SW3200701_SSW-SWU-101-Application-DEMLR-SPU Oct 2013_20200806

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
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 W Q M mt 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 for use as an original
I lei 0113 of;7101►101 Nu r:11 Y [110
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
2. Location of Project (street address):
3100 Providence Road South
City: W axhaw County: Union Zip :28173
3. Directions to project (from nearest major intersection):
From I-485 Outer, Take exit 57 to NC-16/Providence Rd towards Weddington
4. Latitude:34° 57.5' 72" N Longitude:80' 45' 22.87" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SWU-102 - Renewal Application Form
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
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 DEMLR
requesting a state stormwater management permit application, list the stormwater project number, if assigned,
and the previous name of the project, if different than currently proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be obtained by
contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 10.54 ac of Disturbed Area
❑404/401 Permit: Proposed Impacts
b. If any of these permits have already been acquired please provide the Project Name, Proj ect/Permit Number, issue date
and the type of each permit: Town of Waxhaw E&SC Permit, Issue Date 04/13/17
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://12ortal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6