SW4120202_CURRENT PERMIT_20120402

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW -4 r 2 D 2,o Z_,
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE-
?,o j Z. o q" b Z
YYYYMMDD

_AS'
-•^=�®
NC®ENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Charles Wakild, P. E.
Director
April 2, 2012
Mr. Kevin T. Hill
236 N. Broad Street
Seagrove, NC 27341
Subject: Stormwater Permit No. SW4120202
Fresh Cuts Grocery
High Density Commercial Sand Filter
Randolph County
Dear Mr. Hill:
Dee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for
Fresh Cuts Grocery on March 16, 2012 after requesting additional information on February 24, 2012. 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. SW6120103, dated April 2, 2012, for the construction, operation and maintenance
of the subject project and the stormwater BMPs.
This permit shall be effective from the date of issuance until April 1, 2020, 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 to Chapter 150B 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 Brian Lowther at [phone]; or
briars. [e-mail].
Sincerely,
for Charles Wakild, P.E.
cc: Winston Salem Regional Office
SW4120202 File
ec: H. Mack Summey, Jr., PE — Summey Engineering Associates, PLLC
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunily 1 Affirmative Action Employer
one
NorthCarolina
Airhma!!y

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State Stormwater Permit
Permit No. SW4120202
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
Kevin T. Hill
Fresh Cuts Grocery
157 North Broad Street, Seagrove, Randolph County
FOR THE
construction, operation and maintenance of one (1) sand filter in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to as the
"stormwater rules") and the approved stormwater management plans and specifications and
other supporting data as attached and on file with and approved by the Division of Water
Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until April 1, 2020, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
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 73,306.53 square feet of impervious area.
3. The tract will be limited to the amount of new 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. SW4120202
7. The following design criteria have been provided in the sand filter and must be
maintained at design condition:
a. Drainage Area, acres:
Onsite, ft2:
Offsite, ft2:
b. Total Impervious Surfaces, ft2:
Onsite, W:
Offsite, ftz:
C. Design Storm, inches:
d. Sediment Chamber Bottom Elev., fmsl
d. Top of Sand Elevation, fmsl:
e. Seasonal High Water Table, fmsl:
f. Sand Depth, feet:
h. Bottom of Sand Elevation fmsl:
i. Sediment Chamber SA, ft�:
i. Sand Chamber SA, ft':
j. Permitted Storage Volume, ft3:
k. Bypass / Storage Elevation, fmsl:
n. Drawdown Time, hours:
o. Underdrain Diameter, inches:
q. Receiving Stream/River Basin:
r. Stream Index Number:
S. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
4.46
103,237.2
91,040.4
73,306.53
73,306.53
0
1.0
282.5
282.5
below 278
2.0
11.5
1,638
723.0
13,005.0
284.5
9.42
6"
UT to Fork Creek / Cape Fear
17-25
..C.,
The stormwater management system shall be constructed in its entirety, vegetated
and operational for its intended use prior to the construction of any built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of the
system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary to
assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader, filter
media, planting media, underdrains, catch basins and piping.
R. 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 shalt summarize
the inspection dates, results of the inspections, and the maintenance work performed
at each inspection.
6. The stormwater treatment system shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
Page 2 of 6

State Stormwater permit
Permit No. SW4120202
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.
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 shalt 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
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. 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 at[ permit conditions until such time
as the Division approves a request to transfer the permit.
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.
Page 3 of 6

State Stormwater Permit
Permit No. SW4120202
4. The issuance of this permit does not prectude 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 2nd day of April, 2012.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
MAN, Md" VE, 5 E !: - I E�
for Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. SW4120202
Fresh Cuts Grocery
Stormwater Permit No. SW4120202
Randolph County
Designer's Certification
I, . , as a duly registered in the State of
North Carolina, having been authorized to observe {periodically l� weekly I
❑ful( time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the best of
my abilities, due care and diligence was used in the observation of the project construction
such that the construction was observed to be built within substantial compliance and intent
of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 5 of 6

