SW3130301_CURRENT PERMIT_20130510

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
� CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
YYYYMMDD

DEHR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Mr. Adam Sellner
Pritnax Properties, LLC
1100 E. Morehead Street
Charlotte, NC 28204
Division of Water Quality
Charles Wakild, P.E.
Director
April 12, 2013
Subject: Stormwater Permit No, SW3130301
Advance Auto Parts -- Rockwell
High Density Commercial Bio-Retention Project
Rowan County
Dear Mr, Sellner:
John E, Skvarla, III
Secretary.CEIVEo
DIVISION OF 10(ATER QUALITY
MAY 10 2013
,Sc:!- - , iON
MOORESVILLE REGIONAL OFFICE
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for the
subject project on Marcli'7, 2013. Staff review of the plans and specifications has deterrnitied that the project,
as proposed, will comply with the Stormwater�Regulations set forth in Title 15A NCAC 211.1000 and Session
Law 2006-246. We are forwarding Permit No. SW3130301, dated April 12, 2013, for the construction,
operation and maintenance of the subject project and the Stormwater BMPs.
This permit shall be effective from the date of issuance until April 12, 2021, and shall be subject to the
conditions and limitations as specified therein, and does not supersede any other agency permit that may be
required. Please pay'special attention to the conditions listed in this permit regarding the Operation and
Maintenance of the BMP(s), recordation of deed restrictions, procedures for changes of ownership,
transferring the permit, and renewing the permit. Failure to establish an adequate system for operation and
maintenance of the stormwater management system, to record deed restrictions, to follow the procedures for
transfer of the permit, or to renew the permit, will result in future compliance problems.
If any ]) .irts,' 1'equirenleriL's,-dr iintit:itiotis,corltairted in this Ilave.the right to
r eilucst.arl adji�ciicatory,66.� rih fz:y`Fwrltt'eil'pr'tition Lvitl� ti�ti office of ifrnini'str�liive l�cai liigs;(,UAfi.),.
wriiLen'petitlon must confdr n'l to Chapter 1.50E3o1'tt e:Nartll'Carolina',General Stattrtes,:f'er' NCGS .143-
-215(LE) tlrc'pe,tition-mtist be frletl vvitli tl�e''{JAH within thirty [3f]) cl7ys of i eceipt of:this permit.. You,should
con6cL,thc:0AIiMidi all quesfiorta'ri~ ardinj; the filing fe ''[rf a ['ling fuel's requ'ired),and/ter-tl>c,details Of, the
filing process at 6714 Mai! Servi'U Center,`Raleigll; NC 27699-6714; pr via telephone at: 919-431=3000, or visit
t'heir-we6teat %vww.NC0All,c0m,'Unless such,tl permitsholl bediinal and binding:
Th'ts project will be kept on file at the Mooresville Regional Office. if you have any questions, or need additional
information concerning this matter, please contact Bill Diuguid at [phone]; or [e-mail].
Sincerely,
4� i ms,�-
for Charles Wakild, P.E., Director
Wetlands and Stormwater Brand
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury 5l. Raleigh, North Carolina 27604
PhDm 919-807-63001 FAX: [phone]
Inlernm wvrw,ncwate rquartty.ory
An Equal (pJPMr)nity 1 AlfinneUva Action Fmptoyer
)Ile
NorthCtu-Mil it
r
r

State Stormwater Permit
Permit No. SW3130301
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE'STORMWATER.MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article.21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Primax Properties, LLC
Advance Auto Parts Rockwell
8620 U. S, Hwy 52 Rockwell, Rowan County
FOR THE
construction, operation and maintenance of one bioretention cell in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to as
the "stormwater rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved by
the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until April 12, 2021, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2, This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 on page 3 of this permit. The stormwater
control,has been designed to handle the runoff from 28,077 square feet of
impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in Section
1.7 of this permit, and per the application documents and as shown on the
approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6 The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
7. The following design criteria have been provided in the bioretention cell and must:
Page 1 of 6

