20121148 Ver 1_Complete File_20121220

AMA
1OC OCR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
Variance Request Form
(For Minor and Major Variances)
Protection and Maintenance of Riparian Areas Rules
NOTE: This form may be photocopied for use as an original.
Check the appropriate box below:
❑ Major Variance
d Minor Variance
Dee Freeman
Secretary
Vt
DEC 2 0 LJ12
DWQ- v ".
W Aota -• t l�lg
Please identify which Riparian Area Protection Rule applies (Note -this must be one of
North Carolina's four buffered river basins. The River Bain map is available at
http: / /h2o .enr.state.nc.us /admin/maps /.)
❑ Neuse River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (15A NCAC 02B.0233)
FN( Tar- Pamlico River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (15A NCAC 02B.0259)
Part 1: General Information
(Please include attachments if the room provided is insufficient.)
1. Applicant's name (tie corporation, individual, etc. who owns the property):
2. Print owner /Signing official (person legally responsible for the property and its compliance)
Name: j ,
i
Title: -QL3 Aa K - -- - - - --
Street address:
City, State, Zip: ONT 011 3
Telephone: �) „7 ► ��
Fax:
IV�:.L)
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3. Contact person who can answer questions about the proposed project:
0
0
Version 6: July 2009

Name:
Telephone:
Fax:
Email:
4. Project name (Subdivision, facility, or establishment name - consistent with project name on
plans, specifications, letters, o eration and maintenance agreements, etc.):
z � SIT 6
5. Project location:
Street'address:
City, State, Zip: ,
Count
Latitud67 ongitude: AN4gVna4 LA I' p 1 a7__e _ $�ro b 0 g 1 g 4 $_t�O P�'iC &ikr `.
6. Date pro* PWP purchased: _told
7. Directions to site from nearest major intersection (Attach an 8 '/Z x 11 copy of the USGS
1 topographic map indicating the location of the site).
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In rb 1
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8. Stream to be impacted by the proposed activity:
Stream name (for unnamed streams label as "UT" to the nearest named stream):
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9. Which of the following permits /approvals will be required or have been received already for this
project?
Required: Received: Date received:
Mi gor_�&LlMot
Permit Type:
CAMA Major
CAMA Minor
401 Certification/404 Permit
On -site Wastewater Permit
NPDES Permit (including stormwater)
Non - discharge Permit
Water Supply Watershed Variance
Erosion/Sedimentation Control ,
Others (specify) IN
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Part 2: Proposed Activity
(Please include attachments if the room provided is insufficient.)
1. Des=t& adobe roposed activity [Also, please attach a map of sufficient detail (such as a plat map
(pdf) format) to accurately delineate the boundaries of the land to be utilized
in carrying out the activity, the location and dimension of any disturbance in the riparian buffers
associated with the activity, and the extent of riparian buffers on the land. Include the area of
buffer impact in fe.:
Ci I Variance Request Form, page 2
Version 6 July 2009

2. Fill in the table below to identify the square footage of impact to Zones 1 & 2 in the protected
riparian buffers and the required mitigation (Fill in the impacts portion of the table, even if
mitigation is not required):
��" \ 0
,e
9 )eZO
*Zone 1 extends out 30 feet perpendicular from the most landward limit of the top of bank or the rooted herbaceous
vegetation; Zone 2 extends an additional 20 feet from the edge of Zone 1.
3. State reasons why this plan for the proposed activity cannot be practically accomplished, reduced
or reconfigured to better minimize or eliminate disturbance to the riparian buffers:
_.-,_ - -_' - _L i._ - L __ - N r% A C_ - - - -1 "A n..ryl
4. Description of any best management practices to be used to control impacts associated with the
proposed activity (i.e., control of runoff from impervious surfaces to provide diffuse flow, re-
planting vegetation or enhancement of existing vegetation, etc.):
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5. Please provide an explanation of the following:
(1) The practical difficulties or hardships that would result from the strict application of this Rule.
C-Ow"es 014 6r&45!
6
(2) How these difficulties or hardships result from conditions that are unique to the property
involved. ,�n ,
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Buffer Impact
Zone of
Impact in
Number
Purpose for
Multiplier
Required
Impact
Square Feet
(Indicate on
the Impact
Mitigation
Plan Sheet
Zone 1
3
Zone 2
WeA 400
1.5
Total
*Zone 1 extends out 30 feet perpendicular from the most landward limit of the top of bank or the rooted herbaceous
vegetation; Zone 2 extends an additional 20 feet from the edge of Zone 1.
3. State reasons why this plan for the proposed activity cannot be practically accomplished, reduced
or reconfigured to better minimize or eliminate disturbance to the riparian buffers:
_.-,_ - -_' - _L i._ - L __ - N r% A C_ - - - -1 "A n..ryl
4. Description of any best management practices to be used to control impacts associated with the
proposed activity (i.e., control of runoff from impervious surfaces to provide diffuse flow, re-
planting vegetation or enhancement of existing vegetation, etc.):
Th&_. Wec esSaPV TnFFSfgx 1%w (?r1^aW1 idck -cry
I
I
It
ho
5. Please provide an explanation of the following:
(1) The practical difficulties or hardships that would result from the strict application of this Rule.
C-Ow"es 014 6r&45!
6
(2) How these difficulties or hardships result from conditions that are unique to the property
involved. ,�n ,
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(3) If economic hardship is the major consideration, then include a specific explanation of the
economic hardships and the proportion of the hardship to the entire value of the project.
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Part 3: Stormwater
1. Provide a description of all best management practices (BMPs) that will be used to control
nutrients and sedimentation impacts associated with the proposed activity. Please ensure to
include all applicable operation & maintenance agreements and worksheets for the proposed
BMPs. Also, include the BMPs on your plan sheets.
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2. Attach a description of how diffuse flow will be maintained through the protected riparian
buffers. Please ensure to include all applicable operation & maintenance agreements and
worksheets for the proposed diffuse flow measure(s). Also, include the diffuse flow measure(s)
on your plan sheets.
3. What will be the annual nitrogen load contributed by this site after development in pounds per
acre per year without structural BMPs (stormwater pond, wetland, infiltration basin, etc)? Attach
a detailed plan for all proposed structural stormwater BMPs.
W/A
Drainage
Size of
Post - development
BMP nitrogen6
Final
Final
basin
drainage
nitrogen6 loading
removal
nitrogen6
nitrogen6
basin
rate without BMPV
efficiency5
loading rate
loading
(ac)
(lbs/ac/yr)
(%)
(lbs/ac/yr)
from
drainage
basin Ibs
1
2
3
4
5
Totals
- - - - --
- - - - --
- - - - --
4 Attach calculations and references.
s Attach calculations and references.
6 Include Phosphorus in the Tar - Pamlico Basin
4. Attach all applicable supplement form(s) and Inspection and Maintenance (I &M) Form(s) to this
completed application. The applicable supplemental form(s) and I &M form(s) for the proposed
BMPs noted in your application can be downloaded from the following website:
hiip://h2o.enr.state.nc.us/su/bmp.fonns.
Variance Request Form, page 4
Version 6 July 2009

