SW4160401_CURRENT PERMIT_20160509

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO. SW
DOC TYPE CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE IQ1z
YYYYM M D D

Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
May 9, 2016
Mr. Daniel Barnes
Crown Lexington Development, LLC
121 N. Crutchfield Street
Dobson, North Carolina 27017
Subject: Stormwater Permit No. SW4160401
PetSmart, Lexington NC in Davidson County
Dear Mr. Barnes:
PAT MCCRORY
Corer..'
DONALD R. VAN DER VAART
Semwt
TRACY DAVIS
NC Department of
Environmental Quality
Received
MAY 11 2016
Winston-Salem
Regional Office
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on May 9, 2016. 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 Section NCAC 2H.1000. We are forwarding Permit No. SW4160401, dated May 9,
2016, for the construction, operation and maintenance of the subject project and the stormwater system.
This permit shall be effective from the date of issuance until May 8, 2024, or until rescinded and shall be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.
This project will be kept on file at the Winston-Salem Regional Office. If you have any questions, or
need additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely,
for Tracy E. Davis, PE, CPM, Director
cc: SW4160401 File, Winston-Salem Regional Office
cc: Channin Bennett, P.E. MLA Design Group, Inc.
Slate of North Carolina I Environmental Quality I Energy, Mineral and land Resources
1612 Mail service Center I Raleigh, North Carolina 27699-1612
919-507-6375

,,'y I ! I "if
0 A i—
tIGMt.Urr
Ll7Ali,GLI;,WGci;

STATE OF NORTH CAROLINA
State Stormwater Permit
Permit No. SW4160401
NC Department of
Environment
l Quality
Receiv
DEPARTMENT OF ENVIRONMENT QUALITY
STATE STORMWATER MANAGEMENT PERMIT
MAY 1 1 20%
Winston-Salem
Regional Office
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
Crown Lexington Development, LLC
PetSmart, Lexington NC in Davidson County
FOR THE
construction, operation and maintenance of one sand filter in compliance with the
provisions of 15A NCAC 2H .1000 (hereafter referred to as the "stormwater rules') and the
approved stormwater management plans and specifications and other supporting data as
attached and 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 May 8, 2024, 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 sand filter 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 sand filter.
5. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
Page 1 of 4

State Stormwater Permit
Permit No. SW4160401
It) 109(rdltrigQ ,)Li
it,l ILtSCHEDUL-Ef0 F COMPLIANCE
b iias9'9
%1 Cf 4Dheri y consulern will ti repaired, ero erosion
kept to a minimum and any eroded areas of a
2..' , The permittee shall at all time provide the operation and maintenance necessary to
'JIM0 Irass7ure the sand filter permitted functions at optimum efficiency. The approved
Operation and Maintenance Plan must be followed in its entirety and maintenance
must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing 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 permitted sand filter. 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 each of the sand filter. The report shall summarize the
inspection dates, results of the inspections, and the maintenance work performed at
each inspection.
5. The sand filter shall be constructed in accordance with the approved plans and
specifications, the conditions of this permit, and with other supporting data.
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 sand filter certifying that the permitted facility has
been installed in accordance with this permit, the approved plans and specifications,
and other supporting documentation. Any deviations from the approved plans and
specifications must be noted on the Certification. A modification may be required for
those deviations.
7. If the stormwater system was used as an Erosion Control device, it must be restored
to design condition prior to operation as a stormwater treatment device, and prior to
occupancy of the facility.
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.
Page 2 of 4

State Stormwater Permit
Permit No. SW4160401
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
have been made.
III. GENERAL CONDITIONS
1. 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 sigred'by both parties; t6 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. SW4160401
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 9th day of May, 2016.
for Tracy E. Davis, P.E., CPM
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW4160401
Crown Lexington Development, LLC
PetSmart, Lexington NC in Davidson
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
cc: NCO-DEMLR Regional Office
SEAL
Page 1 of 1

