SW7060825_CURRENT PERMIT_20021115

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
jf�&'�
YYYYMMDD

State Stormwater Management Systems
Permit No. SW7060825
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
Albemarle Hospital Authority
Albemarle Hospital
Pasquotank County
FOR THE
construction, operation and maintenance of stormwater management systems in compliance with the provisions of
15A NCAC 21-1.1000 (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 for wet detention ponds to serve the Albemarle Hospital located at 1144
N. Road Street in Elizabeth City, NC.
This permit replaces permits SW70021021 issued November 15. 2002 and SW7940703 issued November 1, 1994
and shall be effective from the date of issuance until January 22, 2017 and shall be subject to the following specified
conditions and limitations:
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 on page
2 of this permit, the Project Data Sheet.
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 approved plans.
4. Approved plans and specifications for this project are incorporated by reference and are enforceable parts of
the permit.

Project Name:
Permit Number:
Location:
Applicant:
Mailing Address:
Application Date:
Receiving Stream:
Classification of Water Body:
Total Project Area:
Drainage Basin:
Drainage Area:
TotalImpervious allowed:
Wet Pond Depth:
Required Storage Volume:
Provided Storage Volume:
Required Surface Area:
Provided Surface Area:
Controlling Orifice:
DIVISION OF WATER QUALITY
PROJECT DATA
Albemarle Hospital
SW7060825
Pasquotank County
Albemarle Hospital Authority
1144 N. Road Street
Elizabeth City, NC 27909
8/31 /2006
Pasquotank River
SC
27.80 ac
Northeast Pond System
5.19 ac
4.19 ac
4.0 ft
14,676 cf
83,508 cf
11,892 sf
12,800 sf
2.0 inch
Southwest Pond System
1.54 ac
1.2 ac
4.0 ft
3.533 cf
7,134 of
3,903 sf
4,982 sf
1.0 inch

5. No homeowner/lot owner/developer shall be allowed to fill in, alter, or pipe any vegetative practices (such as
swales) shown on the approved plans as part of the stormwater management system without submitting a
revision to the permit and receiving approval from the Division.
6. The following items will require a modification to the permit:
a. Any revision to the approved plans, regardless of size
b. Project name change
C. Transfer of ownership
d. Redesign or addition to the approved amount of built -upon area
e. Further subdivision of the project area.
In addition, the Director may determine that other revisions to the project should require a modification to the
permit.
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.
It. SCHEDULE OF COMPLIANCE
1. The permittee will comply with the following schedule for construction and maintenance of the stormwater
management system.
a. 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 surfaces except roads.
b. During construction, erosion shall be kept to a minimum and any eroded areas of the system will be
repaired immediately.
2. The facilities must be properly maintained and operated at all times. The approved Operation and
Maintenance Plan must be followed in its entirety and maintenance must occur at the scheduled intervals.
3. The permittee shall at all times provide the operation and maintenance necessary to assure the permitted
stormwater system functions at optimum efficiency including, but not limited to:
a. Semiannual scheduled inspections (every 6 months)
b. Sediment removal
C. Mowing and revegetation of side slopes
d. Immediate repair of eroded areas
e. Maintenance of side slopes in accordance with approved plans and specifications
f. Debris removal and unclogging of outlet structure, orifice device and catch basins and piping.
4. Records of maintenance activities must be kept and made available upon request to authorized personnel of
DWQ. The records will indicate the date, activity, name of person performing the work and what actions were
taken.
5. This permit shall become voidable unless the facilities are constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
6. Upon completion of construction 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. Mail the Certification to the Washington Regional Office, 943 Washington Square Mall,
Washington, North Carolina, 27889, attention Division of Water Quality.
A copy of the approved plans and specifications shall be maintained on file by the Permittee for a minimum of
five years from the date of the completion of construction.
III. GENERAL CONDITIONS
1. This permit is not transferable. In the event there is a desire for the facilities to change ownership, or there is
a name change of the Permittee, a formal permit request must be submitted to the Division of Water Quality
accompanied by an application fee, documentation from the parties involved, and other supporting materials
as may be appropriate. The approval of this request will be considered on its merits and may or may not be
approved.
2. 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 accordance with North Carolina General Statute 143-
215.6(a) to 143-215.6(c).
3. 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)
which have jurisdiction.
4. 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.
5. The permit may be modified, revoked and reissued or. terminated for cause. The filing of a request for a
permit modification, revocation and reissuance or termination does not stay any permit condition.
6. The Permittee, at least six (6) months prior to the expiration of this permit, shall submit in writing a request for
an extension along with appropriate application fee.
Permit issued this the 22 nd day of January, 2007.
TH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
L `'
.1.-
for Alan W. Klimek, P.E. Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number SW7060825

