SW4210501_Application Form_20210525

DWQ 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 WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This fort 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.):
Dollar General _ Burhn ton Ala.unance Co.
2. Location of Project (street address):
NC Hw . 62 and Porter Sha e Rd.
Gty:Burlington County:Alamance Zip:27215
3. Directions to project (from nearest major intersection):
210 feet from the intersection of Porter Sha e Rd. and NC Hwv. 62 going NE towards Kimesville Rd.
4. Latitude:36° 00' 49.3" N Longitude:790 30' 42.5" W of the maul 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 SiM.I-102 - Renewal Application Forin
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 Complete& ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density ®High Density El 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 DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, and the previous nine 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: 1.88 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 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:.
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: hitp:Upon-tal.ncdenr.orglweblwcljws/su/stateswfrules Jaws
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III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated goverimtent official, individual, etc. who owns the project):
Applicant/Organization:Glaiidois Forest Equi1y, LLC
Signing Official & Title:George Venters - member/manager
b. Contact information for person listed i1 item 1a above:
Street Address:3825 Barrett Dr., Suite 100
City:Ra leigh
Mailing Address (if applicable):
City:
Phone: (919 ) 459-2602
Email:gi [e-mail]
State:NC Zip:27609
State:
Zi
Fax: [phone]
c. Please clieck the appropriate box. The applicant listed above is:
❑ The property owner (Skip to Contact Information,. iteni 3a)
❑ 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)
® 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/Organization5barpe G M Heirs, CIO Beverly Corbett -PEA
Signing Official & TitleTroperty Owners
b. Contact information for person listed in item 2a above:
Street Address:3733 Clapp Mill Rd
City:Burlilgton Si ate:NC Zip:27215
Mailing Address (if applicable):.
City: State:
Phone: ( ) Fax:
Zip:
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:Glandon Forest Equity, LLC
Signing Official & Title
b.Contact information for person listed in item 3a above:
Mailing Address3825 Barrett Dr., Suite 100
City:
Phone: (919 ) 459-2602
Email:[e-mail]
4. Local jurisdiction for building permits: Alamance Coi
Statn:NC
Zip:27609
Fax: (919 ) 459-2604
Point of Contact:Robert Key Phone #: (336 ) 570-4060
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IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Storm water runoff from the develo ed areas of the 5ite will be ca itured and treated in a st rnpwater we
2. a. If claiming vested rights, identify the supporting documents provided and the daLe! they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Data:
❑ 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 - 1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 2.03 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:2.03 acres
+ Total project area shall be calculated to exclude the follozoin * the tiormal pool of impounded structures, the area
betuKc°�t tlrc brrrrks of strearus arzd rivers, the area b&ow fire . artnid High Water (NHM Brie or Mea?z Hi Water
(M14M lint; anal coastal wetlands laradw and from the NNW (or MIIIN) luxe. The resultant project area rs used to
calcirliitr nzYrrrrll pc'rcerrt built ripora area (Bt1A). Non -coastal zr1etlrarrds laind?4w-d of the NNW (or MHW) liiae may
be included iir th.c total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 43.91 %
9. How many drainage areas does the project have?1 (For high densihj, count 1 for each proposed eugineered
stormwater BMP. For low densihj and other projects, use 1 for the whole properhj 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
Drainage Area 1
Drainage Area _
Drainage Area
Drainage Area
Receiving Stream Name
Big Alamance�
Creek
Stream Class
WS-IV; NSW;CA
Stream hndex Number *
16-19-(2.5)
Total Drainage Area (sf)
48,714
On -site Drainage Area (sf)
48,714
Off -site Drainage Area (sf)
Proposed impervious Area** (sf)
38,022
% Impervious Areas`'` (total)
78.05
Impervious— Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
10640
On -site Streets (sf)
On -site Parkin (sf)
25,566
On -site Sidewalks (sf)
1,816
Other on -site (sf)
Future (sf)
Off -site (sf)
Existing BUA'''`* (sf)
Total (sf):
38,022
* Stream Class and Index Number can be determined at: ht ortal.ncdeizr.oi u;eb u; �s esu classi cations
Form SWU-101 Version 06Aug2012 Page 3 of 6