State Stormwater Permit
Permit No. SW4120202
Certification Requirements:
1. The drainage area to the system contains approximately the permitted acreage.
2. The drainage area to the system contains no more than the permitted amount
of built -upon area.
3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
7. Under drains are located per the approved plans.
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 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 sediment chambers,
sand chambers, under drains, and outlets.
15. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Winston Salem Regional Office
Surface Water Protection
565 Waughtown Road
Winston Salem, NC 27107
Page 6 of 6

Permit Number: 4w V ZaZOZ
(Io be provided hr I)11'Q)
Drainage Area Number:
Sand Filter 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 will be carefully managed to reduce the sediment load to the sand filter.
— The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds
six inches.
Once a year, sand media will be skimmed.
The sand filter media will be replaced whenever it fails to function properly after maintenance.
The sand filter will be inspected quarterly 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:
PotentiaM661M
W 11HP—wnlMill
remediate the roblem:
Entire BMP
Trash/debris is present.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as
applicable)
pavement surface.possible.
Perimeter of sand filter
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed.
gully, and then plant a ground cover and
water until it is established. Provide lime
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height.
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too large for repair.
Forebay or pretreatment area
Sediment has accumulated to a
Search for the source of the sediment and
depth of greater than six inches.
remedy the problem if possible. Remove
the sediment and stabilize or dispose of it
in a location where it will not cause
impacts to streams or the BMP.
Erosion has occurred.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
roblems.
Weeds are present.
Remove the weeds, preferably by hand, If
a pesticide is used, wipe it on the plants
rather than spraying.
Forrn SW401-Sand Filter O&M-Rev.4 2009Sept17 rage 1 ol'3

jBMP element:P,oten_tialj'
oliZem1
0 remediate the rotilem:
Filter bed and underdrain
Water is ponding on the surface for
Check to see if the collector system is
collection system
more than 24 hours after a storm.
clogged and flush if necessary. If water
still ponds, remove the top few inches of
filter bed media and replace. If water still
Ponds, then consult an expert,
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the
sediment offsite.
The outlet device is damaged
Re air or replace the outlet device.
Receiving water
Erosion or other signs of damage
Contact the NC Division of Water Quality
have occurred at the outlet.
401 Oversight Unit at 919-733-1786.
Form SW401-Sand Filter O&M-Rev.4 2009Sept l7 Page 2 ol'3

Permit Number:
(to he provided hp 1)WQ)
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
Fresh Cuts
BA41' drainage area number:
Print name: Kenneth 1-I. Hill
Title: Owner
Address: 236 N. Broad Street Sea�,,rove NC 27341
Phone: [phone]
Signature: a �� �✓�
Date:
Note: The legally responsible party should not be a homeowners association unless more than 50% ofthe lots have been
sold and a resident of the subdivision has been named the president.
I, a Notary Public for the State of
Gl County of l� r!'� do hereby certify that
personally appeared before me this day of
and acknowledge the due execution of the forgoing sand filter
maintenance requirements. Witness my hand and official seal,
AMY T. SPENCER
Notary Publie
North Carolina
Randolph CountyNo- I
SEAL
My commission expires I i ( rC�o ) Lf
Form SW40I -Sand Filter O&M-Rev.4 2009Sept 17 Page 3 of")

Permit Number
{to be provided by DWQ)
�pF W A rgRO
.-A -0
NCDENR Y
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
SAND FILTER SUPPLEMENT
This form must be filled out on line, printed and submitted with all of the required information.
Make sure to also fill out and submit the Required Items Checklist (Section //I) and the I&M Agreement (Section IV)
I. PROJECT INFORMATION
Project name Fresh Cuts Grocery
Contact name
Phone number
Date
Drainage area number
H. Mack Summey, , Jr., PE
336-328-0902
February 15, 2012
1
{I. DESIGN INFORMATION
Site Characteristics
Drainage area (AD)
194,277.60 ft2 OK
Impervious area
73,181,00 ft2
% Impervious (IA)
37.7% %
Design rainfall depth (RD)
1.00 in
Peak Flow Calculations
1-yr, 24-hr runoff depth
2.79
in
1-yr, 24-hr intensity
0,12
inlbr
Pre -development 1-yr, 24-hr runoff
0.06
ft3lsec
Post -development 1-yr, 24-hr runoff
0.11
ft3lsec
Pre/Post 1-yr, 24-hr peak control
0.05
ft3lsec
Storage Volume
Design volume (WOV)
13,005,00 ft'
Adjusted water quality volume (WQVAdi)
9,753 75 h3
Volume contained in the sedimentation basin and on top of the sand filter
13,005,00 ft3
Top of sand filter/grate elevation
282.5 ft amsl
Weir elevation (between chambers)
284.5 ft amsl
Maximum head on the sedimentation basin and sand filter (hM,,;FA,,)
2,00 ft
Average head on the sedimentation basin and sand filter (hA)
1.00 ft
Runoff Coefficient (Rv)
0.39 (unitless)
Type of Sand Filter
Open sand filter? Y
Y or N
SHWT elevation
278.00 ft amsl
Bottom of the sand filter elevation
280,50 ft amsl
Clearance (dsHWT)
2.50
Closed/pre-cast sand filter? N
Y or N
SHWT elevation
ft amsl
Bottom of the sand filter elevation
h amsl
Clearance (dsHwr)
If this is a closed, underground dosed sand filter: The clearance between
the surface of the sand filter and the bottom of the roof of the underground
ft
structure (dsp,,)
OK
OK
OK
Form SVV401-Sand Filter-Rev.5 20095ept17 Parts I and 11. Project Design Summary, Page 1 of 2

Permit Number:
(to be provided by DWQ)
Sedimentation Basin
Surface area of sedimentation basin (As)
Sedimentation basinichamber depth
Sand Filter
Surface area of sand filter (AF)
Top of sand media filter bed elevation
Bottom of sand media filter bedidrain elevation
Depth of the sand media filter bed OF)
Coefficient of permeability for the sand filter (k)
Outlet diameter
Outlet dischargeiflowrate
Time to drain the sand filter (t)
Time to drain the sand filter M
Additional Information
Does volume in excess of the design volume bypass the sand filter?
Is an off-line flow -splitting device used?
If draining to SA waters: Does volume in excess of the design volume flow
evenly distributed through a vegetated filter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
Is the BMP located at least 30ft from surface waters (50ft if SA waters)?
If not a closed bottom, is BMP located at least 100ft from water supply wells?
Are the vegetated side slopes equal to or less than 3:1
Is the BMP located in a recorded drainage easement with a recorded access
easement to a public Right of Way (ROW)?
What is the width of the sedimentation chamberlforebay (Ws J?
What is the depth of sand over the outlet pipe (dpipe)?
Z Vf\.` IVIUMto IIIIIIIIIIUIII, uul IIIGy IIzUU lu UC IIIUCd6CU IU
1,638.00 It
2.00 ft
Z II luma I: Jul Ialx GI Gd.I lllJ VW III alau 111GI CdJG Lilt;
723.00 ft
282.50 ft amsl
280.50 ft amsl
2.00 ft
3.50 (ft/day)
6.00 in
0,30 ft3isec
9,42 hours OK, Submit drainage calculations.
0.39 days
Y
YorN
OK
N
Y or N
Insufficient flow splilter.
N
Y cr N
Excess volume must pass through filter.
0.00 ft
N
Y or N
Show how flow Is evenly distributed.
Y
Y or N
OK
Y
Y or N
OK
Y
Y or N
OK
Y
Y or N
OK
10.00 ft
OK
1.50 ft
OK
Form SW401-Sand Filter-Rev.S 2009Sep117
Parts I and II. Project Design Summary, Page 2 of 2