Date Received
Fee Paid
Permit Number
AUG-3 1 P006
1 4 &20("lp
I bW7 U H UD
H 2 V.
r r^. f f�f r State of North Carolina SWACK -6�3 I �4�P
��' ` ` `t t `Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Applicants name (specify the name of the corporation, individual, etc. who owns the project):
2. Print Owner/Signing Official's name and title (person legally responsible for facility and compliance):
Nrctto-�as 64t-AGU1RC♦ EY-
3. Mailing Address for person listed in item 2 above: '
IIyy N. Roaa s+rat P.o. r�ox 15g7
City:E]-z_wit, C;iv---- State: NC Zip: 2799A
Telephone Number. ( 1152, ) 3 3s - 05-3
4. Project Name (subdivision, facility, or establishment name - should he consistent with project name on plans,
specifications,letters, operation and maintenance agreements, etc.):
r' f� 1
iLp ,I. 4cn:�l.ul C, -..n V 4..MOrut./�cV IIGne W'Iri�^-� �h1J�✓.t le✓�C
5. Location of Project (street address
I19-4 N Po a Siree+
County:PWVAoi-ur,k
6. Directions to project (from nearest major intersection):
_Ft ,+ i,Q inru3eGlliYl of US—ISi K IN -S 61J d' LA-1-7/ 1V• P-4 S+>%qE--V, h ,el
_None U 11[�R��aS+, _ o.� M,les.
1,
7. Latitude: W lit yy Longitude: 36- 16, Pi of project
8. Contact person who can answer questions about the project
Name: t,9enKo C,NMIhJ1S Telephone Number:. Lq0y 287-Saoo
v ;�'tv Ode11 (li�o/t; feet of
11. PEIRMIT INFORMATION:
I. Specify whether project is (check one): _X New Renewal Modification
-1k Tko is an JA-Mona( pl- . of UeJe�opr e�f +v pn exisi n� hiq hly
dense S-Je. c i:f5
Form SWU-101 Version 3.99 Page I of (1 17 0

TX1,

2. If this application is being submitted as the result of a renewal or modification to an existing permit, list the
existing permit number and its issue date (if known)
3. Specify the type of project (check one):
Low Density Fligh Density Redevelop General Permit Other
4. Additional Project Requirements (check applicable blanks):
_CAMA Major _Sedimentation/Erosion Control _404/401 Permit _XNPDES Stormwater
Information on required state permits can be obtained by contacting the Customer Service Center at
1-877-623-6748.
III. PROJECT INFORMATION
1. In the space provided below, summarize how Stormwater will be treated. Also attach a detailed narrative
(one to two pages) describing Stormwater management for the project .
2. Stormwater runoff from this project drains to the PC'414Jc- k River basin.
3. Total Project Area:_ 9 7 8 O ' acres 4. Project Built Upon Area: 13
3, b O f ..S C DcS r��FD)
5. How many drainage areas does the project have?
6. Complete the following information for each drainage area. If there are more than two drainage areas in the
project, attach an additional sheetwith the information for each area provided in the same format as below.
Basin hifoi m tUorr" u'+`
�, 4 Drainage Area 1 �''.- ` +!'
° `� `` s 1D�aiii e kea 2 ' ^ 1,
Receiving Stream Name
e e.n
Receiving Stream Class
r
Drainage Area
r> .19
Existing Impervious' Area
3.94
Proposed ImperviousArea
4.19
% Impervious* Area (total)
°
Impervious Surface Area- _,
; , _' i` Drainage Area 1
;,' , ;Drainage Area 2
On -site Buildings
0,7
On -site Streets
0.00
On -site Parking
On -site Sidewalks
Other on -site
Off -site
Total: L( 9
Total:
' Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking arras,
sidewalks, gravel areas, etc.
Form SWU-101 Version 3.99 Page 2 of 4