i DEMLR USE ONLY
' Date Received
f Fee P. 'd
P it b r
1
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph 11- Post Constr ction
(select all that apply) ❑ Non-CoastalSW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina N C Department of
Environmental Quality ,
Department of Environment and Natural Resources Received
Division of Energy, Mineral and Land Resources APR 2 9 2016
STORMWATER MANAGEMENT PERMIT APPLICATION ,:9'ORWis
nston-Salem `•'S'
This form may be photocopied for use as an original
Regional Office
1. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent,u ith m.ect name on plans,
specifications, letters, operation and maintenance agreements, etc.): HEClE VV ER
PetSmart .t,l t U
2. Location of Project (street address):
City:Lexington County:Davidson
DENR-LAND QUALITY
of
ality
3. Directions to project (from nearest major intersection):
Approximately 400 feeet East of the intersection of Cotton Grove Road and Lowes Boulevard. MAY t 1 2016
Winston-Salem
Regional Office
4. Latitude:35° 47' 28.78" N Longitude:80° 15' 39.25" W of the main entrance to the project.
IL PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificatiiont
tRenemals with modifications also requires SWU-102 - Renewal 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
2. Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite 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):
❑CAMA Major
®Seclimentation/Erosion Control: 1.87 ac of Disturbed Area
❑NPDES Industrial Stormwater 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:
5. Is the project located within 5 miles of a public airport? ZJ<No ❑Ye:
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr.org/web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page I of

({trnlfllJal Ii�++�''
p�d�ll.bl:
�nnrn�un�ut'�1 (3r,yli(,''
MC
N VPIVI.�:il VU.ICIJ
A,1111G1a
SG; CIACq
t-Gml.nuwG6(91 LSns; '
IAC Or,baLru-su(o!

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 proiect):
Applicant/Organization: Crown Lexington Devleopment, LLC
Signing Official & Title:Daniel Barnes, Principal
b.Contact information for person listed in item la above:
Street Address:121 N. Crutchfield Street
City:Dobson State:NC Zip:27017
Mailing Address (ifapplicable):PO Box 341
City:Dobson State:NC Zip:27017
Phone: (336 ) 386-9790 Fax: (336 ) 386-9785
Email:danielb©crown-companies.com
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: Lexington Development Co LLC
Signing Official & Title: U:�,A-iD L— M1 co" — MA A10,4isAf%- ^ df
b. Contact information for person listed in item 2a above
Street Address:1250 Springfield Suite 200
City:Cincinnati State:OH Zip:45215
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
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: Stab
Phone: ( ) Fax:
4. Local jurisdiction for building permits: Davidson County
Point of Contact Beau Chollett Phone k: (336 ) 242-2239
FormSWU-101 Version Oct. 31,. 2013 Page 2of6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The stormwater will be treated in the proposed above ground sandfilter which provides the necessary surface
area and infiltration to remove 85% of the TSS generated from the post developed site.
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 Yadkin- Pee Dee River basin.
4. Total Property Area: 1.74 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': 1.74 acres
Total project Wren shall be calculated to exclude the follotningg the rmrrual pool of imppounded structures, Ore area
betneen the barks of st reams and rivers, the area below the Norrual Il�ig�lh Water (NHW) line or Metal High !Water
(MHW) line, and coastal wetlands landioard from flit, NHW (or MHW) line. The resultant project area is used to
culcalale overall percent built upon area (BUA). Non -coastal wetlands Inurdtoard of the NHW (or MHW) line pray
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 83 %
9. I -low many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
sloruanater BMP. For Iota density and other projects, use 1 for flit, 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
Abbotts Creek
Stream Class *
C
Stream Index Number *
12-119-(6)
Total Drainage Area (so
60,496
On -site Drainage Area (so
56,664
Off -site Drainage Area (so
3,832
Proposed Impervious Area*" (so
46,191
% Impervious Area** total
76
Impervious** Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area
On -site Buildings/Lots (so
18,159
On -site Streets (so
0
On -site Parking (so
20,639
On -site Sidewalks (so
1,795
Other on -site (so
1,595
Future(so
0
Off -site (so
85
Existing BUA*** (so
3,918
Total (so:
46,191
" Stream Class and Index Nurrrber can be determined at Ir�r://uortnl.ncdenr.ore/taebftoq/ps/csrdclussificnfious
Ila�ervious area is defined as flue built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 oft,

