SW7091002_CURRENT PERMIT_20091106

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

Beverly Eaves Perdue
Governor
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
November 6, 2009
Mr. Charles E. Trefzger, Jr., Member Manager
Currituck Health Investors, LLC
1270 25th Street Place, SE
Hickory, NC 28602
Subject: Stormwater Permit No. SW7091002
Currituck Assisted Living Center
High Density Commercial Wet Pond Project
Currituck County
Dear Mr. Trefzger:
Dee Freeman
Secretary
The Washington Regional Office received a complete Stormwater Management Permit Application for
Currituck Assisted Living Center on October 29, 2009. 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 M. SW7091002
dated November 6, 2009, for the construction of the subject project.
This permit shall be effective from the date of issuance until November 6, 2019, 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 adtudicatory 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 1 06 of the
North Carolina General Statutes, and filed with the Office of Administrative Hearings, P.O. Drawer
27447, Raleigh, NC 27611-7447. 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 Scott
Vinson, or me at [phone].
�inc i rely,
8
Al Hodge
Regional Supervisor
Surface Water Protection Section
AH/ sv: S:\WQS\STORMWATER\PERMIT\SW7091002
cc: Sean Robley, PE
Currituck County Building Inspections
L.�ashington Regional Office
Central Files
North Carolina Division of Water Quality Internet: w .nc vaterqualiy org One
943 Washington Square Mall Phone :[phone] FAX [phone] NOrtitCilPOtllld
Washington, NC 27889 FAX: [phone] tima��ly
An Equal Opportunity \Affirmative Action Employer Nbia

State Stormwater Management Systems
Permit No. SV 7091002
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
Currituck Health Investors, LLC
Currituck Assisted Living Center
Moyock Landing Road, Moyock in Currituck County
FOR THE
construction, operation and maintenance of a wet detention pond 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 November 6, 2019, 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. The stormwater control has been
designed to handle the runoff from 96,257 square feet of impervious area.
3. The tract will be limited to the amount of built -upon area indicated in Section I. of
this permit, and per approved plans. The built -upon area for the future
development is limited to 4,441 asquare feet.
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
Permit No. SV 7091002
7
The following design criteria have been provided in the wet detention pond and
must be maintained at design condition:
a. Drainage Area, ft2:
b. Total Impervious Surfaces, ft2:
C. Design Storm, inches:
d. Pond Depth, feet:
e. TSS removal efficiency:
f. Permanent Pool Elevation, FMSI :
g. Permanent Pool Surface Arei, ft
h. Permitted Storage Volume, ft :
i. Temporary Storage Elevation, FMSL:
j. Controlling Orifice:
k. Permitted Forebay Volume, W:
I. Fountain Horsepower, HP
M. Receiving Stream/River Basin:
n. Stream Index Number:
o. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
202,485
96,257
1.50
3.27 avg.
90 %
4.50
11,436
17,547at temporary pool e
5.75
2.25"0 pipe
5,432
0, (no fountain allowed)
Moyock Run / Pasquotank
30-1-2-2-1
"C; Sw"
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.
q. 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. Decorative spray fountains will not be allowed in the stormwater treatment
system.
Page 3 of 7

State Stormwater Management Systems
Permit No. SW7091002
8. 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.
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.
10. 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.
11. 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.
12, 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.
13. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
14. 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.
Page 4 of 7

State Stormwater Management Systems
Permit No. SW7091002
3. 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 143-215.6A 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 2006-
246, Title 15A NCAC 2H.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 November 6, 2019.
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 6ch day of November, 2009.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for
Division of Water Quality
By Authority of the Environmental Management Commission
Stormwater Permit No. SV 7091002
Page 5 of 7

u
State Stormwater Management Systems
Permit No. SV 7091002
Currituck Assisted Living Center
Stormwater Permit No. SW7091002
Currituck 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. SW7091002
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 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
Currituck County Building Inspections
Page 7 of 7

