SW4201101_Stormwater Permit Application_20201124

tl_,u W, I
DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: El Coastal SW - 1995 F-1 Coastal SW - 2008 El Ph 11 - Post Construction
(select all that apply) D Non -Coastal SW- HQW/ORW Waters 0 Universal Stormwater Management Plan
F1 Other WQ Mamt Plan: 111
State of North Carolina
Degartment of Environment and
Division of Ener�3.,, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form inay be photocopied for use as an original
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Heritage Oaks, Section 11 - Residential Subdivision
2. Location of Project (street address):
Pin #5897-43-2848.00, 5897-44-0046.00, 5897-34-7223.00 and 5897.44.6250.00; 5426 Heritage Oaks Lane
City:Winston Salem County:ForEth Zip:27106
3. Directions to project (from nearest major intersection):
From the intersection of —adkinville Road and Olivet Church Road go south on Olivet Church Road. Turn on
the first street to the left Heritage OaksLane. Project is located at the terminus of Heritage Oaks Lane,
4. Latitude:36' 08' 36.98" N Longitude:800 22'35.40" W of the main entrance to the project.
Il. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ZNew FlModification ❑ Renewal w/ Modificationt
tReneU 7a15 With modifications ralso requires SKU-102 - Renezoal Application Form
b. If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number N/A , its issue date (if known) and the status of
construction: ®Nat Started [Partially Completed* 7 Completed* *provide a designer's certification
2. Specify the type of project (check one):
®Law Density [High Density ❑Drains to an Offsite Stormwater System 70ther
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, ,N/A and the previous name of the project, if different than currently
proposed, N/A
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
7NPDES Industrial Stormwater
ZSedimentation/ Erosion Control: 5,76 ac of Disturbed Area
F-1404/401 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:EC ]2ermit EN1800113 by Forsyth County/City of WS
5. Is the project located within 5 miles of a public airport? _nNo Dyes
1f yes, see S.L. 2012-200, Part V1, web jr/rules-and-rions
FormSWU-101 Version Oct. 31, 20.13 Page 1 of 6

I
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the l2rojec ):
Applicant/ Organization: Heritage Oaks Holdings. LLC By Scott Craver
Signing Official & Title:Scott Craver, Member -Manager
b. Contact information for person listed in item la above:
Street Address: 5426 Heritage Oaks Lane
City:Winston Salem State: NC Zip:27106
Mailing Address (if applicable):Same
City: State: Zi
Phone: L336 399-3744 Fax:
Email:cra [e-mail]
Please check the appropriate box. The applicant listed above is:
Z The property owner (Skip to Contact Information, item 3a)
F-1 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)
F] 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 Address:
City: State: Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone: Fax:
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: State: Zip:
Phone: Fax:
Email:
4. Local jurisdiction for building permits: City of Winston SalemdoriWh County
Point of Contact:WS Insl2ections Phone #: L336 727-2625
Fon-n SNkU-101 Version Oct, 31, 2013 Page 2 of 8

I t 4
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The project consists of 27 lots fronting on ribbon pavement streets with side ditches. The sideditches will
provide some some water quality treatment. The water will be transported from the side ditches using gpen
throat boxes with pipe running down the side property lines at planned intervals. Outlet ditches will be lined
with vegetative cover for a minumun of 100'after exiting the pipes to provide for the final water treatment.
The development is less than 2 lots ger acre and less than 24% planned impervious.
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 - 1,995 ® Ph 11 - Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee -Dee River basin,
4. Total Property Area: 15.822 —acres
5. Total Coastal Wetlands Area: 0.0 acres
6. Total Surface Water Area: 0.275 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area': 15.547 acres
+ Total project area shall be calculated to exclude the followin : the normal pool of im ounded structures, the area
between the banks of streams and rivers, the area below the following:
HIRh Water (Nm line or Mean High Water
(MHM line, and coastal wetlands landward from the NHW (or MFR/V) line. The resultant roject area is used to
calculate overall percent built upon area (B UA). Non -coastal wetlands landward of the NW (or MTRA� line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 223 & 1.70 lots/ac %
9. How many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
stormwater BMP. 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.
Form S WU- 10 1 Version Oct. 31, 2013 Page 3 of 8

Basin Information .-Drainage
Area 1
Drainage Area
DrainagLeArea
DrainageArea
Receiving Stream Name
Oil Mill Branch
Stream Class *
C
Stream Index Number
12-94-6
Total Drainage Area (sf)
698,200
On -site Drainage Area (sf)
698,200
Off -site Drainage Area (sf)
N/A
Proposed I!n pervious Area" (sf)
150,850
% Impervious Area** (total)
22.3% or 1.7
Lots/ac
�evioqs� Surface Area
''Piaira Le Area I
2LaLma e Axea
2ELma LArea
=
Drainage Area
On -site Buildings/Lots (sf)
102,600
On -site streets (so
37,500
On -site Parking (sf)
0
On -site Sidewalks (sf)
0
Other on -site (sf)
N/A
I
Future (sf)
N/A
Off -site (sf)
N/A
Existing BUA*** (sf)
10,750
Total (so:
150,850
'"G"111 %"UDD "It" Index Number can be determined at: litW.-aortal,ncdenr.orgl-w-ebZzilq&,qlcsti.Iclassificahon
imyervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
e
s ewalks, gravel areas, etc,
'Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. NZ
Projects in UW21foungy: Contact DE ER 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 15A NCAC 02B. 0600,
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 1.
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
htt :ZZ12ortal,nccienr.org/webZwg/--ws/su/stateswZfori-ns-,docs. 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: / aZws/su/`maPS.)
Please indicate that the -following re aired information have been 2rovided 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 11ttp:.Z,�vortal.ncdenr.ory /woh kwn /NA!" stz q4­_,+..­ 14:,,,-- A __ S.
1. Original and one copy of the Stormwater Management Permit Application Form. Initials
_ AC-
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants AG
Form. (if required as per Part V11 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 A<-
http://wwhLtEytt!Ror pages onesto ex ress htn for information on the Express program -
Form SWU-101 Version Oct. 31, 2013 Page 4 of 8

