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
4. Total Property Area: 2.11 acres
River basin.
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+: 2.11 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
(MHi) line, and coastal wetlands landward from the NHW (or MHTA j line, The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (orMHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =
33
51.
9. How many drainage areas does the project have? 1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low densihj and other projects, use I for the whole propert j 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
Pinch Gut Creek
_
_
Stream Class *
C
Stream Index Number *
11-129-5-7
Total Drainage Area (so
42,955
On -site Drainage Area (so
42,955
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
29,512
Impervious Area** total
68%
Impervious' ervious' Surface Area
Drainage Area 1
Drainage Area
Drainage Area
Draina e.Area
On -site Buildings/Lots (so
8,960
On -site Streets (so
0
On -site Parkin (sf)
19,262
On -site Sidewalks (so
1,290
Other on -site (sf)
0
Future (sf)
0
Off -site (so
0
Existing BUA*** (so
0
Total (sf): 129,512
Stream Class and index Number can be determined at: ht!p,*ortal.-ncdenr.or_eblwoslcsulclassiflcations
Im ervious area is defined as the built upon area including, but not limited to, buildings, roads, partang areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

"Report oxhl dial r►MOM rt of eristiug RUA thatl rt?fIt r_'c�rttrrirr Oer devclopmenL Do clot report any existing BLIA that
is to be reurovol and which will be irplaceif l)y rrc►u BUA.
11, How was the off -site impervious area listed above determined? Provide documentation, Field Survey
PEE ge i ► Union tCou ►t : Contact DE-110? C'cutrcrl (1/)We Skjfpndithin a Threatened
c/lcjt cttPr
1:racicrrrl,�ercct.Sjx�eitrs crater herd that rnuy be sur jevl to rrrores su'Jrrgcrlt storrrru arer rcytrlr'cuterars us peer 15A NC AC 02l3,0000.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management perinit 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
frona l�till?ort�tl.n�cicnr or i�+t'l1 ta�c ���s 4►t b.nlria�ltati.
VI. SU13MI-TTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral. and
Lana Resource4 (DEMLR). A complete package includes all of the items listed below. A detailed application
Instruction sheet and BMP checklists are available from
l�ttp;/lt?c►' t1C[If'11.()r��/W(?U�1h`a/�s/s► statesrn For►ns flocs. 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 ►uap at htlla})�lrtal.nclle►1E'.ol' wGUj ti� c tivs su n1a ,s.)
Please indicate that the following re aired inforniatl n have been vrovided by initialing in the space provided
for each item, Ali original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from E�ttl_,:f,_ i-)orta1,ncdertnor /web/wc ws su J statesw/forms flocs,
E1i:tl is
I. Original and one copy of the Stormwater Management Permit Application Toren,
2. 01-igirtal Mid ar►e Coliy of the signed and notarized Deed Restrictions & Protective Covenants
Corm. (if required as per fart V11 170070)
I 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 ljoyable to NCDENR. (For all Express review, refer to
1 tt :►: ww w F vhel .or S I pages onesto )ress,htin] 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
6. A USGS neap identifying the site location. if the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 112 mile of the site boundary, include the a/z
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8, Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
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.
11. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded sta'uctures, tie banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of Hie MHW or N1 lW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded .
structures, the banks of strea►ns or rivers, and the MHW (or NNW) of tidal waters,
L 'Dimensioned property/project boundary with bearings & distances.
J. Site Layout with all BUA identified rind dimensioned.
k, Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control pleasures,
n1. 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).
Form SWU-101 Version occ 31, 2013 Page 4 ofG

p. Vegetated buffers (where required).
9, Copy of any applicable soils report with the associated Sl IWTelevations (Please Identify
elevations in acidit'ton to depths) cis well as a inap of the borin locations with the existing
elevations and boring logs. Include ail 8.5"x1I" cop of the N C5 County Soils map with the
project area clearly delineated. for projects with in filtration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of deterniming the infiltration rate.