State Stormwater Permit
Permit No. SW3130301
be maintained at design condition:
a.
L�
C.
d,
e.
f:
h,
1�
k.
1.
M.
n.
o,
p�
q.
r.
S.
Drainage Area, ycres:
Onsite, ft :
Offsite, ftz:
Total Impervioug Surfaces, ft2:
CPnsite, ft
Offsite, ft2`.
Design Storm, inches:
Max. Ponded Depth, feet:
Seasonal High Water Table, fmsl:
Planting Media Depth, feet:
Cell Dimensions, feet:
Planting Elevation, fmsl:
Planting Surface Area, ftz:
Permitted .Storage Volume, W:
Bypass / Sta1rage: Elevation, fmsl:
Precle'46pment 1 year 24 hour:
Post development 1 year 24 hour:
Drawdown Time, hours:
Underdrain Diameter, inches:
Total number of plants provided:
Receiving Stream/River Basin:
Stream Index Number:
Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
43,840
43,840
0`
28077
28077
;0;
1.0
12°
759
2
76x35
761
2400
2400
764
0.030 cubic feet/sec
1.720 cubic feet/sec
20
6°
Bermuda sod.
Ut to -Second Creek 1 Yadkin
12-117-2
1. The stormwater management system shall be constructed .in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface,
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to.
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times,
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
5. The permittee shall submit to the Division of Water {duality an annual summary
report of the maintenance and inspection records for each BMP. The report
shall summarize the inspection dates, results of the inspections, and the
maintenance work performed at each inspection.
6. The stormwater treatment system shall be constructed in accordance with the
Page 2 of 6

State Stormwater Permit
Permit No. SW3130301
approved plans and specifications, the conditions of this permit, and with other
supporting data.
T. -,Upon coipletion of�cohstruction,,zprior,to issuance:of a Certificate,af Occupancy,
and pronto opei-atiiari of J' his,,permitted facility,;a certifi6jtion 'iiiust be':received "
from,an:appropriate designer for the,system'�nstalled:certifying;thattlie petrrlitt o
facility, has. been. installed -in accordance,With this.permit,,the-approved-pipn's;and
specifications;, and�dther,supporting;documentation': Any-d.eviations`;from'the
approved plans and>.specifications-must be..nated.on.the:Certificatibh,-,A
modification,, -may 6'e required. for-.those;deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
0. Access to the stormwater facilities shall be maintained via appropriate recorded
easements at all times.
10. The permittee shafi'submit to the.Director and sh6li'have,receive dd:a. provalior
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
belovi:
a. Any"revisidn.to,any'item':shown on -the approved.plans;;including the
stormwater management measures, built-upon`area, details; etc.
b.. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined.as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Maior.permit.was spught'
f. Filling,�n, akte'ring, or piping of 'any ;vegetative ;conveyance sh6Wn'- on the
approved plan.
11. The permittee shall submit -final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified.in the notice, the permittee.shall.submit a written time schedule to the
..Director fo'r modifying the.slte,to meet -minimum requirerrients. The,permittee.
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
III. GENERAL_ CONDITIONS
1.. This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed;,Name/Ownership Change form signed by both pasties, to the
Division'-of`!Water.Qualit' ;,accompanied b y.: the supporting docpmehtation as
listed on page 2 of the form. The approval'of this request will be-corisidered on
its merits and may or may not be approved.
2. The:pe�r ittee,is responsible for;compliance,with,all permit conditions until,such
time:as.th6 Division apprdvesia °regiaest to tra6sfer1'the;permit.
Page 3 of 6

State Stormwater Permit
Permit No. SW3130301
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all. statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required -by this Division, such as the construction of
additional or replacement stormwater management systems.
6: The permittee grants DENR Staff permission to enter the property during normal
business hours -for the purpose -of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the, Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 16A NCAC 2H.1000, and NCGS 143-215,1 et.al.
11 The permitteeshall nofify'.th'e•,Division*ih writing:=of any name; ownership,or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 12 day of April, 2013.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Charles Wakild, rector
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. SW3130301
Advance Auto Parts -Rockwell
Stormwater- Permit No. SW3130301
Rowran CobritY
Designer's Certification
1, , as a duly registered . in the
State of North Carolina, having been authorized to observe (periodidallyl weekly/
full time) the construction of the -project,
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due -care and diligence was used in the observation of the project
construction such that the construction.was observed to be built within substantial
compliance and intent of the approved,,plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
.SEAL
Page 5 of 6

State Stormwater Permit
Permit No. SW3130301
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area,,
-3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
.5. The outlet/bypass structure elevations are per the approved,plan,
6: The outlet structure is located per the approved plans.
71. Trash rack is provided on the outlet/bypass structure,
.8. All slopes are grassed with permanent vegetation, per the vegetation plan.
9, Vegetated slopes are no steeper than 3:1.
1.0. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
1,1. The permitted amounts of surface area and/or volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13, All required design depths are provided.
,14. All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
15c The required system dimensions.are provided per the approved plans.
CC' NCDENR-DWQ Regional Office
inspector, Rowan County Building Inspections
Page 6 of 6

