SW3210401_Application Form_20210608

Date Received Fee Paid Permit Number
Applicable Rules: 0 Coastal SW - 1995 0 Coastal SW - 2008 0 Ph 11 - Post Construction
(select all that apply) 0 Non-CoastaISW- HQW/ORW Waters 0 Universal Stormwater Management Plan
0 Other WO MLrmt Plan:
State of North Carolina
Department of Envirorunent and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
'niisform may be photocopiedfor iise as an original
L 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.):
MOVIDENCE COMMONS - CALIBER COLLlSON
2- Location of Project (street address):
3621 S. Providence Road
City-3YANka_w County:UNION Zip:28104
3. Directions to project (from nearest major intersection):
3800'NORTH OF THE INTERESCENT OF PROVIDENCE ROAD AND WAXHAW PARKWAY
4. Latitude:34* 56' M" N Longitude:-80* 45'U" W of the main entrance to the projecL
EL PER!M[IT INFORMATION:
1. a. Specify whether project is (check one): JONew DModification D Renewal w/ Modificationt
tRenewals with WdiflWtiOnS 41SO requires SVVU-102 - Renewal Applic4tion Form
b. If this application is being submitted as the result of a modification to an eAsting permik list the existing
permit number , its issue date (if known) . and the status of
construction: []Not Started F]Partially Completed* [I Completed* *prouide a des4w's certification
7- Specify the " of project (check one):
FlLow Density Zi-ligh Density E]Drains to an Offsibe Stormwater System E]Other
3. If ffils application is being submitted as the result of a previously returned application or a letter from
DEMLR r6questing 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):
E]CAMA Major E]Sedimentation/Erosion Control: 17 ac of Disturbed Area
nNPDES Industrial Stormwater E]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-UNION-2019-054
5. Is the project located within 5 miles of a public airport? nNo E]Yes
Ifyas� see S.L. 2012-200, Part V1. htW:L�portal.ncdenr.org/weblr/r--�uies-and-regulations

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 project):
APP]icant/Organization:Providence Commons, LLC
Signing Official & Title:Steyhen Rosenburgh, ManaStr
b. Contact information for person listed in item la above:
Street Address:5925 Carnegie Boulevard, Suite 200
City:Charlotte State:NC Zip:28209
Mailing Address ffapplicable):
Citr
Phone: (704 ) 973-9038
EmaiI:srosenbur&1L@usdeveI2Rm nts.com
State: Zip:
Fax: (
c. Please check the appropriate box. The applicant listed above is:
The property owner (Skip to Contact Edormation, item 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)
El 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: V )
Email:
4. Local jurisdiction for building permits: UNION COUNTY
Point of Contact:BUILDING CODE ENF. — Phone#: VO4 283-3816

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff wiU be treated.
OUT OF STREET STORMWATER SHEET FLOWS OR RUNS INTO VEGETATED SWALES THAT FEED
INTO PIPED STORM DRAINAGE SYSTEM. IN-SMET ELORMWATER FLOWS DIRECTLY INTO PIPED.
STORMWATER sysrEm. sysrEm OUTFALLS AT WE-r POND TO NORTH WEST OF DEVELOPMENT,
WATER IS TREATED AND LATER OUTFALLS INTO NEARBY STREAM.
2. a. If clainking vested rights, identify the supporting documents provided and the date they were approved:
El 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:
El Coastal SW - 1995 n Ph H - Post Construction
3. Stormwater runoff from this project drains to the CATAWBA River basin.
4. Total Property Area: 27.5 —acres 5. Total Coastal Wetlands Area: - acres
6. Total Surface Water Area: 0.0527 —acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Aree: 27.4473 acres
+ Total project area shall be calculated to exclude thefollowing: the normal ool of i unded stru tures, the area
13 "M gh W
between the banks of streams and rivers, the area below the Normal ffi�h 12ter �4 line or Mcean Hi ater
(MHVV) line, and coastal wetlands landwardfrom the NHW (or MHM line. The resultant project area is used to
calculate overall percent built upon area (B UA), Non -coastal wetlands landward of the NHW (or MHM line may
be induded in the total prqect area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 31.36 %
9. How many drainage areas does the project have?l (For high density, count I for each proposed engineered
stormwater BMP. For low density and other prejects, 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.

