SW6211003_Application Form_20211130

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 Mgnnt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
Tlds form nzay be plzotocopied 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.):
Dollar General - Red Sprin s Hoke County
2. Location of Project (street address):
NC 211 (Red Svrinvs Rd) and N Old Wire Rd (SR 1105)
City:Red S rings County:Hoke Zip:28377
3. Directions to project (from nearest major intersection):
1.36 ft. from the intersection of Old Wire Rd. and Walter Gibson Rd. 1,Ycoin NE towards Red Springs Rd., izn
0 s r +• 1 of project,
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenezoals with modifications also requires SWU-102 - Renezonl Application Form
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 I',ii n%v ii) I and the status of
construction: El Not Started ❑Partially Completed* El Completed' "provide a designers certifuatim
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 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 ® Sedimentation/ Erosion Control: 2.34 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:
5. Is the project located within 5 miles of a public --- -- ........ .........
p 1 p airport? ONo Yes
If yes, see S.L. 2012-200, Part VI: 1-ittD://vortal.ncdei-ir.org/webLwq/­­W������s/­`su/­­S--tatesw rules laws
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hnpervious� Surface Area Drainage Area 1 Drainage Area �I Drainage Area
On -site Buildings/Lots (sf)
10640
On -site Streets (sf)
.. _
p
.m.. _.... ...
On -site Parking (sf)
22064
On -site Sidewalks (sf)
1675
Other on -site (sf)
p
w�..... w
.........
Future (sf)
_...........ma—..�....�........... .....�..._
0
Off -site (sf)
0
Existing BUA*** (sf)
.......... _ .._
p
...._ _ ew
. ......................_ .,.
Shearr► laTotal (sf) 34379
grad Index umber **
er can be tic;tcrutarred at:
Drainage Area
lrtr aerza�aus artist s d� nerl' as the built' upon area including, but not limited to, buildings, roads, parking areas,
8t rya 5, grave ar. . s, e c.
* Deport only that amount of existing lWA th0t Will amin after development. Do not report any existing BLIA that is
to be removed and which -(trill be replaced by nrut BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. uka, '
Contact DWQ Central office staff to check of the project is located within a "Threatened
Endangered Species watershed that may be subiect to rrrrrre ,stri rgcrat ,s°tcrrnaw�cata r° requirements as per I'SA N(AC 02B .060o.
V. SUPPLEMENT AND O&M FORMS
The applicable stag storaaawvater ananagem ent pertnit supplernent and operation and maintenance (Oc M) forraas
must be submitted for each BM.P specified for dais project. The latest versions of the fortis can be downloaded
from hl, /.fr�l,tdr�,o.�11_.pcl.ttt.l ra.t'aatat,a).
VI. SUBMITTAL REQUIREMENTS
O"1Y complete application pack ages 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 irons Lalli.'. _:..l� r�R hN wwl.�w.dot:wtr The complete
application package should be submitted to the appropriate 1;1WQ Office. (The apprc)priate office may be
found by locating project on the interactive online map at )',a4t," fipe'i(nawt�rw�tt�t-tom )
Please iaadi t %t Ali � wit .i�o taut _ prtttt a:d �t 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 p / �A ,vY (t t1 ,
1. Original and one copy of the Stormwater Management Permit Application Form. tta 1.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form fif required as per Part VII belmo)
3. Original of the applicable Supplement Form(s) ( �,� � � imd O&M
a,gmernent(s) for taCh BMR
4. Permit application prOCessing fee of .$5tla payable to NCl.)IuNR, (For an 1 «xpr ss review, refer to 7� �
w n �t � fear infi rnaation on the Express program and
tlae associated fees. Contact t �e appropriate regioa7al offtce l xpanss permit Coordinator for
additional information and to srhedtale the xeuired. allalication nay*etiztg.)
Form SWU-101 Version 06Aug2012 Page of 7

