SW3170801_CURRENT PERMIT_20170912

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO. SW
DOC TYPE CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATIOWINSPECTION
DOC DATE
YYYYMMDD

Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
September 12, 2017
Mr. Robert Langdon
RHGC Spencer, LLC
223 Hwy 70 East Point, Suite 100
Garner, NC 27529
Subject: Stormwater Permit No. SW3170801
Davita Spencer
Spencer, North Carolina in Rowan County
Dear Mr. Langdon:
ROY COOPER
Govemor
MICHAEL S. REGAN
Secretary
TRACY DAVIS
Director
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on August 01, 2017. Staff review of the plans and
specifications has determined that the project, as proposed, will comply with the Stormwater Regulations
set forth in Title 15A NCAC 2H.1000 rules. We are forwarding Permit No. SW3170801, for the
construction, operation and maintenance of the subject project and the stormwater system. This permit
shall be effective from the date of issuance and shall be subject to the conditions and limitations as
specified therein, and does not supersede any other agency permit that may be required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing by filing a written petition with the Office of Administrative Hearings
(OAH). The written petition must conform to Chapter 150B of the North Carolina General Statutes. Per
NCGS 143-215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this
permit. You should contact the OAH with all questions regarding the filing fee (if a filing fee is required)
and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via
telephone at 919-431-3000, or visit their website at www.NCOAH.com. Unless such demands are made
this permit shall be final and binding.
After 30 days, this project will be kept on file at the Mooresville Regional Office. Before then, if you
have any questions, or need additional information concerning this matter, please contact Richard Riddle
at [phone]; or [e-mail].
Sincerely,
OuOvd 44-ed 4 Ro/raad Z RRu(d& �h.
for Tracy E. Davis, PE, CPM, Director
ec: SW3170801 File,
Mooresville Regional Office
Matt Johnson, RE, Triad Design Group
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
1612 Mail Service Center 1 512 North Salisbury Street I Raleigh, NC 27699-1612
919 707 9200 T

State Stormwater Permit
Permit No. SW3170801
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT QUALITY
STATE STORMWATER MANAGEMENT PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North
Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
RHGC Spencer, LLC
for Davita Spencer °cc
1287 N. Salisbury Rowan County Spencer NC yoo(os /��s�<��0/j
FOR THE �ooWaoq
construction, operation and maintenance of the 1 Stormwater Control Measures (SCM11n
compliance with the provisions of 15A NCAC 2H .1000 (hereafter referred to as the
"stormwater rules') and the approved stormwater management plans, specifications and
other supporting data as on file with and approved by the State and considered a part of
this permit.
This permit shall be effective from the date of issuance until September 12, 2025, and shall
be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. The SCM is approved for the management of stormwater runoff as described in the
application documents and as shown on the approved plans.
3. All stormwater collection and treatment systems must be located in either dedicated
common areas or recorded easements. The final plats for the project will be
recorded showing all such required easements, in accordance with the approved
plans.
4. The runoff from all built -upon area within the permitted drainage area of this project
must be directed into the SCM.
5. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
II. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of the
system will be repaired immediately.
The permittee shall at all time provide the operation and maintenance necessary to
assure every SCM functions at optimum efficiency. The approved Operation and
Maintenance Plan must be followed in its entirety and maintenance must occur at
Page 1 of 4

State Stormwater Permit
Permit No. SW3170801
the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowiny and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader, filter
media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
3. .Records of maintenance activities must be kept for the SCM. The reports will
indicate the date, activity, name of person performing the work and what actions
Were taken.
'4. The permittee shall submit an annual summary report of the maintenance and
inspection records for the SCM. The report shall summarize the inspection dates,
results of the inspections, and the maintenance work performed at each inspection.
I it
,h
5. Th@ SCM shall be constructed in accordance with the approved plans and
�:"'specifications, the conditions of this permit, and with other supporting data.
6=i'�) Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received from
an appropriate designer for the SCM certifying that it has been installed in
accordance with this permit, the approved plans and specifications, and other
supporti t, documentation. Any deviations from the approved plans and
specifications must be noted on the Certification. A modification may be required for
those deviations.
7. SCMs impacted by sedimentation and erosion control during the construction phase
shall be cleaned out and converted to its approved design state.
8. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project area.
The project area is defined as all property owned by the permittee, for which
Sedimentation and Erosion Control Plan approval was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
A copy of the approved plans and specifications shall be maintained on file by the
Permittee for a minimum of eight years from the date of the completion of
construction.
10. The Director may notify the permittee when the permitted site does not meet one or
more of the minimum requirements of the permit. Within the time frame specified in
the notice, the permittee shall submit a written time schedule to the Director for
modifying the site to meet minimum requirements. The permittee shall provide
copies of revised plans and certification in writing to the Director that the changes
Page 2 of 4