Advance Auto Parts -Rockwell
Stormwater Permit No. SW3130301
Ri3wanCoutity
Designer's Certification
State Stormwater Permit
Cff��++II �^ /�'' Permit No. SW3130301
7i�Flc, G,1 OF i_k`� :) RcS0Ur;V`�.
+ 01D QUALITY Sc-u O^'
AUG 7 2013
UErmsto..,`ty+ yr ",vvlriUl•MENI
Amm iiNniFsfu nF-SOURCES
�
I, ,q a e . G-ow4w as a duly registered crr�r.,-- in the
State of, North .-Carolina,, having. been authorized to observe fper,f dical yl weekly/
_ full-time)..th6.construction.of,the.project,
��Vmee e 0--A
Name)
for trri e 5 (Project Owner) hereby state that, to the
best of myabilities; db&6are and diligence was used in the observation of the project.
construction such.,that the construction was observed to be built within substantial
compliance and intent of the approved -plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification -
SEAL
`,151\0.111fill,
Signatureof— �.� 0" CARo
.•••••o.
Registration Number ¢ �pFESS%p ��.�'';
Q
Ice
Date T ���/3 _ SEAL -
24434
,, � • O
9 �NE�o�p
► EE
. �+L ti`��1�
Page 5 of 6

State Stormwater Permit
Permit No. SW3130301
Certification, Requirements:
% 1; The drainage area to the system contains approximately the permitted
acreage.
✓ 2 The drainage area to the system contains no more than the permitted.
amount of built -upon area.
vl '3: All the built -upon area associated with the project is. graded such that the
runoff drains"to the -system:
✓
4':
All roof drains are located such that.the runoff is directed into the system.
5 .
The outlet/bypass structure elevations are per the approved plan.
✓
6,r
The outlet structure is -located per the approved plans.
A
-7,
Trash rack is provided on the outlet/bypass structure.
ti%
S:
All slopes are grassed with permanent vegetation, per the vegetation plan.
_.91.
Vegetated slopes are no steeper than 3:1.
1:0'
The inlets are located per the approved,plans and.do not cause short-
circuiting �of the system.
T-.
The permitted. amounts of surface area and/or volume have been
provided.
1 Z
Required drawdown devices are correctly sized. per the -approved plans.
Tf 13; All required design depths are provided:,.
14: All required,parts of the system are provided, such as a:vegetated shelf,
and a forebay.
✓ .1;5: The required system dimensions are provided per the approved, plans.
c_c: NCDENR7DWQ Regional Office
inspector, Rowan County Building Inspections
Page 6 of 6

40A
�r� A
�+ CDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Primax Properties, LLC
Attention: Mr. Adam Sellner
1100 E. Morehead Street
Charlotte, NC 28204
Dear Mr. Sellner:
John E. Skvarla, III
Secretary
August 21, 2014
Subject: Stormwater Permit No. SW3130301
Advance Auto Parts -Rockwell
High Density Commercial Bio-Retention
Project
Rowan County, North Carolina
Attached is a copy of the subject permit inspection conducted on August 20, 2014
By Samar Bou-Ghazale of this Office.
The report should be self-explanatory; however, should you have any questions
concerning the report, please do not hesitate to contact Mr. Bou-Ghazale at (704)
235-2199.
Sincerel
Zahid S. Khan, CPM, CPESC, CPSWQ
Regional Engineer
Land Quality Section
Attachment
Division of Energy, Mineral, and Land Resources
Land Quality Section - Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Telephone: [phone] I FAX: [phone] • Internet: http://portal.ncdenr.org/web/Ir/land-quality
An Equal Opportunity /Affirmative Action Employer— 50% Recycled 110% Post Consumer Paper

Compliance Inspection Report
Permit: SW3130301 Effective:04/12/13 Expiration: 04/12/21
Project: Advance Auto Parts - Rockwell
Owner: Primax Properties LLC
County: Rowan Adress: 8620 US Hwy 52
Region: Mooresville
City/StatelZip: Franklinton NC 27525
Contact Person: Adam Sellner Title: Phone: [phone]
Directions to Project:
Site is located on US Hwy 52 at the intersectin of US Hwy 52 and Wilcoy Rd
Type of Project: State Stormwater - General Permit
Drain Areas:
On -Site Representative(s):
Related Permits:
Inspection Date: 0812012014
Primary Inspector: Samar E Bou Ghazale
Secondary inspector(s):
State Stormwater - HD - Bioretention
Entry Time: 03:25PM
Reason for inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ® Compliant ❑ Not Compliant
Question Areas:
® State Stormwater
(See attachment summary)
Exit Time: 04:05PM
Phone: [phone] Ext.2199
Inspection Type: Compliance Evaluation
page: i