7. How was the off site impervious area listed above derived? 1114-
IV. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
The following italicized deed restrictions and protective covenants are required to be recorded for all
subdivisions, outparcels and future development prior to the sale of any lot. If lot sizes vary significantly, a table
listing each lot number, size and the allowable built -upon area for each lot must be provided as an attachment.
1. The following covenants are intended to ensure ongoing compliance with state stormwater management permit number
as issued by the Division of Water Quality. These covenants may not be
changed or deleted without the consent of the State.
2. No more than square feet of any lot shall be covered by structures or impervious materials.
Impervious materials include asphalt, gravel, concrete, brick, stone, slate or similar material but do not include wood
decking or the water surface of swimming pools.
3. Swales shall not be filled in, piped, or altered except as necessary to provide driveway crossings.
4. Built -upon area in excess of the permitted amount requires a state stormwater management permit modification prior to
construction.
5. All permitted runoff from outparcels or future development shall be directed into the permitted stormwater control
system. These connections to the stormwater control system shall be performed in a manner that maintains the integrity
and performance of the system as permitted.
By your signature below, you certify that the recorded deed restrictions and protective covenants for this project
shall include all the applicable items required above, 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 State, and that they will be recorded prior to the sale of any lot.
V. SUPPLEMENT FORMS
The applicable state stormwater management permit supplement form(s) listed below must be submitted for each
BMP specified for this project. Contact the Stormwater and General Permits Unit at [phone] for the status
and availability of these forms.
Form SWU-102
Wet Detention Basin Supplement
Form SWU-103
Infiltration Basin Supplement
Form SWU-104
Low Density Supplement
Form SWU-105
Curb Outlet System Supplement
Form SWU-106
Off -Site System Supplement
Form SWU-107
Underground Infiltration Trench Supplement
Form SWU-108
Neuse River Basin Supplement
Form SWU-109
Innovative Best Management Practice Supplement
Form SWU-101 Version 3.99 Page 3 of

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. The complete application package should be
submitted to the appropriate DWQ Regional Office.
Please indicate that you have provided the following required information by initialing in the space provided
next to each item.
Initials
• Original and one copy of the Stormwater Management Permit Application Form 35;
• One copy of the applicable Supplement Form(s) for each BMP AIZ#,
• Permit application processing fee of $420 (payable to NCDENR) Fj
• Detailed narrative description of Stormwater treatment/management
• Two copies of plans and specifications, including: SSS
- Development/Project name
- Engineer and firm
-Legend
- North arrow
- Scale
- Revision number & date
- Mean high water line
- Dimensioned property/project boundary
- Location map with named streets or NCSR numbers
- Original contours, proposed contours, spot elevations, finished floor elevations
- Details of roads, drainage features, collection systems, and Stormwater control measures
- Wetlands delineated, or a note on plans that none exist
- Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations
- Drainage areas delineated
- Vegetated buffers (where required)
VIL AGENT AUTHORIZATION
If you wish to designate authority to another individual or firm so that they may provide information on your
behalf, please complete this section. v
Designated agent (individual or firm): ari Gh Si^tw�r lii �"�) �/l ,•�+�tr —�O/'q 4.te�
Mailing Address: Sol Xe\l ep_, Alsnc,C [Pc.r�.w.y ,SH•i� 300
City:_ Clke
ity_CkQ tn�_-(e // State: VA Zip: a33 .Z 0
Phone: 7S 7 ) 548 — 730O
VIII. APPLICANT'S CERTIFICATION
Fax: ( 75-7 ) 5yg--7301
1, (print or type name ofperson listed in General Information, item 2) (`1 1� )%a'4S &G O q V'C h t 4
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 15A
NCAC 2H .1000.
Form SWU-101 Version 3.99
Page 4 of 4
Date:_p 26

Permit No.
(to be provided by DWQ)
State of North Carolina WE LGU V E V
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM OEC 15 2006
WET DETENTION BASIN SUPPLEMENT ®WQ-WAR®
This form may he photocopied for use as an original
DWO Stormwater Management Plan Review:
A complete stormwater management plan submittal includes an application form, a wet detention basin
supplement for each basin, design calculations, and plans and specifications showing all basin and outlet
structure details.
I. PROJECTINFORMATION
Project Name: 41&--mhMte lfoSP 7*1- S4R1e-eay /},up 9Me46CNc.y ,DEPAR7-M6.v7- ),5AA*A/-1X✓
Contact Person: AlrUt Phone Number: (a6A;) 39Y- y9�SV
For projects with multiple basins, specify which basin this worksbeet applies to:
®" elevations
Basin Bottom Elevation
— a .2-�o ft.
(/loon of the basin)
Permanent Pool Elevation
/. 7-0 ft.
(elevation of the orifice)
Temporary Pool Elevation
ft.
(elevation of the discharge structure overflow)
OKareas
Permanent Pool Surface Area / a sq.
ft. (water surface area at the on/ice elevation)
Drainage Area
5- /q ac.
(on -site and off -rite drainage to the basin)
Impervious Area
ci. /9 ac.
(on -site and off -site drainage to the basin)
vohunec
Permanent Pool Volume
1/0) ` 9A - cu.
ft. (combined valuate of main basin and fbrebay)
Temporary Pool Volume
83d 5'09 cu.
ft. (volutne detained above the pernnanent pool)
Forebay Volume
a _4 56r cu.
ft. (approximateli; 20%oftotal volinne)
Other parameters
01" 4ppr;'=' 4-t- 'LMP"vza4S Ate#
SA/DA
BasRp
5, a6 90 (suface area to drainage area ratio from DWQ table)
Diameter of 0rif ice
I in.
(2 to 5 day temporary pool draw -clown required)
Design Rainfall
6 .3 in.
(to - Y"A)
Design TSS Removal 2
85- %
(mininmm 85%requu-ed)
Form SWU-102 Rcv 3.99 Page I of 4