State Stormwater Permit
Permit No. SW3170801
have been made.
11. SCMs that allow stormwater to infiltrate shall not be located on or in areas with
contaminated soils.
12. Plats for residential lots that contain SCMs shall include: the specific location of the
SCM on the lot; a typical detail for SCM to be used; and a note that the SCM on the
property has been required to meet stormwater regulations and that the property
owner may be subject to enforcement procedures as set forth in G.S. 143, Article 21
if the SCM is removed, relocated, or altered without prior approval.
13. The O&M Agreement shall be referenced on the final plat and shall be recorded with
the county Register of Deeds upon final plat approval. If no subdivision plat is
recorded for the site, then the O&M Agreement shall be recorded with the county
Register of Deeds so as to appear in the chain of title of all subsequent purchasers.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director. In
the event of a change of ownership, or a name change, the permittee must submit a
completed Name/Ownership Change form signed by both parties, to the State,
accompanied by the supporting documentation. The approval of this request will be
considered on its merits and may or may not be approved.
2. The permittee is responsible for compliance with all permit conditions until such time
as the Division approves a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the State, in accordance with North
Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with any
and all statutes, rules, regulations, or ordinances, which may be imposed by other
government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action, including
those as may be required by this Division, such as the construction of additional or
replacement stormwater management systems.
6. The permittee grants DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated. The
permit may be modified, revoked and reissued or terminated for cause. The filing of
a request for a permit modification, revocation and re -issuance or termination does
not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference and
are enforceable parts of the permit.
Page 3 of 4

State Stormwater Permit
Permit No. SW3170801
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit as
allowed by the laws, rules and regulations contained in Session Law 2006-246, Title
15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or mailing
address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 12th day of September, 2017.
or racy E. Davis, P. ., P
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW3170801
Davita Spencer
1287 N Salisbury, Spencer, NC
Rowan County
Designer's Certification
I, as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
cc: NCDEQ-DEMLR Regional Office
Page 1 of 1

€Z l DDL-►t
:.DEMLR,USEONLY.. .'..... .... .: . .. ;.
ate Received
Fee
Permi Numb r
i +
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 1913h 11 -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 - shou
specifications, letters, operation and maintenance agreements, etc
2. Location of Project (street address):
DENR-LAND QUALITY
Ci ty:Spencer County: Rom
3. Directions to project (from nearest major intersection):
Zip:28144
From Salisbury head north on US 29 through Spencer. Site is on North Side of Spencer at corner of N
Salisbury Ave/US 29 and Sowers Road.
4. Latitude:35° 42' 21" N Longitude:80° 24' 48" W of the main entrance to the project.
II. PERMIT INFORMATION:
a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
iReuemnls With umrlifncations also requires SWLI-102 - Renen al Application Forrn
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
Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsile 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):
[]LAMA Major ®Sedimentation/Erosion Control:
❑NPDES Industrial Stormwater 0404/401 Permit: Proposed Impacts
ac of Disturbed Area
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: littp:llportal.ncdefir.org/web/`lt-/­ruies-ajid-regLli',)tiOlIS
Form SWU-101 Version Oct. 31, 2013 Pape I of 6

III. CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the oroiect):
Applicant/Organization:RHGC Spencer LLC
Signing Official & Title:Mr. Robert Langdon - Managing_ Member
b.Contact information for person listed in item la above:
Street Address:223 Hwy 70 East Point, Suite 100
City:Garner State:NC Zip:27529
Mailing Address (if applicable):
City: State: Zip:
Phone: [phone] Fax: (919 ) 662-1002
Email:[e-mail]
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 properly that the project is located on):
Property Owner/Or
Signing Official & Ti
b.Contact information for person listed in item 2a above:
Street Address:
Sta
Mailing Address (if applicable):
City: State: Zio:
Phone:
Email:
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: Matt Johnson, P.E. - Triad Design Group
Signing Official & Ti
b.Contact information for person listed in item 3a above:
Mailing Address:4807-C Koger Blvd
City:Greensboro State:North Carolina Zip:27407
Phone: (336 ) 218-8282
Email:miohnson@triad-desig_ngrottp.com
4. Local jurisdiction for building permits: Town of Spencer
Fax: (336 ) 218-8010
Point of Contact: Phone #:
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the slormwater runoff will be treated.
All runoff from proposed impervious Surfaces will flow to and be treated by a proposed wet detention pond
deisgned to NCDEO standards.
2. a.lf 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 regulations) the project has been designed in accordance with:
❑ Coastal SW —1995 ® Ph 11— Post Construction
3. Stormwater runoff from this project drains to the Yadkin-PeeDee River Basin River basin.
4. Total Property Area: 8.19 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-: acres
Total project area shall be calculated to exclude the following: the nornml pool of impounded stnmttres, the area
betzoeen the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landzard from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BL1A). Non -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 = 13.92 %
9. How many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
storrrrzoater BMP. For lozv density and other projects, use 1 for the zohole 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
Draina e'Area
Drainage Area
-Drainage Area
Receiving Stream Name
Grants Creek
Stream Class *
C
Stream Index Number *
12-110
Total Drainage Area (sf)
94,750
On -site Drainage Area (sf)
82,394
Off -site Drainage Area (sf)
12,356
Proposed Impervious Area** (sf)
46,790
% Impervious Area** (total)
49.38%
im ervious"'Surface. Area ,• ;
,Draiha' e Area._
Drainage Area,_
Drainage Area:_
'Drainage Area _
On -site Buildings/Lots (sf)
9024
On -site Streets (sf)
0
On -site Parking (so
34,497
On -site Sidewalks (sf)
3,137
Other on -site (sf)
Future (sf)
2,937
Off -site (sf)
5,820
Existing BUA*** (sf)
Total (sf):
49,595
Stream Class and index Number can be determined at: ltttp://portal.nedenr.orghoeblwrl[ps/csnlclassifications
*" Lnpervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 20t3 Page 3 of 7