***Report only that mnount of existing BUA that Will remain after rfenelopinent. Do not report any existing BUA flint
is to be removed aad vohicb will be replaced by new BLIA.
11. How was the off -site impervious area listed above determined? Provide documentation. See sheet C-5 for
proposed sidewalk connection to existing sidewalk
Pro meets in Union County: Contact UF.MLR Central Office staff to check if the project is located irithin a Threatened k
Endangered Species watershed that malt, be subject to more stringent slor»nrater requirements as per 15A NOI C 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 htti2://i2ortal.iicdeiir.ory_/web/wg/w,s/su/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
http://portal.iicdeiir.org/web/w9/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. fhe appropriate office may be found by locating project on the
interactive online map at httu://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 httLl://portal.ncdeiir.orr/web/wq/ws/sti/statesw/forms does.
Initials
1. Original andone copy of the Stormwater Management Permit Application Form. tf
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.eiivhelp.ory/12ages/oiiestopexpress.litiiil 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'/z mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5 x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
c. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
Form SWU-101 Version Oct. 31. 2013 Page 4 o1'6

m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications anti 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 SI-IWT 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 8.5xl 1" copy of the NRCS County Soils map with the
project area clearly delineated. Por 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: Scbedide a site visit for DEMLR to verifij the SHWA prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: SOko Page No: HC(o F
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 1 a, 2a, and/or 3a per 15A NCAC 21-1.1003(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.
httD: / /www.secret,,irv.state.nc.us/CorLioration-q/CSeai-cli.ast)x
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 littki://Ilortiii.iicLienr.org/web/ir/stite-sttlrtiiwater-
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.
VILL 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 EngineerChannin FI Bennett, P.E.
Consulting Firm: MLA Design Group, Inc
Mailing Address:120 Club Oaks Court Suite 100
City:Winston Salem State:NC Zip:27104
Phone: (336 ) 765-1923 Fax: ( )
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
Section) a�.J' ✓'P L- n 0
1, (print or type name of person listed in Contact Ltforrmntimn, items 2m) 5 e � ,rao certify that I
own the property identified in this permit application, and thus give permission o (print or type tame of person
listed in Contact Information, item le) Daniel Barnes with (print or type mane oforg tizntion listed in
Contact Information, itetm lei) Crown Lexington Development, LLC to develop the project as cur ntly proposed. A
copy of the lease agreement or pending property sales contract has been provided with the so ittal, which
indicates the party responsible for the operation and maintenance of the stormwater system.
r
Porn SWU-101 Version Oct. 31. 2013 Page 5 uf6 M4," 04'k.,i

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 DEMI..R 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 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.
2/
Date: -/ /? Jt
I, LU�,. �i �/P�2— /Y/'*�p'�r�/ , a Notary Public for the State of &Ite., County of
I, - /
do hereby certify that .��/4� personally appeared
before me this 7May of O /6 , and a t o ledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, /,l lgIe
...munpupn,.
SEAL
Sheri Vee Draft
Notafy Pubk Sate of No
My COMUM EOw1QM9
My commission expires /D 'o? 0 —.2 ZP / i
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item la) Daniel Barites
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 rulers under 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Date
1, �¢nni� N �GfLirl2� —a Notary Public for the State of N C . County of
do hereby certify that 1 kl(\IP []GI,(ley personally appeared
before me tl is I V�day of Tf' I , ZOi(o . and cknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
`rnu utt tt
N. Gg9O.:
\0TAq)_ Rom;
=N AVBLIG C)
SEAL
My commission expires
FormSWU-101 Version Oct. 31,2013 Page 6of6

crvk'