Footnotes:
When using the Division SA/DA tables, the correct SA/DA ratio for permanent pool sizing should be computed based upon the
actual impervious % and permanent pool depth. Linear interpolation should be employed to determine the correct value for non-
standard table entries.
2 In the 20 coasted counties, the requirement for a vegetative filter may be waived if the wet detention basin is designed to provide
90% TSS removal. The NCDENR BMP manual provides design tables for both 85% TSS removal and 90% TSS removal.
IL REQUIRED ITEMS CHECKLIST
The following checklist outlines design requirements per the Stormwater Best Management Practices Manual
(N.C. Department of Environment, Flealth and Natural Resources, February 1999) and Administrative Code
Section: 15 A NCAC 21-I .1008.
Initial in the space provided to indicate the following design requirements have been met and supporting
documentation is attached. If the applicant has designated an agent in the Stonnwater Management Permit
Application Form, the agent may initial below. If a requirement has not been met, attach justification.
Is
a. The permanent pool depth is between 3 and 6 feet (required minimum of 3 feet).
b. The forebay volume is approximately equal to 20% of the basin volume.
c. The temporary pool controls runoff from the design storm event.
d. The temporary pool draws down in 2 to 5 days.
e. If required, a 30-foot vegetative filter is provided at the outlet (include non -erosive flow
calculations)
f. The basin length to width ratio is greater than 3:1.
g. The basin side slopes above the permanent pool are no steeper than 3:1.
It. A submerged and vegetated perimeter shelf with a slope of 6:1 or less (show detail).
X i. Vegetative cover above the permanent pool elevation is specified.
j. A trash rack or similar device is provided for both the overflow and orifice.
A/ q k. A recorded drainage easement is provided for each basin including access to nearest right-
of-way.
I. If the basin is used for sediment and erosion control during construction, clean out of the
basin is specified prior to use as a wet detention basin.
N A in. A mechanism is specified which will drain the basin for maintenance or an emergency.
III. WET DE TENTION BASIN OPERATION AND MAINTENANCE AGREEMENT
The wet detention basin system is defined as the wet detention basin, pretreatment including forebays and the
vegetated filter if one is provided.
This system (check one) dues 0 does not incorporate a vegetated filter at the outlet.
This system (check one) 0 does does not incorporate pretreat uent other than a forebay.
Form SWU-102 Rev 3.99 Page 2 of 4

Maintenance activities shall be performed as follows:
After every significant runoff producing rainfall event and at least monthly:
a. Inspect the wet detention basin system for sediment accumulation, erosion, trash accumulation,
vegetated cover, and general condition.
b. Check and clear the orifice of any obstructions such that drawdown of the temporary pool occurs within
2 to 5 days as designed.
2. Repair eroded areas immediately, re -seed as necessary to maintain good vegetative cover, mow vegetative
cover to maintain a maximum height of six inches, and remove trash as needed..
3. Inspect and repair the collection system (i.e. catch basins, piping, swales, riprap, etc.) quarterly to maintain
proper functioning.
4. Remove accumulated sediment from the wet detention basin system semi-annually or when depth is
reduced to 75% of the original design depth (see diagram below). Removed sediment shall be disposed of
in an appropriate manner and shall be handled in a inannerthat will not adversely impact water quality (i.e.
stockpiling near a wet detention basin or stream, etc.).
The measuring device used to determine the sediment elevation shall be such that it will give an accurate
depth reading and not readily penetrate into accumulated sediments.
When the permanent pool depth reads —/.30 feet in the main pond, the sediment shall be removed.
When the permanent pool depth reads —/ 30 feet in the forebay, the sediment shalt be removed.
BASIN DIAGRAM
(fill in the hlanks)
V Permancin Pool Glcvation /, ` D
Sediment Ren oval'GI. —/. 30 75' o
-------- - Sediment Removal Elevation —/. 30 75"/0
Bottom Glc •ation —%.30 % ------------------------------ —
Bottom Elevation —d•30 25%
FOREBAY MAIN POND
Remove cattails and other indigenous wetland plants when they cover 50% of the basin surface. These
plants shall be encouraged to grow along the vegetated shell -and forebay berm.
6. If the basin must be drained for an emergency or to perform maintenance, the flushing of sediment through
the emergency chain shall be minimized to the nuiximum extent practical.
Fonn SWU-102 Rev 3.99 Page 3 of

