SW4120604_CURRENT PERMIT_20130114

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

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P. E.
Governor Director
January 14, 2013
Mr. William H. Long
Long Hill, LLC
P.O. Box 11625
Winston-Salem, NC 27116
Subject: Stormwater Permit No. SW4120604 ; Modification
Accessory Garage Addition & Site Improvements for 1275 Old Belt Way
High Density Commercial Sand Filter
Forsyth County
Dear Mr. Long:
John E. Skvarla, III
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application to modify
the subject permit on January 2, 2013, with additional information received January 10, 2013. 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 modified
Permit No. SW4120604, dated January 14, 2013, for the construction, operation and maintenance of the subject
project and the stormwater BMP(s).
This permit shall be effective from the date of issuance until June 25, 2020 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 or 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 by filing a written petition with the Office of Administrative Hearings (OAH).
The written petition must conform to Chapter 150B of the North Carolina General Statutes. Per NCGS 143-
215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this permit. You should
contact the OAH with all questions regarding the filing fee (if a filing fee is required) and/or the details of the
filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via telephone at 919-431-3000, or visit
their website at www.NCOAH.com. 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,
n cc: SW4120604 File'
ec: Sue Homewood -- Winston-Salem Regional Office
for Charles Wakild, P.E. Vincent C. Townsend, PE, PLS - Green Mountain
Engineering, PLLC
Wetlands and Stormwaler 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.nowaterqualily.org
An Equal Opportunity l Affirmative Aelion Employer
NorthCarolina
naturally

State Stormwater Permit
Permit No. SW4120604
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
TATE 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
Long Hill, LLC
Accessory Garage Addition & Site Improvements for
1275 Old Belt Way, Rural Hall, Forsyth County
FOR THE
construction, operation and maintenance of a sand filter 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 June 25, 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 1.7 of this permit. The stormwater
control has been designed to handle the runoff from 38,690 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. SW4120604
7. The following design criteria have been provided in the sand filter and must
be maintained at design condition:
a. Drainage Area, acres:
1.54
Onsite, ftz:
60,716
Offsite, ftz:
6,244
b. Total Impervious Surfaces, ftZ:
38,690
Onsite, ftZ:
36,502
Offsite, ftz:
2,188
C. Design Storm, inches:
1.0
d. Sediment Chamber Bottom Elev., fmsl:
919.00
d. Top of Sand Elevation, fmsl:
914.75
e. Seasonal High Water Table, fmsl:
below 909.0
f. Sand Depth, feet:
2.0
h. Bottom of Sand Elevation, fmsl:
912.75
i. Sediment Chamber SA, ftz:
596
i. Sand Chamber SA, ftz:
503
j. Permitted Storage Volume, ft3:
2,773
k. Bypass / Storage Elevation, fmsl:
917.00
n. Drawdown Time, hours:
32
o. Underdra'in Diameter, inches:
4.0
q. Receiving Stream/River Basin:
Grassy Creek / Yadkin - Pee Dee
r. Stream Index Number:
12-94-7-3
S. Classification of Water Body:
"C"
ll. SCHEDULE OF COMPLIANCE
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded
areas of the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance
necessary to assure the permitted stormwater system functions at optimum
efficiency. The approved Operation and Maintenance Plan must be followed in
its entirety and maintenance must occur at the scheduled intervals including,
but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level
spreader, filter media, planting media, underdrains, catch basins and
piping.
g. Access to the cell and outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work
and what actions were taken.
5. The permittee shall submit to the Division of Water 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 2 of 6

State Stormwater Permit
Permit No. SW4120604
6. 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
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.
Page 3of6

State Stormwater Permit
Permit No. SW4120604
2. Th.e 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 Permitted 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 141h day of January, 2013.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4of6
z .

