Loading...
HomeMy WebLinkAboutSW4100302_CURRENT PERMIT_20100713STORMWATER DIVISION CODING SHEET POST —CONSTRUCTION PERMITS PERMIT NO. SW 'YZ'Nf/.�cY� DOC TYPE � CURRENT PERMIT ❑ APPROVED PLANS ❑ HISTORICAL FILE DOC DATE 7/�3 YYYYMMDD f I �A NCDENR North Carolina Department of Environment and Natural Resou Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Governor fJrector l June �9, 2010 Mr. Gart Evans, Chairman Piedmont Triad Ambulance & Rescue, Inc. l PO Box 534 High Point, NC 27261 i Subject: Stormwater Permit No. SW4100302 i Piedmont Triad Ambulance & Rescue; Inc. High Density Commercial Infiltration Trench Project Randolph County Dear Mr. Evans: RECEIVED JUL 13 2010 Regional Office Dee Freeman Secretary The Stormwater Permitting Unit received a completed Stormwater Management Permit Application for Piedmont Triad Ambulance & Rescue, Inc. on June 8, 2010. Staff review of the plans and specifications has determined that the project, as proposed, will comply with the Stormwater Regulations set forth in Title 15A NCAC 2H.1000 and Session Law 2006-246. We are forwarding Permit No. SW4100302, dated June 9, 2010, for the construction, operation and maintenance of the subject project and the stormwater BMPS. r This permit shall be effective from the date of issuance until June 8, 2010, and shall be subject to the conditions and limitations as specified therein. Please pay special attention to the Operation and Maintenance requirements in this permit. Failure to establish an adequate system for inspection and maintenance of the stormwater management system will result in future compliance problems. If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to request an adjudicatory hearing upon written request within thirty (30) days following receipt of this permit. This request must be in the form of a written petition, conforming tolChapter 150B of the North Carolina General Statutes, and filed wit!i,i.he Office of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC 27611-7447. Unless such demarr;is are made this permit shall be final and binding. This project will be kept on file at the Winston-Salem Regional Office. If you have any questions, or need additional information concerning this matter, please contact Cory Larsen at (919) 807-6365 or cory.larsen@ncdenr.gov. r Sincerely, j forColeen H. Sullins cc: Winston-Salem Regional Office Central Files I SPU Files Mr. H Mack Summey Jr, PE, Summey Engineering Associates, PO Box 968, Asheboro, NC 27204 Wetlands and Stormwater Branch ? 1617 Mail Service Center, Raleigh, North Carolina 27699-1617 ' One Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 NorthCarrlol ina Phone: 919-607-63001 FAX: 919-607-64941 Customer Service: 1-877-623-6748 l �lltlir�l�l�� Internet: www.ncwatergLiality.org vv j An Equol Opportunity %Affirmative Action Employer v, 5 State Stormwater Permit Permit No.SW4100302 STATE OF NORTH CAROLINA �1 DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES DIVISION OF WATER QUALITY STATE STORMWATERI 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 II PERMISSION 15 HEREBY GRANTED. TO Piedmont Triad Ambulances & Rescue, Inc. (Permittee) Piedmont Triad Ambulance & Rescue, Inc. (Project) 108 East Balfour Avenue, Asheboro, Randolph County FOR711E i construction, operation and maintenance of eight (8) underground. infiltration trenches in compliance with the provisions of 15A'NCAC 2H .1000 and S.L.I2006-246 (hereafter referred to as the "stormwater rules'l 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 June 8, 2020, 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 1.6 of this permit. The stormwater control has been designed to handle the runoff from 23,910 square feet of impervious area. 3. The tract will be limited to the amount of built -upon area indicated above in this permit, and per the approved plans. 4. All stormwater collection and treatment systems must be located in either dedicated common areas or recorded easements. The final plays for the project will be recorded showing all such required easements, in accordance with the approved plans. The runoff from all built -upon area within th'e permitted drainage area of this project must be directed into the permitted stormwater control system. The following design criteria have been provided for the infiltration trenches and must be maintained at design condition: a. Infiltration Trench #1 as per the attached approved Infiltration Trench #1 Supplement form dated February 19, 2010. Page;11 of 6 .I State Stormwater Permit Permit No.SW4100302 b. Infiltration Trench #2 as p,�r the attached approved Infiltration #2 Trench Supplement form dated February 19, 2010.' C. Infiltration Trench #3 as per the attached approved Infiltration #3 Trench Supplement form dated February 19, 2010.� i i d. Infiltration Trench #4 as per the attached approved Infiltration #4 Trench Supplement form dated February 19, 2010, it I e. Infiltration Trench #5 as per the attached approved Infiltration #5 Trench Supplement form dated February 19, 2010. 11 f. Infiltration Trench #6 as per the attached approved Infiltration #6 Trench Supplc:rriew. form dated February 19, 2b10. " • , g. Infiltration Trench #7 as per the attached approved Infiltration #7 Trench Supplement form dated February 19, 2010. h. Infiltration Trench #8 as'per the attached approved Infiltration #8 Trench Supplement form dated February 19, 2010. L Receiving Streams/River Basin: Penwood Branch / Cape Fear j. Stream Index Number: 17I 12-1 k. Classification of Water Body: SCHEDULE OF COMPLIANCE 1 The stormwater management system shall be constructed in its entirety, vegetated and operational for its intended use prior to thl, 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 times provide thli operation and maintenance necessary to assure the permitted stormwater system functions at optimum efficiency. The approved Operation and Maintenance Plan must be followed irk 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. I� C. Mowing and revegetation of slopes and the vegetated filter. d. Immediate repair of eroded areasjj e. Maintenance of all slopes in accordance with approved plans and specifications. f. Debris removal and unclogging oflloutlet structure, orifice device, flow spreader, catch basins and piping. g. Access to the outlet structure must be available at all times. 4. Records of maintenance activities must be kept and made available upon request to authorized personnel of DWQ. The records will indicate the date, activity, name of person," , performing the work and what acti. ns veere taken, 5. The facilities shall be constructed as shown on the approved plans. This permit shall become voidable unless the facilities are constructed in accordance with the conditions of this permit, the approved plans and specifications, and other supporting data. I 1, 6. Upon completion of construction, prior to issuance of a Certificate of Occupancy, and prior to I Pane ? of 6 State Stormwater Permit Permit No.SW41 00302 operation of this permitted facility, a certification must be received from an appropriate designer for the system installed certifying that the,permitted facility has been installed in accordance with this permit, the approved 1plans and specifications, and other supporting documentation. Any deviations from the approved plans and specifications must be noted on the Certification. A modification may be required -for those deviations. . ", 7. 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. 8. Access to the stormwater facilities shall bel maintained via appropriate easen cents at all times. 9. The permittee shall submit to the Director and shall have received approval for revised plans, specifications, and calculations prior to con truction, for any modification to the approved plans, including, but not limited to, those lis ed below: a. Any revision to any item shown onitke 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 10. 11, 12. area. Further subdivision, acquisiti project area is defined as';all Sedimentation and Erosion C Filling in, altering, or piping c plan. The permittee shall submit final site shown on the approved plans, prior t r sale of all or part of the project area. The wned by the permittee, for which i approval or a CAMA Major permit was sought. !tative conveyance shown on the approved grading plans for any permitted future areas tion. 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 otj the completion of construction. The Director may notify the permittee whenithe 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 schele to the Director for modifying the site to meet minimum requirements. The permittee shall provide copies of revised plans and certification in writing to the Director that the changes have been made. 111. GENERAL CONDITIONS 1. This permit is not transferable except afterhot ice 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, to the Division of Water Quality, signed by both parties, and accompanied by supporting documentation has listed on page 2 of the form. The project must be in good standing with the Division. The approval of this request will be considered on its merits and may or may not be approved. 2. The permittee is responsible for compliance with all permit conditions until such time as the Division approves the transfer request. 3. Failure to abide by the conditions and limitations contained in this permit may subject the Permittee to enforcement action by the DivI"ision of Water Quality, in accordance with North .Carolina General Statute 143-215.6A to 143- 215.6C. A. The iss; ance of this permit does not precluide,rhe 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 j` risdiction. 5. In the event that the facilities fail to perform satisfactorily, including the creation of nuisance Page 3 of 6 State Stormwater Permit Permit No.SW4100302 conditions, the Permittee shall take immediate corrective action, including those as may be required by this Division, such as the consitruction of additional or replacement stormwater management systems. I I 6. The permittee grants DENR Staff permission to enter the property during normal business hours for the purpose of inspecting all co Id i10nents of the permitted stormwater management facility. 