SW6210901_Application Form_20210908

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 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.):
Gates Farm Subdivision
2. Location of Project (street address):
Near the intersection of Turni2ike Rd. and Lemont Dr.
City:Raeford County:Hoke Zip:28376
3. Directions to project (from nearest major intersection):
The project.is located approximately.17 miles from the intersection of Turnpike Rd. and Lemont Dr. going
SW towards Angus Ln.
4. Latitude:34° 59' 12" N Longitude:79° 15' 36" 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: El Started []Partially Completed* Completed* *provide a designer's certification
2. Specify the type of project (check one):
[]Low Density ®High Density ❑Drains to an Of -site 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 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):
❑CAMA Major
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 16.45 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? ®No . '❑Yes
If yes, see S.L. 2012-200, Part VI.- htttl2:L�poriil.ncdenr.org/�yeb/�vglwslsu/statesw/rules laws
Form SWU-101 Version 06Aug2012 Page 1 of 6

IIl. 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 utSprings Holdings, LLC
Signing Official & Title:T. Allen Tordan, Tr./Member.
b. Contact information for person listed in item la above:
Street Address:275 S. Bennett Str.
City:Southern Pines State:NC Zip:28387
Mailing Address (if applicable):
City; Stag:
Phone: f910 ) 693-1700 Fax:
Email: j ohnallenjord anjrfgrnail. com
Zip;
c. 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 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/Organization:Robert A. and Shirley Wright
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:750 Tune Tohnson Rd.
City —Raeford State:NC Zip:28376
Mailing Address (if applicable):
City: State: Zip:
Phone: f ) Fax:
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:
Phone: f
State: Zip:
Fax: I )
4. Local jurisdiction for building permits: Hoke County Planning/Zoning
Point of Contact:Robert Farrell Phone #: '(910 _) 875-8407
Form SWU-101 Version 06Aug2012 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff from the developed areas of the site will be caRtured and treated in a wet pond
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 11- Post Construction
3. Stormwater runoff from this project drains to the Lumber River basin
4. Total Property Area: 16.75 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+: 0 acres
Total project area s]ui21 be calculated to exclude thefollowing: the normal pool of impounded structures, the area
between the banks of streams and rivers, t1w area below the Normal Hi. h Water (NHM line or Mean High Water
(MHW) line, and coastal wetlands landward pnn the NHW (or MHV j line. 71w resultant project areas used to
calculate overall percent built upon area (R Aj Nan -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area (Total Impervious Area / Total Project Area) X 100 = 41.85 %
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
Little Creek
Stream Class *
C
Stream Index Number *
14-2-17
Total Drainage Area (so
689,291
On -site Drainage Area (sf)
689,291
Off -site Drains a Area (sf)
0
Proposed hn ervious Area** (so
305,418
% Impervious Area** (total)
44.31
Impervious" Surface Area
Drainage Area 1
Drainage Area
Drainage Area _
Drains Area
On -site Buildings/Lots (sf)
203,000
On -site Streets (sf)
82,915
On -site Parkin (s
On -site Sidewalks (so
19,503
Other on -site (s
Future (so
Off -site (so
Existing BUA*** (sf)
Total sf):
305,418
* Stream Class and Index Number can be determined at: lrtipaportal.ncdvir.orglwe it /p. csy classi Lions
Impervious area is definerl as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel amps, etc.
Form SWU-101 Version 06Aug2012 Page 3 of 6

'Report only that amount of existing BUA 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
Prokets in Union County: Contact DWQ Central ice staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements asper 15A 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 hitp.j / portal.ncd_ennorg/web/wq/ws/su1bmy-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 httg//Portal.ncdenr.org/web/weglws/sulstatesw/forms does. The complete
application package should he submitted to the appropriate DWQ Office. (rhe appropriate office may be
Found by locating project on the interactive online map at htW: I1portat.ncdenr.org/web/wq/ws/su/maps.)
Please indicate that the following required information have been provided by initialin 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 littp://pgrtaLncdenr.org/web/wq/ws/su/statesw/forins does.
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 1V11 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
h!W://www.,envhelD.org/12aggs/onestoRgxpLess.hbA 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
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 M1-W 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).
p. Vegetated buffers (where required).
KL
Ad"
for
ML
ML
yLA (—
Form SWU-101 Version 06Aug2012 Page 4 of 6