Permit: SW3130301 Owner - Project: Primax Properties LLC
Inspection Date: W2012014 Inspection Type Compliance Evaluation Reason for visit: Routine
Inspection Summary:
Site was found in good operational condition. Maintenance as noted in the inspection is to be performed at the pond.
Also, Please submit the soil annual report to the Mooresville Regional Office. The address is located on the cover letter.
Also, you could e-mailed to: [e-mail]
Built Upon Area Yes No NA NE
Is the site BUA constructed as per the permit and approval plans? ® ❑ ❑ ❑
Is the drainage area as per the permit and approved plans? 9 ❑ ❑ ❑
Is the BUA (as permitted) graded such that the runoff drains to the system? ® ❑ ❑ ❑
Comment:
SW Measures Yes No NA NE
Are the SW measures constructed as per the approved plans? N ❑ ❑ ❑
Are the inlets located per the approved plans? U ❑ ❑ ❑
Are the outlet structures located per the approved plans? RE ❑ ❑ ❑
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? ❑ ®❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to ❑ ❑ ❑
DWQ upon request?
Comment: Please maintain the Bio-Retention Dond's vegetation by removing the weeds. Please note that soil
annual test is to take place at the Bio-Retention Pond. Refer to the Bioretention Operation and
Maintenance Agreement.
File Review Yes No NA NE
Is the permit active? 9 ❑ ❑ ❑
Signed copy of the Engineer's certification is in the file? ® ❑ ❑ ❑
Signed copy of the Operation & Maintenance Agreement is in the file? ® ❑ ❑ ❑
Copy of the recorded deed restrictions is in the file? ❑ ®❑ ❑
Comment: Please submit a cosy of the recorded deed restrictions fo_r_stormwater collection and treatment systems
per the permit requirements.
page: 2

Permit Number:
(to be provided by DWQ)
AG'tA
0�6,q�G E IVED
NCDENR DI1/�- .�T=- w � .., �¢,LI T v
STORMWATER MANAGEMENT PERMIT APPLICATION FORM MAY 1 U 2013
401 CERTIFICATION APPLICATION FORM
BIORETENTION CELL SUPPLEMENT
MOORESVILLE REt TONAL OFFICE
This form must be filled out; printed and submitted.
The Required Items Checklist (Part W) must be printed, filled out and submitted along with all of the required information.
I...PROJECT:INFOF2MATIONk _ xp
Project name Advance Auto -Rockwell
Contact name
Phone number
Date
Drainage area number Bio-Retention Pond
II. DESIGN INFORMATION
Site Characteristics
Drainage area 43,840 ft /� �f
Impervious area 28,077 ft2 ✓ r� U NB� dew
Percent impervious 64.0% %
Design rainfall depth 1.0 inch
Peak Flow Calculations
Is prelpost control of the 1-yr, 24-hr peak flow requlred?
1-yr, 24-hr runoff depth
1-yr, 24-hr intensity
Pre -development 1-yr. 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
PretPost 1-yr, 24-hr peak control
Storage Volume: Nan -SA Waters
Minimum volume required
Volume provided
Storage Volume: SA Waters
1.5" runoff volume
Pre -development 1-yr, 24-hr runoff
Post -development 1-yr, 24-hr runoff
Minimum volume required
Volume provided
Cell Dimensions
Ponding depth of water
Ponding depth of water
Surface area of the top of the bioretention cell
Length;
Width:
-or- Radius
Media and Soils Summary
Drawdown time, ponded volume
Drawdown time, to 24 inches below surface
Drawdown time, total:
In -situ soil.
Soil permeability
Planting media soil:
Soil permeability
Soil composition
Sand (by volume)
% Fines (by volume)
% Organic (by volume)
Phosphorus Index (P-Index) of media
Form SW401-Bioretention-Rev.8
June 25, 2010
Y (Y or N)
2.81 In
�,.•..�a�zrifre
• /!.
0.24 inthr
�xa
0.030 ft'/sec
1.720 ft3lsec
1 690 ft3lsec
STnAL
_
2,272.0 f13
/
L °w Fpl,V
qi�
3
2,400-0 f1
OK
►��///
i
.f�
c
ly i y.
ft3
ft3
ft3
0 ft3
ft3
12 inches
OK
1.00 ff
2,400.0 fie
OK
76 ft
OK
35 ft
OK
ft
6 hr
OK
Z�
y /
14 hr
OK
rf
•
20 hr
/
0.40 in/hr
.5 Z
Insufficient. Increase
✓
infiltration rate or include=,nderdrainfsD
2.00 in/hr
OK
87% OK
8% OK
5% OK
Tota l: 100%
10 (uNttess) OK
Parts I and 11. Design Summary, Page 1 of 2

