SW7110716_CURRENT PERMIT_20110804

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
DOC TYPE
CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
;a?6
YYYYMM DD

©A Waite
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
Mr. Don Nichols, Vice President
Realty VANC, LLC
263 Wagner Place
Memphis, TN 38103
Subject: Stormwater Permit No. SW7110716
Wendy's - Havelock
High Density Project
Craven County
Dear Mr. Nichols:
The Washington Regional Office received a complete Stormwater Management Permit
Application for Wendy's - Havelock on July 27, 2011. Staff review of the plans and
specifications has determined that the project, as proposed; will comply with the Stormwater
Regulations set forth in Session Law 2008-211 and Title 15A NCAC 2H.1000. We are
forwarding Permit No. SW7110716 dated August 4, 2011 for the construction of the subject
project.
This permit shall be effective from the date of issuance until August 4, 2021 and shall be
subject to the conditions and limitations as specified therein. Please pay special attention to
the Operation and Maintenance requirements in this permit. Failure to establish an adequate
system for operation and maintenance of the stormwater management system 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 upon written request within thirty (30) days
following receipt of this permit. This request must be in the form of a written petition,
conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of
Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. Unless such
demands are made this permit shall be final and binding.
If you have any questions, or need additional information concerning this matter, please
contact Samir Dumpor, or me at [phone].
ZIcerely,odg
Regional Supervisor
Surface Water Protection Section
AH/ sd: K:\WQS\STORMWATER\PERMIT\SW7110716
cc: Keith Broderick, PE, Civil Designs, PA (PO Box 39283, Greensboro, NC 27438)
Craven County Building Inspections
L%ashington Regional Office
North Carolina Division of Water Quality Internet: wv w.ncwaterquality ow,
943 Washington Square Mall Phone: [phone] One
Washington, NC 27889 FAX [phone] NorthCarolliina
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper Natura &

State Stormwater Management Systems
' Permit No. SW7110716
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH 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
Realty VANC, LLC
Wendy's - Havelock
Craven County
FOR THE
construction, operation and maintenance of one wetland basin, in compliance with the
provisions of Session Law 2008-211 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 Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until August 4, 2021, 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. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 of this permit.
3. The tract will be limited to the amount of built -upon area indicated in Section I. of
this permit, and per 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.
6. The built -upon areas associated with this project shall be located at least 50 feet
landward of all perennial and intermittent surface waters.
Page 2 of 7

State Stormwater Management Systems �7
Permit No. SW71 10716
The following design criteria have been provided in the Wetland Basins and must
be maintained at design condition:
WETLAND
a.
rai�nageArea, ft2:
50,100
b.
Total Impervious Surfaces, ft2:
32,223
C.
Design Storm, inches:
1.5
d.
Wetland Forebay Depth, feet:
2.50
e.
TSS removal efficiency:
85%
f.
Permanent Pool Elevation, FMS,2:
27.50
g.
Permanent Pool Surface Areq, ft :
2,300
h.
Permitted Storage Volume, ft :
4,598
i.
Temporary Storage Elevation, FMSL:
28.33
j.
Controlling Orifice:
1.00" 0 pipe
k.
Permitted Forebay Surface Area, ftZ:
685
I.
Receiving Stream/River Basin: Slocum
Creek/Neuse River Basin
M.
Stream Index Number:
27-112
n.
Classification of Water Body:
"SC; Sw, NSW"
II. SCHEDULE OF COMPLIANCE
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
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 vegetated filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans and
specifications.
f. Debris removal and unclogging of outlet structure, orifice device, level
spreader, filter strip, catch basins and piping.
g. Access to the outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
records will indicate the date, activity, name of person performing the work and
what actions were taken.
The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance inspection records for each BMP. The report shall
summarize the inspection dates, results of the inspections, and the maintenance
work performed at each inspection.
6. Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
7. The facilities shall be constructed as shown on the approved plans. This permit
shall become void unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other
supporting data.
Page 3 of 7