Inn )ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks., gravel areas, etc.
***Report only that amount of existing BUA that zoill remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by nezv BLIA.
11. How was the off -site impervious area listed above determined? Provide documentation. NA
Proieets in Union County: Contact DWQ Central Office staff to check if the project is located i0thin a Threatened &
Endangered Species ii,atershed that may be subject to more stringent stornrl+)ater requirements as per 15,4 NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormiwater 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 http:/(portal.ncdenr.org/web/wu/ws/su/binp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from hMp:/IportaLncdenr.orglweb/wq/ws/su/statesw./forms flocs. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at htt ortal.ncdenr.or w(�b w ws su ma -3s.)
Please indicate that the following_reauired information have been provided by initialin 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 http://i?ortii.ncderv.org/web/wq/ws/su/statesw/fonns dots.
ll�als
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) (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
http:l/www.envlielp.org/panes/c)iiQ ca-Express.litnil 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 1/2 mile of the site boundary, include the 1/2
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 link of tidal
waters, and any coastal wetlands landward of the MHW or NHW lilies.
• 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.
in. 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.
for
CT
/�6
1<7.(-�-
Form SWU-101 Version 06Aug2012 Page 4 of 6

o. Drainage areas delineated (included in the maul 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" ropy of the NRCS County Soils map with the
Project area cloa.rly 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 DWQ to verifij the SHWT prior
to submittal, [phone].) J
10. A copy of the most current property deed. Deed book: 3338 Page No: 0570 CT
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC A
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.
hitp:/ /www.stx.-retary.state.nc.us/CorporationsJCSearL:h.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
c ovenanls are required to bo recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table Iisting each lot number, lot size, and the allowable built -upon area must be
provided as an attachment to the completed alid notarized deed restriction form. The appropriate deed
restrictions and protective covenants forms can be downloaded from
ll[Lp:l/porLal.n(-.dt-iir.org/wcbZml/ws/su/sLatesw/fonaLdgtes. ❑owidoad 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 DWQ, 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:Matt Lowder, PE
Consulting Firm: Triangle Site Des!m PLLC
Mailing Address:4004 Barrett Drive Suite 101
City:Raleigh State:NC Zip:27609
Phone: (919 ) 553-6570 Fax: ( }
Email:tiilowderCr) rianglesitedesilrn.com
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed in Contact Information, item 2a) Sharpe G M HeirsReverly Corbett certify that I
own the property identified in this permit application, and thus give permission to (print or hjpe name of person
listed in Contact Information, item 1a) George Venters with (print or hjpe name of organization listed in
Contact Information, item 1a) Glcrndon Forest Egt[it?t, LLC 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.
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As the legal property owner 1 acknowledge, understand, and agree by my siglzature below, that if my designated
agent (entity listed in Contact Infonnation, item 1) dissolves their company and/or cancels or defaults an their
Iease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ 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's
Date:.71
1, a V' L3f1 a Notary Public forrthe State of r� C& lI ' County of
�1 ► rCi , do hereby certify that Uer� 5 • C_D,� personally appeared
before me this Ikday of A!P%r%l O 1 and ackn ue1;tof the application for
a stormwater permit. Witness my hand and official seal, 1T
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of per02d
�'n Contact Information, item 1a) George Venters
certify thaJinla 'ed on this permit application form is, to the best of my knowledge, correct and
that the p' ormance with the approved plans, that the required deed.restxictions
and proteord d, and that the proposed project complies with the requirements of the
applicable 5 NCAC2H .7000 and. ana? otlher applicable state stormwater requiremtents.
Signature: Date: E 5-
I, ti 1n a Notary Public for the State of County of
O�ZA.:&4L) do hereby certify that personally appeared
before me this —C-> day of 202I , and cknowlecige the due exe the application for
a stormwater permit. Witness my hand and official seal, A coa
Cl�
NOTARY
co MY
sQ C;pMMISS1dME�(PfREs
t°L1BL\ A,
SEAL
My commission expires QU ^ O S - Z3
Form SWU-101 Version 06Aug2012 Page 6 of 6