Permit Number:
(to be provided by DWQ)
Basin Elevations
Temporary pool elevation
Type of bioretention cell (answer "Y" to only one of the two
following questions):
Is this a grassed cell?
Is this a cell with treesishrubs?
Planting elevation (top of the mulch or grass sod layer)
Depth of mulch
Bottom of the planting media soil
Planting media depth
Depth of washed sand below planting media soil
Are underdrains being installed?
How many clean out pipes are being installed?
What factor of safety is used for sizing the underdrains? (See
BMP Manual Section 12.3.6)
Additional distance between the bottom of the planting media and
the bottom of the cell to account for underdrains
Bottom of the cell required
SHWT elevation
Distance from bottom to SHWT
Internal Water Storage Zone (IWS)
Does the design include IWS
Elevation of the top of the upturned elbow
Separation of IWS and Surface
Planting Plan
Number of tree species
Number of shrub species
Number of herbaceous groundcover species
Additional information
Does volume in excess of the design volume bypass the
bioretention cell?
Does volume in excess of the design volume flow evenly distributed
through a vegetated filter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
Is the BMP Located at Least 30 feet from surface waters (50 feet if
SA waters)?
Is the BMP localed at least 100 feet from water supply wells?
Are the vegetated side slopes equal to or less than 3:1?
Is the BMP located in a proposed drainage easement with access
to a public Right of Way (ROW)?
Inlet velocity (from treatment system)
Is the area surrounding the colt/ likely to undergo development in
the future?
Are the slopes draining to the bioretention cell greater than 20%?
Is the drainage area permanently stabilized?
Pretreatment Used
(Indicate Type Used with an "X" in the shaded cell)
Gravel and grass
(flinches gravel followed by 3-5 ft of grass)
Grassed Swale
Forebay
Other
765.00 fmsl
Y (Y or N) OK
N (Y or N)
764 fmsl �-,.�
0 inches Insufficient mulch depth, unless installing grassed cell.
762 fmsl
2ft
0 ft
Y (Y or N)
5
OK
2
OK
1 ft
761 fmsl
759 fmsl
2 it
OK
N (Y or N)
fmsl
764 ft
1
0
0
Recommend more species.
Y (Y or N) OK
Y
(Y or N)
OK
ft
N
(Y or N)
Show how flow is evenly distributed.
Y
(Y of N)
OK
Y
(Y or N)
OK
Y
(Y or N)
OK
Y
(Y or N)
OK
2 fUsec
Insufficient inlet velocity unless energy dissipating devices are
being used.
N
(Y or N)
OK
N
(Y or N)
OK
Y
(Y or N)
OK
X
ma
Form SW401-Bioretention-Rev.8
June 25, 2010 Parts I and 11. Design Summary, Page 2 of 2