5. A detailednarrative� two pages) g iaagementfor
�� the
edioadditionto the brief summary provided in the Project
project. This is r"r quir�
Information, item 1.
6. A USG'S map identifying the site location. If the receiving stream is reported as class SA or the
�
receiving stream d.raains to class SA waters within 1h mile of the site boundary, include the 1h
mile
radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to ll'.S'" ]Ail (sealed, signed, & dated), including:
a. Developnient,/Projectnarne.
b. Engineer and firm.
c. Loc.artiorr map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates,
la. Identify all surface waters on the plans by d't lineatinIg the normal pool elevation of
banks the MHW or NHW line of tidal
impounded structures, the of streams and rivers,
waters, and any coastal wetlands landward of die MHW or NHW lines.
° Delineate the, vegetated buffer landward fronn the normal pool elevation of inapct�cmded
structures, the banks of streams or rive:r.s, and the MHW (or NHW) of tidal waters.
i. 13imen:sioned property/project boundary with hearings & distances.
d Site layout with all BUA identified and di,me.nsicned.
k Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Del 'ails of roads, drainage., feaat-tires, collection systems, and stormwater control measures.
rta. "d etdarid s delineated, or a note oil the plans that: tone exist. (Must be delineated by a
clualified person, provide documentation of qualifications and identify the person who
made the deterininatiora on the plans.
n. Existing drainage (including off -site), dralraage-°, easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plaits, not as a separate doc'urcient).
P. vegetated buffers (where roqurred). �/
9. Copy of any applicable snarls report with theassociated SHWT elevations (Please identify ( 2
elevations in addition to depths) as well as a naap of the boring locations with the existing
elevations and boring togs Include: an 8 5"xll" copy of the NRCS County 'Soils map with the
project area cleanly delineated. For projects with infiltration 0Ml's,, the report should also
include the soil) type:., expected infiltration rate, and the method of determining the infiltration rate.
Onfiltration Devices subrnitt:ed to WiRO: Sclied tale a site visit for DWQ to verify the SHWTprior to
submittal, [phone].)
10. A copy of the most current property deed. Deed book: 290 _ Page No: 5, 59
1L d"or corporations and limited liability corporations (LI 0, Provide documentation from the NC
:secretary of State or other official docrrmc.ntation, wlardr supports the titles and positions held by
the persons, listed in Contact lnforniaation, item la, 2 a, and /or 3a per 1.5ANCAC 2H.1003(e).
The corporation or l..l.0 must belisted as an active corporation in good standing wrtlr the NC
Secretary of State, otherwise the application will be returned, htt a:-Lwivw.sCccretaxw.sta�te rae..u�s�
C'orpora�tiot1s tm Sear h_a x
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outpaarcels, arid future: development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the :sale of any lot. Iflot sizes vary significantly or they proposed
BUA allocations vary, a table listing each lot nuraabewr, lot sizea, arid the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The approlariate deed restTictrons and
protee:trve covenants forms can be downloaded fr'orta 11ti� _, .12gr Gd roc dr r rr rat"'f rcrc"1: �vw�l ! ,r s ari.dylmria.a,ci.
for nrs does. Download the latest versions for each submittal.
In the instances
stances 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 faun 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
oil the forms available on the website, that the covenants will be binding, on all, parties and persons claiming
under there, 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 stile of any lot.,
Form SWU-101 Version 06Aug2012 Page 5 of 7

VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete tl-rrs section if you wish to designate authority to another individual and/or firrn (such as a
consulting engineer and /or firma) :so that they rn.ay provide information on you behalf for this project (sucl"r as
addressing requests for additional information.).
Consulting F,:ngirac c r: a -r, lr, " 1� 111 _
m a
Consulting l rr°raa Z r�,
Mailing Address:4004 Barrett Drive Suite 101
("ity a®.IT.-... _ State:NC Zip:27609
Phone: ] 9 — T) 551-6970 _._— Fax:
Email:talcrwdcwr^�?�r'itrtlg���7tmr�ra~w �.
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) I?: )rya sJr—, -....._ , 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) (r;rrrrc7sa _ - __-- 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.
y y signature ww, Y esignated.
�� tlac� legal last°rlrr�rt o�vr�rer° l arr:tarrrrr�la.dl�r, rarrrler�•t<rrrdk ��rncl s�ree b lrrr �wi .,r�ra4rrre lreio that it rrr r.
l,tnt (c" y steel it r nd or carrttis or defaults on their
lease a '=reernerrt, or laending sale., responsibility for compliance with the DW " l s
ntmit li a Contact tnfornratio t, item 1) dissolves tl eir cram an � a
g � `1 fatormarter%-rerr"rart reverts back to
rrac, the property owner, As the property owner, it is my responsibility to notify DWQ immediately and submit a
1 w P g . days; otherwise 1 will be operating a stornawater treatment.
completed C'�lanac. �'t�wrae rshi� Change e 1^orra-r witlamra tl da s•
facility without a valid, permit" l understand that the operation of a stornawater trcatrnent facility without a valid
permit is a violation o C General Statue 143-21.1. and may result in appropriate enforcement action including
the assessment
of dvil penalties of up ho $25,000 per- day, pursuant to NCGS 143-215.6�.
Signatu.
Bate: 1"
I,
f r Y-) �� f M�� a Notary Public for the State of County of
m do hereby certify thatd (� L s ._ P l personally appeared
before me this ('0 day of 0Cfyk'X',/ and ackK ataawted ,e� t.le e � execution of the application for
�_
a stormwater permit. Witness m hand and official seal, �
P � Y � �
SEAL
My commission expi:r°es_-
*J-11AJ
Form SWU-101 Version 06Aug2012 Page 6 of 7

X. APPLICANT'S CERTIFICATION
1, (print tv IjII)enaine qfj)erson lisled in Conlacl Inforination, Wntla) JLgjnie-Enchv')S
(x,,,,aif thattheinforniation inClUded on thispen�nit application form is, tothebest of niy knowledge, cori"(12*0 and
if
that t�le pi-oject will be constructed in conformance° with the approved plans, that the required (feed restrictions
�ind pt-otective covenants will [v jvcord6i, and that the [-)j-(,)posecj ­M-oj(�Tt complies with the i-equii-enients of the
applicable stonnwater rules tindei, 15A NCAC 214 .1000 ana any other applicable state slormwatet, ivquirements.
Date. -
I, JLXJD1J11LQ�0 1 1'-)(,J'Z'J 1-101"C;121 a Notary Public for the State of J,,j_Ckj County of
KAOO ge "U'Y"o ----- - do hereby certify that ,,1(, -L ..,,,,_,,-,,,-personally appeared
before me this day of b("-,' R _�, 20211 andjo' cknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
I M M-- -... i.
SEAL
My commission expirejq�
)Liilj
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