SW4110802_CURRENT PERMIT_20111011

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW�
DOC TYPE
/Ind CURRENT PERMIT
c❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
/ -9 ov/s f
YYYYMMDD

ALIT,
NCDENR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue
Governor
Mr. Joseph S. Sheetz
PTM, L.P.
5700 Sixth Avenue
Altoona, PA 16602
Coleen H. Sullins
Director
October 11, 2011
Subject: Stormwater Permit No. SW4110802
Sheetz, Inc.
High Density Commercial Bio-Retention Project
Stokes County
Dear Mr. Sheetz:
Resources
Dee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit
Application for Sheetz, Inc. on October 10, 2011. 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.
SW4110802, dated October 11, 2011, for the construction, operation and maintenance of the
subject project and the Stormwater BMPs.
This permit shall be effective from the date of issuance until October 10, 2021, and shall be
subject to the conditions and limitations as specified therein, and does not supersede any
other agency permit that may be required. Please pay special attention to the conditions
listed in this permit regarding the Operation and Maintenance of the BMP(s), recordation of
deed restrictions, procedures for changes of ownership, transferring the permit, and renewing
the permit. Failure to establish an adequate system for operation and maintenance of the
stormwater management system, to record deed restrictions, to follow the procedures for
transfer of the permit, or to renew the permit, will result in future compliance problems.
If any 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 to Chapter 150E of the North Carolina General Statutes, and filed with the Office
of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC 27611-7447. Unless such
demands 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 Robert
Patterson at [phone]; or [e-mail].
Sincerely,
cc: SW4110802 File
ec: Sue Homewood - Winston-Salem Regional Office
for Coleen H. Sullins Ken Binkley, PE - Stimmel Associates, PA
Wetlands and Stormwater Branch One
1617 Vail Service Center, Raleigh, North Carolina 27699-1617 North Carolina
Locahr:n: 512 N. Salisbury St. Ralf:gh, North Carahna 27604 r
Phone: [phone] FAX: [phone]' ,ustomer Service: 1-877-f,::3-6748 Nwrmallty
Intern� . vvww.ncwaterquality.org U
An Ern1al Opportur..ylAffirmativeA6,)n Employer

State Stormwater Permit
Permit No. SW4110802
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
PTM, L.P.
Sheetz, Inc.
70.3 E. King St., King, Stokes County
FOR THE
construction, operation and maintenance of a bioretention cell in compliance with
the provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred
to as the "storm water rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved
by the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until October 10, 2021, and
shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of
stormwater described in the application and other supporting data.
2. This stormwater system has been approved for the management of
stormwater runoff as described in Section 1.7 of this permit. The stormwater
control has been designed to handle the runoff from 76,665 square feet of
impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in
Section 1.7 of this permit, and per the application documents and as shown on
the approved plans.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the
project will be recorded showing all such required easements, in accordance
with the approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6. The built -upon areas associated with this project shall be located at least 30
feet landward of all perennial and intermittent surface waters.
Page 1 of 6