7. All components of the wet detention basin system shall be maintained in good working order.
I acknowledge and agree by my signature below that I am responsible for the performance of the seven
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior to any
changes to the system or respon ible party.
y �,I,V,,K Jn14s5
Print name: /V !C k tJQ la. q tkoc/ c k JP.
Title: P-r0, PCr 1) rPcTo
Address: 1P1Y N. le6Yeol S FYe-e-C �iLCzGr�f% ��) NC. d-790
Date: __ /,.C// 7/c,/ &
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.
I, G iti Woc� , a Notary Public for the State
/7of A10A CA✓v It wu >
County of Ca n .Q. v do hereby certify that N; C d 4-s
personally appeared before me this J116' day of Q2CLn.h er- 200 �, and acknowledge the due
execution of the forgoing wet detention basin maintenance requirements. Witness my hand and official seal,
�c
t'
.I•
My commission
t,�,� =nlFOR/�Arronl
IJFt-�u�H�oN 5
SEAL
6.21-D
?2ovr-PED ZS t3ISEp ON SHE 6RZ&ZA/AL dESZ&N
Fo,e r#6 E .1z5 MV 6, POND 7-h 4-r' A✓A's cO�VrrR ac r5'o
q/t t XtSrrntis c4tcwG+r-z l S kRE UA)eLL649- 40WEVER BkstD OAJ YZEL D
o35Fpv47- ZT A+PEARS T-HA-T" + PekraErEr SHELF ZS Pa0=0E-D•
Form SWU-102 Rev 3.99 Pase 4 of 4

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WuV 17 2006
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
DUVf3-WARD SEDIMENTATION POLLUTION CONTROLACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before, this..
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, If
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name 41-a`M�AL'B //D t Pz-r*z- 54RGERY Ave rA &"4Y DEPARrAYAW�
2. Location of land -disturbing activity: County PRS©uoTiFN/f City or Township ,ELta qW# esry
Highway/Street HYL/ Amr# Re+e50,, Latitude 36'Iy AS° Al Longitude 96013' b6" 14
3. Approximate date land -disturbing activity will commence: /g/a Vob
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ,#osPrr,#L
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.60 AG'
6. Amount of fee enclosed: $ POO, 0— . The application fee of $50.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $450).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity: 1
Name Nur aAGhGNAc#.ror 7A. E-mail Addressnbo/v reS'kLo/6e.no�/c
Telephone C3 S-A) 3 8 y-ygs0 Cell #
Fax# [phone]JI5 9
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pasquotank County 252-335-0865 252-335-0866
Name Telephone Fax Number
P. 0. Box 39
:urrent Mailing Address
206 E. Main Street
Current Street Address
Elizabeth City, NC 27907 Elizabeth City NC 27909
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide - a
comprehensive list of all responsible parties on an attached sheet):
Albemarle Hospital
Name
P. 0. Box 1587
Current Mailing Address
E-mail Address j
1144 North Road Street
Current Street Address` --
Elizabeth City, NC 27906 Elizabeth City, NC 27909
City State Zip City Slate Zip
Telephone [phone] Fax Number 252-384-4677

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there by any change in the information provided herein.
f ro' ec1- D i/eoo r1 eVA i ?"(TeZ;
Type or print
name 9y �, Title or Authority j
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Signature Date
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a Notary Public of the County of (­'Z: Y"'z t
State of North Carolina, hereby certify that /1,°+J,Al , /36 14c;r.,ii appeared
personally before me this day and being duly sworn acknowled ed that the above form was
executed by him.
Witness my hand and notarial seal, this • 1 Jay of G : 4 b •,- 20 0 4v
Notary
Seal
My commission expires L' I -0 ��