SWA000125_Application Form_20211208

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
SW Program(s): Q Coastal SA-HQW ❑ Coastal SA-ORVV ❑ Coastal FW-ORW ❑ Coastal Other
❑ Non -coastal HQW ❑ Non -coastal ORW ❑ Urbanizing Areas ❑ USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to Application Instructions
A. ELIGIBILITY FOR FAST -TRACK PERMITTING
To be considered for a Fast Track ATC Permit, all of the items below must be checked. if any item cannot
be checked, then the project must apply under the Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project) will meet all applicable
requirements of 15A NCAC 02H .1000 - .1062, including the Minimum Design Criteria (MDC), upon project
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Director's
Certification.
® The project is not out of compliance with an existing stormwater permit or any other environmental permit.
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined in 15A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seal of a professional licensed pursuant to either Chapter 89A
or 89C of the NC General Statutes.
® I understand that at project completion, an application with the as -built stormwater plans (as described in 15A
NCAC 02H .1044 must be submitted, and DEQ will review the as -built stormwater plans to confirm
compliance with the MDC. Approval of the as -built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1 Project Name: Cleveland County_ Water Operations Center _
2. Previous Project Name (if applicable): NIA
3. Location of Project (street address): 715 Polkville Rd
City:ShelbV County: Cleveland Zip:28086
4. Directions to project (from nearest major intersection):
1400 LF South of Intersection of NC 226 and the New Shelby Bypass
3100 LF North of interection of NC 226 and Grover Street
5. Latitude:350 18' 50" N
C. PERMIT INFORMATION
Longitude:-81 ° 34' 16" W of the main entrance to the project.
1. Specify whether project is (check one):
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: SWA
By choosing this option, you are also requesting that DEQ rescind the previous Fast Track ATC Permit
upon issuance of the new Fast Track A TC Permit.
Stormwater Fast Track ATC Application Form Page 1 of 9 Feb. 10. 2018

❑ Major Modification, replacing an existing stormwater permit— provide existing permit number: SW
Status of construction? ❑ Not Started ❑ Partially Completed ❑ Completed
Major modifications must be submitted by the original permittee and are allowed only If the SW permit is
not expired. Minor modifications must use Standard Permitting Process. By choosing this option, you
are also requesting that DEQ rescind the previous SW Permit upon issuance of the new Fast
Track ATC Permit.
❑ Transfer of existing Fast Track ATC Permit — provide existing ATC permit number: SWA
2. Applicable state stormwater program(s) (check all that apply):
❑ Coastal SA-HQW ® Urbanizing Areas (Phase 2)
❑ Coastal SA-ORW ❑ Non -Coastal HOW
Is any portion of the project within 575 feet
of SA-ORWwaters? ❑ Yes ❑ No ❑ Non -Coastal ORW
❑ Coastal Freshwater ORW ❑ USMP
❑ Coastal — Other
3. Other Permits (as applicable, write "NA" for those permit types that are not applicable):
Project Name
PermitlAppl
Issue Date
Other Information
No.
CAMA Major
NA
NA
Erosion &
Cleveland County Operations
Disturbed Area 6.4
Sedimentation Control
acre
Center
NPDES Industrial
NA
NA
Stormwater
404/401 Permit
NA
Proposed Impacts
Iflac
4. Local jurisdiction for building permits: City Of Shelby
Point of Contact. -Tyler Brooks - Stormwater/Engineering Phone #: 7( 04 ) 669-2064
D. CONTACT INFORMATION
Applicant/Financially Responsible Party (may be an Organization): Cleveland County Water
Signing Official Name & Title: Brad Cornwell - General Manager
Street Address:439 Casar Lawndale Rd
City: Lawndale State -.NC Zip:28090
Mailing Address (if different) -.PO Box 788
City-.Lawndale State: NC Zip:28090
Phone: [phone] _ Fax:
Email: brad. cornweI1 clevelandcount water.com
2. If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the Secretary of
State):
Name of Registered Agent
Mailing Address:
City: State:
Phone: Fax:
Email:
Zip:
Stormwater Fast Track ATC Application Form Page 2 of 9 Feb. 10, 2018