7. The permit issued shall continue in force effect until revoked or terminated. The permit It may be modified, revoked and reissued or'Iterminate�d for cause. The filing of a request for a permit modification, revocation and re -issuance or termination does not stay any permit condition. i 8. Unless specified elsewhere, permanent'seeding requirements for the stormwater control must follow the guidelines established in the Ndrth 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 15A NCAC 2H.1000, and NCGS 143-215.1 et:al. 11. The permittee shall notify the Division p; any -name, ownership or mailing addr'.ss changesLat least 30 days prior to making such chang �s. 12. The permittee shall submit a renewal req est with all required forms and documentation at least 180 days prior to the expiration date of this permit. Permit issued this the 91" day of June, 2010. �I NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION forColeen H. Sullins, Director . Division of Water Quality By Authority of the Environmental Manag Commission Pnn'$4nf6 ' State Stormwater Permit (0/, Permit No.SW4100302 PIEDMONT TRIAD AMBULANCE & RESCUE, INC. EAUG cl r� Stormwater Permit No. SW4100302 N.C.Randolph County 1 2U10 on..,. - Designer's Certification nal o-`: I, _ 1 S+IMn►i cif as a duly registered _Tf1�I in the State of North Carolina, having been authorized to observe (;mo(riodically/ weekly/ full time) the construction of the project, Piedmont Triad Ambulance & Rescue, Inc. (Project) for 1 T PA, r-c_ (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. I The checklist of items on page 2 of this form is included in the Certification. Noted deviations from approved plans and specification: Signature JJ' f RegistrationNumber & `7 `7 l sa Date d —11-1a SEAL HA I I '4+�0 o' QQ 9 AL r. 26447 4-1 IA o !!f?+III}}plll Page 15 of 6 State Stormwater Permit Permit No.SW4100302 Certification Requirements: Y contains the 1. The drainage area to the system approximately permitted acreage. V 2. The drainage area to the system contains no more than the permitted amount of built - upon area. V 3. All built -upon area assor.'.:Aed 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 as specified on. plans. N/A 5. The outlet/bypass structure elevations are per the approved plan. NIA 6. The outlet structure is located per the approved plans. N/A 7. Trash rack is provided on,the outlet/bypass structure. �8. All slopes are grassed with permanent vegetation. ✓9. Vegetated slopes are no steeper than 3:1. / �/ 10. The inlets are located per the approved plans and do not cause short-circuiting of the system. 1. 11. The permitted amounts of surfacE area and/or volume have been provided.. _v/_12. Required drawdown devices Zr2 correctly sized per the approved plan,--. ✓ 13, All required design depths are provided. _V_/14. All required parts of the system are provided, such as a vegetated shelf, and a' forebay, if required. , �15. 4 The dimensions the required system are provided per approved plans. Upon.completion of the project please submit thissDesjgner's Certification to: Winston-Salem Regional Office Surface Water Protection 585 Waughtown Street Winston-Salem, NC 27107 Page 6 of 6 State Stormwater Permit Permit No.SW4100302 PIEDMONT TRIAD AMBULANCE & RESCUE, INC. StormwatF',' Permit No. SW4100302 RanOolph Court Designer's Certification I, , as a duly regis North Carolina, having been authorized to observe the project, Piedmont Triad Ambulance & Rescue, Inc. (Project) rered in the State of (!,)eriodically/ weekly/ full time) the construction of 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 G'i;F-101 5of6 State Stormwater Permit Permit No.SW4100302 Certification Requirements: .1. 2. 3 4. _NIA 5. _NIA 6. _NIA 7. 8. 9. 10 15 The drainage area to the system d' ntains approximately the permitted acreage. The drainage area to the system contains no more than the permitted amount of built - upon area. All built -upon area associ;Ited with the project is graded such that the runoff drains to. the system. All roof drains are located such,th t the runoff is directed into the system as specified on plans. The outlet/bypass structure ClevaJions are per the approved plan. r The outlet structure is located per the approved plans. Trash rack is provided on the outE It/bypass structure, All slopes are grassed with permanent vegetation. Vegetated slopes are no steeper tan 3:1. The inlets are located per the approved plans and do not cause short-circuiting of the system. The permitted amounts of surface area and/or,volume have been provided. Required drawdown-devices are correctly sized per the approved plans. I All required design depths are provided. All required parts of the system ar provided,, such as a vegetated shelf, and a forebay, if required. The required system dimensions J,r e provided per the approved plans. Upon completion of the project please submit this igner's Certification to: Winston-Salem Regional Office Surface Water Protection '• 585 Waughtown Street Winston-Salem, NC 27107 Pane16 of 6 f ' 108 East Balfour Avenue, Asheboro, NC - Google Maps http://maps.google-corWmaps?Fq&source=s_q&hl=en&geocode=&... Googlemaps Address 108 E Balfour Ave Get Google Maps on your phone Asheboro, NC 27203 - Text the word "GMAPS" to466453 i� f� Gr�een4�vn 5 1 I fn; a Ic Spero.Rd � S`viimm ng oo1 4� P5, 2 4 s.' ' t �o. � I'�!-.-fntltK�S!•'E:SlnClerSt`1 r� V, . .A. 220 �' v Sharon Ave J sh�ai Elein aryl SchoolA. ff f1jJ ff _�' k North Asheboro: Irt4iddle{{School w8ar i I • �1- f6y� ^�y LPopIaFS1`�. � EBalleyst 220 . a �Unda orsl 1 w.eeas�ey.st Y • , �� ,-Jvl,- r , �' q � '�.F•lughgs 51 . �'`.. w I ter__- 2 �Ashleyis,r . � i! '��7rcmoeit:Pr VZ { aft �,Cnglish:St V II o 220 s m 1 ��•••• .. i 4 rS 5 .m ySaIlR�efS�r P ®2011"Google'- Map data ®2011,G 1 of 1 7/6/2011 l 1:29 AM Permit No. 5 W �Ll eO307- (to be provided by DWQ) STORMWATER MANAGEMENT PERMIT APPLICATION FORM . .�. 401 CERTIFICATION APPLICATION FORM MCDENR INFILTRATION TRENCH SUPPLEMENT This form must be filled out, printed and submitted, The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information. TRWI:CUNFOR ATION r Ewa f ,��;us,, 1y� :��y•� g�g r , ,, :. .,, ,. ,x sr, a,. 4 ^3:x% ...i�:k9tt r. e.#'vs er.n,,.s.'A Project name Piedmont Triad Ambulance &' Rescue Contact person H. Mack Summey, Jr., PE _ Phone number :33W28.0902 Date 2/19r2010 Drainage area number 1 II: DESIGN1INFAORMATIONf, s I � " ;'..M ' �"-1::r4.f 902 Site Characteristics Drainage area Impervious area Percent impervious Design rainfall depth Peak Flow Calculations 1-yr, 24-hr rainfall depth 1-yr, 24-hr intensity Pre -development 1-yr, 24-hr discharge. Post -development 1-yr, 24-hr discharge Pre/Post 1-yr, 24-hr peak flow control Storage Volurr'e: Non -SA Waters Minimum volume required Volume provided Storage Volume: SA Waters 1.50 runoff volume Pre -development 1-yr, 24-hr runoff volume Post -development 1-yr, 24-hr runoff volume Minimum volume required Volume provided. Soils Report Summary Soil type Infiltration rate SHWT elevation Trench Design Parameters Drawdown time Perforated pipe diameter Perforated pipe length Number of laterals Stone type (if used) Stone void ratio Stone is free of fines? 110,142.00 ft 9,237.00 ft2 91.1% % -1.00: in 2.79 'in .0.12 .. ' ':. in/hr 0.01 :, ft3Isec .0.02 ::..:,. it3lsec 0.01 1 ft3lsec,, .735.02:- ... ft3 ✓ 800.00 . r:. ft3. ft3 ft3 ;ft3 ft3 ft 3 Sandy Clay Loam:`- '2.50 inlhr 96.20 . r, :fmsl Approved �rnr=,,>r.�..�;' Construction in required by the pt;rr,it. North Carolina rules require that the s nrrr :v, #, : system designer Inspect during construcjir ; Ck`' iFy confnrmrty w th the plans and specs; and cc';;ity c mpiiance wv th the . storrnwater rules. (€ 5A ,100a (t)) 6 q D Permit # SL4 4[! o 0� d L _ _ D 3t,, —I i1 N,(. D.;vision of?Afater Quality OK for non -SR waters 0.15.. days OK 0.00 in : 0.00:.: It 0: 57 0.4.. y (Y or N) OK Form SW401 •lnfiltralion Trench-Rev.4 Parts I. & II. Design Summary, Page i of 2 = Permit No. (to be provided by DWQ) Trench Elevations Bottom elevation 99.20 lmsl ' OK , ..- Storageloverflow elevation 10E.20 fmsl, Top elevation 102.20 fmsl . Trench Dimensions Length (long dimension) 125.00 ft Width (short dimension) 8.00 ft Height (depth) 2.00 ;:. ft OK Additional Information Maximum volume to each inlet into the trench? 0:02 ac-in OK Length of vegetative filter for overflow 30.00 '-ft OK Number of observation wells 1.. r OK Distance to structure . 15.00 ft OK Distance from surface waters 30.00 ft OK for non -SA waters Distance from water supply well(s) 1-,000.00 ft OK Separation from impervious soil layer 6.00 ;;. .ft OK Depth of naturally occuring soil above SHWT 6.00 h OK Bcttom covered with 4-in of clean sand? y (Y or N) OK Proposed drainage easement provided? y _ (Y or N) OK Capures all runoff at ultimate build -out? y (Y or N) OK Bypass provided for larger storms? y „ . (Y or N) . OK Trench wrapped with geotextile fabric? y ? :.:: (Y or N) OK Pretreatment device provided grass strip prior to trench f Form SW401-Infiltration Trench-Rev.4 Parts 1. & 11. Design Summary. Page 2 of 2 Permit No. (to be provided by DWQ) STORMWATER MANAGEMENT PERMIT APPLICATION FORM 401 CERTIFICATION APPLICATION FORM NC®ENR INFILTRATION TRENCH SUPPLEMENT This form must be filled out, printed and submitted. The Required Items Checklist (Part tit) must be printed, filled out and submitted along with all of the required information. L:PRO:IECTINFORMAiiONx:`i�;��'��. Project name Piedmont Triad Ambulance & Rescue Contact person H..Mack Summey,'Jr., PE Phone number 336.328-0902 Date 2/19/2010 Drainage area number 2 ll D1SIGN1[F.,aRMATION�1''` #1t.`:r k.;fir` .' Site Characteristics Drainage area Impervious area 2,536.00`.