State Stormwater Management Systems
Permit No. SW71 10716
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.
9. 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.
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. 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.
12. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
13. A copy of the approved plans and specifications shall be maintained on file by
the Permittee at all times.
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, to the Division of Water
Quality, signed by both parties, and accompanied by supporting documentation
as listed on page 2 of the form. The project must be in good standing with the
Division. 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 the transfer request.
Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
Page 4 of 7

State Stormwater Management Systems e
Permit No. SW7110716
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 DENR 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 2008-
211, Title 15A NCAC 21-1.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division of any name, ownership or mailing
address changes at least 30 days prior to making such changes.
12. This permit shall be effective from the date of issuance until August 4, 2021.
Application for permit renewal shall be submitted 180 days prior to the expiration
date of this permit and must be accompanied by the processing fee.
Permit issued this the 4th day of August, 2011.
N? TH;ROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Z- for
Ilin ,Director
Division of Water Quality
By Authority of the Environmental Management Commission
Stormwater Permit No. SW7110716
Page 5 of 7

State Stormwater Management Systems
Permit No. SW7110716
Wendy's - Havelock
Stormwater Permit No. SW7110716
Craven 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)
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.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 6 of 7

State Stormwater Management Systems
Permit No. SW7110716
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet/bypass structure is located per the approved plans.
7. Trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation.
9. Vegetated slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and/or volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13. All required design depths are provided.
14. All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
15. The required system dimensions are provided per the approved plans.
cc: NCDENR-DWQ Washington Regional Office
Craven County Building Inspections
Page 7 of 7

CivilDesigns, P.A.
Consulting Civil and Environmental Engineering
3817-C Lawndale Drive
Greensboro, North Carolina 27455
Telephone [phone]
FAX [phone]
Transmittal Letter
To: Mr. Samir Dumpor
North Carolina Division of Water Quality
943 Washington Square Mall
Washington, NC 27889
Project: Wendy's Havelock
US Highway 70
Havelock, Craven County, NC
Permit No. SW7110716
We Transmit:
( X) herewith
( ) under separate cover
For Your:
( X) approval
( ) review & comment
( ) use
The Following:
Date: February 1, 2012
Project No.: 11180
RECEIVED
FEB - 3 2012
DWOMARO
Copies Date Description
1 Designer's Certification
Remarks:
Please let us know if you require any further information. Thank you.
Copies to:
Sincerely,
�! el ""
Keith V. Broderick, PE & PLS

ISECE0A ®

State Stormwater Management Systems 1
Permit No. SW7110716
Wendy's - Havelock
Stormwater Permit No. SW7110716
Craven County
Designer's Certification
I, ke LA\,\ �. �3zAerv-L , as a duly registered An tn.eer- in the
State of North Carolina, having been authorized to observe �ll weewy/Arn--
-titer) the construction of the project,
na�'s - �4a,)eocl
(Project)
for \IRNC , L- LL (Project Owner) hereby state that, to the
best of my abi'ties, 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.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification: 2
0S , e ct7er.s of veJe-�1c� SloPeo �4rpe -, �Uoktli s{c��t '` tom`✓ 3: t \
le.-?e r" 5A-0 J--J e ae.)1J:,- l l`,� C-U .�t� 0.`J Gun3 17c-�'C.C.(js Zp.3S �erclesv✓)1 l
-D Pe're/w%L4 Plan-.�`�j s are proJ.ded x3r at
Ver�FeP�c� a� �YrtAt- i�pe vNa,tibe7-. PL-As 5LWL)1d e�fe e �. 5pnn� zoiZ
�joMe a re"s Vn J been per u uwx.�t4s �}� b:l zez �it12S- �ceF�ypede) eto�ers eL. r�Ve�J>� s. 1ce�}.�aeae s�vl` SEA e sP—i
Signature e,�i/� (w> ,o•ocN CARo%
Registration Number NC_ 11-1-6-5 :
EAL
Date Dec.e b ar 7-2 , Zo t t W. . 12283
FtGINEEPr'��j�
BROti�Q;�'`M
Page 6 of 7

