SW5210302_Green Hill Ph 1_Stormwater Management Permit Application_Signed_20210316

Date Received f Fee Paid IPermit 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 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 for 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.):
Green Hill Subdivision - Phase 1
2. Location of Project (street address):
City:l � UJsb,Qrg County:Franklin
3. Directions to project (from nearest major intersection):
500 T F southcaSt Of tilt! intersection of NC Hwy 401 (. Bickett jt c).)
S
Zip:27, 49
4. Latitude:36° 0 '_6.82" N_ Longitude:78° 18' 09.34" 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 _ y — W , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
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):
❑CAMA Major ®Sedimentation/Erosion Control: 20.06 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:
Is the project located within 5 miles of a public airport? ❑No ®Yes
If yes, see S.L. 2012-200, Part VI: htttt-)orta1.nt`d n , g1web Ir rules and -regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

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 projec ):
Applicant/ Organization:,0reen Mill Drive, LLC
Signing Official & Title:�Mrc la�) A lloss, MaiEger
b. Contact information for person listed in item 1a above:
Street Address:PO Box 61,,0
City: Yau rrgsv il.de State:NC Zip:27596
Mailing Address (if applicable):Same as Above
City: ......... — __.___ __-.,,.._.......___ State: � Zip:
Phone: (919 ) 556-4700 Fax:
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 agreeriont and complete Contact Information, item 2a and 2b below)
❑ Parrcdiaser" (Attaclx 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 Address;
City:._.. ,�. Artate: Zip:
Mailing Address (if applicable):,.,,,
City: _ _,_. ....... ............ State: Zip:
Phone: ( l Fax: f l
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: ,,
SigningOfficial & Title:,...............................m........�W�W..........................................................�W�W..........................
b. Contact information for person listed in item 3a above:
MailingAddress: ............................. .......... ,�.W.................. �._... . .
City: .. _ State: Gip:
Phone: ( ) Fax: l l
4. Local jurisdiction for building permits: Town of Louisburg
Point of Contact:111U iJ2 SW.(e ,_Z, r 1,g Administrator
Phone #: (9,19_ ...... ) 497-1003
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.
�i nRi7 ater will be directgt! to a„firer nnanent stormwater control measure (SCM) in [lie north -central part of
the site, I'lrt,ingj;va)11 I e d"arectecf klta s pt .l ,�t_ tk�r rt rwFulc, ,ctr ; r }r 1t,_ a L d k,LL.which will outlet into the C'
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,,, ...................................- m..,...
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW —1995 ❑ Ph II — Post Construction
3. Stormwater runoff from this project drains to the Tar -Pamlico River basin.
4. Total Property Area: 23.02 acres
5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: 0.65 acres
7. Total Property Area (4) — Total Coastal Wetlands Area (5) — Total Surface Water Area (6) = Total Project Area+:
22.37.......................� acres
�'Total�rro'e project area shall be calculated l 1 tted to exclude the fillowins: t:lre normal nool o/`irnl7oimded structures, the.°area
between the banks olstr�eams and urivers, flat, area belovy the Ne rrrnc, Ili l�r Nater (N IM line or Mean fliSh Water
(Ml°1W,) lane, and coastal rvi,,Wanuls hOU17aUrd from the N14VV" (or MI-IM lime. The resraltant p lliect area is used to
calcidate overall percent boll upon arc,a (l LIA). Non -coastal wetlranrds landward of the NllW (or MIIW) line way
be in•ludtd in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 29.0 ''✓o
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 1 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
Drains e Area 1
_
Drains a Area
Drainage Area
Drainage Area
Receiving Stream Name
Tar River
Stream Class *
WS-V;NSW
Stream Index Number *
28-(24.7)
Total Drainage Area (sf)
1,694,675
On -site Drainage Area (sf)
W
1,694,675
Off -site Drainage Area (sf)
Proposed Impervious Area** (sf)
679,520
% I il2ervious Area** (total) 1
40%
I4 ious** Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area
On -site Buildings/Lots (sf)
374,500
On -site Streets (sf)
198,721
On -site Parking (sf)
On -site Sidewalks (sf)
66,299
Other on -site (sf)
40,000
Future (sf)
Off -site (sf)
Existing BUA*** (sf)
Total (sf):
679,520
* Stream Class and Index Number can be determined at: h� g Care b 'ttr.1,sa14lra,Jfl atiorts
** hn��arerarious areaa is dt ined as the built upon area including, but not limited to, buildings, roads, parking areas,
sitTewalks, gnmrvel 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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation. N/A
Projects in Union County: Contact DEMLR 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.
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 ittp°/Iptapt«�I E'1� ws su/bnl -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
I tkl : o� tr (,r tdelar ctg web q ws su sdoc . 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 ht',1 portaI.ntclenr.01, w(A)m+vq wr tr ,ts7«zl .)
Please indicate that the folio 'z g i°eoau'i:red ic�rformation l�av� l�eaia proviclecl 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 litt': docs.
Initials
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. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) ( d a dand dateLjj and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
luttp:/ /www.c«�yh�t +, ti�i fr«-ges/otiesColiexlii,ess.l,itnil 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
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 V2 mile of the site boundary, include the'ri
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 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).
for
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

