SW4160501_CURRENT PERMIT_20160927

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO. SW
l�v�l/ r
DOC TYPE CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION. INSPECTION
DOC DATE 2016
YYYYMMDD

r-i�
Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
August 16, 2016
Shahid Chaudhary, Port Owner
4386 New Walkertown Road
Winston Salem, North Carolina 27105
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
TRACY DAVIS
Dirvcmr
NC Department of
Environmental Quality
Received
SEP 2 7 2016
Winston-Salem
Regional Office
Subject: Stormwater Permit No. SW4160501
Discount Auto Parts LLC
Walkertown, Forsyth County
Dear Mr. Chaudhary:
The Stormwater Permitting Unit received a complete package for the Discount Auto Parts on
May 26, 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 NCAC 2H.1000 and
Session Law 2006-246. We are forwarding this Stormwater Management Permit No.
SW4160501, issued August 16, 2016, for the construction, operation and maintenance of the
subject project and the stormwater BMPs.
This permit shall be effective from the date of issuance until August 16, 2024, and shall be
subject to the conditions and limitations as specified therein, and does not supersede any other
agency permit that may be required. Please pay special attention to the conditions listed in this
permit regarding the Operation and Maintenance of the BMP(s), recordation of deed restrictions,
procedures for changes of ownership, transferring the permit, and renewing the permit. Failure
to establish an adequate system for operation and maintenance of the stormwater management
system, to record deed restrictions, to follow the procedures for transfer of the permit, or to
renew the permit, will result in future compliance problems.
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 150E 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.
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
1612 Mail Service Center 1 512 Noah Salisbury Street I Raleigh, NC 27699-1612
919 707 9200 T

't
State Stormwater Permit
Permit No. SW4160501
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
LOW DENSITY DEVELOPMENT
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
Discount Auto Parts, LLC
4386 New Walkertown Road, Walkertown, North Carolina
Cumberland County
FOR THE
construction, operation and maintenance of low density development in compliance with
the provisions of Session Law 2006-246 and 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 Division of Energy, Mineral and Land Resources, Land Quality Section, and
considered a part of this permit.
This permit shall be effective from the date of issuance until August 16, 2024, and shall
be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as shown on the approved site plan for this project, the stormwater
application and all supporting data as referenced in Section 1.7 of this permit. The
stormwater control has been designed to handle the runoff from 31,960 square
feet of impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in Section
1.2 of this permit, and per the application documents and as shown on the
approved plans.
4. 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.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
Page 1 of 6

State Stormwater Permit
Permit No. SW4160501
The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
The design criteria for the low density development can be found on the
approved, stamped and signed site plan for this project and it is incorporated into
this permit by reference and the project stormwater management system must be
maintained at design condition as shown on the approved site plan.
II. SCHEDULE OF COMPLIANCE
The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the completion of the
construction of any built -upon surface and the issuance of any certificate of
occupancy.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system 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.
q. Access to the cell and outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
The permittee shall submit to the Division of Energy, Mineral and Land
Resources, Land Quality Section, an annual summary report of the maintenance
and inspection records for each BMP. The report shall summarize the inspection
dates, results of the inspections, and the maintenance work performed at each
inspection.
The stormwater treatment system 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 system installed 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.
Page 2 of 6

State Stormwater Permit
Permit No. SW4160501
8. 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.
Access to the stormwater facilities shall be maintained via appropriate recorded
easements at all times.
10. 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 or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
11. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. 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
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
Division of Energy, Mineral and. Land Resources, Land Quality Section,
accompanied by the supporting documentation as listed on page 2 of the form.
The approval of this request will be considered on its merits and may or may not
be approved.
The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to transfer the permit.
Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Energy, Mineral
and Land Resources, Land Quality Section, in accordance with North Carolina
General Statute 143-215.6A to 143-215.6C.
Page 3 of 6

ct
State Stormwater Permit
Permit No. SW4160501
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.
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 16th day of August, 2016.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Original Signed by Richard L. Riddle, Jr.
Richard L. Riddle, Jr., Plans Reviewer
for Tracy E. Davis, P.E., Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Page 4 of 6

