SW4100302_CURRENT PERMIT_20100713

STORMWATER 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 [phone] or
[e-mail].
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: [phone] FAX: [phone] 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

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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: [phone]
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: [phone]
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: [phone]
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: [phone]
4. Local jurisdiction for building permits: Asheboro E
Point of Contact:Mr. Larry Trotter - i Phone #: [phone]x231
. 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, [phone].)
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