9. Copy of any applicable soils report with [lac* assrrciated SI'[W"1 elevations (Please identify
elevations in addition to depths) as well as a reap of theboring locations with the existing
olevations and boring logs. Include an 8.5"xll" copy of tyro NRC.S County Snails neap with the
project arca clearly delineated, For projects with infiltration 13MI's, they report should also
include the, soil type, expected infiltration rate, :and the method of a:' otermining the infiltration rate.
(infiltration Devices submitted to W'iRO: Schedule rr site visit.for DEMLR to the S'I- WF prior
to srihnittal, (l]'ltl) 796-7378J
10. A copy of the most current property deed. Deed book: 2233 Page No: 111 -113
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 15A 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.
tittp. /rvavw c.crrwt .r state..nC USX0rporeatirrns�4 ,fir- rrcllmm
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 lrfltLa;llcntGal.raatia rlr°.or wrl lr ftrte
stormwater-forms docs. 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 yot.r wish to designate authority to another individual and/or firm (such as a
cor'I^'alltin enginmr .and/or firm) so that they may provide information on your behalf for this project (such as
addressing rec nests for additional information),
Consulting Engines i-Jon D. Frazier, PE
Consulting Firm: FI,MN gat veer in Inc
MailingAddress:PO BOX 91727,,,.W�.................................................................................................................M ...........................
City:Raleir h .w. State:NC Zip:27675
Phone: 91( 9 J.__ 610-1051 Fax:
Email. j fra r ier@fl raaa�r3g �aaG c r ilt„l� corn
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (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 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 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 assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
I, mm— 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
X. APPLICANT'S CERTIFICATION
1, (print or t Yfre nrarne q person dried hi Contact lat�aar�ra�nalion, �itein 'l.ra,) Michael A. ai� oss
certify that the information included on this permit application form is, to the: best of nay knowledge, correct and
that the project will be constructed in conformance with the approved playas, that, the regUired dood restrictions
and protective covenants will be recorded and that the: proposed project complies with the reclasirements of the
applicable stormwater r riles u.ndq NCAC: 2:H .1000 and any rather applicable state stormwater reqUirenlents.
Signature:-- Date: ... 17atca.....n.
1 ry�t `n f""C C ..`... <a Notary Public for the. State of .. .U, ,- Ofuli (.rC� , County of
6 do hereby certify that _ m)-1AQCJ_ personally appeared
before me this ._r"clay of,� C �� Q,1 and acknowledge they due execu
tion of the application for
c
a stormwater permit. Witness my hand and official sea
IN
Y,0
�C
t�ft Cab''
SEAL
y p• t -,�
M commission expires ..
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6