` DEMLR USE ONLY
Date Received
fee Pai
Pe f tuber
Applicable Rules: ❑ Coastal SW -1995 Coastal SW - 2005 ❑ Ph it - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Storm water 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 far use as an original
1. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
17"sCLOVn-I- I?UfO locrrj-s LLG
2. Location of Project (street address):
/3 e a A/Eu, Cv c I ker 4etwti R oo.d
City: �()a I k r -�2a, iA- County: 1O rS aL Zip: '2. % (O 5
3. Directions to project (from nearest major intersection):
4. Latitude:3/e ° O9 ' ?4l " N Longitude: 90 ° (O ' 35 " W of the main entrance to the project.
It. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ZNew ❑Modification ❑ Renewal w/ Modificationt
tReneteats with modifications also requires SIVU-102 - Renemal Application Forrn
b.if this application is being submitted as the result of a modification to an existing permit, Est 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 Ell-ligh Density ❑Drains to an Offsite Stormwater System ❑Other
.V
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 ®Sedimentation/Erosion Control: loq ac of Disturbed Area
❑NPDES industrial Stonnwater 0404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Nante, Project/Permit Number,
issue date and the type of each permit: �POSiOr1 C'11.10 Grad,'nc�hermftbcas
5. is the project located within 5 miles of a public airport? UNo QQYe:
If yes, see S.L. 2012-200, Part Vi: hMt/112ortal.ncdenr.org/web/Ir/rules-and-regulations
FormSWU-101 Version Oct. 31.2013 Page Iof6

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 orojectl:
Applicant/ Organization:_._ Shahid C%4udhary
Signing Official & Title: s5/Ut, 6 ) d C-11 &U d � ur'
b.Contact information for person listed in item ]a above:
Street Address: 4/ 3 S C� /Ye u., CUa / k ee j--� ,; jt 11�o ac(
City: C01'ne,4dM SCL/em State: %JL Zip: a7/Os
Mailing Address ffapplicable): S'OM& QS' O.h04C.
City. State
Phone: ( 3 36 1 a 9,6— Zo ZO Fax:
Email: -5hc A- i cjnn ) com
Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the 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/Organ
Signing Official & T
b.Contact information for person listed in item 2a above
Street Address: 4/- P�.7 Nr'uJ / //Q I KPr
City: �/f �e ✓� ,SQ �20%1 State: Zip:
Mailing Address (i(npplicable).tr
.a.
City: State: Zip
Phone: ( 1 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
Signing Official &
andct ll G. K 1p-
b.Contact information for person listed in item 3a above:
Mailing Address: 3
State: N G Zip: all O 3'
Form S WU-101 Version Oct. 31. 2013 Page 2 of 7

Phone. (336P 7GE-C-) :;.50
Email: ka(�cN9r c26b U'CCU II'&tt_
J �
4. Local jurisdiction for building permits: r`Ur°s
Point of Contact:
1V. PROJECT INFORMATION
Far: (334- ) 7C,e-- cu2Sl
Phone #:
In the space provided below, briefly summarize how the stormwater runoff will be treated.
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 i'QC>+kiti t ems.'De,-- River basin.
4. Total Property Area: /-(: 00 `7 acres
5. Total Coastal Wetlands Area: tV A acres
6. Total Surface Water Area: Nf? . acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area-: 5/ 00.7 acres
Total project area slrall be calculated to exclude the followingg the normal pool cif -impounded structures, the area
between the banks of streams and rivers, the area beltnv fire Normal High Water (NHIN) line or Mean High Water
(MHIN) line, and coastal wetlands landward from the NHW for MHW) line. The resultant project area is used to
calodate ozrerall percent huilt upon area (BUA). Non -coastal zoetlaads lardarard of the NHIA' (or MHW) lime nand
he included ill fire total Project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = (� • °6
9. How many drainage areas does the project have? I (For high densittl, count 1 for each proposed engineered
storn zoater BMP. For hav density and other projects, use 1 fi>r file whole properh/ area)
10. Complete the followinginfonnation 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 be the same format as below.
Form SWIJ-101 Version Oct. 31. 2013 Page 3 of 7