'Report only that amount of existing BLIA that Will remain after development. Do not report any existing BLIA that
is to be rentoved and which will be replaced by new BLIA.
11. How was the off -site impervious area listed above determined? Provide documentation. T000graohic Topo
Survey and CAD software
Projects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that inay be subject to more stringent stornnvater requirements as per 15A NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state slormwater 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 littt_k:////kiortal.ncdenr.org/web/wq/ws/stt/bmp-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
httu:////portal.ncdenr.org/web/wq/ws/su/statesw/forms does. 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 Itttp://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 from http//portal.ncdenr.org/web/wq/ws/su/statesw/forms does.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. M WZ
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VIl 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
hup://wT ww.enviielp.org/pages/onestopexpress.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
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
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'h mile of the site boundary, include the'h
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.
,�
#` -kV-),T
Mw
Form SWU-101 Version Oct. 31, 2013 Page 4 of 7

• 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). <
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 NRCS 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 DEMLR to venfy the SH WT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: Page No: `-1
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC (-w
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.
littl2://www.secret,iry.state.nc.tis/Cori2orations/CSearch.aspx
VIL 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 htto://12orta1.ncdenr.org/web/ir/state-stormwater-
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 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.
VHI. 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 W. Johnson, P.E.
Consulting Firm: Triad Design Groan, PC
Mailing Address:4807-C Koger Blvd
City:Greensboro State:NC Zip:27407
Phone: (336 ) 218-8282 Fax: (336 ) 218-8010
Email:[e-mail]
Form SWU-t01 Version Oct. 31, 2013 Page 5 of 7

IX. PROPERTY OWNER AUTHORIZATION (if Contact 6 f rmation, item 2 has been filled out, complete ibis
section)
1, (print or type name 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 type name of person
listed in Contact Information, item 1a) with (print or type 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.
As the legal properly 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 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 1 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.
a Notary Public for the State of , County of
do hereby certify that
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
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7

X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item Ia)
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 requirements.
Signature: v[ � (Date: F -21i-�7
1, a No ry Public for the State of n �a County of
do hereb certify
�• .Gslla/s✓ 1'Z personally appeared
h
before me this day of o2�/7, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, L24/t G� (,,V
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SEAL
My commission expires //'.16'17
Form SWU-101 Version Oct. 31, 2013 Page 7 of 7

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Operation & Maintenance Agreement
Project Name:
Project Location
DaVita Spencer
Spencer NC
maintenance recoras snail De Kept on the Touowing bmrtsl. i ms maintenance recora snail De Kept to a iog in a Known set
location. Any deficient BMP elements noted in the inspection will be corrected, repaired, or replaced immediately. These
deficiencies can affect the integrity of structures, safety of the public, and the pollutant removal efficiency of the BMP(s).
The BMP(s) on this project include (check all that apply & correspc
Bioretention Cell
Quantity:
Dry Detention Basin
Quantity:
Grassed Swale
Quantity:
Green Roof
Quantity:
Infiltration Basin
Quantity:
Infiltration Trench
Quantity:
Level SpreaderNFS
Quantity:
Permeable Pavement
Quantity:
Proprietary System
Quantity:
Rainwater Harvesting
Quantity:
Sand Filter
Quantity:
Stormwater Wetland
Quantity:
Wet Detention Basin
Quantity:
1
Disconnected Impervious Area
Present:
No
User Defined BMP
Present:
No
O&M tables
Location
Location
Location
Location
Location
Location
Location
Location
Location
Location
Location
Location
Location
Location
Location
will be added automatically):
(s):
(s):
(s):
(s):
(s):
(s):
(s):
(s):
(s):
(s):
(s):
(s):
(s): 1287 N. SalisburyAve
(s)
(s):
I acknowledge and agree by my signature below that I am responsible for the performance of the maintenance procedures listed
for each BMP above, and attached O&M tables. I agree to notify NCDENR of any problems with the system or prior to any
changes to the system or responsible party.
` Responsible Party:
Title & Organization:
Street address:
City, state, zip:
Phone number(s):
Email:
County of
personally appeared before me this
Mr. Robert Langdon
RHGC Spencer, LLC
223 Hwy 70 East Pointe, Suite 100
Garner NC 27529
919-662-1001
[e-mail]
Date: (
a Notary Public for the State of !21 [- ,
do hearby certify that
day of �e ,?U/% and
acknowledge the due execution of the p r 'oils and Maintena cce__Agreement .
Witness my.hand and official seal, K
Notary Publlo
Franklin Counter
commission Is$
1112612017
C
Version 1.4
My commission expires 11-26 -17 8T2r2017
Page 1 of 5