State Stormwater Management Systems
Permit No. SVV7091002
Currituck Assisted Living Center
Stormwater Permit No. SV 7091002
Currituck County
OCT - 4 2010
Designer's Certification
I, Sean C. Robey , as a duly registered Professional Engineer In the
State of North Carolina, having been authorized to observe (periodically/ weekly/ full
time) the construction of the project,
Currituck Assisted Living Center
(Project)
for currituck Health TnveGtn s , r.r.r• (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:
SEAi�wwwu��i
Signature \`\���e.rpEssiN CA... 1* Z"
� o''••.'�
Registration Number— 18550 3 SEAL
Date 18550
Page 6 of 7

State Stormwater Management Systems
Permit No. SW7091002
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.
J�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.
_v,--�6. The outlet 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
Currituck County Building Inspections
Page 7 of 7

- DWQ.USE ONLY
Fee Paid Cat Z,Wg
Permit Number
1` v-. 8 d
I S-v\J-,09CO 7-
Applicable ONsQ 8 Mastal SW -1995 Wr Coastal SW- 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters O Universal Stormwater Management Plan
er WQ M mt Plan:
State of North Carolina 1'r�
Department of Environment and Natural Resources _n�
Division of Water Quality G C4
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original U
I. 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.):
Currituck Assisted Living Center
2. Location of Project (street address):
City: Moyock County: Currituck Zip: 27958
3. Directions to project (from nearest major intersection):
From the intersection of US 168 and NC 34, travel north on US 168 approximately 9 miles Moyock Landing
Road will be on the right. Turn on Moyock Landing Road. Travel 1000' project will be on the left
4. Latitude: 36° 32' 04" N Longitude: 76' 10' 56" W of the main entrance to the project.
II. 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 cert�fication
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):
❑CAMA Major
❑NPDES Industrial Stormwater
MSedimentation/Erosion Control: 6 ac of Disturbed Area
❑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 07July2009 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 ownsthe project):
Applicant/Organization: Currituck Health Investors. LLC
Signing Official & Title: Charles E. Trefzger, It. - Member/Manager
b. Contact information for person listed in item la above:
Street Address: I270 25t° Street Place, SE
City: Hickory State: NC Zip: 28602
Mailing Address (if applicable): P:07135T2568-7
City: Hickory State: NC Zip: 28603-2568
Phone: ( 828 1 322-5535 Fax: ( 828 1 322-3897
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/
Signing Official &
b. Contact information for person listed in item 2a above:
Street Address:
State:
Mailing Address (if
City: State
Phone: 11_ _ _ 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 Person/Organization: Smith/Packett Med-Com. LLC
Signing Official & Title: Clayton Perry
b. Contact information for person listed in item 3a above:
Mailing Address: 4423 Pheasant Ridge Road. Suite 301
City: Roanoke State: VA Zip: 24014
Phone: [phone] Fax: ( 540 1 772-6470
Email: [e-mail]
4. Local jurisdiction for building permits: Currituck County
Point of Contact: Donna Voliva Phone k: ( 252 ) 232-2055
Form SWU-101 Version 07July2009 Page 2 of 6

IV: PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
All runoff from impervious surfaces will be collected in a combination of underground ping and grass lined
swales. The piping and swales will route runoff to a wet detention basin designed for 90% TSS removal.
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.Identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW -1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Pasauotank River basin.
4. Total Property Area: 6 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': 6 acres
Total project area shall be calculated to exclude the followingg the normal pool of hnppounded structures, the area
between the banks of streams and rivers, the area below the Nornal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHIline. 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.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 37.43 %
9. How many drainage areas does the project have? 2 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density 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.
Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
Receiving Stream Name
Moyock Run
Moyock Run
Stream Class *
C; SW
C; SW
Stream Index Number *
30-1-2-2-1
30-1-2-2-1
Total Drainage Area (so
202,485
58,875
On -site Drainage Area (so
202,485
58,875
9
Off -site Drainage Area (sf)
0
0
Proposed Impervious Area" (so
96,257
1,560
DW8
% Impervious Area** total
47.53%
2.65%
rnv
Impervious— Surface Area
Draina e Area 1
Draina e Area 2
Draina e Area _
Draina e Area _
On -site Buildings/Lots (so
35,221
0
On -site Streets (so
0
0
On -site Parking (so
48,709
398
On -site Sidewalks (so
7,486
1,162
Other on -site (so
400
0
Future (so
4,441 1
0
Off -site (so
0
0
Existing BUA*** (so
0
0
Total (so:
96,257
1,560
* Stream Class and Index Number can be determined at: http://h2o.enr.state.nc.us/birns/re2orts/reportsWB.htrnl
frn ervious 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 removed and which will be replaced by new BUA.
Fonn SWU-101 Version 07Ju1y2009 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation.
Projects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
fromhttr)://h2o.enr.state.nc.us/su/bmn forms.htm.
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 http://h2o.enr.state.nc.us/su/bmp forms.htm. 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://h2o.enr.state.nc.us/su/msi maps.htm.)
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:/Zh2o.enr.state.nc.us/su/bmp forms.htm.
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. #q6Cc>
4. Permit application processing fee of SbBr payable to NCDENR. (For an x ress review refer to
htto://www.envhelp.org/pages/onestopexpress.html for information on t e xpress program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/management for
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within'/: mile of the site boundary, include the'/t
mile radius on the map.
7. Sealed, signed and dated calculations.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
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 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).
—Dm
WA-
Form SWU-101 Version 07July2009 Page 4 of 6