State Stormwater Permit
Permit No. SW4120604
Accessory Garage Addition & Site Improvements for 1275 Old Belt Way
Stormwater Permit No. SW4120604
Forsyth 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
Page 5 of 6

State Stormwater Permit
Permit No.-SW4120604
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 6of6
i

?A T TIE-te-C opv
DWQ USE ONLY
JDatp Received
Fee Paid
Permit Number
2 2. 1 3
505%LMI
5FVf 1204-0V M0 7>
Applica le ules: ❑ Coastal SW -1995 ❑ Coastal SW -- 2008 OR -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
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.):
Accessory Garage Addition and Site Improvements for 1275 Old Belt Way T ��
2. Location of Project (street address):
1275 Old Belt Way
City:Rural Hall County:lf" s yT/f Zip. 27045
3. Directions to project (from nearest major intersection):
US 52 North; take exit NC 65 turn right on 65Z Bethania-Rural Hall Rd and drive approximately 1 4 mile;
turn right on Forum Parkway, drive approximately "l /2 mile; turn right on Old Belt Way, drive
approximately 300 feet, site is on the left.
4. Latitude:36° IT 43.1" N Longitude:80° 17' 40.2" W of the main 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 SW4120604 , its issue date (if known) 06/25,L2012 , and the status of
construction: ❑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):
❑CAMA Major
❑Sedimen tation/Erosion Control
❑NPDES Industrial Stormwater ❑404/40'1 Permit: Proposed Impacts
ac of Disturbed Area
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:Note: local permitting authori for sedimentation erosion control
issued by Forsyth County Inspection Department, Grading Permit number: 205517. __..
Form SWU-101 Version 07]un2010
Pagel of 6

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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: Long Hill, LLC
Signing Official & Title: 1VILLAAM N. C-c ✓(r
b.Contact information for person listed in item 1a above:
Street Address: 4401 North Patterson Avenue
City:Winston-Salem State:NC Zip:27105
Mailing Address (if applicable):P.O. Box 11625
City:Winston-Salem State:NC Zip:27116
Phone: (336 ) 744-01.55 Fax: (336_ ) 744-0941
Email:wbrewer®longbro.com
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:
Signing Official & Title:
b.Contact information for person listed in item 2a above:
Street Add res
City: State:
Mailing Address (if applicable):
City:
Phone:
Email:
Zip:
State: Zip:
Fax: ( }
a. (Optional) Print the name and title of another contact such as the projects construction supervisor or other
person who can answer questions about the project:
Other Contact Person/ Organization:Tim Mabe
Signing Official & Title: VP of construction
b.Contact information for person listed in item 3a above:
Mailing Address: P.O. Box 11625
City: Winston-Salem State: NC Zip: 27116
Phone: (336 ) 744-0155 Fax: (336 ) 744-0941
Email:
4. Local jurisdiction for building permits: Winston-Salem/Forsyth Coun . Inspections Department
Point of Contact: Joe Kube Phone #: (336 __)_727-2626
Form SWU-101 Version 07Jun2010 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
An impervous area greater than the new additional impervious area will be treated in a permanent sand
filter. A flow diversion will be installed to route intense rainfall events around the sand filter.
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 11- Post Construction
3. Stormwater runoff from this project drains to the Yadkin River basin.
4. Total Property Area: 3.25 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+:3.25 acres
+ Total project area shall be calculated to exclude thefollowing. file normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NNW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHM line. ne resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal zoetlatids landward of the NHW (or MHW) lice pray
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 56.31 %
9. How many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
stormwater BMP. For loin density and other projects, rise I for the rnitole 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.
Basin Information
Drainage Area _
Drainage Area
Drainage Area
Drainage Area
Receiving Stream Name
Grassy Creek
Stream Class *
C
Stream Index Number *
12-94-7-3
Total Drainage Area (sf)
66,960
On -site Drainage Area (sf)
60,716
Off -site Drainage Area (sf)
6,244
Proposed Im ervious Area*" (sf)
38,690
Impervious Area* total
57.8%
Impervious" Surface Area
Drainage Area
Drainage Area
Drainage Area
Drainage Area
On -site Buildings/Lots (so
3,750
On -site Streets (so
On -site Parking (so
30,312
On -site Sidewalks (so
11000
Other on -site (so
-1,440
Future (so
n/a
Off -site (so
2,188
Existing BUA' (so
Total (so:
38,690
* Stream Class and Index Number (-all be determined at: lrttp://portal.ucderrr.or nebAi)q ps/csrr/rlassi cations
** fill ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidperoalks, gravel areas, etc-.
*** Report only that amount of existing BUA that will remain after development. Do Prot report any existing BUA that
is to be removed and which will be replaced by nav BUA.
Form SWU-101 Version 07Jun2010 Page 3 of 6