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c , Wet Detention Pond Maintenance Requirements
The wet detention basin system is defined as the wet detention basin, pretreatment including forebays and the vegetated filter if
one is provided.
Important maintenance procedures:
Immediately after the wet detention basin is established, the plants on the vegetated shelf and perimeter of the
basin should be watered twice weekly if needed, until the plants become established (commonly six weeks).
No portion of the wet detention pond should be fertilized after the first initial fertilization that is required to
establish the plants on the vegetated shelf.
Stable groundcover should be maintained in the drainage area to reduce the sediment load to the wet detention
basin.
If the basin must be drained for an emergency or to perform maintenance, the flushing of sediment through the
emergency drain should be minimized to the maximum extent practical.
Once a year, a dam safety expert should inspect the embankment.
After the wet detention pond is established, it should be inspected once a month and within 24 hours after every storm event
greater than 1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance should be kept in a
known set location and must be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately.
BMP element:
Potential problem:
How I will remediate the problem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the BMP
Areas of bare soil and/or
Regrade the soil if necessary to remove the gully, and then plant a
erosive gullies have formed.
ground cover and water until it is established. Provide lime and a one-
time fertilizer application.
Vegetation is too short or too
Maintain vegetation at a height of approximately six inches.
long.
The inlet device
The pipe is clogged.
Unclog the pipe. Dispose of the sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the swale if necessary to smooth it over and provide erosion
swale.
control devices such as reinforced turf matting or riprap to avoid future
problems with erosion.
Stone verge is clogged or
Remove sediment and replace with clean stone.
covered in sediment (if
applicable).
The forebay
Sediment has accumulated to
Search for the source of the sediment and remedy the problem if
a depth greater than the
possible. Remove the sediment and dispose of it in a location where it
original design depth for
will not cause impacts to streams or the BMP.
sediment storage.
Erosion has occurred.
Provide additional erosion protection such as reinforced turf matting or
riprap if needed to prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by hand. If pesticide is used, wipe it on
the plants rather than spraying.
The vegetated shelf
Best professional practices
Prune according to best professional practices
show that pruning is needed
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the problem: soils, hydrology, disease, etc.
dying.
Remedy the problem and replace plants. Provide a one-time fertilizer
application to establish the ground cover if a soil test indicates it is
necessary.
Weeds are present.
Remove the weeds, preferably by hand. If pesticide is used, wipe it on
the plants rather than spraying.
STORM-EZ 8/2/2017
Version 1.4 O&M Manual Page 3 of 5

I Wet Detention Pond Maintenance Requirements (Continued) I
he main treatment area
Sediment has accumulated to
Search for the source of the sediment and remedy the problem if
a depth greater than the
possible. Remove the sediment and dispose of it in a location where it
original design sediment
will not cause impacts to streams or the BMP.
storage depth.
Algal growth covers over 50%
Consult a professional to remove and control the algal growth.
of the area.
Cattails, phragmites or other
Remove the plants by wiping them with pesticide (do not spray).
invasive plants cover 50% of
the basin surface.
The embankment
Shrubs have started to grow
Remove shrubs immediately.
on the embankment.
Evidence of muskrat or
Use traps to remove muskrats and consult a professional to remove
beaver activity is present.
beavers.
A tree has started to grow on
Consult a dam safety specialist to remove the tree.
the embankment.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair. (if applicable)
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the local NC Department of Environment and Natural
damage have occurred at the
Resources Regional Office.
outlet.
The measuring device used to determine the sediment elevation shall be such that it will give an accurate depth reading and not
readily penetrate into accumulated sediments.
STORM-EZ 8/2/2017
Version 1.4 O&M Manual Page 4 of 5

I Wet Detention Pond Design Summary I
-,�
Wet Pond Diagram
WET POND ID FOREBAY MAIN POND
Wet Pond No 1
Permanent Pool El.
736.5
Permanent Pool El.
Temporary Pool El:
737.75
Temporary Pool EIPretreatment
other NoClean
Out Depth:
4.5
Clean Out Depththan
IM
forebay?
Sediment Removal El:
732
Sediment Removal El:Has
Vag. Filter? No
Bottom Elevation:
731
Bottom Elevation:
STORM-EZ 6/2/2017
Version 1.4 O&M Manual Page 5 of 5