Basin information -
Drainage Area L
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
(=ra.'ziee Coe
Stream Class *
C
Stream Index Number *
_q '- _6_1
Total Drainage Area (sf)
110.500
On -site Drainage Area (sf)
_ (p 560
Off -site Drainage Area (so
pp
Proposed Impervious Area** s
--J34�
0
% Impervious Area** total
18.1
Impervious** Surface Area
Draina e Area _
Draina e Area _
Draina e Area _
Draina a Area _
On -site Buildings/Lots (so
8,000
On -site Streets (so
cf, j-- o
On -site Parking (so
,SD
On -site Sidewalks (so
Gn
Other on -site (sf),
'
Future (so
Off -site (so
Existing BUA*** (st)
Total (so
1
Strewn Class and Index Number can be determined at: httpj/portaLncde)ir.org/u ebAt?g(ps/csu/classificatious
`* Irmppeeraious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, grnpel areas, etc.
*** Report only that amount of existing BUA that will retmain after development. Do not report any existing BUA that
is to be removed and which will be replaced by mezo BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
Projects in Union County: Contact DEAILR Central Office svafj'io check t(the project is located irithin a Threatened S.
Endm:gered Species watershed thcu menu be subject to more sn•ingent storatmater requirements as per 15.4 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 13MP specified for this project. The latest versions of the forms can be downloaded
from http://portai.ncdenr.ore/web/wq/ws/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). Acomplete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
submitted to the approp
interactive online map at
The complete application package should be
office may be found by locating project on the
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 dots.
hnitials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part Vih 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 pm/able to NCDENR. (For an Express review, refer to
hqp://%%,%N,w.eiivhelp.org/pages/onestopexprLss.htmifor 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.)
Form SWU-101 Version Oct. "1. 201' Pa-e 4 of 7

5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
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 �/2 mile of the site boundary, include the 16,
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, Sr dated), including: _
a. Development/Project name.
b. Engineer and firm,
c. i.ocation map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
I. 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 NTIW) of tidal waters.
i. Dimensioned property/project boundary with hearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
L 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"xl1" copy of the MRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(infiltration Devices submitted to WiRO: Schedule a site visitfir DEMLR to verifij the SMAIT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: Page No: _
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per 15A NCAC 2H.1003(e),
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise.the application will be returned. '
httu: / / www.secretary.sta tL,.nc:us / Comora tions/ CSLarch.as ox
_ y
V11. 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 httu://12ortaLncdenr.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.
Form SWU-101 Version Oct. 31. 2013 Page 5 of 7

VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
COnsultingEngineer: Rondo It G_ Kale,
Consulting Firm:
Mailing Address: 3-55C2 Ve5'71- Mil/
City: Cl/t'n c 7(64 Sa le as7
Phone:
Email: %Q�eer1N@-�lSOU7%/• /IP_-f'
State: NQ- Zip: 2 7/a3
Fax: (336 )761?- fJa,S/
iX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section) / _ / -/_�� �,�,y
I, (print or hype name of person listed in Contact btformation, item 2a) S/IllGV-0IKJII Lu/ �[ertify that I
own the property identified in this permit application, and thus give permission to (print or htpe n}fine of person
listed in Contact Information, itma 1a) with (print or hype name of organization listed in
Contact Information, item 'I a) 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 property owner i acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed ih Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibilih, for compliance with the DE.MLR Stornovater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEt\9LR immediately and
submit a completed Name/Ownership Change Form within 30 days; otherwise f 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 ass lit '1-perratlies f up to S25,000 per day, pursuant to NCGS 143-215.6.
Signature: U Date:
a Notary Public for the State of r�' C , County of
s l do hAer/eby certify that r_&�'r LG-tiGLSGl �� personally appeared
b re me thislO day of !� K�JLG and acknowledge the due execution of the application for
a stormwater, permit.. Witness my hand and official seal, _
cssubb
SEAL.
My commission expires &K (7 . i n / C/
..........
Form SWU-101 Version Oct. 31, 2013 Page 6 ol'7

X. APPLICANT'S CERTIFICATION
I, (print or hjpe xmne of person listed in Contact Information, item In)
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project mll 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 Linder 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
I, 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,
E
SEAL
My commission
FormSWU-101 Version Oct. 31.2013 Pa,-, e7of7

X. APPLICANT'S CERTIFICATION
V /
f ►, (print or h/l'e name of person fisted in Contact 6tfinnmtiat, item la) Spa-L�.C(/ Ckt;�
certify, that the information included on this permit application form ts, to the best of my knowledge, correct and O
j that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective, covenants will recorded, and that the proposed project complies with the requirements of the
applicable stormwater rul ,fleT 15 tied any other applicable state stormwater requirements.
C/
Signature: •• Date: i 3 Zo /4
1, �� ll VGLIi/GLG . a Notary Public for the State of _�/
Ci Counh of
do hereby certify that_persorally appeared
-- � ��/� 7
fore me this aday of _Q_Z_lam. and acknowledge thedueexecution of the application for
a stormwater permit. Witness my hand and official seal,rY�/iG
SEAT.
-f I Ai)' commission expires --Lac—
...........
-
Font SWU-101 Version Oct. 31. 2013 � Page 7 of 7