SW1190801_Form_(Application)_20200610

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DEMLR USE ONLY
Date Received
Fee Paid
Pemtit Number
Applicable Rules'. ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II -Post Conshuction
(select nli tlrnt nyyly) ❑tion-Coastal SW- HQW/ORW Waters ❑Universal Stormwater Management Plan
❑ Other WQ M t Plan:
State of North Cazolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
17ris form nmy be yhotocoyied for vse ns mr o»giunl
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operatlon and maintenance agreements, etc.):
Leicester Volunteer Fite Department
2. Location of Project (sweet address):
City:Leicester Covnty:Btmcombe Zip:37660
3. Duections to project (floor nearest major intersection):
Pahon Ave. to New Leicester Hi lg twat', Right on Alexander Rd.
4. LaEtude:35° 39' 29.6" N Longitude:82° 41' 35.9" W of the n><tin entrance to the project.
II. PERMIT INFORMATION:
1. a. Syecify whetlter project fs (check one): ®New ❑Modification ❑Renewal w/ ModificaEont
tRerremals with modifications also requires 54V1i-102 - RettewalApplication Form
b.If tlds appllcatlon is being subntihed as the result of a modification to an existlng permit, Est the existing
permit number ,its issue date (if known) ,and the stahrs of
constluctlon: ❑Not Started ❑Partially Completed• ❑Completed" "provide rt desigrwr's ctvtificntiotr
Specffy the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System ❑Otlter
3. If tltis applicatioi is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state Stormwater management permit application, list Eie stotmwater project munbeq
if assigned, and the previous name of the project, tl different than currently
proposed,
4. a. AddiEottal Project Requirements (check applicable blmtks; inforvtatlon on requhed state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major ®Sedimentation/Erosion Control: 4.68 ac of Dishubed Area
❑NPDFS Etdush9al Stormwater ❑404/401 Pernit: Proposed Impacts
b.If any of these perutits have already Veen acquired please provide the Project Name, Project/Petntit Number,
issue dale and the type of each pern»t:
5. Is the
projeft located within 5 Holes
of a public airport?
�No
UYe:
If yes,
see S.L. 2012-200, Part VL http:!/vortal�ncdenr.org/web/lr/rules-and-regulations
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III. CON'CACT [NFORMA'CION
1. a. Print Applicant /Signing O[[icial's name and title (specificall}' the developer, properly owner, lessee,
designated government official, individual, etc. rvho owns the oroicct):
Signing Official &Title: Ted Godleski, �®isNtiet-C1tfeE
b.Contact information for person listed in item la above:
Sheet Address2852 New Leicester Hi lv tw:�y
City: Leicester State: NC Zip:28748
Mailing Address (ij'npplicnble):PO BOX 100
City: Leicester State: NC Zip:28748
Phone: (828 ) 6833433 Ext. 17 Phone: (828 ) 552-1094
Fax: ( )
Email: tzodleski®leicesterfire.com
c. Please check the appropriate box. The applicant Bsted above is:
® The property owner (Skip to Contact Infornrahon, item 3a)
❑ Lessee' (Attach a copy of the lease agreement and complete Contact Information, item 2a and 26 below)
❑ Purchaser° (Attach a cop}' of the pending sales agreement and complete Contact I»forntation, item 2a and
2b below)
❑ Developer` (Cou�plete Contact htformahort, item 2a and 2b below.)
2. a. Print Property Owner's
name and title below, if you are fire lessee,
pm�chaser or
developer.
(This is the
person who owns the
property that the project is located on):
.
Signing Official &
b. Con6ut irdonnation for person listed in item 2a above: {j {{
Sheet Address: �.0 i Z �1�w f � i r.�-5 hFi �i'rn Itiwr. .!
city: L�,i .z �-�er state: N , �, zip: 2t37 �j-�
Mailhtg Address (i(rrypGcnblL): '�- !� � CJ � j tr U
City: Y_P i G�._S7CP State: �'1 , �., Zip: �t'*s-%�-U
Phone: (i�2t5) Cvfi�--e34-3:5 Fax: ($Lt3 ) locsa'3.- `a �%.
Email:-�-a ��ll��J �•'. ��i G�S'{2 /' �th�, Ccrr�..