3. The Applicant is the (check all that apply):
® Property Owner
❑ Lessee (Attach a copy of the lease agreement & complete Item 4.)
❑ Purchaser (Attach a copy of the pending sales agreement & complete Item 4.)
❑ Developer (Attach a copy of the development agreement & complete Item 4.)
4. If the Applicant is NOT the Property Owner (skip to Item 5 if the Applicant IS the Property Owner):
Property Owner Name/Organization:
Signing Official & Title:
Street Address:
City: State: Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
5. The licensed Design Professional that will be retained for the duration of the project, who may provide
information on the Applicant's behalf, and who will prepare and certify the as -built package:
Consulting Engineer/Landscape Architect:B. Chad Houser
Consulting Firm: TGS Engineers
Mailing Address:201 W. Marion St
City:Shelby State:NC Zip:28150
Phone: (704 ) 476-0003 ext 311 Fax: ( )
Email:chousera-tgsengineers.com
6. [OPTIONAL] If you would like to designate another person to answer questions about the project
Name & Title:B. Chad Houser. Professional Enaineer
Organization: TGS Engineers
Mailing Address:201 W. Marion St
City:Shelby State:NC Zip:28150
Phone: (704 ) 476-0003 ext 311
Email:chousera-tgsengineers.com
PROJECT INIFORMATIO_
1. Specify the type of project (check one): ❑ Low Density
Fax: ( )
® High Density
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
The erosion control silt basins will be converted to wet ponds after grading is complete.
3. Stormwater runoff from this project drains to the Broad
River basin(s).
4. Receivinq water information (if more than 3 receivinq waters, provide additional information on an attached sheet):
Receiving
Water 1
Receiving
Water 2
Receiving
Water 3
Receiving Stream Name
Brushy Creek
Stream Classification
C
Stream Index Number
9-50-29
Stormwater Fast Track ATC Application Form Page 3 of 9 Feb. 10, 2018

5. Project area and density information:
Total Property Area
765,785 sf
Total Surface Water Area
13,100 sf
Considered to include:
• the normal pool of impounded structures;
• the area between the banks of streams and rivers, and
• the area below the Normal High Water (NHVIO line or Mean High Water (MHM line.
Total Coastal Wetlands Area
0 sf
Considered to include: coastal wetlands landward from the NHW (or MHM line.
Total Project Area
752,685 sf
Excludes the surface water area and coastal wetland area identified above.
May or may not be the same as Property Area.
Built -Upon Area (BUA) associated with Existing Development
0 sf
"Existing development" means those projects that are built or those projects that have established a
vested right under North Carolina law as of the effective date of the state storm water program or
applicable local government ordinance to which the project is subject.
Proposed New BUA
118,140 sf
Includes proposed new BUA that is not associated with existing development.
`BUA" is defined in N. C. G. S. 143-214.7(b2). It includes, but is not limited to: buildings, roads, parking
areas, sidewalks, and some gravel areas. The design volume of SCMs must take into account the runoff
from build out from all surfaces draining to the SCMin accordance with 15A NCAC 02H .1050(1).
Project Density
w/ Existing Development: Project Density = [New BUA]/[Total Project Area —Existing BUA] x 100 or
15.7 %
w/o Existing Development: Project Density = [New BUA]/Total Project Area] x 100
6. Anticipated construction start date March 2022
7. Is the project located within 5 miles of a public airport? ® No ❑ Yes
If `Yes,' see S.L. 2012-200, Part VI: http://www.ncleg.net/Sessions/2011 /Bills/Senate/PDF/S229v6.pdf and
DEQ Stormwater Design Manual Chapter E-4 Airports.
8. For projects in Union County: Contact DEMLR Central Office Stormwater staff at 919-707-9200 to determine
if the project is located within a Threatened & Endangered Species watershed that may be subject to more
stringent stormwater requirements per 15A NCAC 02B .0600.
Stormwater Fast Track ATC Application Form Page 4 of 9 Feb. 10, 2018