State Stormwater Management Systems
Permit No. SW7110716
Certification Requirements:
X1.
The drainage area to the system contains approximately the permitted
acreage.
X 2.
The drainage area to the system contains no more than the permitted
amount of built -upon area.
X 3.
All the built -upon area associated with the project is graded such that the
runoff drains to the system.
)C 4.
All roof drains are located such that the runoff is directed into the system.
Vie. aej,,, . e
oticerkJ .A �5.
_ . .
The outlet/bypass structure elevations are per the approved plan.
_�<_6.
The outlet/bypass structure is located per the approved plans.
t'N/14 7.
Trash rack is provided on the outlet/bypass structure.
X 8.
All slopes are grassed with permanent vegetation.
5 ee- dei n F«s co
on ce tc9.
Vegetated slopes are no steeper than 3:1.
�10.
The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11.
The permitted amounts of surface area and/or volume have been
provided.
X 12.
Required drawdown devices are correctly sized per the approved plans.
)13.
All required design depths are provided.
x 14. All required parts of the'system are provided, such as a vegetated shelf,
and a forebay:
_15. The required system dimensions are'provided per the approved plans.
cc: NCDENR-DWQ Washington Regional Office
Craven County Building Inspections.
Page 7 of 7

EXPRESS
27 2011 OF WA7E9
�� A JUL a� o�
NCDENR NC DENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WETLAND SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all the required information.
INP.R09EC;TiI N F,OROTION
Project name
Wendy's Havelock
Contact name
Keith Broderick, PE & PLS
Phone number
[phone]
Date
July 27, 2011
Drainage area number
2
II J[DESIGN1lN_FORMQTIQN
Site Characteristics
✓
Drainage area
50,100.00 ft2
Impervious area
32,223.00 ftz
Percent impervious
64.3% %
Design rainfall depth
1.50 inch ✓
Peak Flow Calculations
1-yr, 24-hr rainfall depth
3.45 in
�J
1-yr, 24-hr intensity
in/hr
Pre -development 1-yr, 24-hr runoff
2.00 ft3/sec
Post -development 1-yr, 24-hr runoff
4.55 ft3/sec
J
Pre/Post 1-yr, 24-hr peak'control
2 55 ft3/sec
Storage Volume: Non -SA Waters
Minimum required volume 3,939.00 ft3
Volume provided (temporary pool volume) 4,598.00 ft3 " OK
Storage Volume: SA Waters Parameters
1.5" runoff volume
ft3
Pre -development 1-yr, 24-hr runoff volume
ft3
Post -development 1-yr, 24-hr runoff volume
ft3
Minimum volume required
ft3
Volume provided
ft3
Outlet Design
Depth of temporary pool/ponding depth (DFla,,$)
10.00 in ✓ OK
Drawdown time
3.00 days t/ OK
Diameter of orifice
1.00 in OK
Coefficient of discharge (CD) used in orifice diameter
✓
calculation
0.60 (unitless)
Driving head (Ho) used in the orifice diameter calculation
0.30 ft OK
Form SW401-Wetland-Rev.6-11/16/09 Parts I and 11. Project Design Summary, Page 1 of 3