3, a. (Optional) Prhtt the name and title of another cont<ut such as the project's cortshuchon supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:Michael Es osito ADW Architects
Signing Official & Title:Principal
b. Contact information for person listed in item 3a above:
Mailing Address:2815 Coliseum Cenhe Drive
City:Charlolte Statc:NC Zip:28217
Phone: (704 ) 379-1919 Fax: ( )
Email: mesvosito�A DYVArchitects.com
4. Local jurisdiction for building permits: Buncombe County
Point of Contact:Ioshua Freeman Phone N: (828 ) 250-4850
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" Strennr Class and Iudet Nmuber' cmt be detenuined nt: httv://uortnl.ucderu�.orghuebhun/vs/csr✓cinss�rntiorrs
»" /nrppervious rtren is defined ns the built uyon men inchtdiug, but xot limited to, buildings, roods, ymking m�ens,
sirtetuniks, grovel Wrens, eta
"""12eyort orr[y tlmt muount o(etistiug BUA tint will rmr�niu ��ter'rleveloyrrrent, Da not reymt Huy misting BLfA Hutt
is to be rmuoved and udric% 7uiil be reylnced tnj Hero B1.TA.
11. How was the off -site impervious area Bsted above determined? Provide documentatlon, The off -site
impervious area was deterntirted by lookings at arhtl photography calculating Bte uea of intperivous
surfaces. See attached storm water report for details.
Protects in Uniou Connly: Contnct DEMI.Ii Cenhal Office str(jj"fo check jf the project is located wifhiu a Threniened &
Endnngered Species untershed thnl nrrry be subject to more stringent storrnn•nter regrrireurenfs ns per I SANCAC 0?B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state storntwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of rite forms can be downloaded
fromll�R ://portaLncdenr.org/web/wq/ws/su/burp-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 appBcation
instruction sheet and BMP checklists are available fxom
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office maybe found by locating project on the
interactive online Wrap at http:/ /portal.ncdenr.org/web/wa/ws/su/maQs.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. AB original documents MUST be signed and initialed itt blue ink. Download the latest versions
for eachsubtniltedapplicaHonpackagefromhttp://portal.ncdenr.org/web/wg/ws/sn/statesw/forms does.
IniBals
1. Originnl mrd orte coyy of the Stotmwater Management Perntlt AppBcatlon Fornt.
2. Otigirml mrd orte royy of the signed utd notarized Deed Reshictimts & Protective Covenants
Form. (if required ns yer Prot VII belarv)
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3. Origins! of the applicable Supplement Pornt(s) (scaled, signed and dated) and O&M _
agrcentent(s) (or each EMP.
4. Permit application processing fee of $505 pnyn6le to NCDENR. (For an Express review, refer to _
h�://www.envhely.org/papes/onestopexpress.lttnil for information on the Express program
and the associated fees. Conhact the appropriate regional office Express Permit Coordinator For
additional information and to schedttle the requh'ed applicahon meeting)
5. A detailed narrative (one to two pages) desa•ibing the slormwatcr treahnent/management fm
G. A tISGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving sh•eam drains to class SA waters within'/z mile of the site boundary, include the bx
mile radius on the map.
7. Sealed, signed and dated caladations (one copy). _
S. Two sets of plans folded to 8.5" x 14" (sealed, signed, � dated), including:
a. Development/Project name.
b. Eugincer and [inn.
c. Location map with named streets and NCSR nwubers.
d. Legend.
e. North an�ow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plots by delineating the noruul pool elevation of
impotmded sh'uchues, the banks of sh'eams utd rivers, fire MHFV or NH4V line of tidal
waters, and any coastal wetlands landward of hte MH4V or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevaion of impounded
shttchues, the banks of streams or rivers, and the N[HW (or NHW) of tidal waters.
i. Dimensioned property/project bounduy tvitlt bearings &distances.
j. Site Layout with a116UA identified and dimensioned.
k. Existing contours, proposed contours, spot elevatious, finished Floor elevations.
1. Details of roads, drainage feahu'es, collection systems, and stornnvaler conh•ol measures.
nt, Wetlands delineated, or a note on the plans that none exist. (bhtst be delineated by a
qualified person. Provide doctunentahon of qualilicatiorts and identify the person wlto
made the detervtinafiwt on flte jtlmts.
n. Existing drah><age (includuig oft -site), drahtage easements, pipe sizes, runoff calttdafiorts.
o, Drah>iige areas delvteated (included in the main set of plots, not as a separate docmuent).
p. Vegetated btdfers (where required).