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQWIORW). Only application packages that include
all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
Initials
BCH 1. Two original signed hard copies and one electronic copy of this State Stormwater Fast Track
Process "Authorization to Construct" (ATC) Permit Application Form.
BCH 2. Permit application processing fee of $505 payable to NCDEQ.
BCH 3. Two hard copies and one electronic copy of a USGS map identifying the project location
and GPS coordinates for the project. If the receiving water is Class SA or the receiving water
drains to Class SA waters within '/2 mile of the project boundary, include the'/z mile radius
on the map. If the project is within 575 feet of Class SA-ORW waters, include the 575-foot
radius on the map.
BCH 4. Two original signed hard copies and one electronic copy of a site plan depicting the boundary
of the project or project phase currently being permitted, including the locations of SCMs,
streams, wetlands, and buffers.
BCH 5. Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased.
BCH 6. A copy of the most current property deed. Deed book: 1759 Page No: 2036
NIA 7. [IF APPLICABLE] When the applicant is a corporation or a limited liability corporation (LLC): Provide
two hard copies and one electronic copy of documentation from the NC Secretary of State, or other
official documentation, which supports the titles and positions held by the persons listed
in Section C.2 per 15A NCAC 2H. 1043(3)(b). The corporation or LLC must be listed as an active
corporation in good standing with the NC Department of the Secretary of State; otherwise, the
application will be returned. https:llwww.sosnc.gov/search/indexlcorp
NIA 8. [IF APPLICABLE] When the applicant is a Partnership or other person engaging in business under
an assumed name, attach a copy of the Certificate of Assumed Name,
NIA 9. [IF APPLICABLE] When the applicant is not the property owner: Provide two hard copies and one
electronic copy of lease agreements, affidavits, pending sales agreement, development agreement,
or other documents showing that the applicant has obtained legal rights to submit a stormwater
permit application within the proposed project area.
NIA 10. [IF APPLICABLE] If modifying an existing permit for completed or partially completed projects, a copy
of the designer's certification.
Stormwater Fast Track ATC Application Form Page 5 of 9 Feb. 10, 2018

G. CERTIFICATION OF APPLICANT/ FINANCIALLY RESPONSIBLE PARTY
The Applicant, who is also the Financially Responsible Party, identified in Section D of this form must sign and have
notarized the following guaranty: �f7;
I, (print or type name of Applicant/Financially Responsible Party) ;/VPA CD/�ll%L� GL
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that:
1. the design has been or will be completed in accordance with the MDC as set forth in Rules 15A NCAC
02H .1050 through .1062, to the best of my knowledge;
2. the completed design meets or will meet the MDC and that the percentage BUA that is the basis for the
design shall not be exceeded, to the best of my knowledge; and
1 As the applicant, I shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as -built package. If I retain another licensed
professional before the project is complete, then I shall provide an updated
guaranty with the current licensed professional's seal. A licensed professional shall inform
the Division if he is no longer associated with this project.
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath
agree to provide corrected information should there be any change in the information provided herein.
21�&�WaL A4wMew
Y102-11 t Title or Authority
rx
Signature
Date
I, Laivvlande, a Notary Public for the State of f 9 ail
County of _LleGc.vl do heJJr eby certify that�->r'.A L7`IrZ(t
personally a geared before me this y day of �fNeAAk bPr- and acknowledge the
cu n d e goe :��ti n as rmwa r permit. Witness my hand and official seat,
SEAL
My commission expires /f - //-?_)0 3
Stormwater Fast Track ATC Application Form Page 6 of 9 Feb. 10, 2018

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be completed by the Design Professional identified in Section D.5.
I, B. Chad Houser, PE, PLS , attest to the following:
1. This application has been reviewed by me and is accurate and complete, to the best of my knowledge;
2. The design has been completed in accordance with the MDC as set forth in Rules 15A NCAC 02H
A050 through .1062, as applicable;
3. The percentage built -upon area that is the basis for the design will not be exceeded; and
4. 1 have the expertise, education, and experience required to design the SCMs proposed in this
application in accordance with the MDC as set forth in Rules 15A NCAC 02H .1050 through .1062.
5. 1 will provide all documents and certified as -built plans in hard copy and electronic format related to
this permit to a new Applicant/Property Owner and to DEMLR upon transfer of this permit to a new
Applicant/Property Owner.
Note: In accordance with N.C.G.S. 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. In addition, any person
who knowingly makes any statement, representation, or certification in any application may be reported to
the appropriate NC prgW,ional ltc�y�sing board.
Signature:
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Stormwater Fast Track ATC Application Form Page 7 of 9 Feb. 10, 2018