SUPPLEMENT-EZ FORM COVER PAGE
Please indicate the types, quantities and locations of SCMs that will be used on this project:
I Quantity
I Location(s)
Infiltration System
Bioretention Cell
Wet Pond
1
Stormwater Wetland
Permeable Pavement
-
Sand Filter
Rainwater Harvesting
Green Roof
�.
Level Spreader -Filter Strip
Disconnected Impervious Surface
Treatment Swale
Dry Pond
Designer information for this project:
Name and Title:
I Matt Johnson, PE Civil Engineer
Organization:
ITriad Design Group
Street address:
I4807-C Koger Blvd
City, State, Zip:
IGreensboro NC 27407
Phone number(s):
336-218-8282
Email:
[e-mail]
SEAL
30521
Dates
Applicant:
Project Name:
DaVita Spencer
Address
1287 N Salisbury Ave
City / Town
Spencer NC
Company:
IRHGC Spencer LLC
Contact:
IMr. Robert Langdon
Mailing Address:
1223 Hwy 70 East Pointe, Suite 100
City, State, Zip:
Garner NC 27529
Phone number(s):
919-662-1001
Email:
Certification Statement:
I certify, under penalty of law: that this Supplement-EZ form and all supporting
information were prepared under my direction or supervision;
- that the information provided in the form is, to the best of my knowledge
and belief, true, accurate, and complete; and
that the engineering plans, specifications, operation and maintenance
agreements and other supporting information are consistent with
the information provided here.
I am aware that there are significant penalties for submitting false
information including the possibility of fines and imprisonment for knowing
violations as well as a report being made to my professional board.
Cover Page 1 11:19 AM 9/5/2017

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WETPOND DaVita Spencer
THE'DRAINAGE AREA
Drainage area number -
1
Break down of BUA in the drainage area both new and existing):
Total coastal wetlands area (sq ft)
at
- Parking / dnveway (art ft)
29574 at
Total surface water area (sq ft)
sf
-Sidewalk (sq It)
2251 at
Total drainage area (sq ft)
97139 at
- Roof (sq ft)
9121 at
RUA associated with existing development (sq ft)
5663 sf
- Roadway (sq M
at
Proposed new BUA (sq ft)
40946 at
- Other, please specify in the comment box below (sq ft)
at
Percent BUA of drainage area
21%
Total BUA aq ft)
40946 sf
COMPLIANCE WITH THE APPLICABLE STORMWATER PROGRAM
Stortnwater pr ram(s) that sops (please specify):
Design rainfall depth (in) 1.0 in
Phase II
Minimum volume re oved (cu ft) 5018 ct
Design volume of SCM ice ft) 8524 cf
GENERAL MDC FROM 02H .3050-
#1 Is the SCM sized to treat the SW ham all surfaces at build -out?
Yes
#7 If applicable, with the SCM be cleaned out after construction Yes
#2 Is the SCM located on or near contaminated soils?
No
#8 Does the mainetenance access comply with General MDC (8)? Yes
#3 What are the side slopes of the SCM (H:V)?
3:1
#9 Does the drainage easement comply with General MDC 9)? Yes
#3 Does the SCM have retaining walls, gabion walls or other engineered side slopes?
No
#10 If the SCM is on a single family lot, does the plat comply with General MDC 10)?
#4 Are the inlets, outlets. and receiving stream protected from erosion (10-year storm)?
Yes
#11 Is there an O&M Agreement that complies with General MDC 11)? Yes
#5 Is there a a bypass for flours in excess of the design flow?
Yes
#12 Is there an 08M Plan that complies with General MDC (12)? Yes
#6 What is the method for dewatenng the SCM for maintenance?
Drawdown Onfice
#13 Was the SCM designed by an NC licensed professional? Yes
WET POND MDC FROM 021-1.1053
#1 Method used
SA(DA
#6 W don of the vegetated shelf (feet)
loft
#1 Surface area of Me main permanent pool (square feet)
5660 sf
#6 Location of vegetated shelf
Q Normal Pool
#1 Volume of the main permanent pool (cubic feet)
13179 cf
#6 Elevafion of top of shelf (tress)
737 ft
#2 Average depth of the main pool (feet)
3 ft
#6 Elevation of bottom of shelf fmsl)
736 ft
#2 Was Me vegetated! shelf included in the calculation of average tlepth?
Yes
#6 Slope of vegetated shelf (H:V)
10:1
#2 Elevation of the bottom of the permanent pool hasp
732 If
#7 Diameter of drawdown orifice (inches)
1.0 in
#2 Elevation of Me top of Me permanent pool fmsl
737 ft
#7 Drawdown time for the temporary pool hours)
52 hrs
#2 Elevation of Me top of Me tempos pool Imsp
738 If
#7 Does Me orifice drawdown from below Me top surface of Me permanent peal?
No
#3 Depth provided for sediment storage (inches)
12 in
#8 Does Me pond minimize impacts to the receiving channel from the 1-yr, 24-hr storm?
Yes
#4 Are Me ialet(s and outlet located in a manner that avoids shodcmad ng?
Yes
#9 Are fountains proposed?
No
#4 Describe any measures, such as berms or baffles, Mat will be taken to improve the flow path:
#9 If yes, is documentation provided per Wet Pond MDC (9)?
Storm Drain inlets into pond on opposite side of Me outlet structure. In addition a Stone Baffle Just Below Nroma Pool
910 Is a (rash rack or other device provided to protect Me outlet system?
Yes
#5 Volume of the foreba (cubic feet) 1 2375
#11 Are the dam and embankment planted in non -clumping turf grass?
Yes
#5 Is this 15-20% of Me volume in the main pool? Yes
#11 Species of turf Mat will be used on Me dam and embankment
Fescue or Bermuda
#5 Depth of forethay at entrance (inches) 24 in
#11 Describe the planting plan for the vegetated shelf:
#5 Depth of forelpay at exit (inches) 60 in
#5 Does water flow out of the foreba in a non -erosive manner?Yes
#5 Clean -out depth for foreba (inches) 12 in
#5 Will Me tomboy be cleaned out when Me depth is reduced to less than Me above? Yes
ADDITIONAL INFORMATION
Please use this space to provide any additional information about this wet pond that you think is relevant to Me review:
Wet Pond 2 11:19 AM 9/5/2017