(Infiltration Devices submitted to WiRO: Sclledi(le a site, rrisit for 1.7EWR to verify the SHWT iarior
to suNnittal, [phone].)
10. A copy of the most current property deed. Deed boob. 2528 Page No: 0202
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 1a, 2a, and/or 3a per 15A NCAC 2I-I.1003(e).
They corporation or l_IwC must be listed as all active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
htt www.gecretar ;stckte.iic.us Cor oratians/C5earclt.aslax
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions anti protective
covenants are required to be recorded prior to the sale of ally 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 httl�:i/1�orta(.i�cdenr.org/rvebllrlst�7ke,
stc�r►3�ti�a#ear fort3�s does. 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(&) 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 f ortns available on the website, that the covenants will be binding on all parties and persons claiming
under theta, that they will run with the land, that the required covenants cannot be changed crx deleted
without concurrence from tire NC DEMY.R, and that they will be recorded prior to the sale of any lot.
VI11. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority toanother individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information oil your behalf for this project (such as
addressing requests for additional Information),
Consulting Engineer:lustin C. Church
Consulting Firm: BREC, PA
Malling Address:1_520_Meado%yview Drive
City: Wilkesboro -- _
Phone: 3 iG ) 844-10$$
Finail:justinf brec.biz
State -NC Zip:28697
Pax: 336 6)9-7726
IX, PROPERTY OWNER AUTHORIZATION (if Contact hiformation, Win 2 has been filled oot, coinrtdtte this
se c. tiotr)
1, (print or idle nmue of person listen hi Contact for fyriuntion, iteut 2a) Micitael MG}tarn , certify that I
own the property identified in this perinit application, and thus give permission to (print or type tune of person
listed its Cont gel Infornfation, itew 1a) ]'4ffi�eit_!_rr iawith (print nr type name of orgallizotion listed 1):
Contact Infi rawflon, ifein 1a) 7ernwo e Construction 1_LC 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 SWIJ-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
ler►se agreement, or pending sale, responsibility for compliance with the DE -MLR Storinwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify bEMLR Immediately and
submit a completed Native/Ownership Change Form within 30 days; otherwise 1 will be operating a stormwater
treatment facility without a valid permit. 1 iincicrstand HIM 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 clay, pursuant to NC:GS 143-215A,
Signature: bate: ; ""'Z-%�
a Notary Public for the State of 11-2'al-drz__.;— —' County of
do.hereby certify that..N_/1Opt
.�dilG" personally appeared
before me this day of. ill / µ „a?Q40_ , and acknowled V
w clue execution of the application for
a stormwater permit, Witness my hand and official seal, ,
Yvette Franqui
r�*err State ofFlorida
My Commission Expires 1011712020
Commission No, GG 39461
X. APPLICANT'S ClrRTIFIC;A'riON
Yvelte Frantiui
SEA)`Mate of Florida
* ' MY Commtssion Expires 1011712020
Commission No. GG 3M
My commission expires/'Wowc>
1, (print or h1pe name of person listed Irt Contact Informatio) i, items in) I'ernrnore Cogtr«rtf rr 1 L - e ret l.mr
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 cojnplies with the requirements of the
applicable stormwater ru�nder 15A.>CAC 2H ,1000 and any other applicable state stormwater requirements.
Signature:.
Date: Z f o, 'U
Notary Public for the State of --a ,004 —, County of
do hereby certify that _:2S-k"-L _ __._—....__ personally appeamd
before me this dot 1 of
_ } W _, Q�� sand ar n wledge tlle due execution of the application for
a stormwater permit. Witness my hand and official seal,
as`�e�eaar,0.0 _
EXPIR,,/E�tS�� pp
w Gt�VII�GX A,
~ SEPTW13FR 2. 202�
eye AS}C0 0.iak
SEAL
My canunission expires 1 �VI
Form SWU-101 Versioii Oct. 31. 2013 Page 6 of 6