State Stormwater Permit
Permit No. SW4110802
7. The following design criteria have been provided in the bioretention cell and
must be maintained at design condition:
a. Drainage Area, acres:
Onsite, ftz:
Offsite, ftz:
b. Total Impervious Surfaces, ftz:
Onsite, ft2:
Offsite, ftz:
C. Design Storm, inches:
d. Max. Ponded Depth, feet:
e. Seasonal High Water Table, fmsl
f. Planting Media Depth, feet:
g. Cell Dimensions, feet:
h. Planting Elevation, fmsl:
i. Bottom Surface Area, ftz:
j. Permitted Storage Volume, ft3:
k. Bypass / Storage Elevation, fmsl:
I. Drawdown Time, hours:
M. Underdrain Diameter, inches:
n. Total number of plants provided:
o. Receiving Stream/River Basin:
P. Stream Index Number:
q. Classification of Water Body:
If. SCHEDULE OF COMPLIANCE
2.27
79,314
19,430
76,665
71,610
5,055
1.0
1.0
1,087.0
3.0
170 x 40
1,100.0
6,720
6,423
1,101.0
12.5
8.0
see approved plan sheet L-1.2
Muddy Creek / Yadkin - Pee Dee
12-94-(0.5)
"C"
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use immediately upon stabilization
of the drainage area.
2. During construction, erosion shall be kept to a minimum and any eroded
areas of the system will be repaired immediately. The bioretention cell shall
be protected from compaction and sedimentation to prevent clogging.
3. The permittee shall at all time provide the operation and maintenance
necessary to assure the permitted stormwater system functions at optimum
efficiency. The approved Operation and Maintenance Plan must be followed in
its entirety and maintenance must occur at the scheduled intervals including,
but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level
spreader, filter media, planting media, underdrains, catch basins and
piping.
g. Access to the cell and outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work
and what actions were taken.
5. The permittee shall submit to the Division of Water Quality an annual
summary report of the maintenance and inspection records for each BMP.
The report shall summarize the inspection dates, results of the inspections,
and the maintenance work performed at each inspection.
Page Z of 6

State Stormwater Permit
Permit No. SW4110802
6. The facilities shall be constructed as shown on the approved plans. The
stormwater treatment system shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with
other supporting data.
7. Upon completion of construction, prior to issuance of a Certificate of
Occupancy, and prior to 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 plans 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.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment
device, and prior to occupancy of the facility.
9. Access to the stormwater facilities shall be maintained via appropriate
recorded easements at all times.
10. The permittee shall submit to the Director and shall have received approval
for revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to
the drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the
permittee, for which Sedimentation and Erosion Control Plan approval
was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on
the approved plan.
11. The permittee shall submit final site layout and grading plans for any
permitted future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. The Director may notify the permittee when the permitted site does not meet
one or more of the minimum requirements of the permit. Within the time
frame specified in the notice, the permittee shall submit a written time
schedule to the Director 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.
III. GENERAL CONDITIONS
1. This permit is not transferable except after notice to and approval by the
Director. In the event of a change of ownership, or a name change, the
permittee must submit a completed Name/Ownership Change form signed by
both parties, to the Division of Water Quality, accompanied by the supporting
documentation as listed on page 2 of the form. 1 he approval of this request
will he co,:sidered c-n its merits and m�.y or may -)et be approved.
Page 3 of 6

State Stormwater Permit
Permit No. SW4110802
2. The permittee is responsible for compliance with all permit conditions until
such time as the Division approves a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality,
in accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying
with any and all statutes, rules, regulations, or ordinances, which may be
imposed by other government agencies (local, state, and federal) having
jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective
action, including those as may be required by this Division, such as the
construction of additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during
normal business hours for the purpose of inspecting all components of the
permitted stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or
terminated. The permit may be modified, revoked and reissued or terminated
for cause. The filing of a request for a permit modification, revocation and re -
issuance or termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the
stormwater control must follow the guidelines established in the North
Carolina Erosion and Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by
reference and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the
permit as allowed by the laws, rules and regulations contained in Session Law
2006-246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 111h day of October, 2011.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
forColeen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Sheetz, Inc.
Page 4 of 6

State Stormwater Permit
Permit No. SW4110802
Stormwater Permit No. SW4110802
Stokes County
Designer's Certification
I, , as a duly registered in the State of
North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the best
of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Certification Requirements:
Page 5 of 6

State Stormwater Permit
Permit No. SW4110802
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that
the runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the
system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
7. Trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation, per the vegetation
plan.
9. Vegetated slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and/or volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13. All required design depths are provided.
14. All required parts of the system are provided, such as a vegetated
shelf, and a forebay.
15. The required system dimensions are provided per the approved plans.
Submit to: NCDENR-DWQ Winston-Salem Regional Office
cc: Todd Cox, City of King Building Inspections
Pagts 6 of 6