Surface Areas of Wetland Zones
Surface Area of Entire Wetland
5,520.00 ft2
OK
Shallow Land
1,985.00 ft2
OK
The shallow land percentage is:
36% %
Shallow Water
2,300.00 ft2
OK
The shallow water percentage is:
42% %
Deep Pool
Forebay portion of deep pool (pretreatment)
685.00 ft'
OK
The forebay surface area percentage is:
12% %
Non-forebay portion of deep pool
550.00 ft2
OK
The non-forebay deep pool surface area percentage is:
10% %
Total of wetland zone areas
5,520.00 ft2
OK
Add or subtract the following area from the zones
0.00 ft2
Topographic Zone Elevations
Temporary Pool Elevation (TPE)
Shallow Land (top)
28.33 ft amsl
Permanent Pool Elevation (PPE)
Shallow Water/Deep Pool (top)
27.50 ft amsl
Shallow Water bottom
27.00 ft amsl
Most shallow point of deep pool's bottom
25.00 ft amsl
Deepest point of deep pool's bottom
25.00 ft amsl
Design must meet one of the following two options:
This design meets Option 0,
Y (Y or N)
Top of PPE is within 6" of SHWT, If yes:
SHWT (Seasonally High Water Table)
27.00 ft amsl
OK
This design meets Option #2,
Y (Y or N)
Wetland has liner with permeability < 0.01 in/hr, If yes:
Depth of topsoil above impermeable liner
4.00 in
OK
Topographic Zone Depths
Temporary Pool
Shallow Land
9.96 in
OK
Permanent Pool
Shallow Water
6.00 in
OK
Deep Pool (shallowest)
30.00 in
OK
Deep Pool (deepest)
30.00 in
OK
Planting Plan
Are cattails included in the planting plan?
N (Y or N)
Number of Plants recommended in Shallow Water Area:
Herbaceous (4'cubic-inch container)
600
Number of Plants recommended in Shallow Land Area:
Herbaceous (Ccubic-inch container), OR
500
Shrubs (1 gallon or larger), OR
80
Trees (3 gallon or larger) and Herbaceous (4+ cubic -inch)
10 and
Number of Plants provided in Shallow Water Area:
Herbaceous (4'cubic-inch container)
575
Number of Plants provided in Shallow Land Area:
Herbaceous (4' cubic -inch container)
153
Shrubs (1 gallon or larger)
20
Trees (3 gallon or larger) and
3
Grass -like Herbaceous (4+ cubic -inch)
210
OK
400
Higher density is required.
More required if not planting shrubs or trees.
More required if not planting herb. and/or trees.
More required if not planting herb. and/or shrubs.
More recommended if planting trees.
Form SW401-Wetland-Rev.6-11/16/09 Parts I and II. Project Design Summary, Page 2 of 3

Additional Information
Can the design volume be contained?
Y
(Y or N)
OK
Does project drain to SA waters? If yes,
n
(Y or N)
Excess volume must pass through filter.
What is the length of the vegetated filter?
it
Are calculations for supporting the design volume provided in the
Y
(Y or N)
OK
application?
Is BMP sized to handle all runoff from ultimate build -out?
Y
(Y or N)
OK
Is the BMP located in a recorded drainage easement with a
Y
(Y or N)
OK
recorded access easement to a public Right of Way (ROW)?
The length to width ratio is:
5.31 :1
OK
'Approximate wetland length
170.00 it
Approximate wetland width
32.00 it
Approximate surface area using length and width provided
5,440.00
fl s
This approx. surface area is within this number of square feet
of the entire wetland surface area reported above:
Will the wetland be stabilized within 14 days of construction?
Y
(Y or N)
OK
a
Form SW401-Wetland-Rev.6-11/16/09 I Parts I and II. Project Design Summary, Page 3 of 3

Permit No.
(to be provided by DWQ)
III. 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.
1. Plans (1" - 50' or larger) of the entire site showing:
CZ. 1 - Design at ultimate build -out,
C3. l Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Wetland dimensions (and length to width ratio),
Pretreatment system,
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Overflow device, and
Boundaries of drainage easement.
GW/
G3- (
2. Plan details (1" = 50' or larger) for the wetland showing:
L(o
Wetland dimensions (and length to width ratio)
Pretreatment system,
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Design at ultimate build -out,
Off -site drainage (if applicable),
Overflow device, and
Boundaries of drainage easement.
G6o
3. Section view of the wetland (1" = 20' or larger) showing:
- Side slopes, 3:1 or lower
- Wetland layers
All wetlands: Shallow land depth, shallow water depth, deep pool depth
Option 1, no clay liner: SLWT depth
Option 2, clay liner: Depth of topsoil on top of liner, liner specifications
�(
4. A detailed planting plan (1" = 20' or larger) prepared by a qualified individual showing:
- A variety of several suitable species (not including cattails),
- Sizes, spacing and locations of plantings,
- Total quantity of each type of plant specified,
- A planting detail,
- The source nursery for the plants, and
- Fertilizer and watering requirements to establish vegetation.
Q�
G3- (
5. A construction sequence that shows how the wetland will be protected from sediment until the entire
drainage area is stabilized.
6. The supporting calculations (including drawdown calculations).
—'2:Zb 7. A copy of the signed and notarized operation and maintenance (0&M) agreement.
4-1 A �,,fr� 1�"" '� 8. A copy of the deed restrictions (if required).
Ln� 9. A soils report that is based upon an actual field investigation and soil borings. County soil maps are not
an acceptable source of soils information.
SW401-Wetland-Rev.6-11116109 Part III, page 1 of 1