- ft2 Percent impervious 85.2% % Appr•ovr_ct E�trrrr? rr ,t §r �s•-r:It �oeurl�ents Design rainfall depth 1.00 .in C arsGtcuctian ifs nc .u: ._,r <; ti,: t. inese do prn,Mnts is required by the stc,�.ir.',w&te, L::rr�i;, North Carolina Peak Flow Calculations rules require that the st01rnwa1er systern desiuner 1-yr, 24-hr rainfall depth 2.7g `; ` :; .in Inspect during constrc3c; o, ; ;_or;;ty conformity vrith the plans and specs: and urtity ",;r,pliancE- w th the 1-yr, 24-hr intensity 0 12 ir1111r stnrrnwater rules. ( I;A NGAC 2t1 .1003 Pre -development 1-yr,24-hrdischarge ;>:>:.0.00 :' ft3lsec Permit# SW&f jOa? uz pate Post -development 1-yr, 24-hr discharge ft3lsec by �L — �t=: Division nf'rrrater Quality Pre/Post 1-yr, 24-hr peak flow control 0.00 ft3iSec ` St1eft #____l,avision prate Storage Volume: Non -SA Waters Minimum volume required 202.60. < ft3 Volume provided 208.00 ft3 OK for non -SR waters Storage Volume: SA Waters 1.5" runoff volume ft3 Pre -development t -yr, 24'hr runoff volume ft3 Post -development 1-yr, 24-hr runoff volume ft3 Minimum volume required ft3 Volume provided ft3 Soils Report Summary Soil type Sandy Clay loam Infiltration rate inittr SHWT elevation 96.20 fmsl Trench Design Parameters Drawdown time 6.16.:' days OK Perforated pipe diameter 0.00 in Perforated pipe length 0.00 ft Number of laterals :0 Stone type (if used) : 57: Stone void ratio 0.4 Stone is free of lines? y (Y or N) OK Form SW401-infiltration Trench-RevA Parts I. & II. Design Summary, Page t of 2 Permit No. (to be provided by D WQ) Trench Elevations Bottom elevation 100.20 fmsl OK Storage/overflow elevation 102.20 fmsl Top elevation 102.20 .fmsl Trench Dimensions Length (long dimension) ; 65.04 It Width (short dimension) 4.00 ft Height (depth) 2.00 : ;; <ft OK Additional Information - Maximum volume to each inlet into the trench? 0.00 ac-in OK Length of vegetative filter for overflow 30.00 :: ft OK Number of observation wells 1 OK Distance to structure ":: ,15.00. . ft OK Distance from surface waters ....30.00 ft OK for non -SA waters Distance from water supply well(s) 1,000.00.:..ft . OK Separation from impervious soil layer '6.00 :` . -A OK Depth of naturally occuring soil above SHWT :-­ :6.00 ::.' . ft OK Bottom covered with 4-in of clean sand? y (Y or N) OK Proposed drainage easement provided? y (Y or N) OK Gapures all runoff at ultimate build -out? _ y ;;: (Y or N) OK Bypass provided for larger storms? _ y (Y or N) OK Trench wrapped with geotextile fabric? y . ', :::< (Y or N) OK Pretreatment device provided : grass'strip prior to trench Form SW401-Infiltration Trench-Aev.4 Parts I. & H. Design Summary, Page 2 of 2 t Permit No. .5W41 00342- (to be provided by DWQ) ,.....,. . STORMWATER MANAGEMENT PERMIT APPLICATION FORM 3 401 CERTIFICATION APPLICATION FORM C ENR INFILTRATION TRENCH SUPPLEMENT This farm must be filled out, printed and submitted. The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information. Project name Piedmont Triad Ambulance & Fescue Contact person H. Mack Surrimey, Jr., PE Phone number 336-328-0902 Date 211412010 brainage area number 3 flF}IC IGNIIN ORMA I Ili F' q :� S 1} m;ti"'i'•�``- ����F� • :i; yu �- .fir w t, 5 t-.... y, a ,y-�,� •r�r:... 7 �'r>,:ir�ldrin:. .:�'.f;��i`n �!'... +.r�```�i�+LS.? fig=,T�•�..G`�'.�y^�:%xc�;lSiiRS"�i''F�i" �::; .,d Site Characteristics Drainage area 4,954.00 . :. ft� Impervious area 4,330.00: 02 Approved Sta rrit'Wate^F 'r"�Mfti t;acuntrrltr Percent impervious 87.4% % CbnstrtlCtiors it scror•:i� t tt, three dacum nos is Design rainfall depth 1.00 in required by the siu}m.w�t,l, NNr tit. North Carolina rules require iha"h Peak Flow Calculations 1-yr, 24-hr rainfall depth 1-yr, 24-hr intensity Pre -development 1-yr, 24-hr discharge Post -development 1-yr, 24-hr discharge Pre/Post 1-yr, 24-hr peak flow control Storage Volume: Non -SA Waters Minimum volume required Volume provided Storage Volume: SA Waters 1.5" runoff volume Pre -development 1-yr, 24-hr runoff volume Post -development 1-yr, 24-hr runoff volume Minimum volume required Volume provided Soils Report Summary Soil type Infiltration rate SHWT elevation Trench Design Parameters Drawdown time Perforated pipe diameter Perforated pipe length Number of laterals Stone type (i used) Stone void ratio Stone is free of fines? In pecf during constrac:;,� :; ccriiiy coriform y yviih the ern desiqer plans and specs; and cciplit" M-m-ptiance with the 2.79 in stnrmwater rules. ( 15A N SAC H .1008 {!) ) 0.12'' in/hr Permit "—�H-L3C z Date to fO tz e Q flO "fi31SeC Y ` _ _ _ NC DiOsion of'rt'afer Quality 3h8irt- 0.01 ft'Isec 345.00. • .: ft3 :360.00 `:.. ftR �'' OK for non -SR waters ft' . ft3 ft3 ' ft3 Sandy Clay loam-.,., ; 2.50 inthr 95.20 fmsl 0.15 days OK 0.00 in 0.00 ft 0 57 0.4 y (Y or N) OK Form SW401 -infiltration Trench-Rov.4 Parts I. & II. Design Summary, Page 1 of 2 Permit No. (to be provided by DWO) Trench Elevations Bottom elevation Storage/overflow elevation Top elevation Trench Dimensions Length (long dimension) Width (short dimension) Height (depth) Additi onal Information Maximum volume to each inlet into the trench? Length of vegetative filter for overflow Number of observation wells Distance to structure Distance from surface waters Distance from water sup'ply well(s) Separation from impervious soil layer Depth of naturally occuring soil above SHWT Bottom covered with 4-in of clean sand? Proposed drainage easement provided? Capures all runoff at ultimate build -out? Bypass provided for larger storms? Trench wrapped with geoiextile fabric? Pretreatment device provided 99.20 fmsl OK 101.20 fmsl 101.20 fmsl .90.00. ft 5.00 .: 111 2.00 ft OK 0.01 ;.:; ac-in OK = 30,00' -ft. OK 1 OK 15.00. ft OK 30.00; .» ' ft. OK for non -SA waters 1,000.00. ft OK 6.00 ft OK 6.00 tt. OK .,:(Y or N) OK Y:.: ::: (Y or N) OK y (Y or N) OK y (Y or N) OK y (Y or N) OK '.grass strip prior to trench I Form SW401-Infiltration Trench•Rev.4 Parts I. & II. Design Summary, Page 2 of 2 Permit No. 5 VJ Lf 100 30 2, i (ro be provided by DWO) STORMWATER MANAGEMENT PERMIT APPLICATION FORM 401 CERTIFICATION APPLICATION FORM 04 HC®EHR INFILTRATION TRENCH'SUPPLEMENT This form must be filled out, printed and submitted. The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information. I'PROJEC7.INPORMATIONt ?r'F' Project name Piedmont Triad Ambulance & Rescue Contact person H: Mack Summey, Jr., PE . Phone number 336-32U902• Date 211912010-.: Drainage area number 4 Site Characteristics' Drainage area 2,351.00 . ft2 Impervious area Percent impervious 1,990.00 0 84.fi/o ftZ o Jo Approved t;trc;t Ci�cument!: Construe,;ion :n �� �,, + ,rFi Design rainfall depth 1.00 in ..;;rn ;t:ese documents is required 6y fire ;;tar�v ,ester pe;,nit. North Carolina rules require that the Peak Flow Calculations ;;c:inwaver ,ystem designer Inspect Ouring constrc;c ,,:r ; Cc:rify conformity with the plans and specs; ancf ccrfi rj cgrrapliance 1 r 24-hr rainfall depth Y � p 2.79:` ' in w'th the storrnwater rules. I'SA r' i W.), ( c ,�.H . a o0a 1 Yr, 24-hr intensity 0.12 . '` inmr / _.L--..-....._._.—__ Date Pro -development 1-yr, 24-hr discharge 0.00:,. ft'/sec by ��' NC Division of Water Quality Post -development 1-yr, 24-hr discharge 0.01.., ft3/sec She"t #= _Revision bate Pre/Post 1-yr, 24-hr peak flow control 0.00 ft3/sec Storage Volume: Non -SA Waters Minimum volume required 159.00 . ft3 Volume provided 246.00 ft3. OK for non -SR waters Storage Volume: SA Waters 1.5' runoff volume Pre -development 1-yr, 24-hr runoff volume ft3 Post -development 1-yr, 24-hr runoff volume 03 Minimum volume required 83 Volume provided ' na Soils Report Summary s Soil type r .- San Clai Loa m Infiltration rate .. :`.<2.50=«.'<'::inlhr SHWT elevation :m 9420 ' fmsl Trench Design Parameters Drawdown time 0r13". .: days OK Perforated pipe diameter 0.00 in Perforated pipe length 0.00 ft Number of laterals 0 Stone type (if used) 57 Stone void ratio ` . 0.4 ` Stone is free of fines? _ .' y (Y or N) OK Form SW40 1 -Infiltration Trench-Rov.4 Parts I. & Ir. Design Summary, Page 1.of 2 Permit (to be provided by DWG?) Trench Elevations Bottom elevation Storage/overflow elevation Top elevation Trench Dimensions Length (long dimension) Width (short dimension) Height (depth) Additional Information Maximum volume to each inlet into the trench? Length of vegetative filter for overflow Number of observation wells Distance to structure Distance from surface waters Distance from water supply well(s) Separation from impervious soil layer Depth of naturally occuring soil above SHWT Bottom covered with 4-in of clean sand? Proposed drainage easement provided? Capures all runoff at ultimate build -out? Bypass provided for larger storms? Trench wrapped with geotextile fabric? Pretreatment device provided 97.70 . -'. fmsl OK 100.20 fmsl 100.20 fmsl 41.00 ft 6.00 ft 2.50 ft OK 0.(,14ac-in OK 30.00 �ft OK OK 15.00 ft OK 30.0^ ft OK for non -SA waters 1,000.60 ' --ft OK . 6.00- :. ' ft OK 6:00 `.' ..:: ft OK Y' (Y or N) OK (Y or N) OK y (Y or N) OK y . (Y or N) _ OK grass strip rior.to trench Form SW401-Infiltration Trench•Rev.4 Parts I. & II. Design Summary, Page 2 or 2 Permit No._ (to be provided by DWO) 5 +�i STORMWATER MANAGEMENT PERMIT APPLICATION FORM ��&2 A, 401 CERTIFICATION APPLICATION FORM NCDENR INFILTRATION TRENCH SUPPLEMENT This form must be filled out, printed and submitted. The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information. INPRWECZINFORMATIOK�"r Project name Piedmont Triad Ambulance &Rescue Contact person H. Mack Summey, Jr., PE Phone number 336-328.0902 . Date 2/19/2010 Drainage area number 5. Site Characteristics Drainage area Impervious area Percent impervious Design rainfall depth Peak Flow Calculations 1-yr, 24-hr rainfall depth 1-yr, 24-hr intensity Pre -development 1-yr, 24-hr discharge Post -development 1-yr, 24-hr discharge Pre/Post 1-yr, 24-hr peak flow control Storage Volume: Non -SA Waters Minimum volume required Volume provided Storage Volume: SA Waters 1.5" runoff volume Pre -development 1-yr, 24-hr runoff volume Post -development 1-yr, 24-hr runoff volume Minimum volume required Volume provided Soils Report SPmmar Soil type Infiltration rate SHWT elevation Trench Design Parameters Drawdown time Perforated pipe diameter Perforated pipe length Number of laterals Stone type (if used) Stone void ratio Stone is free of fines? 869.00 ftz 600.00 ftz 69.0% % 1.00 in :.2.79 '..' ;:, in 0:12..:::.: inmr : 0.w : . , ftyfsec 4.00. ft3lsec 0.00 ft3lsec 46.00 .. ft3 140.00 ft3 ft3 ft3 rya ft3 ff° Sandy Clay. Loam . 2.50. inlhr 92.20 fmsl Pjb days 0.00 in 0.00 ft 0 .ri7 . Adsprove d a._ , .�;, ; ,sc:rrmen[r Construction irs C1CM.„�.. •,;;1;: t`e:te 6: umant,5 is required by the 'rh t. rr;nu North Carolina rules require: that the stor'nrov:s,er system de,inner Inspect during construc.t;cr, C'e tify conror.nity viith the plans and specs; and O-Aitp c,-.'Opliance w;th the stormwater rules. (15A MCA- } -I Permit# SwKfeo3d`?_ oate� JO rfo by--..0 L _ _.� i,G Division of Wa:er Quality Shea # — Revision hate . ` OK for non -SR waters Ce . 