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11. How was the off -site impervious area listed above determined? Provide documentation. Accurate
topography and proposed plans were used to determine areas using AutoCAD polylines.
Projects in Union County; Contact DWQ Central Office staff to check if the project is located within a T hreatened &
E'ndangered Species watershed that may he sahject 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 hU://portal.ncdenr.org/web/wq/ws/su/binp-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://portal.ncdenr.org/web/wg/ws/suZstatesw/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://portal.ncdenr.org/web/wg/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space
provided for each item. All original documents MUST be signed and initialed in blue ink. Download the latest
versions for each submitted application package from
http://portal.ncdenr.org/web/wq/ws/su/statesw/fornis docs.
Initial
1. Original and one copy of the Stormwater Management Permit Application Form. oc
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants 0O__Gr[AMQ
Form. (if required as per Part Vll below) 0111
3. Original of the applicable Supplement Form(s) sealed signed and dated and O&M Now~ 777
agreement(s) for each BMP. O O K ft — (d e- *q 0 "e)
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.envhelp,org/pages/onestopexpress.htmI for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.) �r
5. A detailed narrative (one to two pages) describing the stormwater treatment/management for `V G
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the ND GdA AK£
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the
mile radius on the map.
7. Sealed, signed and dated calculations. LU.0
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: CV. C1277
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 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).
Form SWU-101 Version 07Jun2010 Page 4 of 6

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9. Copy of any applicable soils report with the associated SHWT elevations (Please identify on c a it IV if
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verify the SHVVT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: Page No:
'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 la, 2a, and/or 3a per NCAC 21-1.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
hU://www.secretaly.state.nc.us/CorporaLions/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.orgZweb/wg/wrs/su/stat_esw/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.
Vill. 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: Vincent C. Townsend, PE, PLS ^
Consulting Firm: Green Mountain Engineering, PLLC
Mailing Address: 609 Stafford Pointe Court
City:Oak Ridge - State:NC Zip:27310
Phone: (336 ) 255-8395
Email:[e-mail]
Fax: (336 ) 298-7021
1X. PROPERTY OWNER AUTHORIZATION (if Corr fact Information, item 2 has been filled out, complete this
section)
1, (print or type nacre of person listed in Contact Infornrafion, item 2a) , 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 1a) with (print or type nacre of organization listed in
Contact Information, item 1a) 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 07Jun2010 Page 5 of 6

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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 penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
I, _ . a Notary Public for the State of . County of
do hereby certify that
personally appeared
before me this _ day of , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person[ listed in Contact Information, itenn 1a) (d t 4,1 AM 11 , Lo NC,
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 NQAC 2H .1000, SL 2006-246 (Ph. II - Post Construction) or SL 2008-2-11.
Signatu
Date:
I, S 2nkUt1 �' G �t'ur� Notary Public for the State of !V County of
I�06,01 , do hereby certify that V 0 11 Ct-yw Hpersonally appeared
before me this day of I and acknowledge the due execution of the pplication for
a stormwater permit. Witness my hand and official seal,
11I
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rotary � _
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SEAL
My commission expires 1,�-i-aoi4
Form SWU-101 Version 07Jun2010 Page 6 of 6