Permit Number:
EXPRESSo be provided by D WQ)
y2oF warFgo9
pw
W JUL 27 2911 os
NCDENR
STORMWATER MANAGPLICATION FORM
401 CERTIFIC RN FORM
GRASSED SWALE SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 111) must also be filled out, printed and submitted along with all of the required information.
I. PROJECT INFORMATION
Project name Wendy's Havelock
Contact name Keith Broderick, PE 8 PLS '
Phone number [phone]
Date July 27, 2011
Drainage area number 1
II. DESIGN INFORMATION
Site Characteristics
Drainage area
39,200.00 ft'
Impervious area
32,223.00 It'
Percent impervious
82.2% %
Design rainfall depth
1.50 inch
Peak Flow Calculations
10-yr storm runoff depth
10-yr storm intensity
Post -development 10-yr storm peak flow
Velocity
Maximum non -erosive velocity (peak 10-year storm)
Soil characteristics (enter "x' below)
Sand/silt (easily erodible)
Clay mix (erosion resistant)
Grass Type (enter Y' below)
Bermuda
Tall fescue
Bahiagrass
Kentucky bluegrass
Grass -legume mixture
Swale type: Fill out one of the options below:
Option 1: Curb Outlet Swale:
Maximum velocity
J.40 in
inlhr
8.42 ft3lsec
5.00 ftfsec
X
X
N (YorN)
Side slopes
:1
Swale length
ft
Option 2: Conveyance Swale, Seeking Pollutant Credit:
Y (Y or N)
Maximum velocity for 10-yr storm
1.00 ft/sec OK
Side slopes
5.00 :1 OK
Swale length
150.00 It OK
Form SW401-Grassed Swale-Rev.3 Parts I and II. Project Design Summary, Page 1 of 2

Permit Number:
(to be provided by DWD)
Swale Characteristics
Swale Shape: Enter an 'Y' in the appropriate cell below:
Trapezoidal
Parabolic
V-shaped
Width of the bottom of the swale
Width of the top of the Swale .
Additional Information
Is the Swale sized for all runoff from ultimate build -out?
Is the BMP located in a proposed drainage easement with a
recorded access easement to a public Right of Way (ROW)?
What is the distance from the bottom of the Swale to the SHWT?
What is the ground level elevation?
What is the elevation of the bottom of the swale?
What is the SHWT elevation?
What is the longitudinal slope of the swale?
What is the depth of freeboard? -
U
4.00 ft
14.00 ft
Y (Y or N)
OK
Y(YorN)
OK
1.00 ft
OK
29.00 fmsl
28.00 fmsl
27.00 fmsl
0.30 %
OK
0.50 ft
OK
Form SW401-Grassed Swale-Rev.3 Parts I and IL Project Design Summary, Page 2 of 2

Permit No:
(to be assigned by D WQ)
III. 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
O
2
Pagel Plan
Sheet No.
Gz. (
G3-(
G�- I
1. Plans (1" = 50' or larger) of the entire site showing:
- Design at ultimate build -out,
- Off -site drainage (if applicable),
- Delineated drainage basins (include Rational C coefficient per basin),
- Swale dimensions (width, length, depth),
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Grass species, and
Boundaries of drainage easement.
Plan details (V = 50' or larger) for the grassed swale showing:
- Swale dimensions (width, length, depth),
- Maintenance access,
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Grass species,
- Off -site drainage (if applicable),and
- Boundaries of drainage easement.
3. Section view of the grassed swale (V = 20' or larger) showing:
- Side slopes,
- Longitudinal slope,
- Freeboard
- Swale dimensions, and
- SHWT level(s)
( 4. Supporting calculations (including maximum velocity calculations for applicable storms)
�4i
5. A copy of the signed and notarized operation and maintenance (0&M) agreement.
6. A copy of the deed restrictions (if required).
SW401-Grassed Swale-Rev.3
Part III, Page 1 of 1