0.4 y (Y or N) OK Form SW401-Infiltration Trench-RavA Parts I. & It. Design Summary, Page 1 of 2 Permit No. (to be provided by DWQ) Trench Elevations Bottom elevation. 95.70 fmsl OK Storage/overflow elevation 98,20 fmsl Top elevation 98.20 fmsl Trench Dimensions Length (long dimension) 20,00 h Width (short dimension} 7.00 fl Height (depth) 2.50 0 OK Additional Information Maximum volume to each inlet into the trench? 0.00 ac-in OK. Length of vegetative filter for overflow 30.00 It OK Number of observation wells 1 OK Distance to structure 15.00 ...;ft OK Distance from surface waters 30.00 : :.: ft OK for non -SA waters Distance from water supply well(s) .1,000.017. `.' it OK Separation from impervious soil layer 6.00 ft OK Depth of naturally occuring soil above SHWT 6.00 :ft OK Bottom covered with 4-in of clean sand? y (Y or N) OK Proposed drainage easement provided? y '(Y or N) OK Capures all runoff at ultimate build -out? ;-` y`:, ..'. (Y or N) OK Bypass provided for larger storms? :.y (Y or N) OK Trench wrapped with geotextile fabric? -y `(Y or N) OK Pretreatment device provided morass strip prior to trench Form SW401-Infiltration Trench-Rev.4 Parts I. & II. Design Summary, Page 2 of 2 Permit No. �W�fI oo3o 7— (to be provided by DWQ) 07 &V4**AV' STORMWATER MANAGEMENT PERMIT APPLICATION FORM lC� .,�,.. 401 CERTIFICATION APPLICATION FORM YHENR INFILTRATION TRENCH SUPPLEMENT This form must be filled out, printed and submitted. The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information, 14PR0JECT;:INF0RMAT1f}N= r � � � �' ��g=tm t� : � _ � � .e �r. ` ���. r`w .� t.>F*;t ".�E� Project name P:eomontTriad Ambulance &Rescue Contact person K Mack Surnmey, Jr., PE Phone number 336-328.0902 Date 2/19/2010 Drainage area number 6 ;;- i DESIGN? NF I' MATT N� M :a 4 Site Characteristics Drainage area Impervious area Percent impervious Design rainfall depth Peak Flow Calculations 1-yr, 24-hr rainfall depth 1 •yr, 24-hr intensity Pre -development 1-yr, 24-hr discharge Post -development 1-yr, 24-hr discharge PrelPosl 1-yr, 24-hr peak flow control Storage Volume: Non -SA Waters Minimum volume required Volume provided Storage Volume: SA Waters 1.5" runoff volume Pre -development 1-yr, 24-hr runoff volume Post -development 1-yr, 24-hr runoff volume Minimum volume required Volume provided Soils Report Summary Soil type Infiltration rate SHVVf elevation Trench Design Parameters Drawdown time Perforated pipe diameter Perforated pipe length Number of laterals Stone type (if used) Stone void ratio Stone is free of fines? 727.00 :... ft2 `'477.00 `` ftz 65.6% % 1.00 in .2.79 in 0.12 inlhr ..::ft315eC 0.00 :::: ,ft3lsec 0.00 ft3/sec 42.00. 1t3 ft3 ft3 ft3 ft3 Sandy Clay Loam. 2.50 "inlhr 92,20 Amsl Approvedf COnstructlOnI1 re uir4d � r , r.i'ei;;3 cir::um�rrltr; is a. y the st�¢'rsv:.;'rr: a North C�irulira I utes require th if the s;rr rrt:;t t r ry;;tern designer lnspectduring ecnstrur.;.:c:r -+ Plans and Specs; and „.rrtE, , ..`,. Y3 COnforrni,,y 4vlth the stol'snwater rules. (15f� a`;:,,. `'1, iarlcc: wah the eaa (l) ) Permit Z Division of `1r+ater QualitJ �+tl't3C --- ' .._F,evision Leta OK for non -SR waters 0.15. days OK 0.00 : in 0.00 . ft 0 57 0.4 y (Y or N) OK Form SW401-Infiltration Trench-Rev.4 Parts I. & 11. Design Summary, Page 1.0f 2 Permit No. (to be provided by DWQ) Trench Elevations Bottom elevation Storageloverflow elevation Top elevation Trench Dimensions Length (long dimension) Width (short dimension) Height (depth) Additional Information Maximum volume to each inlet into the trench? Length of vegetative filter for overflow., Number of observation wells Distance to structure Distance from surface waters Distance from water supply well(s) Separation from impervious soil layer Depth of naturally occuring soil above SHWT Bottom covered with 4-in of clean sand? Proposed drainage easement provided? Capures all runoff at ultimate build -out? Bypass provided for larger storms? Trench wrapped with geotextile fabric? Pretreatment device provided 96:20 fmsl OK 98,20 fmsl 98.20 fmsl 15.00 ft . 3.50 ft 2.00 ft OK 0.00 :ac-in OK 30.00 Aft OK . t: OK 15.00 ; ft OK 30.00 ft OK for non -SA waters 1,000.00. : <; ft OK . 6.00 ft OK 6.00 It OK - y ': (Y or N) OK y : (Y or N) OK y '. (Y or N) OK y (Y or N) OK y ': (Y or N) OK grasastrip prior to trench :. t , Form SW401-Infiltration Trench-Rev.4 Parts I. & 11. Design Summary, Page 2 of 2 Permit No. t wo Z_ (to be provided by DWQ) AMMAI STORMWATER MANAGEMENT PERMIT APPLICATION FORM 401 CERTIFICATION APPLICATION FORM ` MCDENR INFILTRATION TRENCH SUPPLEMENT This form must be filled out, printed and submitted. The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all of the required information. s I-PRQJECTtiINF08MATIONWk sti , Project name Piedmont Triad Ambulance & Rescue Contact H person „• - -- p .Mack Summey, Jr., PE . Phone number 336-328-0902 Date 2/19/2010 Drainage area number 7; Site Characteristics Drainage area 2,475:00 ft2 Impervious area _ 1,792.00 ft2 . Percent impervious 72.4% % , pps cvcwf i •„ .«,, :! s,,.; , : ;,:; i:�umentz Design rainfall depth 1.00 in Conslrucby;a�e,•e dc�cumonts is required by trtie si +r :;:rci :,, ,; ,;nit. North Carolina Peak Flow Calculations rules require. that tP;e ItJ;*r .r3iit 5 d . y..terr esicsrei• 1-yr, 24-hr rainfall depth 2.79 in Inspect during conforrniiy with the plans and spacs: nand :npliance with the 1-yr, 24-hr intensity 0.12 inlhr aorrnwater rules. Pre development 1 yr, 24 hr discharge 0.00 ;. ft%ec Permit ir— Sy/�_id4,�Q 2.__� Date 6% to Post -development 1-yr, 24-hr discharge 0.01 :: ft3lsec by— -� �' — — C Division of'iVater Quahly Pre/Post 1-yr. 24-hr peak flow control 0.00 ft3lsec Sheet ---- 1 'evision Date — Storage Volume: Non -SA Waters Minimum volume required <144.00 ft3 Volume provided ::J M,00.: ft3 OK for non -SR waters Storage Volume: SA Waters 1,5" runoff volume ft3 Pre -development 1-yr, 24-hr runoff volume ff3 Post development 1 yr, 24 hr runoff volume n3 Minimum volume required ft3 Volume provided:ft3 Soils Report Summary o Soil type ' • Sandy Clay. Loam Infiltration rate `2.50 " ::.inlhr SHWT elevation 94.20 :.fmsl Trench Design Parameters Drawdown time 0.20 : days OK Perforated pipe diameter 0,00 in Perforated pipe length ':' 0.00 . ' <` it Number of laterals 0 :. Stone type (if used) 57 Stone void ratio 0.4' Stone is free of fines? Y :Ay or N) OK Form SW401-Infiltration Trench-Rev.4 Parts I. & If. Design Summary, Page 1 of 2 Permit {to be provided by OWQ) Trench Elevations Bottom elevation Storage/overflow elevation Top elevation Trench Dimensions Length (long dimension) Width (short dimension) Height (depth) Additional Information Maximum volume to each inlet into the trench? Length of vegetative filter for overfiow, Number of observation wells Distance to structure Distance from surface waters Distance from water supply wells) Separation from impervious soil layer Depth of naturally occuring soil above SHWT Bottom covered with 4-in of clean sand? Proposed drainage easement provided? Capures all runoff at ultimate build -out? Bypass provided for larger storms?. Trench wrapped with geotextile fabric? Pretreatment device provided 97.70 fmsl OK 100.20 fmsl 100'.20 fms9 r 37A ft 4.00 ft 2.50 ft , OK 0.00 ac-in OK 30.00 ft OK 1 OK 15.00 It OK 30.00 It OK for non -SA waters .1,000.00. ft OK 6.00 :ft OK 6.00 It OK y (Y or N) OK ":.y : (Y or N) OK y (Y or N) OK y (Y or N) OK .. y . (Y or N) OK rass strip prior to trench Form SW401-Infiltration Trench-Aev.4 Parts 1, & 11. Design Summary, Page 2 of 2 Permit No. __7WLf 100 3 02— (to be provided by D INQ) AVmh STORMWATER MANAGEMENT PERMIT APPLICATION FORM 401 CERTIFICATION APPLICATION FORM EN IL RED INFILTRATION TRENCH SUPPLEMENT KDK This form must be filled out, printed and submitted. The Required Items Checklist (Part III) must be printed, filled out and submitted along with all of the required information. Project name Pidd.mont Triad Ambulance & Rescue Contact person H; Mack Summey,'Jr., PIE. Phone number 336-328-0902. Date 2JI912010 Drainage area number 8 II: D E S I G N; I N F 0 R MATI 0 IN 16 9; a - M, m g: 3fe' Site Characteristics Drainage area 3,596.00 fi2 Impervious area ::.2,948.00 ft2 Percent impervious 82.0% % Design rainfall depth 1.00 in Peak Flow Calculations -yr, 24-h r rainfall depth 239 in I -yr, 24-h r intensity 0;12::::.,:. in/hr'- Pre-development 1 -yr, 24-hr discharge 0.00.... ft/sec Post -development 1 -yr, 24-hr discharge It"i'sec Pre/Post 1 -yr, 24-hr peak flow control HO _0/sec Storage Volume: Non -SA Waters Minimum volume required :236.00 ft3 Volume provided 240.00 ft3 V" Storage Volume: SA Waters 1.5" runoff volume ft3 Pre -development I yr, 24-h r runoff volume ft3 Post -development 1-yr, 24-hr runoff volume ft3 Minimum volume required ft3 -Volume provided ft3 Solis Report Summary Soil type Sandy Claylbam. Infiltration rate 2.50 in/hr SHVW7 elevation 94.20:.: :-':':fmsl Trench Design Parameters Drawdown lime 0.1&.:`. days Perforated pipe diameter :0.00'.:_Jn Perforated pipe length ;0.00" '—ft Number of laterals ..0 Stone type (it used) 57 Stone void ratio 0.4 Stone is free of fines? y ' (Y or N) Ap;.iroved -%>cument3 Construction irk ;- i" 'e;e documents is required by the North Carolina rules require that ffjtj Ly,.1em desipneT Inspect during com;trw:',conformity with the plans and specs; and r, ii u, cr.;­,jhance with the stormwater rules. ( 1�.k 1W8 (i Permit*-- _StVH_u9(D3dL- by—a L_ . - pate LlIV-11-f _0 Sheet # — , ___ 11,C Division 01"Nater Quality __Revision Date— — OK for non -SR waters OK OK Form SW401-Infiltration Trench-ROVA Parts I. & H. Design Summary, Page 1 of 2 Trench Elevations Bottom elevation Storageloverflow elevation Top elevation Trench Dimensions Length (long dimension) Width (short dimension) Height (depth) Additional Information Maximum volume to each inlet into the trench? Length of vegetative filter for overflow Number of observation wells Distance to structure Distance from surface waters Distance from water supply well(s) Separation from impervious soil layer Depth of naturally occuring soil above SHWT Bottom covered with 4-in of clean sand? Proposed drainage easement provided? Gapures all runoff at ultimate build -out? Bypass provided for larger storms? Trench wrapped wiih geotextile fabric? Pretreatment device provided ' � 1 Permit No. t -(to be provided by DWQ) 99.20 fmsl OK 102.20 