& Maintenance A
Project Name:
Project Location:
DaVita Spencer
Spencer NC
Maintenance records shall be kept on the following BMP(s). This maintenance record shall be kept in a log in a known set
location. Any deficient BMP elements noted in the inspection will be corrected, repaired, or replaced immediately. These
deficiencies can affect the integrity of structures, safety of the public, and the pollutant removal efficiency of the BMP(s).
The BMP(s) on this project include (check all that e
Bioretention Cell
Dry Detention Basin
Grassed Swale
Green Roof
Infiltration Basin
Infiltration Trench
Level SpreaderNFS
Permeable Pavement
Proprietary System
Rainwater Harvesting
Sand Filter
Stormwater Wetland
Wet Detention Basin
Disconnected Impervious Area
User Defined BMP
O&M tables wi
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
I acknowledge and agree by my signature below that I am responsible for the performance of the maintenance procedures listed
for each BMP above, and attached O&M tables. I agree to notify NCDENR of any problems with the system or prior to any
changes to the system or responsible party.
- Responsible Party:
Title & Organization:
Street address:
City, state, zip:
Phone number(s):
Email:
Mr. Robert Lan don
RHGC Spencer, LLC
223 Hwy 70 East Pointe, Suite 100
Garner NC 27529
919.662-1001
[e-mail]
Signa q�Q 2�lii Date: 9�5'
1, , a Notary Public for the State of A no
County of �� , do hearby certify that �14( ` Ls9���
personally appeared before me this S day of /JG L Xe,, 2017 and
acknowledge the due execution of the.,.,O0��pJp���r//r��Nt1ons andd Ma�iinttena cp Agreement .
Witness my.hand and official seal, �j97r,.�4 L: /�s2C.(r<x.
HptWy Public
f1cown County ut
commlulo
1112612011 W
r .? .
°PJN CAa°`
1.4
My commission expires 11-24 -17
BrMO17
Page 1 of 5

I Wet Detention Pond Maintenance Requirements
The wet detention basin system is defined as the wet detention basin, pretreatment including forebays and the vegetated filter if
one is provided.
Important maintenance procedures:
_ Immediately after the wet detention basin is established, the plants on the vegetated shelf and perimeter of the
basin should be watered twice weekly if needed, until the plants become established (commonly six weeks).
_ No portion of the wet detention pond should be fertilized after the first initial fertilization that is required to
establish the plants on the vegetated shelf.
_ Stable groundcover should be maintained in the drainage area to reduce the sediment load to the wet detention
basin.
_ If the basin must be drained for an emergency or to perform maintenance, the flushing of sediment through the
emergency drain should be minimized to the maximum extent practical.
- Once a year, a dam safety expert should inspect the embankment.
After the wet detention pond is established, it should be inspected once a month and within 24 hours after every storm event
greater than 1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance should be its in a
known set location and must be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately.
BMP element:
Potential problem:
How I will remediate the problem:
The entire BMP
Trash/debris is present.
Remove the trashldebris.
The perimeter of the BMP
Areas of bare soil and/or
Regrade the soil if necessary to remove the gully, and then plant a
erosive gullies have formed.
ground cover and water until it is established. Provide lime and a one-
time fertilizer application.
Vegetation is too short or too
Maintain vegetation at a height of approximately six inches.
long.
The Inlet device
The pipe is clogged.
Unclog the pipe. Dispose of the sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the swale if necessary to smooth it over and provide erosion
swale.
control devices such as reinforced turf matting or riprap to avoid future
problems with erosion.
Stone verge is clogged or
Remove sediment and replace with clean stone.
covered in sediment (if
applicable).
The forebay
Sediment has accumulated to
Search for the source of the sediment and remedy the problem if
a depth greater than the
possible. Remove the sediment and dispose of it in a location where it
original design depth for
will not cause impacts to streams or the BMP.
sediment storage.
Erosion has occurred.
Provide additional erosion protection such as reinforced turf matting or
riprap if needed to prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by hand. If pesticide is used, wipe it an
the plants rather than spraying.
The vegetated shelf
Best professional practices
Prune according to best professional practices
show that pruning is needed
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the problem: soils, hydrology, disease, etc.
dying.
Remedy the problem and replace plants. Provide a one-time fertilizer
application to establish the ground cover if a soil test indicates it is
necessary.
Weeds are present.
Remove the weeds, preferably by hand. If pesticide is used, wipe it o
the plants rather than spraying.
STORM-Pl 8/212017
Version 1.4 O&M Manual Page 3 of 5