State Stormwater Permit
Permit No. SW4110802
Stormwater Permit No. SW4110802
Stokes County
Designer's Certification
(Kenneth A. Binkley, as a duly registered Engineer in the State of
North Carolina, having been authorized to observe eriodical weekly/
full time) the construction of the project,
Sheetz- King, NC
(Project Name)
for Sheetz, INC. (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:
* SURVEY PICKED UP SOME SIDE SLOPES SLIGHTLY STEEPER THAN 3:1, BUT
STABILIZED WITH SOD
Signature �v` a. Ln�
Registration Number NCPE4 36769
Datel�-
Certification Requirements:
e,\\JllII/////
CAROB
����• o�tiSS/*d k'
Z ;aL SEAL r•
36769
•
S EAR /10111 1,110
Page 5 of 6

State Stormwater Permit
Permit No. SW4110802
X 1. The drainage area to the system contains approximately the permitted
acreage.
X 2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
X 3. All the built -upon area associated with the project is graded such that
the runoff drains to the system.
X 4. All roof drains are located such that the runoff is directed into the
system.
X 5. The outlet/bypass structure elevations are per the approved plan.
X 6. The outlet structure is located per the approved plans.
N/A 7 Trash rack is provided on the outlet/bypass structure.
X 8. All slopes are grassed with permanent vegetation, per the vegetation
plan.
9. Vegetated slopes are no steeper than 3:1.
X 10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
X 11. The permitted amounts of surface area and/or volume have been
provided.
X 12. Required drawdown devices are correctly sized per the approved plans.
X 13. All required design depths are provided.
X 14. All required parts of the system are provided, such as a vegetated
shelf, and a forebay.
X 15. The required system dimensions are provided per the approved plans.
Submit to: NCDENR-DWQ Winston-Salem Regional Office
cc: Todd Cox, City of King Building Inspections
Page 6 of 6

Stimmel 601 N. Trade Street date: 411112012 job #: 10-139
Suite 200
.,✓"� Winston Salem. NC project: Sheetz -King, NC
Landscape Architecture 27101-2916
Civil Engineering p; 336.723.1067 cIt
Stimmel Associates, PA Land Planning F: 336.723.1069 KC.Deat. of I NR
letter of transmittal I
APR 11 2012
Wlnaton-Salem
attn: Corey Basinger sent via: r. � the
to: NCDENR DWQ-WS Regional Office r Under Separate Cover
585 Waughtown St. r U.S. Mail r By Hand
Winston-Salem, NC 27107 F Over Night Service r For Pick -Up
r. Fax#
# of pages total =
We are sending you the following items:
r7o Prints C Calculations r Base Drawings r Diskette/CD
r Reproducibles r Information i- Correspondence r Email with Attachments
r Originals Specifications""' Change Order/Addendum r
copies
sheet
dated
description
1
Cert.
4111/2012
State SW Permit No. SW4110802 Certification
remarks, comments, & details:
Corey,
Attached is the State Stormwater Permit No. SW4110802 Engineer Certification for your records. If
you have any questions or concerns, feel free to contact me.
Thanks,
Kenneth A. Binkley, PE
Stimmel Associates, PA
[phone] Ext. 118
kbinkley@stim melpa.com
If noted enclosures are not received, please notify us.
copies to: File by: Ken Binkley