fmsl .102.20 fmsl 75.00 ft 4.00: , ft 2.00 ft OK 0.01 ac-in OK 30.00 ft OK 1 OK 15.00 ft OK 30.00 ': ft �Ta,000.00 OK for non -SA waters ft OK 6.00 . ft OK 6.00 ;ft OK y >::: ,:... (Y or N) OK y`.,:;>..: (YorN) OK y . . (Y or N) OK y (Y or N) �! OK y (Y or N) OK grass strip prior to trench Form SW401-Infiltration Trench-Rev.4 ` Parts I. & II. Design Summary, Page 2 of 2 Compliance Inspection Report Permit: SW4100302 Effective: 06/09/10 Expiration: 06/08/20 Owner: Piedmont Triad Ambulance & Rescue Inc Project: Piedmont Triad Ambulance & Rescue Inc County: Randolph 108 E Balfour Ave Region: Winston-Salem Contact Person: Gart Evans Directions to Project: Title: Chairman Type of Project: State Stormwater - HD - Inf4tration Drain Areas: 001 - (Penwood Branch) (03-06-09 ) ( C) 002 - (Penwood Branch) (03-06-09 ) ( C) 003 - (Penwood Branch) (03-06-09 ) ( C) 004 - (Penwood Branch) (03-06-09) ( C) 005 - (Penwood Branch) (03-06-09) ( C) 006 - (Penwood Branch) (03-06-09) ( C) 007 - (Penwood Branch) (03-06-09) ( C) 008 - (Penwood Branch) (03-06-09 ) ( C) On -Site Representative(s): Related Permits: Inspection Date: 07/0612011 Entry Time: 12:45 PM Primary Inspector: Sue t- Homewood Secondary Inspector(s): Reason for Inspection: Routine Permit Inspection Type: State Stormwater Facility Status: ■ Compliant ❑ Not Compliant Question Areas: ® State Stormwater (See attachment summary) Asheboro NC 27203 Phone: 56 Exit Time: 01:00 PM Phone: 336-771-4964 Inspection Type: Compliance Evaluation Page: 1 Permit: SW4100302 Owner - Project: Piedmont Triad Ambulance & Rescue Inc Inspection Date: 07/06/2011 Inspection Type: Compliance Evaluation Reason for Visit: Routine Inspection Summary: File Review Yes No NA N Is the permit active? ■ n n n Signed copy of the Engineer's certification is in the file? ■ n n n Signed copy of the Operation & Maintenance Agreement is in the file? ■ n n n Copy of the recorded deed restrictions is in the file? n n n ■ Comment: Built Upon Area Yes No NA NE Is the site BUA constructed as per the permit and approval plans? ■ n n n S Is the drainage area as per the permit and approved plans? ■ n n n Is the BUA (as permitted) graded such that the runoff drains to the system? ■ n n n Comment: CW Maaciirac Yes No NA NE Are the SW measures constructed as per the approved plans? ■ n n ❑ Are the inlets located per the approved plans? ■ n n n Are the outlet structures located per the approved plans? ® n n n Comment: Operation and Maintenance Yes No NA NE Are the SW measures being maintained and operated as per the permit requirements? n n n n Are the SW BMP inspection and maintenance records complete and available for review or provided to DWQ ❑ n n ■ upon request? Comment: Other Permit Conditions Yes No NA NE Is the site compliant with other conditions of the permit? ■ n n Comment: Other WQ Issues Yes No NA NE Is the site compliant with other water quality issues as noted during the inspection? ■ n n n Comment: Page: 2 Permit Number: S t'✓ `f 1 "X O 2 (to be provided by DWQ) Drainage Area Number:_ Infiltration Trench Operation a'nd.Maintenance Agreement I will keep a, maintenance record on this BMP This nkaintenance 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. i Important maintenance procedures: I The drainage area of the infiltration trench will be carefully managed to reduce the sediment load to the sand filter. - The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 in&s (or 1.5 inches if in a Coastal County). I The infiltration trench will be inspected once a quarter 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 "own set location and will be available upon request. Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately. j i BMP element: Potentialproblem: I How I will remediate theproblem: The entire BMP Trash/debris is eres6nt. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to other pretreatment area 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. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and dispose of it -in a location where it will not cause impacts to streams or ' the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure -Of applicable) j of any sediment off -site. The structure is dam ged. Make any necessary repairs or replace if damage is too large for repair. Form SW40I-Infiltration Trench O&M-Rev.3 Page 1 of 3 BMP element: Potential roblem: I How I will remediate theproblem: The trench Water is ponding on the Remove the accumulated sediment surface for more than' 24 from the infiltration system and hours after a storm. dispose in a location that will not impact a stream or the BMP. The depth in the trench is Remove the accumulated sediment reduced to 75% of the original from the infiltration system and design depth. dispose in a location that will not i im act a stream or the BMP. . Grass or other plants are Remove the plants, preferably by growing on the surface of the hand. if pesticide is used, wipe it on trench. the plants rather than spraying. The observation well(s) The water table is within one Contact the DWQ Stormwater Unit foot of the bottom of the immediately at 919-733-5083. system for a period of three consecutive months. i The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf E matting or riprap if needed to iprevent future erosion problems. The outflow pipe is damaged. Repair or replace the pipe. The emergency overflow Erosion or other sign of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. I repair. The re'ce:ving water Erosion or other sign's of Contact the NC Division of Water damage have occurred la t they . Quality 401 Oversight Unit at 919- outlet. . 1 733-1786. Form SW401-Infiltration Trench O&M-Rev3 I Page 2 of 3 Permit Number: SW f "3 0 L (to be provided by DWQ) I I 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:Piedmont Triad Ambulance & Rescue, Inc. BMP drainage area number: 1 E Print name: Mr. Gart Eyans Title: Chairman i Address: P.O. Box 534 High Point NC 27261 I Phone: 336_.287-34.11,,. I Signature: Date:, Note: I, The legally responsible party should not be a homeowners association unless more than 50% of the to ve been sow and a resident of t subdivision has been named the president. i ai , a Notary Public for the State of ry , County of CSPU-417'OK17 do hereby certify that' p &LAM s I personally appeared before me this f day ofat�- , z7 I , and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official I seal, SEAL I ' E My comis :ion expires � % � � 7 � Z� m% l Form SW40 1 -Infiltration Trench O&M-Rev.3 ! Page 3 Of 3 Permit Number: 5W L1► 0 0 3 O Z (to be provided b DWQ) Drainage Area Number: Infiltration Trench Operation and Maintenance Agreement I.will keep a maintenance record on -this BMP! This maintenance record will be kept -in a log 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 maintenance procedures: — The drainage area of the infiltration tr finch will be carefully managed to reduce the sediment load to the sand filter. — The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once a quarter 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 location and: will be available upon request. I Inspection- activities shall be performed as follows. Any problems that are found shall be repdixed immediately. , BMP element: Poteritial problem. I How I will remediate theproblem: The entire BMP Trash/debris is pres6nt. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to other pretreatment area erosive gullies have formed. remove the gully, and then plant a ground cover and water until it is I established. Provide lime and a one-time fertilizer a2plication. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure (if applicable) I of any sediment off -site. The structure is damaged. Make any necessary repairs or replace if damage is too large for ! repair. Form SW401-Infiltration French O&M-Rev.3 I Page 1 of 3 BMP element: Potentialproblem: ( How I will remediate theproblem: The trench Water is ponding on1the Remove the accumulated sediment surface for more than 24 from the infiltration system and hours after a storm. i dispose in a location that will not impact a stream or the BMP. The depth in the trerich'is Remove the accumulated sediment *' reduced to 75% of the original from the infiltration system and design depth. i dispose in a location that will not impact a stream or the BMP. Grass or other plants are Remove the plants, preferably by growing on the surface of the hand. If pesticide is used, wipe it on trench. the plants rather than sera in . The observation well(s) The water table is within one Contact the DWQ Stormwater Unit foot of the bottom of the immediately at 919-733-5083. system for a period of three consecutive months. + The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to prevent future erosion problems. The outflow pipe is damaged. Repair or replace the pipe. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. I repair. The receiving water Erosion or other sign's of Contact the NC Division of Water damage have occurred at the Quality 401 Oversight Unit at 919- outlet. i 733-1786. Form SW401-Infiltration Trench O&M-Rev.3 . I - Page 2 of 3 Permit Number: SV `f 1003Q z (to be provided by DWQ) I acknowledge and agree by my signature bel iw 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:Piedmont Triad BMP drainage area number: 2 lance Print name: Mr. Gart Evans ! Title: Chairman Address: P.O. Box 534 Hip-h Point, NC 2 Phone: Signature: Date: '' I � I y a V 4 Note: The legally responsible party should not be a homeowners association unless more than 50% of the have been sold and a resident of the subdivision has been named the president. i , a Notary Public for the State of ell' 'VCounty of _ . _ i , do hereby certify that personally appeared before me this day of ' LQ-�'t �'�, and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official seal, My commission expires Form S W40 I -Infiltratio n Trench 0&M-Rev.3 Page 3 of 3 Permit Number: 5("`fl ao3o Z- Infiltration Trench Operation (to be provided by DWQ) Drainage Area Number:_ d Maintenance Agreement I will keep a maintenance record on this BMP j lgiis maintenance record will be kept in a log. 