EXPRESS
JUL 27 2011
Permit Name:
(to be provided by DWQ)
1�9DE��ppR Drainage Area Number: (
assseKwale Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will 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 removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area of the grassed swale will be carefully managed to reduce the
sediment load to the grassed swale.
— After the first-time fertilization to establish the grass in the swale, fertilizer will
not be applied to the grassed swale.
The grassed swale will be inspected once a quarter. 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:
Potentialproblem:
How I will remediate theproblem:
The entire length of the
Trash/debris is present.
Remove the trash/debris.
swale
Areas of bare soil and/or
Regrade the soil if necessary to
erosive gullies have formed.
remove the gully, and then re -sod
(or plant with other appropriate
species) and water until established.
Provide lime and a one-time
fertilizer application.
Sediment covers the grass at
Remove sediment and dispose in an
the bottom of the swale.
area that will not impact streams or
BMPs. Re -sod if necessary.
Vegetation is too short or too
Maintain vegetation at a height of
long.
approximatelysix inches.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW40 I -Grassed Swale O&M-Rev.3 Page 1 of 2

r �' 1

Permit Number:
(to be provided by Dn'Q)
Drainage Area Number: Z
Stormwater Wetland Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will 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 removal efficiency of the BMP.
Important maintenance procedures:
- Immediately following construction of the stormwater wetland, bi-weekly inspections will be
conducted and wetland plants will be watered bi-weekly until vegetation becomes established
(commonly six weeks).
- No portion of the stormwater wetland will be fertilized after the first initial fertilization that is
required to establish the wetland plants.
- Stable groundcover will be maintained in the drainage area to reduce the sediment load to the
wetland.
- Once a year, a dam safety expert should inspect the embankment.
After the stormwater wetland is established, I will inspect it monthly 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:
Potentialproblem:
How I will remediate theproblem:
Entire BMP
Trash debris is present.
Remove the trash debris.
Perimeter of wetland
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed.
gully, and then plant a ground cover and
water until it is established. Provide lime
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height.
Inlet device: pipe or
The pipe is clogged (if applicable).
Unclog the pipe. Dispose of the sediment
swale
offsite.
The pipe is cracked or otherwise
Replace the pipe.
-damaged if applicable).
Erosion is occurring in the Swale (if
Regrade the swale if necessary to smooth
applicable).
it over and provide erosion control
devices such as reinforced turf matting or
riprap to avoid future problems with
erosion.
Form SW401-Wetland O&M-Rev.4 Page 1 of 3

I

Forebay Sediment has accumulated in the
forebay to a depth that inhibits the
forebay from functioning well.
Deep pool, shallow water
and shallow land areas
Micropool
Outlet device
Receiving water
Erosion has occurred.
Weeds are present.
Algal growth covers over 50% of the
deep pool and shallow water areas.
Cattails, phragmites or other invasive
plants cover 50% of the deep pool and
shallow water areas.
Shallow land remains flooded more
than 5 days after a storm event.
Plants are dead, diseased or dvina.
Best professional practices show that
pruning is needed to maintain optimal
plant health.
Sediment has accumulated and
reduced the depth to 75% of the
original design depth of the deep
pools.
A tree has started to grow on
An annual inspection by appropriate
professional shows that the
embankment needs repair.
Evidence of muskrat or beaver activity
Sediment has accumulated and
reduced the depth to 75% of the
original design depth.
Clogging has occurred.
The outlet device is damaged
Erosion or other signs of damage have
occurred at the outlet.
Permit Number:
(to be provided by DWQ)
I
Search for the source of the sediment and
remedy the problem if possible. Remove
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
a pesticide is used, wipe it on the plants
Consult a professional to remove and
control the algal growth.
Remove invasives by physical removal or
by wiping them with pesticide (do not
sorav) - consult a professional.
Unclog the outlet device immediately
Determine the source of the problem:
soils, hydrology, disease, etc. Remedy the
problem and replace plants. Provide a
one-time fertilizer application to establish
the around cover if necessarv.
Prune according to best professional
practices.
Search for the source of the sediment and
remedy the problem if possible. Remove
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP.
Consult a dam safety specialist to remove
the tree.
Make all needed repairs.
Consult a professional to remove muskrats
or beavers.
Search for the source of the sediment and
remedy the problem if possible. Remove
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP.
Clean out the outlet device. Dispose of the
sediment off -site.
Repair or replace the outlet device.
Contact the NC Division of Water (
401 Oversight Unit at 919-733-1756.
Forth SW401-Weiland O&M-Rev.4 Page 2 of 3

