SW3190601_Form_(Application)_20200311

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Standard Permitting Program — No Fee for Minor Modification
Express Permitting Program — See gA rest Fee Schedule
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: http:lldeq.tic. govicont: ct/rec for ,l-offkq s.
a
This form is to only to be used by the current permittee to notify the Division of a minor
modification. Pursuant to Rule 15A NGAC 02H .1002, a minor modification is a change to the project that:
1) does not increase the net built -upon area; and/or
2) does not change the size or design of the SCM(s).
1. State Stormwater Permit Number: SW3190601
2. Current Permit Holder's Company Name/Organization: Publix North Carolina LP
3. Signing Official's Name: William W. Rayburn, IV
4. Signing Official's Title: Vice President of Real Estate Assets
5. Mailing Address: PO BOX 407
City: Lakeland State: FL ZIP: 33802
6. Street Address (if different): 3300 Publix Corporate Parkway
City: Lakeland State: FL ZIP: 33811
7. Phone: (863) 61&5743 Email: woody.rayburri aiipublix.com
8. Describe the minor modifications that you are requesting, including any revised BUA allocations (attach
additional pages or supporting tables similar to Section IV,10 of the original application, if needed):
Wet Pond 1 on the approved plans has been slightly shifted and reshaped. The modified pond has the
same drainage area, storage capacity, and water quality volume as the approved pond, lust has a different
shape. Calculations for the modified pond and updated plans have been included with this submittal.
Please mark "Y" to confirm the items are included with this form. Please mark `X" if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. Two hard copies (with original signatures) and one electronic copy of this completed form.
Y 2. Two hard copies and one electronic copy of the revised plan sheets (must be a revision of the
originally approved plan sheets).
N/A 3. If there is reallocation of lot BUA, a copy of the revised recorded deed restrictions and protective
covenants OR the proposed recorded deed restrictions and protective covenants documenting
the changes and a signed agreement to provide the final recorded document.
NIA 4. If applicable, the appropriate Express review fee.
Stormwater {permit Farrr� i: [1rlir�r�r Mc�cification F'ac�s 1 oaf 2 luly ^r�, ?_Q�7

1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name: Chris Bostic, P.E.
Consulting Firm: Kimlev-Horn and Associates,_ Inc.
Mailing Address: 421 Fayetteville Street, Suite 600
City: Raleigh State: NC Zip: 27601
Phone: [phone] Fax: ( )
Email: chris.bostic(d)kimley-horn.com
2. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name &Title: Tim Carter, EI
Organization: Kimlev-Horn and Associates Inc.
Mailing Address: 421 Fayetteville Street, Suite 600
City: Raleigh State: NC Zip: 27601
Phone: [phone] Fax: ( )
Email: tim.carter(c kimley-horn.com
C}. C�RIF[CA� iCi� �3 PERMTTEE
I, AW "k(A44j�Nf,� L� , the current permittee, certify that I have authorized the minor modifications listed
in Section A and shown in the attached revised plan sheets. I further attest that this information is accurate and
complete to the best of my knowledge
Signature: W44ti A
I, «'.l.�t a Notary Public for the State of
County of ��l do hereby certify that Lw1111QyY1 (1 q
personally appeared before me this the I C I hday of Ge jof
acknowledge the due execution of the forgoing instrument. Witness my hand anti
(Notary Seal)
Notary Signature
My commission expiresSUMNER
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N�'V?,h�o� Cxplres November 12, 2021
s 7F4oe Bonded lhru Budget Notary Services
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official seal,
Stormwater Permit Farm 7: Minor Modification Page 2 of 2 C�ci h, tG17