Part 8: Checklist
A complete application submittal consists of the following components. Incomplete submittals will
be returned to the applicant. The complete variance request submittal must be received 90 days prior
to the EMC meeting at which you wish the request to be heard. Initial below to indicate that the
necessary information has been provided.
Applicant's
Item
Initials
U_
• Original and two copies of the Variance Request Form and the attachments
listed below.
• A vicinity map of the project (see Part 1, Item 5)
0 Narrative demonstration of the need for a variance (see Part 2)
• A detailed narrative description of stormwater treatment/management (see Part
4)
• Calculations supporting nitrogen (phosphorus in the Tar - Pamlico Basin)
loading estimates (see Part 4)
N/A
• Calculations and references supporting nitrogen (phosphorus in the Tar-
JU�A
Pamlico Basin) removal from proposed BMPs (see Part 4)
• Location details for
and all proposed structural stormwater BMPs (see Part 4)
• Three copies of the applicable Supplement Form(s) and I &M Form(s) for each
BMP and /or narrative for each innovative BMP (see Part 4)
a Three copies of plans and specifications, including:
l
0 Development/Project name
0 Engineer and firm
0 Legend and north arrow
0 Scale (I"= 50' is preferred)
0 Revision number & date
0 Mean high water line (if applicable)
0 Dimensioned property/project boundary
0 Location map with named streets or NC State Road numbers
0 Original contours, proposed contours, spot elevations, finished floor
elevations
0 Details of roads, parking, cul -de -sacs, sidewalks, and curb and gutter
0 Footprint of any proposed buildings or other structures
0 Wetlands delineated, or a note on plans that none exist
0 Existing drainage (including off - site), drainage easements, pipe sizes,
runoff calculations
0 Drainage basins delineated
0 Perennial and intermittent streams, ponds, lakes, rivers and estuaries
0 Location of forest vegetation along the streams, ponds, lakes, rivers and
estuaries
Variance Request Form, page 6
Version 6 July 2009

Part 4: Proposed Impacts and Mitigation
Provide a description of how mitigation will be achieved at your site pursuant to 15A NCAC 213.0242
for the Neuse Basin and 15A NCAC 213.060 for the Tar - Pamlico Basin.
If buffer restoration is the method you are requesting, be sure to include a detailed planting plan to
include plant type, date of plantings, the date of the one -time fertilization in the protected riparian
buffers and a plan sheet showing the proposed location of the plantings. A guide to buffer restoration
can be downloaded at the following website: http: / /www.nceea .net /news /reports /buffers.pdf
If payment into a buffer restoration fund is how you plan to achieve your mitigation requirement, then
include an acceptance letter from the mitigation bank you propose to use stating they have the
mitigation credits available for the mitigation requested.
Part 5: Deed Restrictions
By your signature in Part 6 of this application, you certify that all structural stormwater BMPs
required by this variance shall be located in recorded stormwater easements, that the easements will
run with the land, that the easements cannot be changed or deleted without concurrence from the
State, and that the easements will be recorded prior to the sale of any lot.
Part 6: Applicant's Certification
(print or type name of person listed in
Part I, Item 2), certify that the information included on this permit application form is correct, that the
project will be constructed in conformance with the approved plans and that the deed restrictions in
accordance with Part 5 of this form will be recorded with all required permit conditions.
Signature: —
Date:
Title:
Part 7: Plan Sheets
Be sure to include a copy of all of your completed application form, plan sheets and maps in Adobe
(pdf) format on a CD or floppy disk.
Variance Request Form, page 5
Version 6 July 2009