SW3191101_Application Form_20211025

fl Date Received
Fee Paid
Permit Number
STORMWATER PERMITTING FORM 7:
1WMOR MODIFICATION
Standard Permitting Program — No Fee for Minor Modification
Express Permitting Program — See Express Pee Schedule
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: h1tlLIr(lcg, tic. cgov/co{Clad/regional-offices.
This form is to only to be used by the current permittee to notify the Division of a minor
modification. Pursuant to Rule 15A NCAC 02H .1002 a minor modification is a change to the project that.-
1) does not increase the net built -upon area; and/or
2) does not change the size or design of the SCM(s).
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW3191101
2, Current Permit Holder's Company Name/Organization: N2ah_ Pilot Knob Road, ILLC
3. Signing Official's Name: Tadd M. Miller
4. Signing Official's Title: Manager
5. Mailing Address: Cresset Dellinger Road
City: Denver State: NC ZIP: 28037
6. Street Address (if different):
City: _ State: ZI P:
7. Phone: [phone] Email: tadd.miller(amilhaus.com
8. Describe the minor modifications that you are requesting, including any revised BUA allocations (attach
additional pages or supporting tables similar to Section IV.10 of the original application, if needed):
Drainage from Passive French drains at Building 7 and parking lot will flow to star water inl t to detention
and as shp_wn on attached plan sheets. OperatiQn and Maintenance Plan to be modified to place owner
as responsible party form—alintenance of these items.
B. SUBMITTAL REQUIREMENTS
Please mark "Y' to confirm the items are included with this form. Please mark "X" if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. Two hard copies (with original signatures) and one electronic copy of this completed form.
Y 2. Two hard copies and one electronic copy of the revised plan sheets (must be a revision of the
originally approved plan sheets).
NA 3. If there is reallocation of lot BUA, a copy of the revised recorded deed restrictions and protective
covenants OR the proposed recorded deed restrictions and protective covenants documenting
the changes and a signed agreement to provide the final recorded document.
NA 4. If applicable, the appropriate Express review fee.
Stormwater Permit Form 7 Minor Modification Page 1 of 2 July 14, 2017

C. CONTACT INFORMATION
1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name:Steven Singleton
Consulting Firm: Bohler Engineering
Mailing Address:1927 S. Tryon Street, Ste_310
City:Charlotte
Phone: [phone]
Email: ssingletonObohlereng,com
State:NC Zip:28203
Fax: [phone]
2. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title: Robert L. Griffin, _PE - PresidentlCEO
Organization: Shield Engineering, Inc.
Mailing Address:4301 Taggart Greek Road
City:Charlotte _
State: NC
Phone: [phone] Fax: f704) 394-6968 _
Email: I)griffinsliieldengineering.com
D. CERTIFICATION OF PERMITTEE
Zip:28208
I, Tadd M. Miller , the current permittee, certify that I have authorized the minor modifications
listed in Section A and shown in the attached revised plan sheets. I further attest that this information is accurate and
complete to the best of
Signatu
Date: 101ao /al
I, _ L01i F1 • 0-` � mW a Notary Public for the State of - —TI\G Ia,n&
County of_ MULn;r• —,do hereby certify that 71121116 M. Vhs Udd
personally appeared before me this the aU day of OCl bbw ,, 20-; L, and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature w a 6ak,,�
_
My commission expires —ND1humr iw a%
��'ul! LORI A GAHIMER
�5�aoil."�. Notary Public, State of Indiana
anti°Shelby County
*: * Commission # 649274
.SEAL
My Commission Expires
`��"r'�"'�`•`�� November 24, 2021
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Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6, 2017