DWQ USE ONLY
Date R , •eived
Fee Paid
Permit Number
.15-ZS 11
41 1l orb z
ApplicableRules:' ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 19'Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may he photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with projeca,�
specifications, letters, operation and maintenance agreements, etc.):
Sheetz, Inc. Or7-� D
2. Location of Project (street address): pFNR 0 ZQ]�
703 E. King St. 44'S4jo
lri
Cit Kin Count Stokes "/_i 27021
Y� g-.��. Y� P� �MC�t
3. Directions to project (from nearest major intersection):
From U.S. Highway 52 North, take the South Main Street exit to King, NC. Flead east into King, turn right
onto King Street (Old U.S. Highway 52), continue east and the site is located at the NE Quadrant of the King
Street and Mountain View Road intersection.
4. Latitude-36' 27-' 94' N of1 esnain entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certifcatioit
2. Specify the type of project (check one):
❑Low Density ®Nigh 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, SW4110802 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):
❑CAMA Major ®Sedimentation/Erosion Control: 2.13 ac of Disturbed Area
❑NPDES industrial Stormwater 0404/401 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: Erosion Control Sheetz, STOKE-2012-001
Form SWU-101 Version 07Jun2010 Page I of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: Pi'M L.P.
Signing Official & Title: Joseph S. Sheetz, Vice President
b.Contact information for person listed in item 1a above:
Street Address: 5700. Sixth Avenue
City: Altoona State: PA Zip: 16602
Mailing Address (if applicable):
City:_
Phone:
Email:
State:
Fax: ( )
c. Please check the appropriate box. The applicant listed above is:
❑X The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:
PTM L.P.
Signing Official & 'Title: same as l(b)
b.Contact information for person listed in item 2a above:
Street Address:
City: State:
Mailing Address (if applicable):
City: State:
Phone: ( ) Fax:
Email:
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization: Sam Smith, Sheetz, Inc.
Signing Official & Title: Engineering Permit Manager
b. Contact information for person listed in item 3a above:
Mailing Address: 5700 Sixth Avenue
City: Altoona State: PA zip: 16602
Form SWU-101 Version 07Jun2010 Page 2 of 7

Phone: ( 814 ) 946-3611
Fax: ( 814 ) 941-5105
Email: sasmi th a sheetz . com
4. Local jurisdiction for building permits:
Point of Contact:Todd Cox Phone #: (336 ) 944-6888 T
IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater will be treated with a Bioretention Cell. Please refer to the Stormwater Management Report
prepared by Stimmel Associates PA for Stormwater Management Narrative.
2, a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ❑ Ph II - Post Construction
Stormwater runoff from this project drains to the Yadkin
4. Total Property Area: 2.087 acres
River basin.
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+:2.087 acres
+ Total project area shrill be calculated to exclude thefollowing: the normal ool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Witter (NHW) line or Mean High Water
(MHW) line, and coastal znetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landzoard 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 = 77.64
9. How many drainage areas does the project have?1 (For high densihj, count 1 for each proposed engineered
stortnzoater BMP. For lore densihj and other projects, use 1 for the whole properhj 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.
Form SWU-101 Version 07Jun2010 Page 3 of 7

Basin Information
Draina e Area 1
Draina e Area _
Draina e Area _
Draina e Area _
Receiving Stream Name
Muddy Creek
Stream Class *
C
Stream Index Number *
12-94-(0.5)
Total Drainage Area (sf)
98744
On -site Drainage Area (sf)
79314
Off -site Drainage Area (so
19430
Proposed Impervious Area** (so
76665
% Impervious Area** total
77.64
Im pervious'* Surface Area
Drainage Area 1
Drainage Area
Drainage Area _
Drainage Area _
On -site Buildings/ Lots (so
5941
On -site Streets (so
0
On -site Parking (so
61812
On -site Sidewalks (so
3857
Other on -site (so
0
Future (so
0
Off -site (so
5055
Existing BUA*** (sf)
0
Total (so:
76665
Streaw Class aird Index Nutirber can be rleterntined at: htt r: rortal.itcdeirr.orveb,vqdLsLcsir classi tcations
* Ira pervious area is defined as the built upon area including, but riot limited to, buildings, roads, barking areas,
sidewalks, gravel areas, etc.
*** Report only that amount of existing BLIA that will remain after development. Do not report airy existing BLIA that
is to be rentoved and which will he replaced by new BLIA.
11. How was the off -site impervious area listed above determined? Provide documentation. Computer generated
area based on site design.
Protects in Union County: Contact I)J),'Q Central Office stuff to check if the prefect is located within a I hreatened 4,
Endangered Species ivaler shed that nigv he suhjecl to more stringent slornnt)aler regairetnents as per NC,4C 028 .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from littp://portal.ncdenr.org/web/wq/ws/su/bmp-manual.
V1. 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://portaLncdenr.org/web/wq/ws/su/statesw/forms does. 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://portaLncdenr.org/web/wq/ws[su/mans.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from httl2://12ortal.ncdetir.org/webZwq/ws/su/­statesw/­foriiis does.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. {r_, 5
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants W/A
Form. (if required as per Part V11 below)
3. Original of the applicable Supplement 1�orm(s) sealed signed and dated and O&M E{
agreement(s) for each BMP. R
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to J
http://www,envhelp.org/gages/onestoL)express,html for information on the Express program
Form SWU-10l Version 07Jun2010 Page 4 of 7

