20210490 Ver 1_Stormwater Application Approved_20210914

0*
WPC*43
Creative Regional Solutions Since 1968
WESTERN PIEDMONT
COUNCIL OF GOVERNMENTS
Planning and Development 1880 2nd Ave. NW
Hickory, NC 28601
[phone]
APPLICATION FOR STORMWATER PERMIT
1NSTRUCUONS: All sections must he completed. Please type or print information. Section 3 must be completed in the presence
of a Notary Public.
APPROVAL OF THIS PERMIT CERTIFIES COMPLIANCE WITH THE APPLICABLE PHASE II STORMWATER ORDINANCE ONLY AND DOES
NOT EXEMPT THE APPLICANT FROM OTHER LOCAL, STATE, OR FEDERAL PERMITTING REQUIREMENTS.
(Print in all fields excluding Signatures)
1) PROJECT INFORMATION
Project Name: Wild Forks Food — Line Implementation Project
Project Address: 1450 Homegrown Ct., Lenoir, NC 28645
Property Identification No. (PIN): 2748058752
Purpose of development (residential / commercial) Commercial
Total Area Disturbed 3.68 Acres acres.
Total Acres of Site 41.12 Acres Circle/Indicate Project Type: Low Density or High Density
Total Built Upon Area: 8.28 Acres Existing BUA: 7.09 Acres Percentage of BUA: 20.14%
Municipality of Project: Lenoir NC
2) CONTACT INFORMATION
Name of Business: Wild Fork Foods
Name of Applicant: Swift Beef Company Date: p`tioSrr?.eII
Name of Project Contact Person: _Diego Pirani
Mailing Address: 1770 Promontory Circle, Greeley, Co. 80634
Street address: 1770 Promontory Circle, Greeley, Co. 80634
E-mail address: val.richards@'bssa.com
Telephone No.: 970-506-8000 Cell No: Fax no:
1
Signature:
Landowner(s) of Record:
3/30/2021 _ < ._I : 6/15/20.21 . I' l 1 i . f i" ` . 21-1-LN R

Name: Swift Beef Company
Mailing Address: 1770 PromontorV Circle Greeley,Co. 80634
Telephone: [phone]
Recorded in Deed Book No. 1968 Page: 755
Person or Firms In-Charge/financially responsible for land disturbing activity:
Name: Swift Beef Company Telephone: [phone]
Mailing address (wl City, state zip): 1770 Promontory Circle —Greeley, Co. 80634
Engineer or Technical Representative: Name: _ L. Allan Hill, PE
Company: Triad Design Group, PC Phone: [phone]
Mailing address (wl City, state zip): 4807-C Ka er Boulevard Greensboro NC 27407
Email: ahill@triad-desiq_nqroup.com
3) The above information is true and correct to the hest of my knowledge and belief and was provided by me
while under oath. (If the financially responsible person is an individual, this form must be signed by the
individual or his attorney -in -fact, if the financially responsible person is not an individual, this form must be
signed by an officer, director, partner, or registered agent with authority to execute instruments for the
financially responsible person.)
Name: MA66-
Date:. o4 Io8 /Z-0-L
Title: Tk6 11L6-R Signat re:
I,kci, 49 t a Notary Public for the County of
, State of
hereby certify that I)!_p_g(Mn is -an r personally appeared before me this day and under oath
acknowledged that the above form was voluntarily executed by him and is correct to the best of his knowledge
and belief. r
Witness my hand and seal, this'S day of 2D2-d
VALARIE RIC,4AF:S Notar
NOTARY PUBLIC - STM, .:. _0:_ORA00 y
NOTARY IO 2G
MY COMMISSION E (P.: =S NUV 3, 2024
,,y. My Commission Expires fa-�

Application/Plan Review Fee
(Indicate which form was paid, last 2 columns are for administration use only):
Check to be mailed to P.O. Box 9026 Hickory, NC 28603
Written to WPCOG, to the attention of Jack Cline or Stormwater
Building/Project size (Square Footage)
Price
Date Payment
was received
Paid
<35,000 (High Density) ❑
$375
35,000 — 100,000 & Major
Subdivisions (High Density)
$600
>100,000 (High Density) ❑
$1000
Low Density Plan Review ❑
$100
01200 — 0000913 — 60218 Finance Number:
Municipality: Lenoir, NC
Applicant Signature: