SW6220203_Application Form_20220225

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph 1I - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Manageinent Plan
❑ Other WQ M it Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Dollar General - Paeford (Hoke Cou11LV)
2. Location of Project (street address):
NC-211 (Aberdeen Rd) and Fulford McMillan Rd
City
County:
3. Directions to project (from nearest major intersection):
440 ft. from the intersection of Aberdeen Rd. and Fulford McMillan Rd.
Zip:28376
SE towards Henderson Str.
4. Latitude:35° 00' 24" N Longitude:79° 18' 16" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRerr«vals u4th modifications also requires SVVU-102 - Rencwal Apl)licahoa Forra
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 kinown) , and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* provide a designer's certification
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: 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 airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: ht rt l.ntdenr.or web w ws su statesw rules laws
Form SWU-101 Version 06Aug2012 Page 1 of 6

'Report only that atnount of existing BLIA that u7ill remain after deveiopinent. Do not report any existing BLIA that
is to be removed and Which Will be replaced by nezv BLIA.
11. How was the off -site impervious area listed above determined? Provide documentation. Design drawings
Projects in Union Count: Contact DII'O Central Once stiff to check if the project is located within a Threatened &
Endangered Species iratershed that may be subject to more stringent stonnimter regatirements as per 154 NC4C 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 http://portal.ncdenr.org/web/wy/ws/su/bmp-manual.
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 1nttli.//Vc)rtal.ncdenr.org/web/wg/wsls-u statesw/forms does. 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 neap at hitp:/./portatncden.r,org/web/wg/ws/su/malls.)
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 htip://portal.ncdenr.org/weblwg/w,,/su/statc�.sw/Forms dom
Initials
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 belozv)
3. Original of the applicable Supplement Form(s) (staled, signedand slated} and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
]hLLj2:ZZwww.envhtiII2.org/pag.(,s/ont,sLopexprEiss.htnLI 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
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 1/2 mile of the site boundary, include the'/z
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
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.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the norinal 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 c alculat.iolts.
o. Drainage areas delineated (included in the main set of plans, not as a sollarate document).
p. Vegetated buffers (where required).
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9. Copy of any applicable soils report with the associated SHWT elevations (Please identify leg —
A copy of the most current property deed. Deed book: 924 Page No: 018
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 hnformation, item 1a, 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.
litLLi://www.s(icTotary.state,jit.-.,us/CtLrpt)raLions/MS arcli.aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
elevations in addition to depths) as well as a clap of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" 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 verifij the SHWT prior
to submittal, [phone].)
_ �CT
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-//porLalmcdolir.org/­web/wQ/w,;/`su/state,sw/fonns does. 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:Matt Lowder PE
Consulting Firm:_ Bowman North Carolina, Ltd.
Mailing Address:4006 Barrett Drive Suite 104
City:Raleigh
Phone: (919 ) 553-6570
Email:.mlowderCbbowman.com
State:NC
Fax:
Zip:27609
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed in Contact Information, item 2a) Robert Kenneth Currie certify that I
own the property identified in this permit application, and thus give permission to (print or hjpe name of person
listed in Contact Information, item 1a) Tamie Encinosa with (print or hjpe name of organization listed in
Contact Information, item 1a) Rhetson Com'anies, Inc _ 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.
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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 '21,111 per day, pursuant to NCGS 143-215.6.
Signature: � � Date:
I,� �rc�1��►�� a Notary Public for the State of �ioit LGtrpli�+c�. , County of
%-nt do hereby certify that B0temj,4L (Lr, personally appeared
before me this day of nC? bt/2annowLledd e the
ddue execution of the application for
a stormwater permit. Witness my hand and official sea,
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X. APPLICANT'S CERTIFICATION
SEAL
My commission expires 4j �. -�-
I, (print or hjpe name of person listed in Contact Information, item 1a) Tamie Encinosa
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 stormwater rules under 15A NCAC 2H .1000 and any other applicable state stormwater requirements,
Signature:
Date:'7 hy I'Z6Z-
I, JennMII' Who1x `R �_, a Notary Public for the State of ,CaM1[nae , County of
mao-9& , do hereby certify that J1mle: Fncino, _ personally appeared
before me this 24_ day of SEQtC-Y1bQR , 2021 am cknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
JENNIFER WNCXL
NOTARY PUBLIC
Moore County
North Carollna
Obn+ *elon E*rea 6M ", M=
SEAL
My commission expires ADO 121, 202 (..O
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