Permit No:
(to be assigned by DWQ)
IIL, REQUIRED. ITEMS CHECKLIST
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An incomplete submittal package
will result in a request for additional information. This will delay final review and approval of the project. Initial in the space provided
to indicate the following design requirements have been met. If the applicant has designated an agent, the agent may initial below. If a
requirement has not been met, attach justification.
Pagel Plan
Initials Sheet o.
MfL C'`5 —J7 1. Plans 0" - 50' or larger) of the entire site showing:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C. coefficient per basin),
Cell dimensions,
Pretreatment system,
High flow bypass system,
Maintenance access,
Recorded drainage easement and public right of way (ROW),
Clean out pipe locations,
Overflow device, and
Boundaries of drainage easement.
✓�� L C—� 2. Plan details (1" = 30' or larger) for the bioretention cell showing.
Cell dimensions
Pretreatment system,
High flow bypass system,
Maintenance access,
Recorded drainage easement and public right of way (ROW),
Design at ultimate build -out,
Off -site drainage (if applicable),
Clean out pipe locations,
Overflow device, and
Boundaries of drainage easement.
Indicate the P-Index between 10 and 30
C~� 3 Section view of the bioretention cell (1" = 20' or larger) showing:
Side slopes, 3:1 or lower
Underdrain system (if applicable), and
Bioretentian cell layers [ground level and slope, pre-treatment, pending depth, mulch depth, fill media
depth, washed sand, filter fabric (or choking stone if applicable), #57 stone, underdrains (if applicable),
p SHWT level(s), and overflow structure]
4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWO, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information. All
elevations shall be In feet mean sea level (fmsl) Results of soils tests of both the planting sail and the in
situ soil must include:
Soil permeability,
Soil composition (% sand, % fines, % organic), and
P-index.
I?rt!G C'8 G�I 5. A detailed planting plan (1" = 20' or larger) prepared by a qualified individual showing:
A variety of suitable species,
Sizes, spacing and locations of plantings,
Total quantity of each type of plant specified,
A planting detail,
The source nursery for the plants, and
Fertilizer and watering requirements to establish vegetation.
1*4L C " U fi. A construction sequence that shows how the bioretention cell will be protected from sediment until the
entire drainage area is stabilized.
k11 LL cS 7. The supporting calculations (includ}ng underdrain calculations, if applicable).
Gyt�L Ks' 8. A copy of the signed and notarized inspection and maintenance (I&M) agreement.
9. A copy of the deed restriction.
Form SW401-Bioretention-Rev.7 Part III, Page 1 of 1

Permit Number:
(to be proOded ht' DIIV)
I]rainage Area Number:
Bioretention Operation and Maintenance Agreement
will keep a maintenance record on this BMP. This maintenance record will be kept in a
Iog in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
Important operation and maintenance procedures:
Immediately after the bioretention cell is established, the plants will be watered
twice weekly if needed until the plants become established (commonly six
weeks).
— Snow, mulch or any other material will NEVER be piled on the surface of the
bioretention cell.
Heavy equipment will NEVER be driven over the bioretention cell.
Special care will be taken to prevent sediment from entering die bioretention cell.
Once a year, a soil test of the soil media will be conducted.
After the bioretention cell is established, I will inspect it once a month and within 24
hours after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal
County). Records of operation and maintenance will be kept in a known set Iocation
and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potential roblems:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
bioretention cell
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
The inlet device: pipe,
The pipe is clogged (if
Unclog the pipe. Dispose of the
stone verge or swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable),
Erosion is occurring in the
Regrade the swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
Stone verge is clogged or
Remove sediment and clogged
covered in sediment (if
stone and replace with clean stone.
applicable).
Form SW40 I -Bioretention O&NI-Rev.3 Page I of 4

BMP element:
The pretreatment area
The bioretention cell:
vegetation
The bioretention cell:
soils and mulch
Potential problems:
Flow is bypassing
pretreatment area and/or
gullies have formed.
Sediment has accumulated to
a depth greater than three
inches.
Erosion has occurred
Weeds are present.
Best professional practices
show that pruning is needed
to maintain optimal plant
health.
Plants are dead, diseased or
dying.
Tree stakes/wires are present
six months after planting.
Mulch is breaking down or
has floated away.
Soils and/or mulch are
clogged with sediment.
An annual soil test shows that
pH has dropped or heavy
metals have accumulated in
the soil media.
How I will remediate the problem:
Regrade if necessary to route all
flow to the pretreatment area.
Restabilize the area after grading.
Search for the source of the
sediment and remedy the problem if
possible. Remove the sediment and
restabilize the pretreatment area.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Remove the weeds, preferably by
hand.
Prune according to best professional
practices.
Determine the source of the
problem; soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Remove tree stake/wires (which
can kill the tree if not removed).
Spot mulch if there are only random
void areas. Replace whole mulch
layer if necessary. Remove the
remaining much and replace with
triple shredded hard wood mulch at
a maximum depth of three inches.
Determine the extent of the clogging
- remove and replace either just the
top layers or the entire media as
needed. Dispose of the spoil in an
appropriate off -site location. Use
triple shredded hard wood mulch at
a maximum depth of three inches.
Search for the source of the
sedimentand remedy the problem if
possible.
Dolomitic lime shall be applied as
recommended per the soil test and
toxic soils shall be removed,
disposed of properly and replaced
with new planting media.
Form SW401-13ioretention O&M-Rev.3 Page 22 of 4