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify N
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" copy of the MRCS County Sons map with the
project area clearly 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 verify the SHVITT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 947 Page No: 697 r'i L-
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC M
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 roust be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
h=://www.secretar.y.state.nc.usZCgrporations/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
ht ortal.ncd.enr.or web w ws su statesw Iforms. dons. 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 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 --Matthew Lowder, PE
Consulting Firm: Triangle Site Design, PLLC
Mailing Address:4004 Barrett I?riveSuite 101
City: ei State:NC Zip:27609
Phone: (919 ) 553-6570 Fax:
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) Robert A. and Shirley Wriht , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item 1a) 1. Allen Jordan, Jr. with (print or type name of organization listed in
Contact Information, item 1a) Spout Springs Holdings, 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
Form SWU-101 Version 06Aug2012 Page 5 of 6

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 cancels or defaults on their
lease 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 resporvsibiIity to notify DWQ immediately and submit a
completed Nanie/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.
Sigi-iatu rc:
I,
a Notary Public for the State of
do hereby certify that
Date:
County of
personally appeared
before me this _ day of and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
X. APPLICANT'S CERTIFICATION
1, (print or type dame of person listed in Contact Information, item 1a) f, Allen Jordan. Jr. _
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 will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2H .1000 and any other applicable state stormwater requires ents,
ZJSignature: 1 �Z� 4— Date: i �o
I, ►� Cn' I U ■ a Notary Public for the State of County of
,. do hereby certify that personally appeared
before me this��ay of Au J and acknowled a the due execution f the application for
a stormwater permit. Witness my hand and official seal, :� f
C N�Cb/ter,, .
r OTAA/ s
� Y
AUB L\(' x
•;
SEAL
My commission expires
Form SWU-101 Version 06Aug2012 Page 6 of 6

As the legal property owner I acknowledge, understand, and al
agent (entity listed in Contact Information, item 1) dissolves the
lease agreement, or pending sale; responsibility for compliance
me, the property owner. As the property owner, it is nay respor
completed Name/Ownership Change Form within 30 days; otl
facility without a valid permit. I understand that the operation
permit is a violation of NC General Statue 143-215.1 and may r(
the assessment of civil penalties of up to $25,000 per day, pursu
.. A _ ., - . .. A .
Signa
e by my signature below, that if my designated
company and/or cancels or defaults on their
ith the DWQ Stormwater permit reverts back to
)ility to notify DWQ immediately and submit a
wise I will be operating a stormwater treatment
a stormwater treatment facility without a valid
It in appropriate enforcement action including
t to NCGS 143-215.6.
Dater (` ` eg-
I, a Notary Public for �e Slate of _ 1 - County of
do hereby certify thatk
before me this 21 day of k n'1okk . and
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expir
X. APPLICANT'S CERTIFICATION
1, (prinf or type name of person listed in Contact Information, item 1a) )
certify that the information included on this permit application fo
that the project will be constructed in conformance with the apprc
and protective covenants will be recorded, and that the proposed
applicable stormwater rules under 15,NCAC 2H .1000 and any c
I, ' r C" ' a Notary Public for
do hereby certify that !
before me this��ay of u � and aclan
a stormwater permit. Witness my hand and official seal, G .
a1ClNi /..,,"
G � s
W 3
A C
U13 0:
SEAL
My commission
personally appeared
the due execution of the application for
is, to the best of my knowledge, correct and
3 plans, that the required deed restrictions
rject complies with the requirements of the
�r applicable state stormwater requirements,
Date;1'51- o 4,.
State of _- A)!�' County of
210 _ personally appeared
the due execution QLthe application for
Form SWU-101 Version 06Aug2012 Page 6 of 6