Permit Number
uo be provided by DWQ)
NCDENR;
69Cl' 17. & iyml aaI&GI[6P1161:181
401 CERTIFICATION APPLICATION FORM
SAND FILTER SUPPLEMENT
This form must be filled out on line, printed and submitted with all of the required information.
Make sure to also fill out and submit the Required Items Checklist (Section lll) and the l&MAgreement (Section 10
Project name
Contact name
Phone number
Date
Drainage area number
II. DESIGNINFORMATION
Site Characteristics
H. Bennett, P.E.
Drainage area (AD)
60,287.00 ft2
Impervious area
1 45,912.001ft2
% Impervious jI
76.2% %
Design rainfall depth (Re)
I 1.001m
Peak Flow Calculations
1-yr, 24-hr runoff depth
1 2.80 lin
1-yr, 24-hr intensity
1 0.12 lin/hr
Pre -development 1-yr, 24-hr runoff
1 0.03 lft'/sec
Post -development 1-yr, 24-hr runoff
1 0.03 lft'/sec
Pre/Post 1-yr, 24-hr peak control
0.00 ft'/sec
Storage Volume
Design volume (WQV)
3,681.00 ft'
Adjusted water quality volume (WQV,I)
2,760.75 ft'
Volume contained in the sedimentation basin and on lop of the sand filter
1 3,940DOIft'
Top of sand filter/grate elevation
I 782.75 Ift amsl
Weir elevation (between chambers)
I 780.5 Ift amsl
Maximum head on the sedimentation basin and sand filter (h,,e,,,)
1 2.251ft
Average head on the sedimentation basin and sand filter (h,)
1 1.131ft
Runoff Coefficient (Rv)
0.74 (unitless)
Type of Sand Filter
Open sand filter?
SHWT elevation
Bottom of the sand filter elevation
Clearance (dsHwr)
Closed/precast sand filter?
SHWT elevation
Bottom of the sand filler elevation
Clearance (dsr )
If this is a closed, underground closed sand filter: The clearance between
the surface of the sand filter and the bottom of the roof of the underground
I y
I Y or N
amsl
amsl
I Y or N
Ift amsl
Ift amsl
1
fit
1 772.001ft
1 778.00Ift
1 6.001
I n
I
I
I
structure (ds�)
OK NC Department of
Environmental Quality
Received
MAY 1 1 2016
Winston-Salem
Regional Office
OK
OK
Ensure that the average is half of the max.
Form SW401-Sand Filler-Rev.5 2009Sept17 Parts I and II. Project Design Summary, Page 1 of 2

N4Q i i SOX
gecc;rn:;a
UAIlODU1S6;yj j-,wipit,
A Dehyuulaur. of

Permit Number:
(to be provided by DWQ)
Sedimentation Basin
Surface area of sedimentation basin (As)
Sedimentation basin/chamber depth
Sand Filter
Surface area of sand filler (AF)
Top of sand media filter bed elevation
Bottom of sand media filter bed/drain elevation
Depth of the sand media filter bed (dF)
Coefficient of permeability for the sand filter (k)
Outlet diameter
Outlet dischargeBlowrate
Time to drain the sand filter (t)
Time to drain the sand filter (t)
Additional Information
Does volume in excess of the design volume bypass the sand filter?
Is an off-line flow -splitting device used?
If draining to SA waters: Does volume in excess of the design volume flow
evenly distributed through a vegetated filter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
Is the BMP located at least 30ft from surface waters (50ft if SA waters)?
If not a closed bottom, is BMP located at least t00ft from water supply wells?
Are the vegetated side slopes equal to or less than 3:1
Is the BMP located in a recorded drainage easement with a recorded access
easement to a public Right of Way (ROW)?
What is the width of the sedimentation chamberflorebay (Ww)?
What is the depth of sand over the outlet pipe (dpipe)?
1 674.00jft2
) 1.00 ft
674.00Ift2
1 780.501 ft amsl
1 779.001 ft amsl
1.50 ft
3.50(fYday)
I 1.001in
( 0.0310sec
39.0211 hours
1.63 days
Y or
Y or
Im,
VI\. IVI=b II I u III I I Ul I I, JUL IIIdy IIUUU fu UU alPtldbbU IU
--- ,.,;_ n... ....A... c,....,...,
VIN. IMUL5 IIII IIIII I UI I I, UUI IIIdy IICtlU lu UU II IUItldSCU W
nn.J..;- r6n .n....:—A ...J..mn :( n..n...ndn. ol----
OK. Submit drainage calculations.
OK
OK
Excess volume must pass through filter.
Y or N
Show how flow is evenly distributed.
Y or
OK
YorN
Y or
OK
YorN OK
OK
OK
Form SW401-Sand Filler-Rev.5 2009Sept17 Parts I and II. Project Design Summary, Page 2 of 2