BMP element:
Potentialproblems:
How I will remediate theproblem:
The underdrain system
Clogging has occurred.
Wash out the underdrain system.
(if applicable)
The drop inlet
Clogging has occurred.
Clean out the drop inlet. Dispose of
the sediment off -site.
The drop inlet is damaged
Repair or replace the drop inlet.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW401-Bioretention O&M -Rev.') Page a of'4

Permit Number:
(to be provicled by D IJIQ)
acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name:Advance Auto Parts - Rockwell, NC
BMP ch-alnage area number: I
Print name:Adam Sellner
'I"itle:Proiect Director
Address:I 100 E. Morehead Street
Phonc:704-954-7224
Signature: C~:� �-
Date: R ciV' k
Note: The legally responsible pally should not be a homeowners association unless more than 50% of'
lire lots have been sold and a resident of the subdivision has been named the president.
I, FA-chpj hq a pf I I a Notary Public for the State of
NIo 1 j County of ��Q4C=f, , do hereby certify that
T f � l
personally appeared before me this
Gi�a no _ _
day of'?, —2u—�and acknowledge the due execution of the
forgoing bioretention maintenance requirements. Witness my hand and official seal,
AA
Comm. ExP
3-8-2017. U
SI Ar"w -_COU
My commission expires '5 J (/ � 101
Dorm SW401-Sioretention I&M-Rev. 2 Page 4 of 4

Is
.._ , .',. ' F => iw,�.`• a, �'
DWQ'USE.ONLY,
Date Received
Fcc Paid
Permit Number
)
l 0
Applicable Rules:
❑ Coastal SW - 1995
❑ Coastal SW - 2008
❑ Ph 11 - Post Construction
(select all that apply)
❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M nit Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
1. 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.):
Advance Auto Parts - Rockwell
2. Location of Project (street address):
8620 US Highway 52
City:Rockwell County:Rowan Zip:27525
3. Directions to project (from nearest major intersection):
Site is located on US Flwy 52 at the intersection of US Hwy 52 and Wilcoy Road
4. Latitude:350 33' 50" N Longitude:80° 24' 59" W of the main entrance to the project.
I1. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
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 certificatioli
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 DWQ
requesting a state stormwater management permit application, list the stormNvater 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):
❑LAMA Major ®Sedimentation/Erosion Control: 1.71 ac of Disturbed Area
❑NPDES Industrial Stormwater Z404/401 Permit: Proposed Impacts 631f stream impact
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:
form SWU-101 Version 07Jun2010
Page I of 6
g@RU V E
MAC 0 7 J2013
NR - WA
�eiw Bray

ill. 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:Primax Properties, LLC
Signing Official & Title:Adam Sellner
b.Contact information for person listed in item la above:
Street Address:1100 E. Morehead Street
City:Charlotte State:NC Zip:28204
Mailing Address (if applicable):
City: State: Zip:
Phone: (704 ) 954-7224 Fax: ( )
Email:asellnerOprim axproperties.com
c. Please check the appropriate box. The applicant listed above is:
❑ TI1e 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: Hoyt Deal
Signing Official & Title:Property Owner
b.Contact information for person listed in item 2a above:
Street Address:8610 US Hwv 52
City:Rockwell State:NC Zip:28138
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) _ Fax: ( )
Email:
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 & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City:
Phone:.(--
Email:
Zi
Fax: (
4. Local jurisdiction for building permits: Town of Rockwell
Point of Contact -Jana McMakin Phone #: (704 ) 279-2180
Fomi SWU-101 Version 07Jun2010 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the storm water runoff will be treated.
Stormwater runoff from the developed areas of the site will drain into a bio-retention pond
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
4. Total Property Area: 2.23 acres
River basin.
5. Total Coastal Wetlands Area: 0.0 acres
6. Total Surface Water Area:_0 acres
Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area*:2.23 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 Higglt Water (NNW) lute or Mean High Water
(MHM line, and coastal wetlands landward front the NHW (or MA), litre. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal uletlatids landward of the NHIN (or MHIN) lure may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 28.9 %
9. How many drainage areas does the project have?1 (For high density, count I for each proposed engincered
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.
3as�n;InFornla onw fi,``.> :^. i;,�I
... �
'�Dr`ama a Area§§p1
,.: , ._f>,ram,-�
��rama e;Area =_x,
Draina e A`rea �:
Drama e,Area
Receiving Stream Name
Trib. to Second
Creek
Stream Class
C
Stream Index Number *
12-117-2
"Total Drainage Area (so
43840
On -site Drainage Area (so
43840
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
28077
Impervious Area** total
64.0
`` ` "� »,, , '
§EIzn ervious Surface Area , ; , „
%T7raina `e;`Aieat7
„ �. _
Drama e°Area _
x.._
na e.A`rea,i==
I7rai �
,
• "
=Drama e.'Area
On -site Buildings/Lots (so
6895
On -site Streets (so
0
On -site Parking (so
20593
On -site Sidewalks (so
589
Other on -site (so
0
Future (so
0
Off -site (so
0
Existing BUA*** (so
0
Total (so:
28077
Stream Class and Index Number can be determined at: ltttl7.aortal.ncdetir.org/meMt) /ps/csu/classi catiotrs
�* Itntpervious urea is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version 07Jun2010 Page 3 of

