SW3191101_Application_20201009

DEMLR USE ONLY
Date Received Fee Paid Permit Number
STORMWATER PERMITTING FORM 7:
MINOR MODIFICATION
Standard Permitting Program — No Fee for Minor Modification
Express Permitting Program — See Express Fee Schedule
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: hifp.11deq_oc.aov/contact/regional-offices.
This form is to only to be used by the current permittee to notify the Division of a minor
modification. Pursuant to Rule 15A NCAC 02H .1002, a minor modification is a change to the project that.
1) does not increase the net built -upon area; and/or
2) does not change the size or design of the SCM(s).
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW3191101
2. Current Permit Holder's Company Name/Organization: North Pilot Knob Road, LLC
3, Signing Official's Name: Jason Jacobson
4. Signing Official's Title: Senior Partner
5. Mailing Address: 460 Virginia Ave
City: Indianapolis _ State: IN ZIP: 46203
6. Street Address (if different): :
City: State: ZIP:
Phone: [phone] Email: iiacobsor)@archcoresidential.com
Describe the minor modifications that you are requesting, including any revised BUA allocations (attach
additional pages or supporting tables similar to Section 1V.10 of the original application, if needed):
Due to recently installed Duke power pole guy wires, minor revisions include the shift of one proposed
manhole. 24" RCP and the addition of one manhole (function) to avoid delays to_.the storm.. infrastructure.
installation.
B. SUBMITTAL REQUIREMENTS
Please mark "Y" to confirm the items are included with this form. Please mark 'X" if previously provided. if not
applicable or not available, please mark N/A.:
Y 1. Two hard copies (with original signatures) and one electronic copy of this completed form.
Y 2. Two hard copies and one electronic copy of the revised plan sheets (must be a revision of the
originally approved plan sheets).
NA 3. If there is reallocation of lot BUA, a copy of the revised recorded deed restrictions and protective
covenants OR the proposed recorded deed restrictions and protective covenants documenting
the changes and a signed agreement to provide the final recorded document.
NA 4. If applicable, the appropriate Express review fee.
Stormwater Permit Form 7: Minor Modification Pagel of 2 July 14, 2017

C. CONTACT INFORMATION
1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name: Steven Singleton
Consulting Firm: Bohler Engineering
Mailing Address:1927 S. Tryon Street. -Ste. 310
City: Charlotte State: NC Zip: 28203
Phone: [phone] _ ..,......,,,.._ Fax: [phone]
Email:: ssingigton(&bohlereng.com
2. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization:
Mailing Address:
City: State: Zip:
Phone: Fax:
Email:
D. CERTIFICATION OF PERMITTEE
I, Jason Jacobson , the current permittee, certify that I have authorized the minor
modifications listed in Section A and shown in the attached revised plan sheets. I further attest that this information is
accurate and c,pmplete to the
Signature:
of my knowledge.
I, 1- 3 r-(eq/' 'uc & A , a Notary Public for the State of
County of_ L0g 6c�c cy do hereby certify that
a)o�.� , 20 Do, and
�s my hand and official seat,
Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6, 2017