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"xlI" 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 ver� the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1102 Page No: 36
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 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.$tate.nc.us/Corl2orations/CSearch.asl2x
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
http:Hh2o.enr.state.nc.us/su/bml2 forms.htm#deed restrictions. 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.
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: Sean C. Robe_y, PE
Consulting Firm: Hyman & Robey. PC
Mailing Address: P. O. Box 339
Phone: ( 252 ) 338-2913
Email: [e-mail]
State: NC Zip: 27921
Fax: ( 252 ) 338-5552
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) 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 la) with (print or type name of organization listed in
Contact Information, item lb) 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.
Form SWU-101 Version 07luly2009 Page 5 of 6

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. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
a Notary Public for the State of
do hereby certify that
before me this _ day of
stormwater permit. Witness my hand and official seal,
SEAL
Date:
County of
personally appeared
and acknowledge the due execution of the application for a
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 2) Charles E. Trefgger, fr.
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 c ormance with the approved plans, that the required deed restrictions
and protective coven s will be recoA4d, and that the proposed project complies with the requirements of the
applicable stormw er es nder hA NCAC 21-I .1000, SL 2006-246 (Ph. fl — Post Construction) or SL 2008-211.
Date: !#,0/04
I, AfCHARG 8. /%&maye4dr a Notary Public for the State of N04f11Ae0&/NA Countyof
CATAA044 do hereby certify that 61ARt[3 E. Ri EPi6E4. TA. personally appeared
before me this2erday of SdRMAt6E2 Abo9 and ac owledge the due execution- f the application for a
stormwater permit. Witness my hand and official seal, 6.
0 Q�ID B HOH�`0
W
CpAM E7�IRES -
o s■ zu
11iBG9 -%1300 ?V
s�4 cooN
SEAL
My commission expires OV12 L//,/
Form SWU-101 Version 07July2009 Page 6 of 6

+ �,
°. 'r f'

EXPRESS
OCT 08 2009
Permit Number:
(to be provided by DWQ)
Drainage Area Number:
Wet Detentigoi*hweration 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.
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):
❑ does ® does not incorporate a vegetated filter at the outlet.
This system (check one):
® does ❑ does not incorporate pretreatment other than a forebay.
Important maintenance procedures:
— Immediately after the wet detention basin is established, the plants on the
vegetated shelf and perimeter of the basin should be watered twice weekly if
needed, until the plants become established (commonly six weeks).
— No portion of the wet detention pond should be fertilized after the first initial
fertilization that is required to establish the plants on the vegetated shelf.
— Stable groundcover should be maintained in the drainage area to reduce the
sediment load to the wet detention basin.
— If the basin must be drained for an emergency or to perform maintenance, the
flushing of sediment through the emergency drain should be minimized to the
maximum extent practical.
— Once a year, a dam safety expert should inspect the embankment.
After the wet detention pond is established, it should be inspected once a month 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 should be kept in a known set
location and must 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 BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the wet
Areas of bare soil and/or
Regrade the soil if necessary to
detention basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide time and a
one-time fertilizer application.
Vegetation is too short or too
Maintain vegetation at a height of
long.
I approximately six inches.
Form SW401-Wet Detention Basin O&M-Rev.4 Page I of 4