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Permit Number:
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project name:Wendy's Havelock
BMP drainage area number:
Print name:Don Nichols
Title:Vice President, Carlisle Corporation
Address:263 Wagner Place, Memphis TN 38103
Note: The legally responsible party should not be a homeowners association unless more than 50% of the lots have been
sold and a resident of the subdivision has been named the president.
MC L�01 icd Cl a Notary Public for the State of
T211Y11o55L� County of S� ot_((7U do hereby certify that
Dior, M ckols personally appeared before me this o?2 day of
UJ9 ZD ( 1 , and acknowledge the due execution of the forgoing stormwater wetland
maintenance requirements. Witness my hand and official seal,
STATE
OF
TENNESSEE
NOTARY
PUBLIC
My Gomm. venxr,
April e. 2015
My commission expires
Form SW401-Wetland O&M-Rev.4 Page 3 of 3

ion I 10T 111, /C
0I
4 i At—[ ;T's ;11
oil, el
To V
\'i';\ Z)Ijfiuq 'U

rvnmr-^^
DWQ USE ONLY
t ce'
Fee Paid
Permit Number
3500 0-d A %moo
5W-1110-1
Applicabl�ttlT oastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all t�itn''t``n''pp y� on -Coastal SW- HQW/ORW Waters ❑ Universal Storm water Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina U C,
Department of Environment and Natural Resources Orlc� S\
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for 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.):
Wendy's Havelock
2. Location of Project (street address):
City:Havelock County:Craven Zip:28532
3. Directions to project (from nearest major intersection):
Approximately 1 /4 mile south of the intersection of US Hwy 70 and Slocum Rd turn right at the signal
(Wal-Mart is on the left) Turn right on the service road and the properttis the existing, car wash facility
4. Latitude:340 54' 50" N Longitude:76° 56' 24" W of the main entrance to the project.
it. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
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 DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major ®Sedimentation/Erosion Control: 1.5 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 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:
Form SWU-101 Version 07Jun2010
Page I of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: Realty VANC, LLC
Signing Official & Title:Don Nichols, Vice President
b.Contact information for person listed in item 1a above:
Street Address:263 Wagner Place
City:Memnhis State:TN Zip:38103
Mailing Address (if applicable):
State:
Phone: (901 ) 526-5000 Fax: (901 ) 271-2564
Email: dnichols@carlislecorp 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 hiformation, 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:Tatarski. Louis Edward Et AI
Signing Official & Title:Gwyn T. Stone, Owner
b.Contact information for person listed in item 2a above:
Street Address:209 Pond Drive
City:Atlantic Beach State:NC Zip:28512
Mailing Address (if
`-'rY State:
Phone: (252 ) 726-7130 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
Signing Official &�
b.Contact information for person listed in item 3a above:
Mailing Address:
City:
Form SWU-101 Version 07Jun201.0 Page 2 of 7

Phone:
Fax:
4. Local jurisdiction for building permits:
Point of Contact:Scott Chase
IV. PROJECT INFORMATION
Phone #: (252 ) 444-6411
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Runoff from the site will drain to the grassed swale and stormwater wetlands devices where the stormwater
will be treated prior to being released offsite
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 1I - Post Construction
3. Stormwater runoff from this project drains to the Neuse River basin.
4. Total Property Area: 1.4 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*:1.4 acres
Total project area shall be calculated to exclude the following the nornial pool of im ounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NM line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 57.9 %
9. How many drainage areas does the project have?2 (For high densihj, count 1 for each proposed engineered
stormwater BMP. For low densihj and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified. in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Form SWU-101 Version 07.lun2010 Page 3 of

Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area
Receiving Stream Name
Slocum Creek
Slocum Creek
Stream Class *
SC; Sw, NSW
SC; Sw, NSW
Stream Index Number *
27-112
27-112
Total Drainage Area (so
39200 1/
50100
On -site Drainage Area (so
39200
50100 V
Off -site Drainage Area (so
0
1 0
Proposed Impervious Area** (so
32223
32223
% Impervious Area** total
82.2
64.3
'Impervious' Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area
On -site Buildings/Lots (so
3940
3940
On -site Streets (so
0
0
On -site Parking (so
27673
27673
On -site Sidewalks (so
610
610
Other on -site (so
0
0
Future (so
0
0
Off -site (so
0
0
Existing BUA*** (sf)
0
0
Total (so:
32223
32223
Strewn Class and Index Number can be determined at: http://portalmcdenr.it eb/wq/ps/csu/classifications
" Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
***Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be renwved and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
Projects in Union County: Contact DWQ Central Office staffto check if the project it located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management per 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 http://portal.ncdenr.org/web/wg/ws/su/bmj2-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from htt ://portal.ncdenr.org/ web /wq / ws / su/ statesw/ forms does. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office.may be
found by locating project on the interactive online map at http / /i)ortal.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 hgp:/ /portal.ncdenr org/web/wq/ws/su/statesw/forms does.
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 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
httn'/lwww.envhelp.org/pai4es/onestopexRress.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.)
FormSWU-101 Version 07Jun2010 Page 4of7

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 1h mile of the site boundary, include the'1h
mile radius on the map. h"
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: G�
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.
i 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"xll" 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 DWQ to verify the SHWT prior
to submittal, [phone].)
10.
it.
A copy of the most current property deed. Deed book: Page No:
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 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.
http://www.secretary.state.nc.us/CorporatiQnsZCSearch.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from
httu://portal ncdenr org/web/wq/ws/su/statesw/forms does. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and 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 DWQ, and that they will be recorded prior to the sale of any lot.
Form SWU-101 Version 07Jun2010 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).
Consulting Engineer:&< ith Broderick PE & PLS
Consulting Firm: CivilDesiens, PA
Mailing Address:P.O. Box 39283
City:Greensboro
Phone: (336 ) 282-5542
Email:keith o civildesignspa com
State:NC Zip:27438
Fax: (336 ) 282-5592
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) L J � & T, 5A-c," certify that I
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) ?bro Nichol S with (print or type name of organization listed in
Contact Information, item la) 990 P y I%A,A: LLc, 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 in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. 1 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 assessor of civil penaltie up to $25,0 0 er day, pursuant to NCGS 143-215.6.
Signatur Date:
I, U 1141a a Notary Public for the
State of County of
(al[+{' of do hereby certify that _ UI/LT� �• S+Dv e, personally appeared
before me this Z I1 day of l L41 I . and ac n wledge the d exeGq ion of the application for
a stormwater permit. Witness my hand and official seal, l%t
T
�V
;v Y os
co p Z =
=m 2 V -
-=,� PUS\\ J2;
"'cQATeR> G° ,
SEAL
My commission
Form SWU-101 Version 07Jun2010 Page 6 of 7

X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item la) Don Nichols
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 2I-I .1000, SL 2006-246 (Ph. II — Post Construction) or SL 2008-211.
Signature:
Date:
1, `J USQYt FVl �f Y�ylg (c� a Notary Public for the State of7pj}48615 ro p County of
L-0 (toll t �
do hereby certify that DY1 i f��+O i 5 personally appeared
before me thisday of J zoI and ackn wledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, (Y-c C� U7 teLQo:
Commission expires
Form SWU-101 Version 07Jun2010 Page 7 of 7