Permit No.
(to be provided by DWQ)
1111. REQUIRED ITEMS CHECKLIST _
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An incomplete submittal
package will result in a request for additional information. This will delay final review and approval of the project. Initial
in the space provided to indicate the following design requirements have been met, If the applicant has designated an agent,
the agent may initial below. If a requirement has not been met, attach justification.
Initials Pagel Plan
Sheet No.
co(
C<.
I
C�
CS
1, Plans (1" - 50' or larger) of the entire site with labeled drainage area boundaries
- System dimensions (length, width, and depth) for both the sedimentation chamber and the filter
chamber,
- Maintenance access,
- Flow splitting device,
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Off -site drainage (if applicable), and
- Boundaries of drainage easement,
2, Plan details (1" = 30' or larger) for the sand filter showing:
- System dimensions (length, width, and depth) for both the sedimentation chamber and the filler
chamber,
- Maintenance access,
- Flow splitting device,
- Vegetative filter strip dimensions and slope (if SA waters),
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Off -site drainage (if applicable), and
- Boundaries of drainage easement.
C3. Section view of the sand filter (1" = 20' or larger) showing:
C� Depth(s) of the sedimentation chamber and sand filter chamber,
Depth of sand filter media,
- Connection between the sedimentation chamber and the sand filter chamber and weir elevation,
- SHWT elevation,
- Outlet pipe, and
- Clearance from the surface of the sand filter to the bottom of the roof of the underground structure (if
applicable).
4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWO, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
P It Ti 5. Supporting calculations (including drainage calculations)
6. Signed and notarized operation and maintenance (0&M) agreement
7. A copy of the deed restrictions (if required).
Form SW401-Sand Filter-Rev.5 2009Septl7 Part III, Page 1 of 1

: : .
�
}3 �
: »
2%
#n� 7:
�3 t
<2 '
�
a i «

Project Name: I PetSmart
Project Location: I Lexington
Maintenance records shall be kept on the following HMN(s). I his maintenance record shall be kept in a log in a known set locatic
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 & cc
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:
Disconnected Impervious Area
Present:
User Defined BMP
Present:
O&M tables
Location(s):
Location(s):
Location(s):
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:
Daniel Barnes
Crown Lexington Development, LLC
121 N. Crutchfield Street
Dobson, INC 27017
336-386-9790 (office) , 336-429-0005 (cell)
[e-mail]
Signature: �' JO Date:�
I, a Notary Public for the State of IBC
County of Suc V do hearby certify that
personally appeared before me this �'th day of TI Zo (.0 and
acknowledge the due execution oft perations and M/alJ;Itenanncp Agreement .
Witness my hand and official seal, r ' • AAdAAA NC Department of
Environmental quality
N G,' I, Received
Z �GTA9 �R
CP
G
G"
APR 2 9 2016
Winston-Salem
r Regional Office
Seal •',, ���r��` My commission expires
STORM-EZ r""" 4/5/2016
Version 1 A 08M Manual Page 1 of 2

nr; �r•r�u ?:j',w
� J.1fLUU�I, ,.105, �jf,9�;t7

I Sand Filter Maintenance Requirements I
Important maintenance procedures:
- The drainage area will be carefully managed to reduce the sediment load to the sand filter.
- The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds six inches.
- Once a year, sand media will be skimmed.
- The sand filter media will be replaced whenever it fails to function properly after maintenance.
The sand filter shall be inspected quarterly 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 will be kept in a known set location and will 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 to remediate the problem:
Entire BMP
Trash/debris is present.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as possible.
applicable)
pavement surface.
Perimeter of sand filter
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 an appropriate height.
long.
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if damage is too large for
repair.
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).
Forebay or pretreatment
Sediment has accumulated to
Search for the source of the sediment and remedy the problem if
area
a depth of greater than six
inches.
possible. Remove the sediment and stabilize or dispose of it in a
location where it will not cause impacts to streams or the BMP.
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 a pesticide is used, wipe it
on the plants rather than spraying.
Filter bed and underdrain
Water is ponding on the
Check to see if the collector system is clogged and flush if necessary.
collection system
surface for more than 24
If water still ponds, remove the top few inches of filter bed media and
hours after a storm.
replace. If water still ponds, then consult an expert.
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.
water
Erosion or other signs of
Contact the local NC Department of Environment and Natural
receiving
damage have occurred at the
Resources Regional Office.
outlet.
STORM-EZ 4/5/2016
Version 1.4 O&M Manual Page 2 of 2

