SW4200501_Signed Application_5/28/2020

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 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.):
Lewisville Middle School
2. Location of Project (street address):
1115 Lewisville -Vienna Road
City: Lewisville County:Forsyth Zip:27023
3. Directions to project (from nearest major intersection):
From Shallowford Road in Lewisville, head away from 421, turn left on Lewisville -Vienna Road
4. Latitude:36° 7' 5.8116" N Longitude:-80° 23' 51.99" 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 SWU-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)N/A , 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, SW4191201 and the previous name of the project, if different than currently
proposed, N/A
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: 30 ac of Disturbed Area
❑NPDES Industrial Stormwater Z404/401 Permit: Proposed Impacts (submitted and under review)
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:Lewisville MS E&SC permit - FORSY-2020-009 Issue Date: 11/5/19
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://12ortal.ncdenr.org/web/lr/rules-and-regulations
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:Winston-Salem / Forsyth County Board of Education
Signing Official & Title:Colon Moore
b. Contact information for person listed in item 1a above:
Street Address:475 Cornorate Square Drive
City:Winston-Salem
State:NC
Zip:27105
Mailing Address (if applicablc):475 Corporate Square Driv
City:Winston-Salem State:NC Zip:27105
Phone: (336 ) 727-2533 ext. 34916 Fax: (N/A )
Email:[e-mail]
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)
❑ 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:N /A
Signing Official & Title:N/A
b. Contact information for person listed in item 2a above:
Street Address:N/A
City:N/A State:N/A Zip:N/A
Mailing Address (if applicablc):N/A
City:N / A State:N / A Zip:
Phone: (N/A ) Fax: (N/AN/A )
Email: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:Kenneth Loring - CLH Design PA
Signing Official & Title:Kenneth Loring - Principal
b. Contact information for person listed in item 3a above:
Mailing Address:400 Regency Forest Drive, Suite 120
City:Cary State:NC Zip:27518
Phone: (919 ) 319-6716 Fax: (919 ) 678-3170
Email:[e-mail]
4. Local jurisdiction for building permits: Cityof Winston-Salemn
Point of Contact:Benjamin Crum Phone #: (336 ) 722-6152
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.
Stormwater will be conveyed through a stormwater pipe network into 2 SCM's. a wet detention basin and a
constructed wetland.
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 Yadkin Pee -Dee River basin.
4. Total Property Area: 66.21 acres 5. Total Coastal Wetlands Area: N/A acres
6. Total Surface Water Area: 1.28 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project Area':
64.93 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 (NHI0 line or Mean High Water
(MHVv) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHM line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 14.2
9. How many drainage areas does the project have?2 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for the whole property 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 2
Drainage Area _
Drainage Area _
Receiving Stream Name
Tomahawk
Creek
Tomahawk
Creek
Stream Class
C
C
Stream Index Number *
12-94-9-1
12-94-9-1
Total Drainage Area (sf)
812,394
89,734
On -site Drainage Area (sf)
792,792
89,734
Off -site Drainage Area (sf)
19,602
0
Pro osed Impervious Area** (sf)
369,545
32,979
Im ervious Area** (total)
45.5
36.8
Impervious- Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
62,264
0
On -site Streets (sf)
93,234
28,348
On -site Parking (sf)
105,490
0
On -site Sidewalks (sf)
23,189
2,017
Other on -site (sf)
56,230
0
Future (sf)
8,712
2,614
Off -site (sf)
19,602
0
Existing BUA*** (sf)
824
0
Total (sf):
369,545
32,979
* Stream Class and Index Number can be determined at: http://portal.ncdenr.or /wg eb/wq&s/csu/classifications
Im ervious 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 BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. this area to be
assumed as 100% impervious for potential future build out.
Proiects 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 I5A 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 http://portal.ncdenr.org/web/wq/ws/su/bmp-manual.
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
http://portal.ncdenr.org/web/wq/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 http://portal.ncdenr.org/web/wq/ws/su/maps.)
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 http://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
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2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
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Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
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agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
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http://www.envhelp.org/pages/onestopexpress.html 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 map identifying the site location. If the receiving stream is reported as class SA or the
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receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the '/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
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8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
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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.
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.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6
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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
Iease 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 Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that 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 day, Pursuant to NCGS 143-215.6.
Signature:
a Notary Public for the State of
do hereby certify that
Date:
County of
personally appeared
before me this _ day of and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires,
X. APPLICANT'S CERTIFICATION
I, (print or hype name of person listed in Contact Information, iteni. la) Colon Mow - Winston-Salem/Forst Forsyth Counhl
Board of Education
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 stormw ter ule nde 15 N AC 2H .1000 and any other applicable state stormwater requirements.
Signatu1re: �} ('Date:
a Notary Public for the State of 1V . �. • County of
t'S hereby certify thatre-
do personally appeared
before me this�ay of \, 12Pand ackn wlez le du execution of the application for
a stormwater permit. Witness my and and official seal, _ t
s,P R.
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440.) v\O TA tp zsS
o "4 `£
Z 80
0000
COUN
SEAL
My commission expires
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6