'Report only that arrlount of existing BUA that zoill remain after developrneni. Do not report any existing BUA that
is to be reuroved and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
N/A
Proiects in Union County: Contact DIVQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that pray be subject to more stringent stormwater requirements as per NCAC 028.0600.
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 Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://portal.ncdenr.orgZweb/n/ws/su/statesw/forms dots. The complete
application package should be submitted to the appropriate DWQ 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 htt ortal.ncdenr.or web w ws su statesw
forms dots.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
fi5
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
AA
Form. (if required as per Part VII belozcr)
3. OriginaI of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
AS
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
ii5
http://www.envhelp.org/pages/onestopexpress.htmi 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 tAo pages) describing the stormwater treatment/managementfor
/i5 �Ca�es
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. if the receiving stream is reported as class SA or the
f!h
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the'/z
mile radius on the map.
7. Sealed, signed and dated calculations.
A�
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.
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 M1-IW (or NHW) of tidal haters.
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.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
in. 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.
Form SWU-101 Version 071un2010 Page 4 ol'6

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 AS
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
project 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 DWQ to verifij the S1 t VF prior
to subtnittal, [phone])
10. A copy of the most current property deed. Deed book: 1011 rage No: Soto
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 NCAC 21-1.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http://www.secretary.state.iic.us/Corporatioiis/CSearch.aspx
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
45
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of an), 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
htt ortaimcdennor web w ws/su/statesw/ forms dots. 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(s) 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 forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
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:Matthew Lowder, PE ^
Consulting Firm: Triangle Site Design, 1'LLC
Mailing Address:4006 Barrett Drive Suite 203
City:Raleigh
Phone: [phone]
Email: m lowder©trianglesitedesign.com
Sta te: NC
Fax:
Zip:27b09
IX. PROPERTY OWNER AUTHORIZATION (if Con fact Information, item 2 has been filled out, complete this
section)
I, (print or type narne of person listed in Contact Information, item 2a) Hoi t Deal certify that i
own the property identified in this permit application, and thus give permission to (print or type name cf person
listed in Contact Inforrtration, item 1a) Adarn Sellner with (print or type natne of organization listen in
Contact Information, item 1a) Printax Pro crties, LLC 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.
Fonn SWU-101 Version 07Jun2010 Page 5 of

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
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ 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 'vial penalties of up to 000-0per day, pursuant to NCGS 143-215.6.
Signature:—y�"`K"-� ' ' `C / 04 Date: ^Z Z- f�
�aa -e� 2-� tl wl S" Y tJ� y , a Notary Public for the State of n :rAV� r Q Co .A�, ounty of
do herd"eby certify that 10LY rLi t Ul) • �0.1 T personally appeared
before me thisaA day of [}l^iIR,VU c�'� and acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal, aAa4i,h,y,t a- iP t �`-
a.:�VNE STORY DEAL
NOTARY PUBLIC
Rl; "WAN COUNTY, NC
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires 8 - - 1 i
I, (print or type name of person listed in Contact Information, item 1a) Adam Sellner
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 .1000, SL 2006-246 (Ph. 1I - Post Construction) or SL 2008-211.
Signature: �L �� Date: fre4a !6y /00 zoa
1, SL4APAL a Notary Public for the State of�i9L�l-(^Y�_ Coulzty of
do hereby certify that 61�d&'111 personally appeared
before me this clay of and acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal,
GA
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Form SWU-101 Version 07Jun2010 Page 6 of