SW5210601_Application Form_20210610

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: 0 Coastal SW - 1995 0 Coastal SW - 2008 0 Ph II - Post Construction
1 (select all that apply) 0 Non -Coastal SW- HQW/ORW Waters 0 Universal Stormwater Management Plan
0 Other WQ Mgmt Plan: J
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
Thisform may be photocopiedfor 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.):
St Stephens Baptist Church
2. Location of Project (street address):
518 S Pine Street
City:S]2ring Hope County:Nash Zip:27882
3. Directions to project (from nearest major intersection):
Take exit 450 on US Highway 64 for NC Highway 581. Take NC 581 toward 5Rring Hope. Turn left on 2-1
Street. Turn left at the 1st cross street onto S Pine Street and 12rpject area will be a1212roximately.4 miles on
the right
4. Latitude:350 56' 8.5344" N Longitude:78' 6'37.566" W of the main entrance to the project.
H. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ZNew []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 , its issue date (if known)- — and the status of
construction: []Not Started E]Partially Completed* [] Completed* *provide a designer's certification
2. Specify the type of project (check one):
F�Low Density ZHigh 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):
F�CAMA Major ZSedimentation/ Erosion Control: 5.1 ac of Disturbed Area
EINPDES 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:
5. Is the project located within 5 miles of a public airport? ZNo FYes
If yes, see S.L. 2012-200, Part VI. httl2://12ortal.ncdenr.org/web/ir/ruies-and-regulations
FormSWU-101 Version Oct. 31, 2013 Page I 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 pro.jec!):
Applicant/ Organization:St Stephen Missionaly Baptist Church
Signing Official & Title:Shirla Sewell -Fisher - Trustee
b. Contact information for person listed in item la above:
Street Address: 51g 's, Pir*)e) �3-r-
city: .son-r-)o t4i�v State: UC —zip:
I �J I
Mailing Address ff applicable):_
City: State: zip:
_5-oqg Fax:
Email: reb0--:,VV6V(CA(�) heh�12�1.eoe�
0
c. Please check the appropriate box. The applicant listed above is:
E The property owner (Skip to Contact Information, 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)
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: 1::�A(?Nesr Pupolsk,
Signing Official & Tifle:_ -P zfi TO (Z
b, Contact information for person fisted in item 3a above:
Mailing Address: '-R0 9L2�>� IS
Ci""— State: C zip:
Phone: t2j�6.7- �-�Q Fax: L
Email: e-Ctv n e-StP-0r2f-,k 02d, I - COrn
4. Local jurisdiction for building permits: SprLnZ Hol2e
Point of Contact:lae Kim - Town Manager Phone #: (252 J­478-5186
Fonn SVVU-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.
Stormwater runoff will be collected and routed via stormwater pipe system to a water qualijy 12ond that
discharges to a level spreader and filter stri12.
2. a. If claiming 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:
E] Valid Building Permit Issued Date:
r-1 Other: Date.
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
E] Coastal SW - 1995 F-1 Ph II - Post Construction
3. Stormwater runoff from this project drains to the Tar-Pamhco River basin.
4. Total Property Area: 14.98 —acres
5. Total Coastal Wetlands Area: —acres
6. Total Surface Water Area: 0.13 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+: 14.85 acres
+ Total project area shall be calculated to exclude thefollowing: the normal pool of impounded structures, the area
between the banks of streants and rivers, the area belon? the Normal H* 11 Water (NRW) line or Mean High Water
(MHK9 line, and coastal wetlands lawhiwrelftom the NHW (or MHM line. 77te resultant project area & used to
calettlate07icralit)erceittliiiiltttpoiiareti(BUA). Non-constal wetlands landward of the NHW(or MHOO line may
be included in t1w total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 17.7 %
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 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.
Basin Information
Drain�Le Area 1
Drainage Area
Drainage Area
Drainage Area
Receiving Stream Name
Hendricks Creek
Stream Class *
QNSW
Stream Index Number
28-55-2
Total Drainage Area (sf)
165528
On -site Drainage Area (sf)
165528
Off -site Drainage Area (sf)
Proposed Impervious Area** (sf)
114998
% Impervious Area** (total)
69
Surface Area
Drainage Area I
Drainage Area
Drainage Area
Drainage Area
.Impervious**
On -site Buildings/Lots (sf)
14431
On -site Streets (so
On -site Parking (so
96944
On -site Sidewalks (so
3623
Other on -site (sf)
Future (sf)
Off -site (so
I Existing BUA*** (SO
Total (sf):
114998
1
E
Stream Class and Index Number can be determined at: http.Aortq1.ncdenr.orgZweh/wqZ
pslcstilclassiflcations
imyervi . ous area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
ewalks, gravel areas, etc.
10 1
Version Oct. 31, 2013 Page 3 of 6

Report only that amount of existing B UA that will remain after development. Do not report any existing B LLA that
'9— '
is to be removed and which will be replaced by new UA.
11. How was the off -site impervious area listed above determined? Provide documentation. N
Pro*ects in Union County: Contact DEMLR Central Office staffto check if theproject is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements asper 15A NCAC 02B4O600.
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 http:ZZI)ortal.iic(letir.org/webZwgZws/`sti/`bnil2-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
http:J Z portal.ncdennorgZ wLb/wqZws/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 atlittp://12ortal.ncdeiir.orgZweb"w Lw S
.§/su/niap .)
Please indicate that the following required information have been pLoyided by initiali 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 http./ Jporta1.ncdenr.oEg/ web/ w!q /ws/su/s&-1teswJforms docs.
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, siMed 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
hft:/ /www.envhelp.org/ pages/ onestol2express.htTnI 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 line of tidal
waters, and any coastal wetlands landward of the MHW or NHW fines.
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).
Forni SWU-101 Veision Oct. 31, 2013 Page 4 of 6
for
01 '

p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify AN
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5-01" copy of the NRCS County Soils map with tile
project area clearly delineated. For projects with infiltration HMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedale a site visit fi)r DEA4LR to verifil the ShWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 2683 Page No: 45
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.
h!W:/ /www.secretary.state.nc.us/Corporations/CSearch.aspx
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 http.Zlpoytal.ncdeni-.orgZweb/it�/`stite-
storm wa ter -form s 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 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:Phillip loyner, Ir
Consulting Firm: Mack Ggy Associates, -PA
Mailing Address:1667 Thomas A Betts Pkhrl
City. -Rocky Mount
Phone: (252 ) 446-3017
Email:phillip@mackg!iypa.com
State:NC Zip:27804
Fax: (
IX PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (print or hjpe 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 hjpe name of person
listed in Contact Information, item 1a) with (print or hjpe 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 fisted 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: - Date;
1, . a Notary Public for the State of County of
do hereby certify that
personally appeared
before me this — day of I . and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seaL.
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
1, (print or hjpe name ofterson listed in Contact Information, item 1a) 6tHP-t*
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 wi I I be recorded, and that the proposed project complies with the requirements of the
applicable stornhwater rule"nder 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Signature:
I, __p , County of
A""e\a. V&. 0ex\'c- a Notary Public for the State of /V C
4
—991.%Lk � do hereby certify that S hi r- 6 i:;s.%%,er personally appeared
before me this 2 Way of tv�k(�- � ZO 2-1 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, rL- J-k
I
ANGELA M CLARK
SEAL NOTARY PUBLIC
NASH COUNTY, NORTH CAROLINA
MY COMMISSION EXPIRES 2-ZO-2
7-C)
My commission expires -
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6