SW3200302_Stormwater Management Permit Application Form_4/6/2020

DEMLR 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 Plan
❑ Other WQ Mgmt 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.):
2. Location of Project (street address):
4401 Helms Road
City: Waxhaw County: Union
3. Directions to project (from nearest major intersection):
Zip:28173
Traveling south west on Helms Road from the intersection of Helms Road and Waxhaw Marvin Road
the project is driectly on the left and a project entrance is the first left turn.
4. Latitude:34° 55' 30" N Longitude:80" 45' 40" 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 number , 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
3. 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, list the stormwater project
number, if assigned, 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
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 22.62 ac of Disturbed Area
❑404/401 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:
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: htt oi•tal.ii denr.or r--5iiid-re ulati jis
Form SWU-101 Version Oct. 31, 2013 Pagel of6

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: Broadstreet Homes
Signing Official & Title:Brian lagnernma, managgr
b. Contact information for person listed in item la above:
Street Address:1312 Camp Creek Road
City: Lancaster State:SC Zip:29720
Mailing Address (if applicable):
City: State: Zi
Phone: [phone] Fax:
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 Iease 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)
® Developer* (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: Paula Buie Hamilton
Signing Official & Title:Paula Buie Hamilton, propgrty owner
b. Contact information for person listed in item 2a above:
Street Address:601 Evans Manor Dr
City:Matthews State:NC Zip:28104
Mailing Address (if applicable):
City: State:
Phone: (7D4 ] 321-2920 Fax: ( )
Email:[e-mail]
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:
Signing Official &
b. Contact information for person listed in item 3a above:
Mailing Address:
City:
Phone: f ]
Email:.
State: Zip:
Fax: f ]
4. Local jurisdiction for building permits: Town of Waxhaw
Point of Contact:Dan Pruss Phone #: VO4 843.2195 ext. 255
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Most of the runoff from the site is directed to two splitter boxes. In the water quality event
these sl2litter boxes direct flow to the 12rol2osed sand filters (SCM A and SCM B . The s litter
boxes direct any runoff exceeding the water qualft volume to the enhanced pond for detention.
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 River basin.
4. Total Property Area: 30 acres 5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: 1.58 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:28.42 acres
Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between. the banks of streamrs and rivers, the area below the Normal High Water (NHW) litre or Mean HiXh Water
(MHW) line, and coastal wetlands la►:dward from the NNW (or MHVV} line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landroard of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 35
9. How many drainage areas does the project have?2 (For high density, count I for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for the whole properhj 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 A
Drainage Area B
Drainage Area _
Drainage Area
Receiving Stream Name
Rone Branch
Rone Branch
Stream Class *
C
C
Stream Index Number *
11-138-4
11-138-4
Total Drainage Area (so
509468
359354
On -site Drainage Area (sf)
459507
359354
Off -site Drainage Area (so
49961
0
Proposed Impervious Area**
(so
223102
208145
I
% Impervious Area**(total).44%
1
58%
Impervious" Surface Area
Drains e Area A
Drainage Area B_
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
On -site Streets (so
On -site Parking (sf)
On -site Sidewalks (so
Other on -site (so
203217
208145
Future (so
Off -site (so
19885
0
Existing BUA*** (so
Total (sf):
223102
208145
* Stream Class and Index Number can be determined at: hitp�&Drtal.azcdenr.or�ebr`cr�[ rslcsxlclasst,�rcrttior►s
* Impervious area is defined as the built upon area including, but not limited to, -buildings', roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

'Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new B UA.
11. How was the off -site impervious area listed above determined? Provide documentation. Off -site impervious
area was measured from available survey and GIS information
Prooects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A NCAC 02B
.0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit 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
from lltt ortal.ncdenr.or web w ws/su/bmiLmanual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed
application instruction sheet and BMP checklists are available from
htt ortal,ncdenr.or web w ws su statesw forms docs. 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 map at httl2.//12c)rtal.ncdenr.org/web/wq/ws/su/majm.)
Please indicate that the following required information have been provided by initialing in the space
provided for each item. All original documents MUST be signed and initialed in blue ink. Download the latest
versions for each submitted application package from
htU2://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms dots.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. JM\
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed signed and dated) and O&M J
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to �
hU:lZwww.envheII2.org/pages/onestol2exl2ress.iitrni 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.) `p
5. A detailed narrative (one to two pages) describing the stormwater treatment/management for\A _
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the _
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map. P�
7. Sealed, signed and dated calculations (one copy). Jh
8. Two sets of plans folded to &5" x 1.4" (sealed, signed, & dated), including: v
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.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

m. 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).
p. Vegetated buffers (where required). \�
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify �1
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
pro ect area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DEMLl2 to verifij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1263 Page No: 811,
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 Iisted in Contact Information, item la, 2a, and/or 3a per 15A KCAC 2H.1003(e).
The corporation or LLC must be Iisted as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hftp:/lwww.secretM.state.nc.us/Corl2orations/CSeiigh.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
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 hillp_jfportal.ncdenr.orglwebllrlstate-
stormwater-forms doc . 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 fo m while applicant is responsibleforensuring
that the deed restrictions are recorded. �,( r-c) 1 . �] ,I .fy 4
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer: on Aldridge PE
Consulting Firm: McAdams
Mailing Address:34,30 Torin don WaySuite 110
City:Charlotte State:NC Zip:28277
Phone: [phone] Fax: (919 ) 361.2269
Email: ald ridge@rncadamsco. corn
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hype name of person listed in Contact Information, item 2a) Paula Buie Hamilton , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item 1a) Brian Ia nemma witf{prin or tl name of organization listed in
Contact Information, item 1a) Broadstreet Homes to c currently proposed. am —a*"` -
Form SWU-101 Version Oct. 31, 2013 Page 5 of 6

A
rE ofa -
Si azure: r Date: 3
��pp
1, '� i Notary Public far the State of=)it'{A tALDll>ounty of
do hereby certi y that persona
before me this Lbday of and acknowledge the due execution of the
a stormwater permit. Witness my hand and officials I
My commission expires
X. APPLICANT'S CERTIFICATION
1, (print or type nanre of person listed in Contact Information, item 1a) Brian Iagnentina ,
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 the
applicable stormwater rules under 15A NCAC 2H .1400 and any other applicable state stormwater
requirements,_.
Date: Z— 2a-- 2 n
I, a otary Public for the State of —'57L4 P iry) hyiounty of
����do herebyc
�yth ___ personally appeared
before me thisi�tay of AWAa and acknowledge the due extecutio e application for
a stormwater permit. Witness my han and official seal
SEAL
My commission expires
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6