Permit
(to be provided by DWQ)
Drainage Area Number:
BMP element:
Potentialproblem:
How I will remediate theproblem:
The inlet device: pipe or
The pipe is clogged.
Unclog the pipe. Dispose of the
Swale
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged.
Erosion is occurring in the
Regrade the swale if necessary to
swale.
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design depth for
possible. Remove the sediment and
sediment storage.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
The vegetated shelf
Best professional practices
Prune according to best professional
show that pruning is needed
practices
to maintain optimal plant
health.
Plants are dead, diseased or
Determine the source of the
dying.
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticide is used, wipe it on
the plants rather than spraying.
The main treatment area
Sediment has accumulated to
Search for the source of the
a depth greater than the
sediment and remedy the problem if
original design sediment
possible. Remove the sediment and
storage depth.
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Algal growth covers over
Consult a professional to remove
50°% of the area.
and control the algal growth.
Cattails, phragmites or other
Remove the plants by wiping them
invasive plants cover 50% of
with pesticide (do not spray).
the basin surface.
Form SW401-Wet Detention Basin O&M-Rev.4 Page 2 of 4

Permit Number:
(to be provided by DWQ)
Drainage Area Number:
BMP element:
Potentialproblem:
How I will remediate theproblem:
The embankment
Shrubs have started to grow
Remove shrubs immediately.
on the embankment.
Evidence of muskrat or
Use traps to remove muskrats and
beaver activity is present.
consult a professional to remove
beavers.
A tree has started to grow on
Consult a dam safety specialist to
the embankment.
remove the tree.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs re air. if applicable)
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose
of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the local NC Division of
damage have occurred at the
Water Quality Regional Office, or
outlet.
the 401 Oversight Unit at 919-733-
1786.
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 5.5 feet in the main pond, the sediment
shall be removed.
When the permanent pool depth reads 3.5 feet in the forebay, the sediment
shall be removed.
Sediment Removal
Bottom
BASIN DIAGRAM
(fill in the blanks)
Permanent Pool Elevation 4.50
I.00 � Pe anen Pool
----------- -- Volume Sediment Removal Elevation -1.00
Volume
--
0.00 -ft Min. ------------- --------------- -----------
-----
Sediment Bottom Elevation -2.00
I-ft- r
Storage
Sedimei
Storage
FOREBAY MAIN POND
Form SW401-Wet Detention Basin O&M-Rev.4 Page 3 of 4

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: Currituck Assisted Living Center
BYIP drainage area number:
Print name: Charles E. Trefuer, Jr.
Title: Member/Manager - Currituck Health Investors, LLC.
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, KtCMAAd J. 11Mayeu rr a Notary Public for the State of
410"tl CA06&4WA County of CAM &d44 do hereby certify that
( t(AQtES E• IAEFaCM, T. personally appeared before me this .78r"
day of SEPISA6" , A089 , and acknowledge the due execution of the
forgoing
seal,
basin maintenan a requirements.
A
TA91MY
COAL
SI O�IRES
L
o : or
q4trtnnr\•
SEAL
My commission expires `r
Witness my hand and official
Form SW401-Wet Detention Basin O&M-Rev.4 Page 4 of 4