t Wet Detention Pond Maintenance Regwrements (Continued) 1
The main treatment area
Sediment has accumulated to
Search for the source of the sediment and remedy the problem if
a depth greater than the
possible. Remove the sediment and dispose of it in a location where it
original design sediment
will not cause impacts to streams or the BMP.
storage depth.
Algal growth covers over 50%
Consult a professional to remove and control the algal growth.
of the area.
Cattails, phragmites or other
Remove the plants by wiping them with pesticide (do not spray).
invasive plants cover 50% of
the basin surface.
The embankment
Shrubs have started to grow
Remove shrubs immediately.
on the embankment.
Evidence of muskrat or
Use traps to remove muskrats and consult a professional to remove
beaver activity is present.
beavers.
A tree has started to grow on
Consult a dam safety specialist to remove the tree.
the embankment.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair. (if applicable)
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the local NC Department of Environment and Natural
damage have occurred at the
Resources Regional Office.
outlet.
The measuring device used to determine the sediment elevation shall be such that it will give an accurate depth reading and not
readily penetrate into accumulated sediments.
STORM•EZ a2201I
Jersion 1.4 O&M Manual Page 4 or 5

I Wet Detention Pond Desian Summary I
Wet Pond Dlaarem
WET POND ID
Wei Pond No 1
FOREBAY
MAIN POND
Permanent Pool El.
Permanent Pool El.
736.5
Temporary Pool EI:
Temporary Pool El:
737.75
Pretreatment other
Clean Out Depth:
RN
Clean Out Depth:
q.5
than forebay?
I:H
Sediment Removal El:
Sediment Removal El:
732
Has Veg. Filter? No
Bottom Elevation:
Bottom Elevation:
731
STORM-EZ 8/2/2017
✓ersion 1.4 O&M Manual Page 5 of 5