9. Coy}' of any applicable soils report with the associated SHWT elevations (Please identify _
elevafiorts in addihon to depths) as well as a nutp of the botvtg lacatiorts with the existutg
elevations and boring logs. Include an 8.5"xll" copy of the NRCS Cotmty Soils map with the
project area clearly delineated. For projects wfth utfiltration BbII's, the report should also
huhrde the soil type, expected irtfilhntion rate, and the method of deternththtg the htfilhahon rate.
(htfiltralion Devices submitted to WiRO: SchcAula n site nisi[ jor DEMLR to vwifi� Ure StllNl'yrior
to snbrnittrtl, [phone].)
10. A copy of the most current property deed. Deed book 4548 Page No: 1277 _
11. For corporations vtd limited Eability corporations (LLC): Provide donmtentation from the i`iC
Secretary of State or other official documentation, which supports the titles and posifions held
by the persons listed in Contact htforntafion, item la, 2a, and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active cot'porafion in good standhtg with the NC
Secretary of Slalc, otherwise the application will be rchuved.
htlp: / / tvwwsecretarystate.nc us/Corporations/ CSearch.aspz
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VII. DIIED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and frrhue development, rite appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot If ]ot sizes vuy sr rcantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable bu' t-upon area must be
provided as an ahaclunent to the completed and notarized deed restriction form. The appropriate deed
restrictions and protective covenants forms can be downloaded from ortal.ncdenr.or web !r state-
stomtwater-forms does. Download the latest versions for each submitta .
hi rite instances where the applicant is different than the property owner, it is rite responsibility of the property
owner to sign the deed reshictions and protective covenants form wl»le the applicant is responsible for ensuring
that the deed reshictiorts are recorded.
By the notarized slgnature(e) below, the permit holders) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all rite items required in the permit and listed
on the fomms available on the website, that the covenants will be binding on all parties and persons claiming
under Ihenr, that they will urn with the land, that the required covenants carrot be changed or deleted
without concunence from the NC DEMLR, and that they will be recorded prior to the Bale of any lot.
VIII. CONSULTANT iNPORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or fine (such as a
consulting enghteerand/or firm) so that they may provide htforntation on your behalf for Bds project (such as
addressing requests for addihortal ittforntaHon).
Consulting Engineer:Tacob Grieb, PE
Consuling Fhm: Mattern & Craig
Mailing Address:403 E Market Street
Cityaohnson Clty State:TN Zip:37601
Phone: (423 ) 979-2220 Fax: ( )
Email: idgr•ielrNrnatternandcraig.com
IX. PROPERTY OWNER AUTHORIZATION (if CortMct Brfonuntion, item 2 has been,„l4d out, mnrylete this
section)
I, (print or h•/pe unnrc of person listed irr Contnct Lrfannntion, item 2n) ,certify that I
own rite property identified in this permit application, and Btus give pertttisslon to (print or h•Ipe rtnrne o(persou
listed in Contnct hrfonrurtiorr, item ln) with (yrint or tie nnrae of orgnnization tisted in
Contnct Grfonrmtion, item 1n) to develop lire project as currently proposed. A copy of
rite lease agreement or pendutg property sales contract has been provided with rite submittal, which htdicates the
party responsible for the operation and maintenance of the stormwater system.
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I, (print m tie nnrue of person listed in Contact Grfonuntiorr, item 1n)
certify that the ixtformation mchtded on this pernxit application form is, to Nxe best of my knowledge, correct and
drat the project will be colt-shucted in conforn>tance with the approved plans, that the required deed resh•icCrons
and protective covenants will be recorded, uui flail the proposed project complies with the requirements of the
applicable stormwater ndes urxde/r 15cAyNCAC 2H .1000 aid an}' offer applicable state stormwater requitements.
Signahue: `" �� ,.9. � Date: I o � e9 � Za l
I, j�r rY.r� ,JZJ �'v'tiS%Y� , a Notary Public for the State of r lOv-td'1 ,County of
(vtG�OLeIQ,I-( ,do hereby certify float I Y�{O[�e�"e �,J , (xOCI LeSICr1esoiallyappeared
before me this` da}' of �� C-7"Z)j'.J��✓ � iGN and ac�lu/xgwledge the due executioYn of theme application for
a stormwater permit Wihxess mp land and official seal, --h(,t L-2- c.- �.�9�ir/e�'M (/C>'�r-t��L/-±J
�_ _ _ _ y �....
Porm SWU-I01 Version Ocl. 3l, 2013
KAREN JOHNSON PERIARD
SEAL Notary Public -North Carolina
Mc Dowell County
My Commission Expires Apr 4, 2022
NIy cwnnxission
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