Y`• "
LYftW
DW2?USA oN_w�'.
i'
Date Received
Fee Paid
Permit Number
5,a5
_WzoBC
I S,,) 1Z a Lo Z
Applicable Rules: ❑ Coastal 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 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 be photocopied for use as an original
I. 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.):
Fresh Cuts Grocery
2. Location of Project (street address):
157 North Broad Street
City:Seagrove County:Randolph Zip:27341
3. Directions to project (from nearest major intersection):
From the intersection of US HWY 220 Business & HWY 705, Go north approximately 500', site on west side of
HWY 220 Business.
4. Latitude:35* 32' 32.29" N Longitude:-79° 46' 47.62" W of the main entrance to the project.
1I. 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 certification
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, N/A _ 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: 2.8 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:
Form SWU-101 Version 07Jun2010 Page I of

z 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:Kevin T. Hill
Signing Official & Title:Kevin T. Hill, Owner
b.Contact information for person listed in item 1a above:
Street Address:236 N. Broad Street
City:Seagrove State:NC Zip:27341
Mailing Address (if applicable):236 N. Broad Street
City -.Seagrove State:NC Zip:27241
Phone: (336 } 302-0190 Fax: (336 } 873-7241
Email:[e-mail]
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
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: Brown Eyes Investments, LLC
Signing Official & TitIe:Kenneth Hill/Owner
b. Contact information for person listed in item 2a above:
Street Address:236 N. Broad Street
City:Sea rove State:NC Zip:27341
Mailing Address (if applicable):236 N. Broad Street
City:Sea rov State:NC _ _ Zip:27341
Phone: [phone] Fax: (336 ) 873-7241
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:
Signing Official & Title:
b. Contact information for person listed in item 3a above:
Mailing Address:
City:
Phone: f
Email:
State:
Fax:
4. Local jurisdiction for building permits: Randolph County
Point of Contact: Phone #: ( )
Form S WU- I0 i Version 07Jun20 10 Page 2 of 6
Zip:

' IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Ali impervious surface area will be directed to a permanent Sand Filter sized to treat 90% TSS.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development PIan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 2.58 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*:2,58 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 Hi h Water (NHVVY line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHX line. The resultant project area is used to
calculate overall percent built upon area (B UA). Non -coastal wetlands landward 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 = 65.22 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density 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.
Basin Information
Drains -e Area
Drainage Area
Drains" e'Area
Drainage Area _
Receiving Stream Name
UT to Fork
Creek
Stream Class
C
Stream Index Number *
17-25
Total Drainage Area (so
194,277.6
On -site Drainage Area (sf)
103,237.2
Off -site Drainage Area (so
91,040.4
Proposed Impervious Area** (so
73,306.53
% Impervious Area"* total
65.22
Im envious"Surface Area
Drainage Area _
Drainage Aiea _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
17,573
On -site Streets (sf)
On -site Parking (so
55,048.53
On -site Sidewalks (so
685
Other on -site (so
Future (so
Off -site (so
Existing BUA*** (so
Total (so:
73,306.53
* Stream Class and Index Number can be determined at: )ittpaortal,iicdeiir.or Aoebhvg&sksiticlassifications
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version 07.1un2010 Page 3 of

'Report only that amount of existing BLIA that will remain after development. Do not report any existing B UA that
is to be removed and which will be replaced by new B CIA.
11. How was the off -site impervious area listed above determined? Provide documentation. Impervious area is
not listed above none located from field survey & field observation.
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 NCAC 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 htttp://portal.ncdenr.org-,/web/w4/ws/su/bmu-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from ht ./ f.portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs. 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 hqp://portal.ncdenr.org/web/Mws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initiated in blue ink. Download the latest versions
for each submitted application package from hqp://portal.ncdenr.org/web/wq/ws/su/statesw/forms does.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. RA_�
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 NCDENR. (For an Express review, refer to
hgR://www.envhelp.2yZ/pages/onestopexRLiLss. 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/managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USG5 map identifying the site Iocation. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within mile of the site boundary, include the I/z
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 MI-IW or NHW tine of tidal
wafters, 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 bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
lc. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
Form S WU-101 Version 07Jun2010 Page 4 of 6