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 stor[nwater treatment/management for
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the 05
receiving stream drains to class SA waters within'/z mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations. 640
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: KATJ
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 MI-IW (or NI-IW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SH WT elevations (Please identify (4,45
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: /I Page No:
11. For corporations and limited liability corporations (L-C): 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.
http:/ / www.secretary.state.nc.us/Corporations/CSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
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
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs. Download the latest versions for each
submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and Iisted
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
Form SWU-101 Version 07Jun2010 Page 5 of 7

VIII. CONSUL`I'AN"r 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 rcqucsts for additional information).
Consulting Engineer: Kenneth l3inkley
Consulting Firm: Stim mel Associates P.A.
Mailing Address: 601 N. Trade St., Suite 200
Citv:Winston-Salem
Phone: [phone]
Enaail:kbinkley«slitnmclpa.com
Statc:NC
!_ip:2710"I
Fax: (336 ) 723-1069
IX. PROPERTY OWNI R AUTHORIZATION (if Contact hiformatioa, ifem 2 has beenfilled nut, complefe flies
section)
1, (prirai or lrfhe name of persoo lisictl ill Corrincf lrtformation, ilem 2(7) certify that I
own the property identified in this permit application, and thus give permission to (yriut or' tyhc n MIC 0f persoat
lisfcrl hl COW(7 t h1p)-malhair, ilcm "la) with (taint or tape rrmue of orgallizatiolr lister! in
Coirlract luformaalioai, ilem N) to develop the project as currently proposed. A copy of
the ]case 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.
As the legal property owner 1 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 wi[[ 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 resu]t in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
Date:
a Notary Public for the State of County of
do hereby certify that
before the this _ day of
personally appeared
and acknowledge the due execution of the application for
a storrtawater permit. Witness my hand and official sC],
SEAL
My commission expires
Form SWU-101 Version 073tm2010 Page 6 of 7

X. APPLICANT'S CERTIFICATION
I, (print or type rrame of person listed in Contact Information, item 1n) Joseph S. Sheetz ,
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be construct d in conformance with the approved plans, that the required deed restrictions
and protective covenants wr b recorded, and that the proposed project complies with the requirements of the
applicable stormwater rule er 15A NCAC 2H .1000, SL 2006-246 (Ph. I1 - Post Construction) or SL 2008-211.
Signature:
Jennifer D.
Date: Its -& -il
a Notary Public for the State of Pennsylvania , County of
Blair -,do hereby certify that Shetetz personally appeared
before me this6th day of October . _2011_, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL_ Llenngr 0. am'or�►toana, t� �lon 6�Nes AprA 7, 2015
My commission expires,
4-7-15
Form SWU-101 Version 07Jun2010 Page 7 of 7

