SW3200701_01-Application_20200707

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: 0 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 Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied far 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.):
Prescot Villa e - Phase 1
2. Location of Project (street address):
3100 Providence Road South
City:Waxhaw County:Union Zip:28173
3. Directions to project (from nearest major intersection):
From 1-485 Outer. Take exit 57 to NC-16/ Providence Rd towards Weddington
4. Latitude ;34° 57.5' 72" N Lon gitude:80° 45' 22.87" W of the main entrance to the project.
If. PERMIT INFORMATION:
I. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Mod ificationt
tRenewals With modifications also requires � WU-102 - Renewal Application Form
b.Ifthis application is being submitted as the result of 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* *provideadesigner' certification
2. Specify the type of project (check one):
❑Low Density NHigh Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of previously returned application or a letter from
DEMLR requesting a state stormwatermanagement 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 ®Sedimentation/ Erosion Control: 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:Town of Waxhaw E&SC Permit, I sue Date 04/ 13/ 17
5. Is the project located within 5 miles of a public airport? NNo ❑Yes
If yes, see S.L. 2012-200, Part VI: http�Irnnrtal.ncdenr_nrg `iveb.4rerules-and-regulatic]ns
Form SWU-101 Version Oct. 31, 2013 Page I of 6

111. CONTACT INFORMATION
L a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the Droject}:
Applicant/ Organization:PNB Holding Co. 2 Inc.
Signing Official & Title:William L. Fuson, Authorized Signer
b.Contact information for person listed in item la above:
Street Address:] 1 ] IW Avenue-S.—Suite 300
City:Nashville State:TN Zip:37203
Mailing Address (ifapplicable):
City: State: Zip:
Phone: (615 ) 743-8411
Em ail:Bill.FusonfaPN FP.com
Fax: (615 ) 743-8598
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, ifyou are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/ Organization:PNB Molding Co. 2. Inc
Signing Official & Title:William L. Fuson, Authorized Signer
b.Contact information for person listed in item 2a above:
Street Address:I l I I0'h Avenue S., Suite 300
City:Nashville State:TN Zip:37203
Mailing Address (ifapplicable):
City: State• Zip:
Phone: [phone] Fax: (615 ) 743-8598
Email:Bill.FusonW!N FP.com
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: State: Zip:
Phone: ( } Fax: ( )
Email•
4. Local jurisdiction for building permits: Town of Waxhaw / Union County
Point ofContact:Chris Rice. Town of Waxhaw E&SC Phone #: [phone] x236
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Wetpond
2. a. if claiming vested rights, identify the supporting documents provided and the date they were approved:
® Approval of Site Specific Development Plan nr PUDApproval Date: 041 13/ 17
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accord an cc with:
❑ Coastal SW — 1995 ® Ph It — Post Construction
3. Stormwater runoff from this project drains to the Catawba River basin.
4. Total Property Area: 10.54 acres 5. Total Coastal Wetlands Area: 0 acres
G. Total Surface Water Area: 0 acres
7. Total Property Area (4) — Total Coastal Wetlands Area (5) — Total Surface Water Area (6) - Total Project Area':
10.54 acres
Total project area shall be calculated to exclude thefollowing. the normal pool of impounded structures, the area
bet►veen the banks ofstreams and rivers, the area belov the Normal High Water (NHW) line or Mean High Water
(MHIV) line, and coastal ►vellrmds landward from the NHIP (or AIHIV) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal ►vellands landward ofthe NHIY (or AIHi1`) line may be
included in the total project area
8. Project percent of impervious area: (Total Impervious Area ; Total Project Area) X 100 = 77.8 %
9. How many drainage areas does the project have?I (Forhigh density, count 1 for each proposed engineered
stormwater BAIP, For low density and other projects, use I for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin. Information
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Twelvemile
Creek
Stream Class *
C
Stream Index Number*
11-138
Total Drainage Area (so
459,122
On -site Drainage Area (sf)
459,122
Off -site Drainage Area (so
0
Proposed Impervious Area **(so1
357,I92
%Impervious Area" (total) 1
77.8
Impervious" Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/ Lots (so
0
On -site Streets (sf)
41,050
On -site Parking (sf)
0
On -site Sidewalks (so
12,093
Other on -site (sf)
0
Future (so
304,049
Off -site (sf)
0
Existing BUA***(sf)
0
Total (so:
357,I92
* Stream Class and Index Number can be determined at: huml-Iportal.ncdenr.arg.''►veb'►vq!pslcsulclassr'Tcations
** hnpervious area is defined as the built upon area including, but not limiled tas buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of