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.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the AX
receiving stream drains to class SA waters within 1/2mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). IV_
8. Two sets of plans folded to 8,5" x 14" (sealed, signed, & dated), including: At,
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 M11W (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).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
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 DEMLR to verify the SHVVT prior
to submittal, [phone].) III&
10. A copy of the most current property deed. Deed book: 3391 Page No: 1004
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC AC,
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.
http://www.secretary.state.nc.us/Cgmorations/­­­`CSearch.asl2x
Form SWU-101 Version Oct. 31, 2013 Page of8

VIL 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/1r/state-
storm w ater-forM s Aocs. 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 DEMLR, 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: Alex Carter, PE
Consulting Firm: Beeson & Carter, PA
Mailing Address:PQ Box 669
City:Walkertown State:NC - Zip:27051
Phone: Q36 1 748-0071. Fax: fflM, 748-0470
Email:[e-mail]
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) 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 la.) with (print or type name 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 Oct. 31, 2013 Page 6 of 8

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 DEMLR Stormwater 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 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 aspessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:—A2�"�t 64" Date: ­7
a Notary Public for the State of NQL44j_C_&YkLj olA_,, County of
is JC344 Elo hereby certify that personally appeared
before me t is 1!5"d"ay of and ac nowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, -
My commission
Furm8WU-l01 Version Oct. 3l,20l3 Page 7of8

1, (print or hjpe name of person listed in Contact Information, item 1a) Heritage Oaks Holdings, LLC bi -Scott Craver
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 rmles under 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Signature: w '1 "4 �.
. ..... Date: b
t,
L 7F
a Notary Public for the State of County of
G_ -do hereby certify that
3- 1 personally appeared
before me this ZAay of 1,14 and�a �nowledge the due execution of the application for
a stormwater permit. Witness my and and �7—
p y and and official seal,
--I
My commission expires I I
—Al —?-
Form SWU-101 Version Oct. 31, 2013 Page 8 of 8

In accordance with Title 15 NCAC 2H,1000 and S.L. 2006-246, the Stormwater Management
Regulations, deed restrictions and protective covenants are required for Low Density Residential
Subdivisions where lots will be subdivided and sold. Deed restrictions and protective covenants are
necessary to ensure that the development maintains a "built -upon" area consistent with the applicable
regulation governing the density level.
1, Scott Craver for Heritage Oaks Holdinas, LLC acknowledge and affirm by my signature below, that
I will cause the following deed restrictions and protective covenants to be recorded for Heritage Oaks,
Sec 11 prior to the sale of any lot:
1. The following covenants are intended to ensure ongoing compliance with State Stormwater
Management Permit Number , asissued by the Division of Energy, Mineral and
Land Resources under the Stormwater Management Regulations.
2. The State of North Carolina is made a beneficiary of these covenants to the extent necessary to
maintain compliance with the stormwater management permit.
3. These covenants are to run with the land and be binding on all persons and parties claiming
under them.
4. The covenants pertaining to stormwater may not be altered or rescinded without the express
written consent of the State of North Carolina, Division of Energy, Mineral and Land Resources.
5. Alteration of the drainage as shown on the approved plan may not take place without the
concurrence of the Division of Energy, Mineral and Land Resources.
6. The maximum allowable built -upon area per lot is 3800 square feet This allotted amount
includes any built -upon area constructed within the lot property boundaries, and that portion of the
right-of-way between the front lot line and the edge of the pavement. Built upon area includes, but
is not limited to, structures, asphalt, concrete, gravel, brick, stone, slate, and coquina, but does
not include raised, open wood decking, or the water surface of swimming pools.
7. In the case of a lot within CAMA's regulated AEC, where the Division of Coastal Management
calculates a different maximum allowable built -upon area for that lot than is shown herein, the
governing maximum built -upon area for that lot shall be the most restrictive of the two.
8. Filling in or piping of any vegetative conveyances (ditches, swales, etc.) associated with the
development except for average driveway crossings is strictly prohibited by any persons.
9. Each lot will maintain a 30* foot wide vegetated buffer between all impervious areas and surface
waters.
10. All roof drains shall terminate at least 30* foot from the mean high water mark of surface waters.
*50 foot for projects located in the 20 coastal counties.
Signature: -7v�j /,I,- Date: '7
V 0m a Notary Public in the
State of L 2-Y 0�O County of
do hereby certify that W-1, -n personally appeared
before me this the day of -,-Tk -1 1 k 1 20 lb and acknowledge
I
the due execution of the foregoing instrument. Witness my hand and official s
'��E
Signature AL #OTAJ�
tp soo
'
My Commission expires Ouz
rN
Form DRPC-5 Rev.2 05Nov2009 Page I of 1 01
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