SW5160601_Application Form_20220314

Y
II Date Received I Fee Paid I Parmi# KI—hcr 1 11
STORMWATER PERMITTING FORM 7:
MINOR MODIFICATION
Standard Permitting Program — No Fee for Minor Modification
Express Permitting Program — See Express Fee Schedule
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: http://deg.nc..qovlcontactlre.gional-offices.
This form is to only to be used by the current permittee to notify the Division of a minor
modification. Pursuant to Rule 15A NCAC 02H .1002, a minor modification is a change to the project
1) does not increase the net built -upon area; and/or
2) does not change the size or design of the SCM(s).
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW5160601
2
3
4
5
Current Permit Holder's Company Name/Organization: Brookwood Farms, Inc.
Signing Official's Name: Mr. Jerry B. "Twig" Wood III
Signing Official's Title: President -Brookwood Farms. Inc.
Mailing Address: 1015 Alston Bridge Road
City: Siler City State: NC ZIP:
27344
6. Street Address (if different): _
City: State: ZIP:
7. Phone: [phone] Email:twigwood brookwoodfarms.com
8. Describe the minor modifications that you are requesting, including any revised BUA allocations (attach
additional pages or supporting tables similar to Section IV.10 of the original application, if needed):
4973sf building addition, 1920sf building addition, and a 6500sf building removal
The existing bmp will not be impacted by this addition.
B. SUBMITTAL REQUIREMENTS
Please mark "Y" to confirm the items are included with this form. Please mark `X" if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. Two hard copies (with original signatures) and one electronic copy of this completed form.
Y 2. Two hard copies and one electronic copy of the revised plan sheets (must be a revision of the
originally approved plan sheets).
N/A 3
N/A 4.
If there is reallocation of lot BUA, a copy of the revised recorded deed restrictions and protective
covenants OR the proposed recorded deed restrictions and protective covenants documenting
the changes and a signed agreement to provide the final recorded document.
If applicable, the appropriate Express review fee.
Stormwater Permit Form 7: Minor Modification Page 1 of 2 July 14, 2017

C. CONTACT INFORIV1 ^ T")N
1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name:
Consulting Firm: Neal Smith Engineering In
Mailing Address:139 Pinehurst Ave. Suite C
City: Southern Pines State. -NC Zip:28387
Phone: [phone] Fax:
Email: :nsmithna nsenaineenno mrn
[OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization: _
Mailing Addres
City:
Phone:
Email:
State:
ax:
Zip:
D. CERTIFICATION OF PERMITTFP
the current permittee, certify that I have authorized the minor modifications listec
in Section A and shown in the attached revised plan sheets. I further attest that this information is accurate aqd
complete to the best of my knowledge.
Signature: \/� ��%!'' 1 �' Date:
I, � a � S a Notary Public for the State of �Ao r W�, Lwo\ t
County of. do hereby certify that QOOd 'a_
personally appeared before me this the \?Jkv�_ day of _ vw , 20_2�-and
acknowledge the due execution of the forgoing instrument. Witn s my hand an fficial seal,
(Notary Seal)PN\I� JOAl�s!r����'<
�D NOTARY
Notary Signature �`----� pUBLlC Q\
My commission expires N P
Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6. 2017