tow,rl

Pennil Number: SW 41 if 0,F0 Z
(to be prorvded bY DIVQ)
Drainage Area Number:
Bioretention 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 operation and maintenance procedures:
— Immediately after the bioretention cell is established, the plants will be watered
twice weekly if needed Lentil the plants become established (commonly six
weeks).
Snow, mulch or any other material will NEVER be piled on the surface of the
bioretention cell.
Heavy equipment will NEVER be driven over the bioretention cell.
Special care will be taken to prevent sediment from entering the bioretention cell.
Once a year, a soil test of the soil media will be conducted.
After the bioretention cell is established, I will inspect it once a month and within 24
hours after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal
County). Records of operation and maintenance will be kept in a known set location
and will be available upon regLrest.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP clement:
Potential roblems:
Flow I will reznediate the roblem:
The entire BMP
Trash/debris is Present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
bioretention cell
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
The inlet device: pipe,
The pipe is clogged (if
Unclog the pipe. Dispose of the
stone verge or Swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the Swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
fLILLn'l' problenis with erosion.
Stone verge is clogged or
Remove sediment and clogged
covered in sediment (if
stone and replace with clean stone.
applicable).
Form SW401-131oresentitm O&M -Rev.;, P.rnc I ol' 4

I b
SMP element:
The pretreatment area
The bioretention cell
vegetation
The bioretention cell
soils and mulch
Potential problems:
Flow is bypassing
pretreatment area and/or
gullies have formed.
Sediment has accuMulaled to
a depth greater than three
inches.
Erosion has occurred
Weeds are present
Best professional practices
show that pruning is needed
to maintain optimal plant
health.
Plants are dead, discascd or
dying.
Tree slakes/wires are present
six months after planting.
MulCli is breaking down or
has floated away.
Soils and/or Mulch are
clogged with sediment
An annual soil test shows that
pl-I has dropped or heavy
metals have accumulated in
the soil media.
How 1 will remediate the problem:
Regrade if necessary to roule all
flow to the pretreatment area.
Restabilize the area after grading.
Search for the Source of the
sediment and remedy (lie problem if
possible. Remove the sediment and
restabilize the pretreatment area.
Provide additional erosion
protection suc11 as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Remove the weeds, preferably by
hand.
Prune according to best professional
practices.
Determine the source of the
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Remove tree stake/wires (which
can kill the tree if not removed).
Spot mulch if there are only random
void areas. Replace whole mulch
layer if necessary. Remove the
remaining much and replace with
triple shredded hard wood mulch at
a maximum depth of three inches.
Determine the extent of the clogging
- remove and replace either just the
top layers or the entire media as
needed. Dispose of (lie spoil in an
appropriate off -site location. Use
triple shredded hard wood mulch at
a maximum depth of three inches.
Search for the source of the
sediment and remedy the problem if
possible.
Dolomitic lime shall be applied as
recommended per the soil test and
toxic soils shall be removed,
disposed of properly and replaced
with new planting media.
Forra SW401-13ioretemion 0 M-Rev.3
Pugs 2 44

BMP element:
Potentialproblems:
How i will retnediate theproblem:
The underdrain system
Clogging has occurred.
Wash otrt the underdrain system.
(if applicable)
The drop inlet
Clogging has occurred.
Clean out the drop inlet. Dispose of
the sediment off -site.
The drop inlet is damaged
Repair or replace the drop inlet.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW401-Bioretentio❑ O&M -Rev. 3 Page 3 of 4

Permit Number: 5ti g1(o9oz-
(1a be provklerl bY DW&
I acknowledge and a�(,rce by my signature beIQW 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.
Pr JJect nwne: SH.hI�T Z - KING
BMP drainage area number: I
Print name: Sheetz, Inc.
Address: 57oo Sixth Avenue, Altoona, PA 16602
Phone: [phone]
Signat
Dale: August 8, 2011
Note: Tlie legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivisicm has been ❑arced the president.
[, Gloria A. K
a Notary Public for- the State of
Pennsylvania County of Blair do hereby certify that
Stanton R. Sheetz
personally appeared befot-e me this 8th
day of August, 2011 and acknowledge the due execution of' the
forgoing bioretention maintenance requirements. Witness my hand and official seal,
r
My commission expires December
2, 2014
COMMONWEALTH OF PENNSYI.VANL4
Notarial Scat
oria A. King, Notary Public
tY Gloria:
Atboona, Blair County
mmission Expires Dec. 2 2014
I orm 51V401-13ioretention I&M Rev. ? [Me;mbWer.en^svlvaniaAssW ti,nofNotar+es
P,wc 4 of 4