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 maintenance procedures: — The drainage area of the infiltration trench will be carefully managed to reduce the sediment load to the sand filter. — The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once i quarter 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 location and will be available upon request. f Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately. BMP element: Potentialproblem: 1 How I will remediate theproblem: The entire BMP Trash/debris is preient. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to other pretreatment area erosive gullies have�formed. remove the gully, and then plant a , ground cover and water until it is established. Provide lime and a i one-time fertilizer a lication. Sediment has accuniulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and i dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure (if applicable) of any sediment off -site. The structure is damaged. Make any necessary repairs or ' replace if damage is too large for i repair. Form SW401-Ini'iltration Trench O&M-Rev.3 Page 1 of 3 BMP element: Potentialproblem: I How I will remediate theproblem: The trench Water is ponding on�'the Remove the accumulated sediment surface for more than 24 from the infiltration system and hours after a storm. dispose in a location that will not impact a stream or the BMP. The depth in the trench is Remove the accumulated sediment reduced to 75% ofthe original from the infiltration system and design depth. dispose in a location that will not impact a stream or the BMP. Grass or other plants' are Remove the plants, preferably by growing on the surface of the hand. If pesticide is used, wipe it on trench. the plants rather than spraying. The observation well(s) The water table is within one Contact the DWQ Stormwater Unit foot of the bottom of the immediately at 919-733-5083. system for a period of three consecutive months. ai The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to prevent future erosion problems. The outflow pipe is damaged. Repair or re lace the piRe. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. repair. The rece}ving water Erosion or other sign's of Contact the NC Division of Water ' damage have occurred at the, Quality 401 Oversight Unit at 919- outlet. 733-1786. Form SW40 I -Infiltration Trench O&M-Rev.3 Page 2 of 3 Permit Number._5� 1 0030 2 (to be provided by DWQ) I 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. r Project name:Piedmont Triad Ambulance & Rescue Inc. BMP drainage area number: 3 Print naiae: Mr. Gart Evans Title: Chairman Address: P.O.-Box 534 High Point, NC 27261 Phone: S ignati Date: Note: The legally responsible party should not be a homeowners association unless more than 50%a of tly3-1Qts have been sold and a resident of the subdivision has been'named the president. I , a Notary Public for the State of County o , do hereby certify that z E+.a.r „ personally appeared before me this day of. c� �fe t U 16, and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official SEAL 4- My. commission expires_ D/ ~ Form SW401-Infiltration Trench O&M-Rev.3 Page 3 of 3 Permit Number: Sti+%Lf f Do30 Z. (to be provided by DWQ) Drainage Area Number:_ Infiltration Trench Operation and Maintenance Agreement I will keep a maintenance record on this BMP. This maintenance record will be kept in a log 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 maintenance procedures:' — The drainage area of the infiltration trench will be carefully managed to reduce the sediment load to the sand filter. — The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once a quarter and within 24 hours after every storm event greater.than TA inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance will be kept in a known set location and will be available upon request. Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately. BMP element: Potentialproblem: How I will remediate theproblem: The entire BMP Trash/debris is 2resent. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to other pretreatment area 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. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion' The structure is clogged. Unclog the conveyance and dispose structure (if applicable) of any sediment off -site. The structure is damaged. Make any necessary repairs or replace if damage is too large for repair. Form SW401-Infiltration Trench O&M -Rev. 3 Page I of 3 BMP element: Potentialproblem: How l will remediate the roblem: The trench Water is ponding on the Remove the accumulated sediment surface for more than 24 from the infiltration system and hours after a storm. dispose in a location that will not impact a stream or the BMP. The depth in the trench is Remove the accumulated sediment reduced to 75% of the original from the infiltration system and s . design depth. dispose in a location that will not impact a stream or the BMP. Grass or other plants are Remove the plants,'preferably by growing on the surface of the hand. If pesticide is used, wipe it on trench. the plants rather than spraying. The observation wells? The water table is within one Contact the DWQ Stormwater Unit foot of the bottom of the immediately at 919-733-5083. system for a period of three consecutive months. The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to prevent future erosion problems. The outflow pipe is lama ed. Repair or replace the pipe. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. repair. 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 SW40 I -Infiltration Trench O&M-Rev.3 Page 2 Of 3 S t,�� l 603oz Permit Number: . • (to be provided by DWQ) I 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:Piedmont Triad Ambulance & Rescue, Inc. BMP drainage area number: 4 Print name: Mr. Gart Evans Title: Chairman Address: P.O. Box 534 High Point, NC 27261 Phone: 336-8$7-]411,;, Signature: 10 Date: ' Note: The legally responsible party should not be a homeowners association unless more than 50% of the ] s have been sold and a resident of the subdivision has been named the president. a Notary Public for the State of County V , do hereby certify that ! l dZot-Q— personally appeared before me this day of ��' , aQ�_� and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official My commission expires_ . _&21 &" a�l� Form SW401-Infiltration Trench O&M-Rev3 Page 3 of 3 Permit Number: (to be provided by DWQ) Drainage Area Number:_ Infiltration Trench Operation and Maintenance Agreement I will keep a maintenance record on this BMP. This maintenance record will be kept in a log in a known set location. Any deficient BMP elements noted in the inspection will be corrected, repaired or replaced immediately. These deficiencies car' affect the integrity of structures, safety of the public, and the removal efficiency of the BMP. Important maintenance procedures: — ` "'he drainage area of the infiltration trench will be carefully managed to reduce the sediment load 'to the sand filter. ' — The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once a quarter 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 location 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 problem: How I will remediate the roblem: The entire BMP Trash/debris is present. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to other pretreatment area 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 apj2lication. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches: possible. Remove the sediment and dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure (if applicable) of any sediment off -site. The structure is damaged. Make any necessary repairs or, replace if damage is too large for re air. Form SW401-Infiltration Trench O&M-Rev.3 Page l of 3 BMP element: Potentialproblem: How I will remediate theproblem: The trench Water is ponding on the Remove the accumulated sediment surface for more than 24 from the infiltration system and hours after a storm, dispose in a location that will not impact a stream or the BMP. The depth in the trench is Remove the accumulated sediment reduced to 75% of the original from the infiltration system and design depth. dispose in a location that will not impact a stream or the BMP. Grass or other plants are Remove the plants, preferably by growing on the surface of the hand. If pesticide is used, wipe it on trench. the plants rather than s ra in . The observation well(s) The water table is within one Contact the DWQ Stormwater Unit foot of the bottom of the immediately at 919-733-5083. system for a period of three consecutive months. The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to prevent future erosion problems. The outflow pipe is damaged. Repair or replace the i e. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. re air. 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- outl et. 733-1786. Form SW401-Infiltration Trench 0&M-Rev.3 Page 2 of 3 Permit Number: 5 W �V# 0.30 Z (to be provided by DWQ) I 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:Piedmont Triad Ambulance & Rescue, Inc. BMP drainage area number: Print name: Mr. Gart Evans Title: Chairman Address:_- P.O. Box 534 High Point, NC 27261 Phone: • 336-887-3411 Signature:'�f 1 - Date: Note: The legally responsible party should not be a homeowners association unless more than 50% of th., 6 ve been sold and a resident of the subdivision has been named the president. a Notary Public for the State of ! G ,County of o , do hereby certify that personally appeared before me this -3 RV day of 64ZA—W and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official seal, My commission- expires Form SW,, J? l -Infiltration Trench O&M-Rev.3 Page 3 of 3 Permit Number: .5'W KG&030 1— (to be provided by DWQ) Drainage Area Numben-47 Infiltration Trench Operation and Maintenance Agreement I will keep a maintenance record on this BMP. This maintenance record will be kept in a log 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 maintenance procedures: — The drainage area of the infiltration trench will be carefully managed to reduce the sediment load to the sand filter. — The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once a quarter 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 location and will be available upon request. Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately. BMP element: Potentialproblem: How I will remediate theproblem: The entire BMP Trash/debris is present. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to other•grptreatment area erosive gullies have fofined. remove the gully, and then plant a ground cover and water until it is established. Provide lime and a one-time fertilizer application. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure (if applicable) of any sediment off -site. The structure is damaged. Make any necessary repairs or replace if damage is too large for repair. Form SW401-Infiltration Trench O&M-Rev.3 Page 1 of 3 BMP element: Potentialproblem: How I will remediate theproblem: The trench Water is ponding on the Remove the accumulated sediment surface for more than 24 from the infiltration system and hours after a storm. dispose in a location that will not impact a stream or the BMP. The depth in the trench is Remove the accumulated sediment reduced to 75% of the original from the infiltration system and design depth, dispose in dlocation that will not impact a stream or the BMP. Grass or other plants are Remove the plants, preferably by growing on the surface of the hand. If pesticide is used, wipe it on �f. trench. the plants rather than spraying. The observation well(s) 14 The water table is withiw one foot of the bottom of the Contact the DWQ Stormwater Unit immediately at 919-733-5083. system for a period of three consecutive -months. The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to prevent future erosion problems. The outflow pipe is damaged. Repair or re lace the Eipe. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired of replaced if beyond outlet, repair. 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-Infiltration Trench O&M-Rev.3 Page 2 of 3 ;r Permit Number: 5w `f (0036 Z. (to be provided by DWQ) I 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: Piedmont Triad Ambulance & Rescue, Inc. BMP drainage area number: Print name: Mr. Gart Evans Title: - Chairman Address: P.O. Box 534 High Point,_NC 2:7261 Phone: 336 87-3411 Signature: *va Date: 31 i l i,Zz. Note: The legally responsible party should not be a homeowners associatiori unless more than 50% of have been sold and a resident of the subdivision has been named the president. IF, , a Notary Public for the State of C_ , County of , do hereby certify that Ca.IL-i'a''"~�+ personally appeared before me this day of Me-O-Ct , _A�OPand aclmowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official My commission expires 99l —O 7 - Z`'% l Form SW401-Infiltration Trench O&M-Rev.3 Page 3 of 3 Permit Number: Sw q 1 d o 3a Z- (to be provided by DWQ) Drainage Area Number:. � _ Infiltration Trench Operation and Maintenance Agreement I will keep a maintenance record on this BMP. This maintenance record will be kept in a log in a known set location. Any deficient BN1P 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 BMW. Important maintenance procedures: — The drainage area of the infiltration trent;h will be carefully managed to reduce the n�:diment load to the sand filter. The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once a quarter 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 location and will be available upon request. Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately. BMP element: Potentialproblem: How 1 will remediate theproblem: The entire BMP Trash/debris is present. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to . other pretreatment area 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 aP21ication. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure (if applicable) of any sediment off -site. The structure is damaged. Make any necessary repairs or replace if damage is too large for repair. Form SW401-infiltration Trench O&M-Rev.3 Page 1 of 3 BMP element: Potentialproblem: How I will remediate the problem: The trench Water is ponding on the Remove the accumulated sediment surface for more than 24. from the infiltration system and hours after a storm. dispose in a location that will not impact a stream or the BMP. . The depth in the trench is Remove the accumulated sediment reduced to 75% of the original from the infiltration system and design depth. dispose in a location that will not impact a stream or the BMP. Grass or other plants are Remove the plants, preferably by growing on the surface of the hand. If pesticide is used, wipe it on trench. the plants rather than spraying. The observation well(s) The water table is within one Contact the DWQ Stormwater Unit foot of the bottom of the immediately at 919-733-5083. system for a period of three consecutive months. The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to revent future erosion problems, The outflow pipe is damaged. Repair or replace the pipe. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. repair. 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-Infiltration Trench O&M-Rev.3 Page 2 of 3 Permit Number: SW 41 oo3 4 'z_ (to be provided by DWQ) I 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:Piedmont Triad Ambulance & Rescue Inc. BMP drainage area number: 7 Print name: Mr. Gart Evans Title: Chairman Address: P.O. Box 534 High Point, NC 27261 Phone,',, 336-887-,3411 Signature:_, Date: Note: The legally responsible party should not be a homeowners association unless more than 50% of ots ave been sold and a resident of the subdivision has been named the president. a Notary Public for the State of r , County of ' , do hereby certify that personally appeared. before me this , day of _ %�, and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official My commission expires l `r�7 Gil 1~6rm SW iOI-Infiltration Trench O&M-Rev.3 Page 3 of 3 Permit Number: $wLfl eo3o2. (to be provided by DWQ) Drainage Area Number: Infiltration Trench Operation and Maintenance Agreement I will keep a maintenance record on this BNM. This maintenance record will be kept in a log in a known set location. Any deficient BNT 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 BN1P. Important maintenance procedures: — The drainage area of the infiltration trench will be carefully managed to reduce the sediment load to the sand filter. The water level in the monitoring wells will be recorded once a month and after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). The infiltration trench will be inspected once a quarter 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 location and will be available upon request. Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately. BMP element: Potentialproblem: How I will remediate theproblem: The entire BMP Trash/debris is present. Remove the trash/debris. The grass filter strip or Areas of bare soil and/or Regrade the soil if necessary to 'other pretreatment area erosive gullies have fo..ned. remove the gully, and then plant a ground cover and water until it is established. Provide Iime and a one-time fertilizer a lication. Sediment has accumulated to Search for the source of the a depth of greater than six sediment and remedy the problem if inches. possible. Remove the sediment and dispose of it in a location where it will not cause impacts to streams or the BMP. The flow diversion The structure is clogged. Unclog the conveyance and dispose structure (if applicable) of any sediment off -site.. The structure is damaged. Make any necessary repairs or replace if damage is too large for repair. Form SW401-Intilfration Trench O&M-Rev.3 Page I of 3 BMP element: Potential roblem: How I will remediate theproblem: The trench Water is ponding on the Remove the accumulated sediment surface for more than 24 from the infiltration system and hours after a.storm. dispose in a location that will not impact a stream or,the BMP. The depth in the trench is Remove the accumulated sediment reduced to 75% of the original from the infiltration system and design depth. dispose in a location that will not impact a stream or the BMP. Grass or,other plants are Remove the plants, preferably by growing on the surface of the hand. If pesticide is used, wipe it on trench. the plants rather than spraying. The oli;ervation well(s) . The water table is within ore Contact the DWQ Stormwater Unit foot of the bottom of the system for a period of three immediately at 919-733-5083. consecutive months. The outflow pipe is clogged. Provide additional erosion protection such as reinforced turf matting or riprap if needed to prevent future erosion problems. The outflow pipe is damaged. Repair or replace the pipe. The emergency overflow Erosion or other signs of The emergency overflow berm will berm damage have occurred at the be repaired or replaced if beyond outlet. repair. 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. „ry I Form SW401-Infiltration Trench O&M-Rev.3 Page 2 of 3 Permit Number:_ S2L M I Q030 -2- (to be provided by DWQ) I 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:Piedmont Triad Ambulance & Rescue, Inc._ BMP drainage area number: 8 Print name: Mr. Gart Evans Title: Chairman Address: P.O. Box 534 High Point, NC 27261 _ Phone: 336-8W- Signature: Date: Note: The legally responsible party should not be a homeowners association unless more than 50% of ots ave been sold and a resident of the subdivision has been named the president. a Notary Public for the State of County o -'t , do hereby certify that personally appeared before me this _cL day of , _ 2416, and acknowledge the due execution of the forgoing infiltration trench maintenance requirements. Witness my hand and official 7. My commission expires Form SW401-Infiltration Trench O&M-Rev.3 Page 3 of 3 DWQ USE ONLY Date Receive Fee Paid Permit Number Applicable Ruteg-t ❑ oastal 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 Water Quality STORMWATER MANAGEMENT PERMIT APPLICATION FORM This form may be photocopied far use as an original L 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.): Piedmont Triad Ambulance & Rescue, Inc 2. Location of Project (street address): 108 E. Balfour Avenue City:Asheboro County:Randolph Zip:27203 3. Directions to project (from nearest major intersection): From intersection of US,Highway_64 and US Hwy 220, take 220 north to Vision Drive exit. Go to stop light which is business 2-20 and turn left. Then turn right onto Balfour Avenue. Site 0.1 mile on right. 4. Latitude:35° 44' 44" N Longitude:79° 48' 32" W of the main entrance to the project. it. 