Basin Information
Drainage Area I
Drainage Area a
Drainage Area
Drainage Area
Receiving Stream Name
East Fork
Twelvemile
Creek
_
Stream Class
C
Stream Index Number
11-138-2
Total DrainaLe Area (sf)
827,640
On -site Dm!2!E Area (so
654,231
Off -site Drainage Area (so
173,409
Pro2osed !Mrvious Area:" (so
469,403
% Impervious Area�* ( 1)
60%
ImPerviOus' Surface Area
Drainage Area 1
Area
Drainage Area
Drainage Area
On -site Buildings/Lots (sf)
20860
-Drainme
On�-site Streets (sf)
14712
On -site Parking (sf)
41080
On -site Sidewalks (so
1320
Other on -site (so
-
Future(sf)
282122
Off -site (SO
Adjacent Parcel -
74,407 SF
ROAD - 20012
Existing BUA*** (so
ROAD - 11,458
SW - 3432
Total (so:
469,403
btream uass; ana index Number can be determined at: htty.ff-jLortal.ncdenr.oM* WaWclass flcations
Impervious 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 BLM that will remain after development. Do not report any existing BLIA 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. Quantities
determined Providence Road sunLey of gavement/sidewalk.
Proiects in Union Count% Contact DEMLR Central Office staffto check ifthe project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requ irements as per 15A NCA C 02B. 0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&K forms
must be submitted for each BMP specified for this project, The latest versions of the forms can be downloaded
from h!IR:ZlRortal.ncdenr.org/web/iAg/ws/­su/­bmR: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
h2R:/ /12ortal.ncdenr.orglweb/n/ws/suZstatesw/­forms-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 hLtR://portal.ncdenr.org/ web w /ws/sulma
-Rs.)
Please indicate that the following required information have been provided bX 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 h=://12ortal.ncdenr.org/web/wg/ws/su/­­statesw/`forms 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. Or�ginal of the applicable Supplement Form(s) Waled, sig[Led and dated) and O&M
agreemenqs) for each BNIP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
httv://www.envheit).org/Rages/onestaRoRress.htini for information on the Express program
and the associated . 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 1h mile of the site boundary, include the �6
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.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Weffimds 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.
for
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"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMF;s, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(MItration Devices submitted to WiRO: Schedule a site visitfor DEMLR to verify the SHVVT prior
to submitt4 [phone])
10. A copy of the most current property deed. Deed book. 7330 Page No: 0547
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 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.
hft,liwww.secEgM.state.nc.us/CoEporations/CSearch.—aspx
41-�
ROMP"

V11. 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
SUA allocaLions vary, a table listing each lot number, lot size, and the allowable built -upon am 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 h tW-rIlpartal-ad en r,orgLw-ebA r/sia tc-
r,tpW)water-fip= d . Download the latest versions for each submittal.
In the instances where the applkant 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, shaH include all the items required in the permit and fisted
on the forms available on the website, that the covenants wW 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.
VIIL CONSULTANT INFORMATION AND AUTHOR17ATION
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 ffiat they may provide information on your behalf for this proW (such as
addressing requests for additional information).
Consulting Engineer.Marc Momsen
Consulting Firm: LANDDMGN
Mailing Address:223 NORTH GRAHAM SrREET
CitT.CH6EL
Phone. VO4 333-025
Ema-mmomsen6landdesign.com
State:NC Ziv:28202
Fax:
D(- PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has beenfilled out, compLete fizis
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 ofperson
listed in Contact Infimnation, item 1a) with (print or type name of orgodzation listed in
Contact Infornwtion, item 1a) to develop the Project as currently proposed. A copy of
the lease agreement or pending property saJes; contract has been provided with the subalitbd, which indicates the
p" responsible for the operation and maintenance of the stormwater system.
FOIMSWU-101 VcrsionOct.31,2013 Page 6 of 7

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 canceL9 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 responsibili r to notify DEMLR immediately and
submit a completed Name/ Ownership Change Form within 30 days; Merwise 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: — Date:
11 - a Notary Public for the State of , County of
, do hereby certify that
personally appeared
before me this — day of - ------------- J and acknowledge the due execution of the application for
a stormwater permit Witness my hand and official se4
SEAL
My commission expires
X APPLICANTS CERTIFICATION
L (print or type name ofterson listed in Contact In/brmation, item I a) SWkn RosenkiMh, Mangger
certify that the information included on Otis permit application form is, to the best of my knowledge, correct and
that the project wflI 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 les. under 15A NCAC 2H .1000and any o er applicable state storm�:ter :requirements.
Signature: ;y eo— te:
(k, A, County of
_.allotaryPublicforthesta ofJJVeeC*Q4�
Lo#j b&IR- do hereby certify that personafly appeared
before me this7eday of 2,0 JJ and ackn d ex 'on application for
a stormwater permit Witness my hand and official seal,
John L HazleShurst
SEAL a le
M i urg County
nh C aina:
res
Comml nn ISIMS :021]
My commission exp
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