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HomeMy WebLinkAboutSW4210704_Application Form_20211210DEMLR USE ONLY Date Received Fee Paid Permit Number Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction (select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan ❑ Other WQ M mt Plan: State of North Carolina Department of Environment and Natural Resources Division of Energy, Mineral and Land Resources STORMWATER MANAGEMENT PERMIT APPLICATION FORM This form may be photocopied for use as an original 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.): Dolcetto 2. Location of Project (street address): 122 Webb Road City:Lexington County:Davidson Zip:27295 3. Directions to project (from nearest major intersection): The site is at the norteast quadrant of the the intersection of West Center Street and Biesecker Road 4. Latitude:35* 50' 48" N Longitude: 80° 16' 36" W of the main entrance to the project. II. PERMIT INFORMATION: 1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt tRenewals with modifications also requires SWU-102 - Renewal Application Form b.If this application is being submitted as the result of a modification to an existing permit, Iist the existing permit number , its issue date (if known) , and the status of construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification 2. Specify the type of project (check one): ®Low Density ❑High Density ❑Drains to an Offsite Stormwater System ❑Other 3. If this application is being submitted as the result of a previously returned application or a letter from DEMLR requesting a state stormwater management permit application, list the stormwater project number, if assigned, DAVID-2021-049 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 ®Sedimentation/Erosion Control: 44.3 ac of Disturbed Area ❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number, issue date and the type of each permit:Dolcetto DAVID-2020-039 5/22/2020 Sediment/Erosion Contol Plan 5. Is the project located within 5 miles of a public airport? ❑No ®Yes If yes, see S.L. 2012-200, Part Vl: http://12ortal.ncdenr.org/web/lr/rules-and-regulations Form SWU-101 Version Oct. 31, 2013 Page I of 6 III. CONTACT INFORMATION 1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee, designated government official, individual, etc. who owns the project): Applicant/Organization: New Ventures Land Development. LLC Signing Official & Title:David Bradley Coe, Member b.Contact information for person listed in item 1a above: Street Address:6638-A NC-109 City: Winston-Salem State:NC Zip:27107 Mailing Address (if applicable):PO Box 36 City:Walburg State:NC Zip:27373 Phone: (336 ) 970-7935 Fax: ) Email:coefor@gmail.com c. Please check the appropriate box. The applicant listed above is: ® The property owner (Skip to Contact Information, item 3a) ❑ Lessee* (Attach a copy of the lease agreement and complete Contact 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/Organization: Signing Official & Title: b. Contact information for person listed in item 2a above: Street Address: City: State: Zip: Mailing Address (if applicable): City: State: Zip: Phone: ( ) Fax: Email: 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: Signing Official & Title: b.Contact information for person listed in item 3a above: Mailing Address: City: State: Zip: Phone: ( ) Fax: ( ) 4. Local jurisdiction for building permits: Davidson County Point of Contact:lennifer Goble Phone #: L336 } 242-2230 Form SWU-101 Version Oct. 31, 2013 Page 2 of 6 IV. PROJECT INFORMATION 1. In the space provided below, briefly summarize how the stormwater runoff will be treated. The stormwater will be treated through a combination of dispersed flow, vegetated conveyances, vegetated setbacks stormwater outlets and a dry detention pond. 2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved: ❑ Approval of a Site Specific Development Plan or PUD Approval Date: ❑ Valid Building Permit Issued Date: ❑ Other: Date: b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with: ❑ Coastal SW -1995 ❑ Ph II - Post Construction 3. Stormwater runoff from this project drains to the Yadkin/Pee-Dee River basin. 4. Total Property Area: 77.73 acres 5. Total Coastal Wetlands Area: acres 6. Total Surface Water Area: 0.45 acres 7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project Area+:77.28 acres + Total project area shall be calculated to exclude the following: the norinat pool of impounded structures, the area between the banks of streams and rivers, the area below the Normal High Water (NHM line or Mean High Water (MHW) line, and coastal wetlands landward from the NHW (or MHM line. The resultant project area is used to calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line niay be included in the total project area. 8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =17.3 % 9. How many drainage areas does the project have?1 (For high densihj, count 1 for each proposed engineered stormwater BMP. For low densihj and other projects, use 1 for the whole properhj 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 _ Drainage Area _ Drainage Area Receiving Stream Name Swearing Creek Stream Class * C Stream Index Number * 12-113 Total Drainage Area (so 3,366,316 On -site Drainage Area (so 3,366,316 Off -site Drainage Area (sf) 0 Proposed Impervious Area** (so 582,314 % Impervious Area** total 17.3 Impervious" Surface Area Drainage Area 1 Drainage Area _ Drainage Area _ Drainage Area _ On -site Buildings/Lots (so 476,000 On -site Streets (so 104,705 On -site Parking (so 1,329 On -site Sidewalks (so 0 Other on -site (so 280 Future (so 0 Off -site (so 0 Existing BUA*** (so 0 Total (so: 582,314 * Stream Class and Index Nuinber can be determined at: Iittp.Y portal.nodetir.orghuebfwc&yp sulclassi cations Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks, gravel areas, etc. Form SWU-101 Version Oct. 31, 2013 Page 3 of 6 impervous area flowing; onto the developed area of the site _ Projects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened & Endangered Species watershed that may be subject to more stringent storm water requirements as per 1 SA 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 from htW://portal.ncdenr.orgjweb/wo/ws/su/bmn-manual. VI, SUBMITTAL REQUIREMENTS Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application instruction sheet and BMP checklists are available from http:/ /portal.ncdennorg/web/wq/ws/su/statesw/forms dots. The complete application package should be submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the interactive online map at hip:/ /portal.ncdenr org/web/wg/ws/su/maps.) Please indicate t the following re uired information have been grovided 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:/ /portal.ncdennom/web/wq,/ws/su/statesw/forms dots. Initials 1. Original and one copy of the Stotmwater Management Permit Application Form. 2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants Form. (if required as per Part VII below) 3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M agreement(s) for each BMP. 4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to 77?*1° http:/ /www envheiR.orgjpages/onestgpexpress html for information on the Express program and the associated fees. Contact the appropriate regional office Express Permit Coordinator for additional information and to schedule the required application meeting.) 5. A detailed narrative (one to two pages) describing the stormwater treatment/management for 6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the 11(� receiving stream drains to class SA waters within % mile of the site boundary, include the 1h mile radius on the map. 7. Sealed, signed and dated calculations (one copy). AZ____ 8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including. L� a. Development/Project name. b. Engineer and firm. c. Location map with named streets and NCSR numbers. d. Legend. e. North arrow. f. Scale. g. Revision number and dates. h. Identify all surface waters on the plans by delineating the normal pool elevation of impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal waters, and any coastal wetlands landward of the MHW or NHW lines. • 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. e ayout 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 an 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). Form SWU-101 Version Oct. 31.2013 Page 4 of 6 9., Copy of any applicable soils report with the associated SHWT elevations (Please identify -r4fdl 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"xl1" 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 DEMLR to verify the SHWT prior to submittal, (9I0) 796-7378.) 10. A copy of the most current property deed. Deed book: 2390 Page No:1111 _ 11 , 11. For corporations and Iimited liability corporations (LLC): Provide documentation from the NC -"14. 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 15A 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. ht 1.I /www.secretary.state nc us/Corporations/CSearch aspx VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and protective covenants forms can be downloaded from httR://vortal.ncdenr.org/web/ir/state- nnw ter- orms doc . 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 DEMLR, 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:Thomas R. Glover, Tr., PE Consulting Firm:lamestown Engineering Group Inc Mailing Address:PO Box 365 City:lamestown Phone: (336 ) 886-5523 Email:r lovelQ.Iamestownengineering com State:NC Zip:27282 Fax: (336 ) 6-5478 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 1a) with (print or type name of organization listed in Contact Information, item 1a) 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 Oct. 31, 2013 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 DEMLR Stormwater permit reverts back to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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. Signature: Date: I, a Notary Public for the State of County of do hereby certify that personally appeared before me this _ day of , and acknowledge the due execution of the application for a stormwater permit. Witness my hand and official seal, SEAL My commission expires X. APPLICANT'S CERTIFICATION I, (print or type name of person listed in Contact Information, item 1a) David Bradleu Coe certify that the information included on this permit application form is, to the best of my knowledge, correct and that the project will be constructed in conformance with the approved plans, that the required deed restrictions and protective covenants will be recorded, and that the proposed project complies with the requirements of the applicable stormwateryules under 15� N�'•� .1000 and any other applicable state stormwater requirements. Signature: -�x� .i!,��,.ir'1�� Date: L. 11it , -a Notary Public for the State of W pair. WOUft4 , Countyof GtyiGiSQ'k, do hereby certify that bard Bmd w Coe- personally appeared before me this Aftair of _,, jai f_[ an knowledge the due execution of the application for a stormwater permit. Witness my hand and official seal, N EBECCA G CREA;1� Notary Public North Carolina Davidson County My commission expires Lq-& •caA Form SWU-101 Version Oct. 31, 2013 Page 6 of 6