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 k*,own) and the staters of conGiruction: j:]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 DWQ 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): ❑LAMA Major ❑Sedimentation/Erosion Control: Q ac of Disturbed Area ❑NPDES Industrial Stormwater ❑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:Piedmont Triad Ambulance & Rescue approved 7-21-09 Form 5WU-101 Version 07July2009 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): Signing Official & Title:Mr. Cart Evans Chairman I b. Contact information for person listed in item la above: i Street Address:P.O. Box 534 City:High Point State:NC Zip:27261 Mailing Address (if applicabie):Same as above City: j State: Zip: Phone: ( ) Fax: ( } Email: 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 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 2�o below) Developer* (Complete Contact' Infornriation, 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/ Signing Official & b. Contact information for person listed in item 2a Street Address:1422 South Main Street City: Mailing Address (if applicable): City:H Phone: State:NC Zip:27260 State:NC Zip:27261 Fax: 336 982-5311 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/ Signing Official & Title b. Contact information for person listed in item 3a above: Mailing, Address:P.O. Box 534 i City:High Point State:NC Zip:27261 Phone: (336 ) 887-3411 j Fax: 336 82-5 11 4. Local jurisdiction for building permits: Asheboro E Point of Contact:Mr. Larry Trotter - i Phone #: (336 626-1204x231 . i I Fomi,'SW,b-101 Version 07July2009 Page 2 of'6 " I IV. PROJECT INFORMATION 1. In the space provided below, briefly summarize how the stormwater runoff will be treated. All lmpervi6ns surface area runoff will be treated by I eight(8) separate_ gravel infiltration trenches. 1',=.fie t i the slow,of the land (barely any slope) this, is the :only geatment device that will work. All BUA is directed to these trenches. 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 PUDApproval Date: ❑ VaIid Building Permit Issued Date: ❑ Other: Date: b.Identify the regulation(s) the project has been designed in accordance with: ❑ Coastal SW —1995 ® Ph 11— Post Construction 3. Stormwater runoff from this project drains to the Cap l Fear River basin. 4. Total Property Area: 1.99 acres 5. Total Coastal Wetlands Area: 0 acres 6. Total Surface Water Area: 0 acres 7. Total Property Area (4) — Total Coastal Wetlands Area (5) — Total Surface Water Area (6) = Total Project Area': 1.99 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 (NHW) line or Mean High Water (MHW) line, and coastal wetlands landwardfrom the NHW (or MHW) line. The resultant project area is used to calculate overall percent built upon area (BUA). Non -coastal wetlands Iandward 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 = 27.58 % 9. How many drainage areas does the project have?8 (For high density, count 1 for each proposed engineered stormwater BMP. For low density and other projects, Iuse 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. Bashi=Infoririation `r,`is < x Drains-enArea 1°, •,Diairia e Area'2', ti-Draiha e'.Area'3",! "Drains` eA`rea 4 Receiving Stream Name UT to Penwood Branch UT to Penwood Branch UT to Penwood Branch UT to Penwood Branch Stream Class * C C C C Stream Index Number * 17-12-1 17-12-1 17-12-1 17-12-1 Total Drainage Area (sf) 10142 2975 4954 2351 On -site Drainage Area (sf) 10142 2975 4954 2351 Off -site Drainage Area (sf) 0 0 0 0 Pro osed ,I6:� ervious Area** (sf) 9237 2536 4330 1990 % I ervibus Area** (total) 91.T ,S5.2 87.4 84.6 Im `envious,: Surface Area ` yM Drains e Area 1"� :Drama e-Area 2; ' Drairia e'Area 3 . -'Drama e Area On -site Buildings/Lots (sf) 2000 0 250 0 On -site Streets (sf) 0 0 0 0 On -site Parking (sf) 7237 2536 4080 1990 On -site Sidewalks (so 0 0 0 0 Other on -site (so 0 0 0 0 Future (so 0 0 0 0 Off -site (so 0 0 0 0 Existing BUA*** (so 0 1 0 0 0 Total (so: 9237 1 2536 4330 1990 * Stream Class and Index Number can be determined at: http://h2o.enr.state.nc.uslbims/re2orts/regortsWB.htn *" Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks, gravel areas, etc. Farm SWU-101 Version 07July2009 Page 3 of 6 Basin Information Drainage Area 5 Drainage Area 6 Drainage Area 7 Drainage Area 8 Receiving Stream Name UT to Penwood Branch UT to Penwood Branch UT to Penwood Branch UT to Penwood Branch Stream Class * C C C C Stream Index Number * .17-12-1 17-12-1 17-12-1 17-12-1 On -site Drainage Area (sf) 869 727 2475 3596 Off -site Drainage Area (sf) 0 0 0 0 Proposed Impervious Area ** (sf) 600 477 1792 2948 Impervious Area ** (total) 69 . 65.6 72.4 82 Impervious ** Surface Area Drainage Area 5 Drainage Area 6 Drainage Area 7 Drainage Area 8 On -site Buildings/Lots (sf) 0 0 0 1250 On -site Streets (sf) 600 _ 477 1792 0 On -site Parking (sf) 0 0- =' 0 1698 On=site Sidewalks (sf) 0 0 0 0. Other on -site (sf) 0 0 0 0 Future (sf) 0 0 0 0 Off -site (sf) 0 0 0 0 Existing BUA *** (sf) 0 0. 0 0 Total (sf): 600 477 1792 2948 * Sream Class and Index Number can be determined at: http://h2o.enr.state.nc.us/bims/reports/reportsWB.html ** Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks, gravel areas, etc. *** 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. *** Report only that amount of existing BUA that will rembin 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. Impervious area is _Projects in Union County: Contact DWQ 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 NCA C 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://h2o.enr.state.nc_us/su//m. bmp forms.htm 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://h2o.enr,state.nc.us/su/bmp forms.htm. 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://h2o.enr.state.nc.us/su/msi maps.htm.) Please indicate that the following required information hale 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 hUp://h2o.enr.state.nc.us/su/bmp forms.htm. 1. Original and one copy of the Stormwater Management Permit Application Form. 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 agreement(s) for each BMP. 4. Permit application processing fee of $505 payable to NGDENR. (For an Express review, refer to htW://www.envheit),org/pages/onestol2exl2ress.htm] 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 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 receiving stream drains to class SA waters withinboundary, include the 1h mile radius on the map. 7. Sealed, signed and dated calculations. 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 MHW (or NHW) of tidal waters. i. Dimensioned property/project boundary with beatings &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 Aelineated, or a note on the plans that noneiexist. (Must be delineated by a qualified person. Provide documentation of qualifications and identify the person who made the det6rmination on the plans. . n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations. i Form SWU-101 Version 07July2009 Page 4 of 6 IIts tlt� Host h 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 Vplicable soils report with the associated SHWT elevations (Please identify elevations iri3addition 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 tl'iz NkCS 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 verify the SHWT prior to submittal, (910) 796-7378.) 10. A copy of the most current property deed. Deed book: 2052 Page No: 670 h1 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 2H.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. VII. DEED RESTRICTIONS AND PROTECTIVE 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 I htt 2o.enr.state.ne.us su m forms.htm#deed restrictions. 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. f 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 11 ill 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: Consulting Firm:_ Mailing Address: City: + I State: Zip: Phony: E '' '? Fax: Email: IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this section) r I, (print or type name of person listed in Contact Information, item 2a) Mr. ��c� FVc: n5 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 Ia) I with (print or type name of organization Iisted in Contact Information, item IN 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. Form SWU-101 Version 07Juiy2009 Page 5. of 6 I As the legal property owner I acknowledge, understand, (d 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. d 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 penal 'es of up to $25,000 per day, pursuant to NCGS 143-215.6. Signa re:� Date: 1 b I, otary Public for the State of / "� County of do hereby certify t at _& 3, C;2a=�� 4-- j/4-vk-0------ personally appeared before me this'3q ay of % and acknowledge the due execution of the application for a stormwater permit. Witness my hand and official seal. SEAL My X. APP4PCANT'SeCERTIFICATION ' IMM"10-M I, (print or type name of person listed in Contact Information, item 2) 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. I1— Post Construction) or SL 2008-211. Signature: I Date: I, a Notary Public for the State of , County of _ do hereby certify that I personally appeared before me this _ day of - _ , an I acknowledge the due execution of the application for a stormwater permit. Witness my hand and official seal. SEA My Form SWU-101 Version 07July2009 Page 6 of 6 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 civil penal 'es of up to $25,000 per day, pursuant to NCGS 143-215.6. Zf Signa re: � i Date: " do hereby certifyt5a- t before me this'g, ay of d stormwater permit. Witness my hand and official seal, SEAT, for the State of / V (�— County of personally.appeared acknowledge the due execution of the application for a My commission 6 xpires U (� X. APPLICANT'S CERTIFICATION I, (print or type name of person listed in Contact Information, item 2) 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 stoor/rmwater les der 1 NCAC 2H .1000, SL 2006-246 (Ph. II — Post Construction) or SL 2008-211. Signa r . L'tI i �� �11r/s Date: 0 I a Notary Public for the State of L, County of 4 do hereby cer ' that _ .1 A-QP personally appeared before me thi day of ��and acknowledge the due execution of the application for a stormwater permit. Witness my hand and official seal, T �� r���•��i }fix ., r [� c� � y,1 Its ♦•��i�.� 4 L!✓�4_ v SEAL My commission Form SWU-101 Version 07July2009 Page 6'of 6