*"*Report only that amount ofexistingBUA that will remain after development. Do not report any existing BUA that is
to be removed and which will be replaced by neiv BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. n/ a
Proiects in Union County: Contact DEMLR Central Office stafjto check if the project is located within a Threatened &
Endangered Species watershed that ntay be subject to more stringent stornnvater requirements as per 1 SA 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 http:/ / portal.ncdenr.org' web' wq1 ws'su1 bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
htta:' nortal.ncdenr.ore/ web! wo' ws/ su/ statesw/ forms dots. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at http:l / portal.ncdenr.org/ web/ wq:` ws.-'su/ maps.)
Please indicate that the following required information have been provided f Y. initialing, in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
foreaeh submitted application package from porial.ncdcnr.urur` %vub.! wg! ws- Su! stateswi forms dges.
In itialp
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (ifrequired as per Part V11 belarnv)
3. Original of the applicable Supplement Form(s)(scaled, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of$505 payable toNCDENR. (For an Express review, refer to
httn:/ / www.envhein.org/ naaes/ onestonexaress.html for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/ management for
the project. This is required in addition to the brief summary provided in the Project
Information, item 1. (SEE LM.CuVrTTW-''S)
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within !.4 mile of the site boundary, include the !'i
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/ Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW orNH W line of tidal
waters, and any coastal wetlands landward of the MHW orNHW 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) oftidal 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.
in. 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.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

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 SHWT elevations (Please identify Nth
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"xl I" 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: Scheduleasite visit far DEXILR toverify theSHIVT prior
losubmittal, (9I0) 796-7378.)
A copy of the most current property deed. Deed book: 7290 Page No: 589
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 15A 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.
httpa / www.secretary.state.nc.us/ Corporation s/_CSearch.aspx
V11. 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 ht42://12ortal.ncdenr.org/webAr/state-stormwater-
forms does. Download the Iatest versions for each submittal.
In the instances where the applicant is d ifferent 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 forthis 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
underthem, that they will run with the land, that the required covenants cannot be changed ordeleted
without concurrence from the NC DEMLR, and that they will be recorded priorto the sale of any lot.
Vlll. 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:Brian LaFranchi, PE
Consulting Firm: Dewberry Engineers Inc.
Mailing Address:9300 Harris Corners Parkway. Suite 220
City:Charlotte State:NC Zip:28269
Phone: (704 )__631-5206
Em ail:blafranch iced ewberry.com
Fax: ( 1
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (print or type name of person listed in Contact Information, item 2a) 1Pilliam L. !-itson , certify that 1
own the property identified in this permit application, and thus give permission to (print or type name ofperson
listed in Contact Information, item la) PNB Holding Co. Z Inc with (print or
type name of organization listed in Contact Information, item Ia) PNB Holding Co. 2. Inc 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
storm water system.
Form SWU-101 Version Oct. 31, 2013 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/ or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLRStormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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 stormwater treatment facility
without a valid p rmit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action includin as ment iI penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
1, a Notary Public for the State of�a &Al q i , County of
do hereby certify that W1.L& ',�, _ personally appeared
before me this day ofImAg.Oif ,�` and ack owledge the du exec tion of the application for a
r �.�.
stormwater permit. Witness my hand and official seal, _-..
you F. $A TFS
Of SEE Z
'[01pftY 0
n0 Pu�t'IG
OF
X- APPLICANT'S CERTIFICATION
�1:rl4
My commission expires
I, (print or type nine ofperson listed in Contact Information, item la) William L. Tnson ,
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 coverkAnts will be recorded, and that the proposed project complies with the requirements of the
applicable st v e rul 5A NCAC 2H .1000 and any other applicable state stormwater requirements.
t
Signature: + Dater
I, � , a Notary Public for the State or�f& 6[&' , County of
do hereby certify that -1 fCyG personally appeared
before me this day ofMkK, and acknowl�the exe tion the application for a
stormwater permit. Witness my hand and official seal,`�•_
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OF
TKNESSEE Z
tyOTARY p
p�'Y� l'USLIC �y
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My commission expires v�
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6