SWA000139_Application ATC_20220317

DEMLR USE ONLY
Date Received
I Fee Paid Permit Number
I GD_d
O5 KO L Lj 4 c 1 SV ., ri
SW Prom(s): o Coastal SA-HQW
O Non -coastal HOW
O Coastal SA-ORW O Coastet W O Coastal Other
O Non -coastal ORW O Urbanizing Areas a USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS: RECEIVE
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to Application Instructions MAR 17 2012
0ENR-L4ND QUAL11
A. ELIGIBILITY FOR FAST -TRACK PERMITTING 6 ORMINATERPERMIT
To be considered for a Fast Track ATC Permit, all of the items below must be checkedif 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 16A 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 16A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seat 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: Slavic Evangelic Church
2. Previous Project Name (if applicable): N/A
3. Location of Project (street address): 6308 MITI Grove Road
City: Hamby Bridge County:Union Zip:28110
4_ Directions to project (from nearest major intersection):
From Idlewild Road proceed North on Mill Grove Road approximately 0 5 miles
Site is on right at 6308 Mill Grove Road
5. Latitude, 34 ° 124 ' 00° N Longitude: 85 " Oe" '
00 " W of the main entrance to the project.
C. PERMIT INFORMATION
1. Specify whether project is (check one):
Stonnwater Fast Track ATC Application Form Page 1 of 11 Fab. 10, 2018

Lnj
New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: SWANLa
By choosing this option, you are also requesting that DEQ rescind the previous Fast Track AFC Permit
upon issuance of the new Fast Track A TC Permit.
Stormwaler Fast Track ATO Application Form Page 2 of 11
i
l
Feb. 10, 2018

❑ Major Modification, replacing an existing stormwater permit — provide existing permit number: SW
NIA Status of construction? ❑ Not Started ❑ Partially Completed ❑ Completed
e or modlfications 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 programs) (check all that apply):
SA -HOW
Urbanizing Areas (Phase 2)
®Coastal
Coastal SA-ORW
Non -Coastal HOW
Is any portion of the pro act within 575 feet
of SA-ORW waters? �] Yes ❑ No
Non -Coastal ORW
❑
Coastal Freshwater ORW
8
USMP
❑
Coastal —Other
3, Other Permits (as applicable; write "NA" for those permit types that are not applicable):
Project Name
Permit/Appl
No.
Issue Date
Other Information
CAMA Major
N/A
Erosion &
Sedimentation Control
Slavic Evangelic Church
UNION_
08/12�2019
Disturbed Area_
6 28 acre
2019-
00
NPDES Industrial
Stormwater
k
40414DI Permit
N/A
Proposed Impacts
0• If/ac
4. Local jurisdiction for building permits: Union Counly N C
Point of Contact Jesse Langston Phone* ( 704 283 3816 1
0, CONTACT INFORMATION
Applicant/Financially Responsible Party (may be an Organization): Slavic Evangelic Church
Signing Official Name & Title: Mialtk Rostislav Registered Agent
Street Address: 6740 Albemarle Road
CIty:Chariotte State:N.C. ZIp:28227
Mailing Address (if different):SAME
City: State: Zip:
Phone: (4/ 6 S O- G 4 c(6 Fax:
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: Mialik Rostislav
Mailing Address: 6740 Albemarle Road
City: Charlotte State:NC Zip:28227
Phone: P
:1
Fax:
Stormwater Fast Track ATC Application Form Page 3 of 11 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 (Affach 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 1S the Property Owner):
Property Owner Name/Organization: N/A
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: Galard Carter Moore III P.E.
Consulting Firm: GCM3 Engineering PLLC
Mailing Address:3031 Spring Fancy Lane
City: Indian Trail State:N.C. Zip:28079
Phone: (704 ) 821-4205 Fax: [phone]
Email:gcm3engineedng @gmail.com
6. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization:
Mailing Address:
City: State: Zip:
Phone: Fax: ]
Email:
E. PROJECT INFORMATION
1. Specify the type of project (check one): ❑ Low Density N High Density
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
Stormwater Fast Track ATC Application Form Page 4 of 11 Feb.10, 2018

I
Construct the building and asphalt/ concrete areas with perimeter curb and gutter to sheet flow drain the -
parking areas and provide roof drainage leaders from the building areas to the single Detention pool.
The retention gaol oufall co trot structure Is designed for a 2yr.. 10yr..25yr. 50yr..and the 100 year storm
event and to retease at pre -development runoff rates.
3. Stormwater runoff from this project drains to the Yadkin -Pee Dee River basins).
4. Receiving water information (if more than 3 receiving waters, provide additional information on an attached
-0---A%-
arrvva .
Receiving
Receiving
Receiving
water 1
Water 2
Water 3
Receiving Stream Name
North Fork Crooked
NIA
nta
Creek
Stream Classification
C
Stream Index Number
13-17-20-1
Stormwater Fast Track ATC Application Form Page 6 of I 1 Feb.10, 2018