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).
Copy of any applicable soils report with the associated SHWT elevations (Please identify A11MW_
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 vernfij the SHWT prior
to submittal, (9I0) 796-7378.)
10. A copy of the most current property deed. Deed book: 2145 Page No: 1225
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.
hU://www.secretary.state.nc.us/Corporations/CSearch.aWx
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
hul/portal.ncdenr.orgJweb/wq/ws/suZstatesw/forms does. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer:H.Mack SummeJr., PE
Consulting Firm: Summey Engineering Associates, PLLC
Mailing Address: P.O. Box 968
City: Asheboro State: NC Zip: 27204
Phone: (336 ) 328.0902
Email: mack®asheboro.com
Fax: (336 ) 328-0922 T
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (print or hjpe name of person listed in Contact Information, item 2a) Kenneth Hill , certify that I
own the property identified in this permit application, and thus give permission to (print or hjpe name of person
listed in Contact Information, item 1a) Kevin Hill with (print or hjpe name of organization listed in
Contact Information, item Ia) Fresh Cuts Groce 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 073un2010 Page 5 of 6

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 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 penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
/a» , ��_�� Date:
a Notary Public for the State of _ County of
do hereby certify that toll M ,_„ personally appeared
before me this&ay of and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
\\`\`\ %W 1 11811 r,j'///i
_ Notary Public
Randolph County
�T
�RTH�C A�ti ?0\`��\
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires
I, (print or type name of person listed in Contact Information, item 1a) Kevin Hill
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 Les under 15A NCAC 21-1.1000, SL 2006-246 (Ph.11- Post Construction) or SL 2008-211.
r1
v/z
Signature: Date: r ��
I, 1 a N tary Public for the State of j U County of
do hereby certify that personally appeared
before me this -`ay of ,-"-"V and Kknowledge the due execution of the application for
a stormwater permit. Witness my hand land official seal,
R.
O�
Notary Public _
Randolph County
" O r�
•,'�%NTH rCIAR�0
SEAL
My commission expires e OI L
Form 5WU-101 Version 07Jun2010 Page 6 of 6

Permit No.
(to be provided by D WQ)
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An incomplete submittal
package YAII result in a request for additional information. This will delay final review and approval of the project. Initial
in the space provided to indicate the following design requirements have been met. If the applicant has designated an agent,
the agent may initial below. If a requirement has not been met, attach justification.
Initials Page/ Plan
Sheet No.
01OH
'>2tq 1, Plans 0" - 50' or larger) of the entire site with labeled drainage area boundaries
Air' - System dimensions (length, width, and depth) for both the sedimentation chamber and the filter
chamber,
Maintenance access,
Flow splitting device,
Proposed drainage easement and public right of way (ROW),
Design at ultimate build -out,
Off -site drainage (if applicable), and
Boundaries of drainage easement.
2. Plan details (1" = 30' or larger) for the sand filter showing:
- System dimensions (length, width, and depth) for both the sedimentation chamber and the filter
chamber,
- Maintenance access,
Flow splitting device,
- Vegetative filter strip dimensions and slope (if SA waters),
Proposed drainage easement and public right of way (ROW),
Design at ultimate build -out,
- Off -site drainage (if applicable), and
- Boundaries of drainage easement.
3. Section view of the sand filter (1" = 20' or larger) showing:
- Depth(s) of the sedimentation chamber and sand filter chamber,
Depth of sand filter media,
Connection between the sedimentation chamber and the sand filter chamber and weir elevation,
SHWT elevation,
Outlet pipe, and
- Clearance from the surface of the sand filter to the bottom of the roof of the underground structure (if
applicable).
4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWQ, by completing & submitting the soils
investigation request form. County soil reaps are not an acceptable source of soils information.
5. Supporting calculations (including drainage calculations)
j 6. Signed and notarized operation and maintenance (OW) agreement
*Kr
7. A copy of the deed restrictions (if required).
Form SW401-Sand Filter-Rev.5 2009Sept17 Part III, Page 1 of 1

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