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Permit Number;?
Ito be provided by DWQJ
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NCDENR p
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 III) and the 1&MAgreement (Section IV}
I. PROJECT INFORMATION
Project name Accessory Garage Addition and Site Improvements for 1275 Old Belt Way
Contact name Vincent C, Townsend, PE, PLS
Phone number 336-255-8395
Date 12/27/2012 (Revision 1)
Drainage area number 1
II. DESIGN INFORMATION
Site Characteristics
Drainage area (AD) 66,960.00 ftZ OK
Impervious area 38,690.00 ft2
% Impervious (IA) 57.8% %
Design rainfall depth (Ro) 1.00 in
Peak Flow Calculations
1-yr, 24-hr runoff depth
in
I-yr, 24-hr intensity
2.87 inlhr
Pre -development 1-yr, 24-hr runoff
ft/sec
Post -development 1-yr, 24-hr runoff
ft3lsec
Pre/Post 1-yr, 24-hr peak control
ft3lsec
Storage Volume
Design volume (WQV) 3,180.00 tt3 Z !�') ?-
Adjusted water quality volume (WQVAJ) 2,385.00 ft3 OK
Volume contained in the sedimentation basin and on top of the sand filter _2,aq&M-07 - s,
Top of sand filterlgrate elevation 914.75 ft amsl
Weir elevation (between chambers) 917 ft amsl
Maximum head on the sedimentation basin and sand filter (hwXw,e) 2.25 ft OK
Average head on the sedimentation basin and sand filter (N) 1.13 ft OK
Runoff Coefficient (Rv) 0.57 (unitless)
Type of Sand Filter
Open sand filter? y
Y or N
SHWT elevation
905.00 ft amsl
Bottom of the sand filter elevation
911.75 ft amsl
Clearance (dsr,w)
6.75
Closedlpre-cast sand filter? n
Y or N
SHWT elevation
ft amsl
Bottom of the sand filter elevation
ft amsl
Clearance (dsHm)
If this is a dosed, underground dosed sand filter. The clearance between
the surface of the sand filter and the bottom of the roof of the underground
ft
structure (ds,.)
4�-
F O-CM ?UVy
Form SW401-Sand Filter-Rev.S 20o9Sept17 Parts I and II. Project Design Summary, Page 1 of 2

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Permit Number:.SW 4 126664
(to be provided by DWQ)
Sedimentation Basin
Surface area of sedimentation basin (As)
Sedimentation basin/chamber depth
Sand Filter
Surface area of sand filter (AF)
Top of sand media filter bed elevation
Bottom of sand media filter bedldrain elevation
Depth of the sand media filter bed (dF)
Coefficient of permeability for the sand filter (k)
Outlet diameter
Outlet dischargelflowrate
Time to drain the sand filter (t)
Time to drain the sand filter (t)
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 dosed bottom, is BMP located at least t00ft 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 (Ww)?
What is the depth of sand over the outlet pipe (dpipe)?
596.00 ft' Un. IVIUMh inumiwni, UUL Mdy HUM IU UC IrIUICdSGU LU
_,._�..... 41,...,,n..!.-A ...i,....,. ;c ,........,-A-.. o�...,.�..
2.00 ft
503.00 ft2 Un. ivituLs uonniiuiii, uuL may iivvu LU UG II IuiudSCu LU
,-A— LN-
914.75 ft amsl
912.75 ft amsl
2.00 ft
3.50 (fVday)
4.00 in
0.02 ft/sec
32.38 hours OK. Submit drainage calculations.
1.35 days
Y Y or N OK
Y Y or N OK
NA Y or N Enter Data
ft
YorN
Y Y or N
OK
Y Y or N
OK
Y Y or N
OK
Y Y or N
OK
18.50 ft
OK
2.00 ft
OK
Form SW401-Sand Filter-Rev,5 2009Sept17 Parts I and II. Project Design Summary, Page 2 of 2