5. Project area and dengi information:
Total Property Area
527500 sf
Total Surface Water Area
Considered to Include:
81200 sf
• the normal pool of impounded structures;
• the area between the banks of streams and rivers; and
• the area below the Normal High Water (NHM line or Mean High Water (MHM line.
Total Coastal Wetlands Area
-0- sf
Considered to include: coastal wetlands landward from the NHW (or MH149 line.
Total Project Area
44s3oo
Excludes the surface water area and coastal wetland area identified above.
S f
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 stonnwater program or
applicable local government ordinance to which the project is subject.
Proposed New BUA
Includes proposed new BUA that is not associated with existing development
00
9725sf
"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 SCM in accordance with 15A NCAC 02H .1050(1).
Project Density
wlExisting Development: Project Density = (New BUAJI[Total Project Area -- Existing BUAJx 100 or
38.7
wlo Existing Development: Project Density = [New BUAJlrotal Project Area] x 100
6. Anticipated construction start date February 2022
7. Is the project located within 5 miles of a public airport? ® No ❑ Yes
!f `Yes,'see S.L. 2012-200, Part V1: http://www.ncleg.net/Sessions/201 1/QHIs/Senate/PQF/S229v6.J?d 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 stor►nwater requirements per 15A NCAC 02B .0600.
Stormwater Fast Track ATC Application Form Page 6 of 11 Feb.10, 2418

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USIVIP, Non -Coastal HQWIOR". Only application packages that Include
a I 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
VZ 1. Two original signed hard copies and one electronic copy of this State Stormwater Fast Track
Process "Authorization to Construct' (ATC) Permit Application Form.
V� 2. Permit application processing fee of $506 payable to NCAEQ.
VZ_ 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 % mile of the project boundary, include the % mile radius
on the map. If the project is within 675 feet of Class SA ORN waters, include the 676-foot
radius on the map.
VZ 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.
VZ _ 6. Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased.
VZ 6. A copy of the most current property deed. Deed book: 649 1 Page No: _ 744
_ N1A 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 Be an active
corporation in good standing with the NC Department of the Secretary of State; otherwise, the
application will be returned. s:os c. ov s archiindexl r
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 Applloatlon Form Page 7 of 11 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:
1, (print or type name of Applicant/Financially Responsible Party) , Mialik Rostislav ,
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
3. 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 I
agree to provide corrected information should there be any change in the information provided herein.
Mialik Rostislav Registered Agent
Type or print name Title or Authority
Signature Date
�i S'P-v &-e4---
I �Aha[:�r a Notary Public for the State of
County of , do hereby certify that M ► i ��il �S �y
personally appeared before m his y day of M G YC ZO Z2. , and acknowledge the
due xecutt Intahe LficUln for a stormwater permit. Witness my hand and official seal,
�,•��`''�VRKHgI
x l�
C6 o �01 AR y��N�, �.
'Z
'. PUBS-�
•
a ON
URG
SEAL.
My commission expires iz [%0V Za
Stormwater Fast Track ATC Application Form Page 8 of 11 Feb. 10, 2018

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be completed by the Design Professional identified in Section D.S.
I, Galard Carter Moore 111 P.E. 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 .1050 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 143-215.6B, 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 false statement, representation, or certification in any application may be reported to
the appropriate NC professional licensing board.
f tz lh'f' t 1L Date: 7� v
Signature: �� ��
SEAL
Stormwater Fast Track ATC Application Form Page 9 of 11 Feb. 10, 2018

i. PROPERTY OWNER'S AUTHORIZATION (IF APPLICANT IS NOT THE PROPERTY OWNER)
I, (print or type name of the Property Ownerj NIA , certify that I
own the property Identified In this permit application, and thus give permission to (print or type name ofAppilcant)
with (print or type name of Applicant's
organization) 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.
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. 1 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;
it , 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,_
Stormwater Fast Track ATC Application form Page 10 of 'i 1 Feb. 10, 2a18

J. CERTIFICATION OF CURRENT PERMITTEE (COMPLETE ONLY IF PERMIT TRANSFER IS
REQUESTED)
I, (print or type name of the Current Permfttee) N/A , am submitting
this request for a transfer of Fast Track ATC permit # SWA L With the submission of this transfer request I
am providing a copy of the most recent permit, all related documents and as-bulit plans certified by my design
professional in hard copy and electronic format to the Proposed Permittee/Applicant Identified in Section G of this
application and to DEMLR . i further attest that this request for a permit transfer is accurate and complete to the
best of my knowledge. I assign all rights and obligations as permlttee to the proposed permittee named In Section
G of this form.
Signature: Date:
Is _ _ , 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
stormwater Fast Track ATC Application Form Page 11 of 11 Feb. 10, 2018