High Density Commercial Subdivisions
Deed Restrictions & Protective Convenances
In accordance with Title 15 NCAC 2H.1000 and S.L. 2006-246, the Management Regulations, deed
restrictions and protective covenants are required for High Density Commercial Subdivisions where
lots will be subdivided and sold and runoff will be treated in an engineered stormwater control facility.
Deed restrictions and protective covenants are necessary to ensure that the development maintains a
built -upon area consistent with the design criteria used to size the stormwater control facility.
�/} U/ Ll L. /Y2D✓,t'S�!/t4' ,�La...-Pvi-�"
I, ✓ /� , acknowledge, affirm and agree by my signature below, that
I wi cause the following d e restrictions and covenants to be recorded prior to the sale of any lot
within the project known as Petsmart — Lowes Boulevard Lexington, NC:
1. The following covenants are intended to ensure ongoing compliance with State Stormwater
Management Permit Number , as issued by the Division of Energy, Mineral
and Land Resources under the Stormwater Management Regulations.
2. The State of North Carolina is made a beneficiary of these covenants to the extent necessary to
maintain compliance with the stormwater management permit.
3. These covenants are to run with the land and be binding on all persons and parties claiming
under them.
4. The covenants pertaining to stormwater may not be altered or rescinded without the express
written consent of the State of North Carolina, Division of Energy, Mineral and Land Resources.
5. Alteration of the drainage as shown on the approved plan may not take place without the
concurrence of the Division of Energy, Mineral and Land Resources.
6. The maximum allowable built -upon area per lot is _63,099 square feet.
*Note: If the BUA per lot varies, please substitute the following statement for the one above and
provide a complete listing of the proposed BUA for each lot:
The maximum built -upon area per lot, in square feet, is as listed below:
Lot # BUA Lot # BUA Lot # BUA Lot # BUA
1 1.06
This allotted amount includes any built -upon area constructed within the lot property boundaries,
and that portion of the right-of-way between the front lot line and the edge of the pavement. Built
upon area includes, but is not limited to, structures, asphalt, concrete, gravel, brick, stone, slate,
coquina and parking areas, but does not include raised, open wood decking, or the water
surface of swimming pools.
7. All runoff from the built -upon areas on the lot must drain into the permitted system. This may be
accomplished through a variety of means including roof drain gutters which drain to the street,
grading the lot to drain toward the street, or grading perimeter swales to collect the lot runoff
and directing them into a component of the stormwater collection system. Lots that will naturally
drain into the system are not required to provide these additional measures.
8. The owner of each lot, whose ownership is not retained by the permittee, is required to submit a
separate stormwater permit application to the Division of Energy, Mineral and Land Resources
and receive a permit prior to construction.
9. The project and each lot will maintain a 30** foot wide vegetated buffer between all impervious
areas and surface waters.
**50 foot for projects located in the 20 coastal counties.
Form DRPC-1 Rev.2 05Nov2009 Page I of2

High Density Commercial Subdivisions
Deed Restrictions & Protective Convenances
State of
do hereby certify that
a Notary Public in the
County of ,
appeared
before me this the 7 day of 44.3.e.20 //� , and acknowledge
the due execution of the foregoing instrument. Witness my hand and official seal,
SEAL
Signature
My Commission expires /O -z 0 - ;?- 0/ /tom
Notary Rw State of ONO
w Com wm BoN IO.&M19
Form DRPC-1 Rev.2 05Nov2009 Page 2 of 2

� %2SJ
� w� 2 a « 3
� � � � Kw 32
�
<2� � a
ea,%��
��» J
t. d/\
, \� � , /