Permit No.
(to be provided by DWO)
EXPRESS
OCT 08 2009
®TA
o2oF WATFgOv
NCDENR
SIC DENR o�<
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
WET DETENTION BASIN 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 of the required information.
1.NRROJECTp INFORMATION
Project name
Cunituck Assisted Living Center
Contact person
Sean C. Robey, PE
Phone number
Dale
Drainage area number
IINDE SIGN I I NF•ORMATION
Site Characteristics
Drainage area
202,485 B2
Impervious area, post -development
96,257 B2
% impervious
47.54
Design rainfall depth
1.5 in
Storage Volume: Non -SA Waters
Minimum volume required
14,309 B1 OK
Volume provided
17,547 ff°
OK, volume provided is equal to or in excess of volume required.
Storage Volume: SA Waters
1.5' runoff volume
g1
Pre -development 1-yr, 24-hr runoff
rya
Post -development 1-yr, 24-hr runoff
it
Minimum volume required
0 Bs
Volume provided B1
Peak Flow Calculations
Is the pre/post control of the lyr 24hr storm peak Bow required? N (Y or N)
1-yr, 24-hr rainfall depth 3.4 in
Rational C, pre -development 0.30 (unifless)
Rational C, post -development 0.55 (unifless)
Rainfall intensity: l-yr, 24-hr storm 3.40 inlhr OK
Pre -development 1-yr, 24-hr peak Bow 4.74 hslsec
Post -development 1-yr, 24-hr peak Bow 8.69 ff°Isec
Pre/Post 1-yr, 24-hr peak Bow control 3.95 ft°/sec
Elevations
Temporary pool elevation 5.75 fmsl
Permanent pool elevation 4.50 fmsl \\\y11GAIII (,/`
SHWT rm elevation (approx. al the pen. pool elevation) 4.50 fmsl \ \ Rn V
Top of 10ft vegetated shelf elevation 5.00 fmsl �� �. • ' ' • ��
Bottom of toff vegetated shelf elevation 4.00 fmsl \OP•'�G :�:.a�G1; •'��i
Sediment cleanout, top elevation (bottom of pond) -1.00 frost • Q� _
Sediment cleanout, bottom elevation -2.00 fast a S c
Sediment storage provided 1.00it
Is there additional volume stored above the state -required temp. pool? N (Y or N) c4;.
VGl?SF�;•.• ��
Elevation of the top of the additional volume fmsl ;, " ON U\�
Form SW401-Wet Detention Basin-Rev.5 Pans I. a 11. Design Summary - DAt, Page 1 of 2

Permit No.
(to be Provided by DWD)
11.7DESI GN IINEORMATION
Surface Areas
Area, tempomry pool
Area REQUIRED, permanent pool
SAIDA ratio
Area PROVIDED, permanent pool, Aoem,
Area, bottom of 10ft vegetated shelf, Abe,,„,
Area, sediment deanout, top elevation (bottom of pond), A.
Volumes
Volume, temporary pool
Volume, permanent pool, Vr,, .
Volume, forebay (sum of forebays If more than one forebay)
Fombay % of permanent pool volume
SAIDA Table Data
Design TSS removal
Coastal SAIDA Table Used?
MountairdPiedmont SAIDA Table Used?
SAIDA ratio
Average depth (used in SAIDA table):
Calculation option 1 used? (See Figure 10-21g)
Volume, permanent pool, Vr,,,.
Area provided, permanent pool, A._,,
Average depth calculated
Average depth used in SAIDA, d,,, (Round to nearest 0.5ft)
Calculation option 2 used? (See Figure 10-2b)
Area provided, permanent pool, A,_.
Area, bottom of 1 Oft vegetated shelf, Ab�,I„r
15,497 ft2
10,894 ft2
5.38 (unitless)
11,436 ft2 OK
8,744 ft'
1,175 ft'
17,547 ft' OK
27,331 ft'
5,432 ft'
19.9% % OK
90 %
Y (Y or N)
N (Y or N)
5.38 (unitless)
N (Y or N)
ft'
It,
ft
Y (Y or N)
11,436 ft2
8,744 ft'
Area, sediment cleanout, top elevation (bottom of pond), A.-,. 1,175 ft'
"Depth' (distance b/w bottom of 10ft shelf and top of sediment)
5.00 ft
Average depth calculated
3.27 It
Average depth used in SAIDA, d,,, (Round to nearest 0.5ft)
3.5 ft
Drawdown Calculations
Drawdown through onfice?
Y
(Y or N)
Diameter of orifice (if circular)
2.25 in
Area of orifice (if -non -circular)
in'
Coefficient of discharge (CD)
0.60 (unitless)
Driving head (Ho)
0.42 It
Drawdown through weir?
N
(Y or N)
Weir type
(unitless)
Coefficient of discharge (C.)
(unitless)
Length of weir (L)
It
Driving head (H)
It
Pre -development 1-yr, 24-hr peak flow
4.74 ft'Isec
Post -development 1-yr, 24-hr peak flow
8.69 ft'Isec
Storage volume discharge rate (through discharge orifice or weir)
0.09 ft'/sec
Storage volume drawdown time
2.37 days
Additional Information
Vegetated side slopes
3 :1
Vegetated shelf slope
10:1
Vegetated shelf width
10.0 ft
Length of flowpath to width ratio
3 :1
Length to width ratio
3.7 :1
Trash rack for overflow & orifice?
Y
(Y or N)
Freeboard provided
3.5 ft
Vegetated filter provided?
N
(Y or N)
Recorded drainage easement provided?
N
(Y or N)
Captures all runa8 at ultimate build -out?
Y
(Y or N)
Drain mechanism for maintenance or emergencies
pump
OK
OK
OK
OK
OK
OK
Insufficient pre -development peak flow.
OK
OK, draws down in 2-5 days.
OK, drawdown time is correct.
OK
OK
OK
OK
OK
OK
C R � C)l��f�/i
���pP 'FE SS1�; � ��• �.
Sr -AL
OK
OK
Insufficient. Recorded drainage easement required.
OK
Form SW401-Wet Detention Bmun-Rev.5 Parts 1. & II. Design Summary- DA1, Page 2 of 2