WET POND
DaVita Spencer
THE DRAINAGEAREA'
1
Dralrape area rarer
i 1
Break Mown of BUA in the drairung. area lboth new and existing):
Total coislal wednila arealw 4)
M
-PaM1og/dnveway(so al
29574 sf
Talal wlfaCe wane area(a, rt)
sl
- SiMawalk(eo a)
i251el
Total droma9u area('e n)
97139s1
-Roof(W e)
9121 s1
BUA essoanted won a.=, aM elapmenl Iw III
5663 sf
. Roadway lea 4t
at
Propossea new BUA (w III
40946 sI
-Omel, please speak kl me OOMMWO t pee below I'g 4)
at
Pertain BUA of trdnage area
i 21%
Total BUA pp rt)
( 409a6 el
COMPLIANCE WITH THE APPLICABLE STORMWATER PROGRAM
Sldnlwatd s)UtM all (laaaa.sped
Devgn rainfall Modi(in)
i 1.0IS
Phase 11
Mdmurn solurre roamed Iw rtl
i Will d
peagn vollme of SCM (w M)
i 8524 d
GENERAL MDC FROM ON 1050
a1 Is mte SCM elaod to Omat me SW horn all surfaces y land.17
i Yea
a? M appor le. wM m SCM to demred do attd cottsplcpon?
Yes
92 Is ma SCM IKalea an or Ma mmammataM inat?
i No
06 DOIa ma rrmMMunce xseeb wim Gme!W MDC 9r!
Yee
a3 Ydat are Ore We mopes of me SCM IH.VT?
3:1
a9 Does me &2WQQ0 easement 00I win Gonna, MDC 9?
i YW
sG Don Me SCM nave reeuen walls, gation. walk or nine, an rend ildo slopes?
i NO
010 lift SCM is ten a le lardl Id -deaf Me - al,om w 0 (neneal MDC 00)?
i
b Are me ldeW, pudel3, and rppmwrp,Maan Pretpcled hem w06ibn (19-yea! itpltlll?
i Yes
all is mine an OSM A MM mat LCmpina Wpm Csen MDC 111)?
i Yale
a5 Is mere e a bypass br lmra in stews of me deelgn aow?
i Yea
012 is mere an OAM PWn m01 cnnpkn with General MOC (12)?
i Yro
RB Wnm W me memoo for dew Me SC,1 W MMnenmtce?
i Orawddwn On5ro
013 Was ere SCM designed by an NC acenyted arolasslenal?
i Yea
WET POND MDC FROM O2N .1053
at MelndMused
i SADA
a6 WgmdNe salad srdl hell
i Ica
at Swan area ell ee main petnanent pod aguma fedl
5660 sl
a6 L w of WIea spelt
i @ Normal Pod
a1 Volume of me mums lelnanant pad[OLIO: fed)
131?9ot
06 Elenmonole olmolfiM1tW)
i ?37n
0 Average dlpm of the mart pool ifeen
3 a
a6 FJevabon al aonom d Snell lMrW 1
i 736 a
92 Was mo veFmtw shelf nc wed in Me calwlaaan d average depm?
i Yes
96 Slope of vegetmem, Snell (H:V)
i 10:1
a2 FJeranan d Mro bosom d ins naa hint
i 732 A
a? Dlemeld Of mewilwn onece fncrwnn
1.0In
92 Eilevalldn of We lop of me pemWneN pout (final)
i 7370
te? Drewrlown pine W me lempore nWR)
52 Ns
92 Elevmnn of men al me impomry poon (ansl)
73a 4
a? Doe, de one. Orawdavn Mani below me top surfxe of Ma pannarom pool?
i No
a3 Depot nnwillecl lor sManem smra Inctles
i 12 in
a6 0. the pail minlmixe imp.m to me receiving channel Man me 1-yr, 2441r stone?
i Yes
04 Are andnOOV.)ale eudet located m a manna mat avoios enpn-Cvctk ?
Yes
a9 Are fonlan" pral"Mad?
i No
a4 Detonate anymeawtn. well as banns ter Eaftna, mat wW W Wken IO improve me flaw am:
M 1f yes, n Mdwmbnaban prewded per Wet Portl IjDC (9)?
i
nine Drain "M kee pond an oppolow side of me MAN,'bltpare. In add'Mon a Stoll Bame tual Below W. Paai
910 ls e Mean nick or olnd dawte provided ro orptact de dmet eystam7
Yea
a5 Vdlae of Me bread plod: tell
2375
all Are me oam and emaaMmant pone W nonrJumping NM grade?
Yes
a5 Is M. 15-20%Of the whams in me main pod?
i Yes
.11 Soodea al lW dal wa il ldM an the dam antl EmaanFmant
i Fesate d Bemum
0 Deem d fereba al andante fleas,)
i 24 m
all Dosrnbp mo pldnang pan for mC vegeldtod sndl:
95 Down of brenov al e+M(Mrmesl
i 60M
tl5 Goes worm sow out Of ale been in a ngmerpsrva rtlamart i Yes
45 Cjwnaut dam fer lorooa (terns') i 12 e
0 Wm the forebay W aeaneo ON wren me Mepm is remtoed to ass pan me ammo? ) Yes
ADDITIONAL INFORMATION
%eaeo u5a Otis space to denote any oddgonal bomaam aaota Ma, wee Pena Mat yoO pink ie re,,o, a ma renew:
Wet Pond 2 11:19 AM 9/5/2017

SUPPLEMENT-EZ FORM COVER PAGE
Please indicate the types, quantities and locations of SCMs that will be used on this projer :
Quantity I Locations)
Infiltration System
Sioretention Cell ! !
Wet Pon 1 I
Stormwater Welland I
Permeable Pavement ' -
Sand Filler
Rainwater Harvesting I _
Green Roof j
Level Spreader -Filler Strip i
Disconnected Impervious Surface I
Treatment Swale I
Dry Pond II
Designer information for this project:
Name an Title:
Mad Johnson, PE Civil Engineer
Organization:
'Triad Design Group
Street address:
4807-C Koger Blvd
City. State, Zip:
iGreensbom NC 27407
Phone numbeds):
:336-216$282
Email:
[e-mail]
SEAL
30521
`Fn'GINEEP�
Smon
igna Designer
'110.611 }
Dates
Applicant:
Project D
DaV'da Spencer
Address
1287 N Salisbury Ave
C !Town
Spencer NC
Company:
IRHGC Spencer LLC
Contact:
.Mr. Robert Langdon
Mailing Address:
223 Hwy 70 East Pointe. Suite 100
City State. Zip:
(Gamer NC 27529
Phone number(s): I919-582-1001
Email:
Certification Statement:
I certity, under penalty of law. that this Supplement-EZ form and all supporting
information were prepared under my direction or supervision:
- that the information provided in the torn is, to the best of my knowledge
an belief. we, accurate, an complete: and
that the engineering plans, specifications. operation and maintenance
agreements and other supporting information are consistent with
the information provided here.
I am aware that there are significant penalties for submitting false
information including the possibility of fines and imprisonment for knowing
violations as well as a report being made to my professional board.
Cover Page 1 11:19 AM 915/2017