SW6210903_Application Form_20210914

DWQ USE ONLY
Date Received
F'cc Paid Permit NUmbcr
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 ❑ Ph I1 - Post Construction
(selecf 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 Water {duality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied fnr use as air 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.):
Carolina Crossina
2. Location of Project (street address):
North Horace Walters Road
City:Raeford County:Hoke 7.ip:28376
3_ Directions to project (from nearest major intersection):
The ro'ect is located approximately 302 ft. from the intersection of North Horace Walters Road and Neill
Sinclair Road Zoing north towards Brown Farm Road.
4_ Latitude:34° 59' 50.32" N Longitude:79° 21' 41.82" W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modification]
IRenenials roill7 modifications also requires 511v'i.1-102 - Reneu?al Applic:alion dorm
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 ®High 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 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: 5.305 ac of Disturbed Area
0404/401 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:
Is the project located within 5 miles of a public airport? ®No ❑Yes
Ify s, see S.L. 2012-200, Part VI: htW:lZj2ortal.ncdenr.orgzweb/wq/ws/su/statesw/rulps taws
Form SWU-101 Version 06Aug2012 Page I of

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: Ryan's Run Properties, LLC
Signing Official & Title:David T. Upchurch / Managing Partner
b.Contact information for person listed in item -1a above:
Street Address:150 S. Page Street
City:Southern Pines State:NC Zip:28387
Mailing Address (i f applicable):
City: State: Zip:
Phone: [phone] Fax:
Email : Lee Oa doubleden .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 Iease 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:
Signing Official & Title:
b.Contact information for person listed in item 2a above:
Street Ad
City:
Mailing Address (if applicable):
City:_
Phone:
Email:
State:
State:
Fax:
Zip:
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/Organiza
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ( - }_ Fax: ( )
Email:
4. Local jurisdiction for building permits: Hoke Count.y Planning/ Zoning
Point of Contact:Robert Farrell Phone #: (910 ? 875-8407
FormSWU-101 Version06Aug2012 Page 2of6

IV. PROJECT INFORMA`i'ION
1. >11 the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff from the develo ped areas of the site will be captured and treated in an infiltration basin
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: 44.436 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 shall be calculated to exclude the followin the normal pool of inr otnded structures, the area
between the batiks of streams arse rivers, the area below the UmaI High Water (NH0v) litre or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (orNlHl�) line. The resultant project area is used to
calculate overall percent bttill rcpon area (BUA). Non -coastal wetlands landtoard c f the NHW (or MHW} litw nifty
he included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 20.41 %
9. How many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
stormwater BMP. For low fie)tsitj and outer projects, rise 1 f?r 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
Draina e Area 1
Draina a Area
Drama e Area _
Draina e Area _
Receivin g Stream Name
Little Creek
Stream Class *
C
Stream Index Number *
14-2-17
Total Drainage Area (sf)
1,504,315
On -site Drainage Area (sf)
1,504,315
Off -site Drainage Area (sf)
0
Proposed Impervious Area* (sf)
395,036
% Impervious Area** (total)
26.3
Impervious- Surface Area
Draina a Area 1
Drainage Area _
Drainage Area
Drainage Area _
On -site Buildings/Lots (so
256,000
On -site Street-, (st)
119,030
On -site Parking (so
On -site Sidewalks (st)
20,006
Other on -site (so
Future (so
Off -site (sf)
Existing BUA*** (sQ
Total (so:
395,036
Strewn Class and Index Nuntlwr cart he determined at: ltttp.- portal,ncctenr.org,,vebfzt;g/ns/cser/classificatiorts
x� Ins peruious area is defined as t1w built upon area including, but not IhOted to, buildings, roasts, parking areas,
sii1ewalks, gravel areas, etc.
Forin SWIJ-101 Version 06Aug2012 Page 3 of'6

Report only that amount of existing RUA that uV11 remain after development. Do not report any existing BUA that
is to be reinoved and which will he replaced by new BUA.
11 _ How was the off -site impervious area listed above determined? Provide documentation. n a
Projects in Union County: Contact DWQ Central Oftce.slaff to check ifthe project is located within a Threatened &
Endangered Species watershed that may he suhfect to more stringent stornm uter requirements as per 15.4 NC,4C 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 ht!p://portal.ncdenr.org/web/wq/ws/su/bml?-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 http.I/portal.ncdeiu.org/web/wq/ws/suZstatesw/forms does. 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 http://portal.ncdenr.org/web/wq ws/su/mans.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item_ All original documents MLTST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from h ortal.ncdenr.or web w ws su statesw forms dots.
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 Covenant-,
Form. (i f mquired as per Part VTI 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
htt www.envhelp.org/12ages/onestol2exi2ress.htmi 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 for _
6. A USCS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 'z mile of the site boundary, include the L/z
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 N 1W 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 BOA 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).
form SWU-101 Version 06Aug2012 Page 4 of 6

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" copy of the MRCS County Soils 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 veri fij the SHIM' prior
to subrrrittal, (910) 7.96-7378.)
10. A copy of the most current property deed. Deed book: 01398 Page No: 0771
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.
littp://www.secrotoLry.state.nc.us/Corporations/CSearcii.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
htt ortal.ncdenr.or, web w ws su statesw forms does. 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 Iisted
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 1 ngineer:Carlo Pardo, PE
Consulting Firm: Triangle Site Design, PLLC
Mailing Address:4004 Barrett Drive Suite 101
City:Ra leigh State:NC Zip:27609
Phone:(919 ) 553-6570 _ Fax: ( )
Email:c ardoC�3trian le.sitedesi i.com
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type nanze of person listed in Contact Information, item 2a) , certify that 1
own the property identified in this permit application, and thus give permission to (print or hjpe name of person
listed in Contact Information, item l(7) with (print or hlpe rrrnne of organization listed in.
Contact 1 rrfbrwation, hear Ia) 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 responsibility to notify DWQ immediately and submit a
completed Name/0-Amership Change Form within 30 days; otherwise I w ill be operating a stormy rater 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 525,000 per day, pursuant to NCGS 143-215.6.
Signature:
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
",Iy commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type manic of person listed in Contract Information, item 1ra) David T. Upch arch
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 21-1.1000 and any other applicable state stormwater requirements.
Signature: Date:
I, a Notary Public for the State of tip- Count of
1 — Y
do hereby certify that , v1&T, U94A-61f-rl, personally appeared
before me this day of and ac ledge the tine execution of the application for
a stormwater permit. Witness my hand and official seal,
a RaY
publiC
SEAL.
My commission expires D—
Form SWU-101 Version 06Au92012 Page 6 of 6