Permit
(to be provided by DWQ)
IIL REQUIRED ITEMS CHECKLIST 11
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.
Pagel Plan
TInitials Sheet No.
I AA 2 to 4 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),
- Basin dimensions,
- Pretreatment system,
- High flow bypass system,
- Maintenance access,
- Proposed drainage easement and public right of way (ROW),
- Overflow device, and
- Boundaries of drainage easement.
8 2. Partial plan (1" = 30' or larger) and details for the wet detention basin showing:
- Outlet structure with trash rack or similar,
- Maintenance access,
- Permanent pool dimensions,
- Forebay and main pond with hardened emergency spillway,
- Basin cross-section,
- Vegetation specification for planting shelf, and
- Filter strip.
8 3. Section view of the wet detention basin (1" = 20' or larger) showing:
- Side slopes, 3:1 or lower,
- Pretreatment and treatment areas, and
-Inlet and outlet structures.
Attached 4. If the basin is used for sediment and erosion control during construction, clean out of the basin is specified
on the plans prior to use as a wet detention basin.
Attached 5. A table of elevations, areas, incremental volumes & accumulated volumes for overall pond and for forebay,
to verify volume provided.
5 6. A construction sequence that shows how the wet detention basin will be protected from sediment until the
n entire drainage area is stabilized.
!1• � Attached 7. The supporting calculations.
Attached 8. A copy of the signed and notarized operation and maintenance (O&M) agreement.
/' NIA 9. A copy of the deed restrictions (if required).
/ )v Attached 10. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. County
soil maps are not an acceptable source of soils information.
Form SW401-Wet Detention Basin-Rev.5 Part III. Required Items Checklist, Page 1 of 1

UCL Ub Ub U1:Jtlp H. Rlm Ula e5e-4J5-bbtlb p.e
Oet 06 09 11:17a Hyman Robeti
October 6, 2009
70 Whom It May Concern:
252 331 2390
As the owner of property adjacent to the proposed Currituck Assisted Living, I hereby
grant permission to Currituck Health Investors, LLC and Smith-Packett Med-Com to
apply for and perform land disturbing activities on my land as necessary to install a
property line drainage swale and to fill a portion of an existing.
p.2
Sincerely,
EXPRESS
,74ner's ignature OCT 08 2009
Printed Name NC ®ENR
Jerry Old, President
CTX, Inc.
378 Caratoke Highway
Moyock, NC 27958
(NOTARY) t. (D__o ik -S�Q N L QYU as a notary public
certify under th'\e�p��ains and enalties of perjury that I witnessed the
signature of l l•Al1 (� and the individual's identity was
verified, on It date 20e, My
commission expires on —a04_Iotq