SW5210603_Application Form_20210817

DEMLR 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 M mt 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.):
Duck Thru at Spring Hone, NC
2. Location of Project (street address):
NC Hwy 581 and US 64 West
City:Spring Hope County:Nash Zip:27882
3. Directions to project (from nearest major intersection):
From US -64 East take Exit 450 toward Spring Hope. Turn Left on NC Hwy 581 and the site is approximately
500 feet on the left.
4. Latitude:35° 56' 03.35" N Longitude:78' 05' 57.48" 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 , its issue date (if known) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density NHigh Density ❑Drains to an Offsite Stormwater System ❑Other
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):
❑LAMA Major
❑NPDES Industrial Stormwater
❑Sedimentation/Erosion Control: 4.92 ac of Disturbed Area
❑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? NNo ❑Yes
If yes, see S.L. 2012-200, Part VI: http://l2ortal.ncdenr.org/webAr/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 project):
Applicant/ Organization:Jernigan Oil Company Inc.l
Signing Official & Title:James Michael Harrell
b. Contact information for person listed in item 1a above:
Street Address:415 East Main Street
City:Ahoskie State:NC Zip:27910
Mailing Address (if applicable):PO Box 688
City:Ahoskie State:NC Zip:27910
Phone: (252 ) 332-2131 Fax:
Email:michaelh(l jerniganoil.com
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 agreement and complete Contact Information, item 2a and 2b below)
® Purchaser* (Attach a copy of the pending sales agreement and complete Contact hlformation, item 2a and
2b below)
❑ Developer* (Complete Contact hlformation, 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:It's Farm Time LLC and Chester H. Brantley Et Al
Signing Official & Title:Brad Mercer, Vice President and Chester H. Brantley
b. Contact information for person listed in item 2a above:
Street Address:337 N Queen Street and 7130 W Old Sppring Hope Road
City:I<inston and Spring Hope State:NC Zip:28501 and 27882
Mailing Address (if applicable)YO Box 277 and PO Box 697
City:Kinston and Spring Hope
Phone: (1800 ) 336-9921 and 252.904.3429
Eniail:brad.mercer3becajun.coni
State:NC
Fax:
Zip:28501 and 27882
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: Kevin Varnell / Stocks Engineering
Signing Official & Title:
b. Contact information for person listed in item 3a above:
Mailing Address:PO Box 1108
City:Nashville State:NC Zip:27856
Phone: (252 ) 459-8196 Fax: (252 ) 459-8197
Eiiiail:kvartiell(@stocksengineering.com
4. Local jurisdiction for building permits: Spring Hope, NC
Point of Contact:Jae Kim Phone #: (252 ) 478-5186 ext. 225
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.
Stormwater will be conveyed through the pipes and into the onsite wet pond The wet pond will outlet into
the NCDOT ditch.
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:
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 -Pam River basin.
4. Total Property Area: 4.87 acres 5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:4.87 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHM line or Mean High Water
(MHM line, and coastal wetlands landward from the NHW (orMHM line. The resultant project area is used to
calculate overall percent built upon area (B UA). Non -coastal wetlands landward of the NHW (or MHV1) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 75 %
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
Drainage 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)
185,466
On -site Drainage Area (sf)
179,621
Off -site Drainage Area (sf)
5,845
Proposed Impervious Area** (so
156,682
% Impervious Area** (total)
84%
Impervious" Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area
On -site Buildings/Lots (so
4200
_
On -site Streets (so
On -site Parking (so
150,286
On -site Sidewalks (so
2,196
Other on -site (so
0
Future (so
Off -site (so
0
Existing BUA*** (so
0
Total (sf):
156,682
* Stream Class and Index Ntimber can be determined at: littpl/portal.ncdenr.org/zvebhvq/ps/csu/classifications
Impervious area is defined as the bttilt upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 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 BUA 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. N/A
Proieets in Union County: Contact DE 1LR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stornnvater requirements as per 1 SA 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 http://portal.ncdenr.oriz/web/wq/ws/su/bmo-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
httl2://12ortal.ncdeiir.org/web/wq/ws/su/statesw/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 http://portal.ncdenr.org/web/wq/ws/su/maps.)
Please indicate that the following required information have been provided 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 fromhttl2://12ortal.ncdenr.org/web/wq/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. 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
htta://www.eiivhelp.org/pages/onestopexl2ress.html 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 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).
for
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6