SW4220302_Application Form_20220322

DEMLR 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 WO MRmt 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 rise 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.):
2. Location of Project (street address):
City:
County: Vr'J 5,01,1
3. Directions to project (from nearest major intersection):
✓ 22 4 -�4 -' '( H8 111-n '5
zip: 2 7 2 ' :5-
4. Latitude: 0 " N Longitude: a ' '� " W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ❑New [OModification ❑ Renewal w/ Modificationt
tRenezoals zoith modifications also regieires SWU-102 - Renezoal Application Form
b. If this applicatia►�j being submitted as the result of a modification .to an existing permit, list the existing
permit number j pe O le � its issue date (if known) �- and the status of
construction: ❑Not Started ❑Partially Completed* v1Comp eted'`` *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
1,111 ' DEMLR 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: 4. e 4l 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: He Lli,
5. Is the project located within 5 miles of a public airport? []No VYes
If yes, see S.L. 2012-200, Part VI: htt ) ortaI, icLienr.or /web IrlrtLe,,-and-re ulations
Form SWU-101 Version Oct. 31, 2013 Page 1 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 awns th�rdec*
Applicant/Organization: cL t cJ! L Z �—
Signing Official & Title: �' N. " '��J�'
b.Contact information for person listed in item 1a above:
Street Address:
City:
Mailing Address (if applicable):
City:
State: Zip: 27 3 7 -3
State:
Zip:
Phone:- d Fax: ( ]
Email:
c. Plew check the appropriate box. The applicant listed above is:
Q The property owner (skip .to Contact Information, item .3a)
7] Lessee* (Attach a ropy 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.
Mailing Address (if applicable):
City:
State: Zi
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: { }
Email:
4. Local jurisdiction for building permits: f '� S OAJ }`
Point of Contact: �rf g' 1 e Phone #: (. ]
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.
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 '' p6i �J)_'ERiver basin.
4. Total Property Area: acres 5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area:_ acres
7. Total Property. Area (4) - Total Coastal Wetlands Area (3) - Total Surface Water Area (6) =Total Project
Area-: 5 a acres
- Total project area shall be calculated to etelude the foIlo7lyirtg: the norrn.r7l pcyol L nic 7oawled. structures, the area
Total en the banks of strc:rrcrrs i�ac.d rizye�s, the rrrer� t7e'low the Normal High Witter (NMV) line or Mean Hig2c Writer
(MH�V} Bice, and coastal ztyetlacids Itzcrdzc�ifr'il frc�irr thNHW (or e MHIV) line. The resultant project area is used to
calculate overall percent built upon area (BLIA). ,1�1G�n- c�rtstt#1 ?tie tlf1rid+ larrdziyi�rd of ilct fVH(cy+ MH1rV) Trite Wall
be ictcluded icc tice total project area.
R Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =
N
10
How many drainage areas does the project have? / (For high densihl, cnu"it I for e.acl' 11 'V sed engijceered
stornmiate•r BMP. For lofty i.lcnsihl and other projects, rise I jor the whole properhl area)
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, attich�an dditionai sheet with the information For each area
provided in the same format as belo�nf. ��
Basin Information
Dray
Receiving Stream Name
S.YVc)
Stream Class *
Stream Index Number
Total Drainage Area (sf)
On -site Drainage Area (sty
Off -site Drainage Area (so
Proposed Impervious ervious Area** (sf)
7'l
Impervious Area** total)
Impervious' Surface Area
On -site Bui€dings/Lots (sf)
On -site Streets (so
On -site Parking (so
On -site Sidewalks (sO
Other on -site (so
Future (so
Off -site (sf)
Existing BUA*** (sf).
Total (s0: f P t j�'17 I.. a
* Streanc Class and Index Nuniber can be determined at: utt �: iortal.naleu.r.or tc��h u c yy csir cftcstic i itioies
Iix 7ervioirs area is hefted as tl:e built icpoic area inclurlicig, bait not limited to, buildings, roads, parking areas,
sidewalks, gravel areim etc.
**" Report only that atnc}lint of existing BLIA that will reinain after developrcent. Do riot report any existing BUA that
is to be re roved and whizli rcyitl he replaced by new BLIA.
Drainage Area _
`76a,000
2 C. 5`7 /. 6 a
Area Drainage Area I Drainage Area
Form SWU-101 Version Oct. 31, 2013 Page 3 of

11. How was the off -site impervious area listed above determined? Provide documentation.
N114
Aro ects in lI'nian County: Contact DEMLR Central Office staff to check if the project is located within a Thr cozened &
Endangered Species watershed that ma}y be subject to more stringent stor•rnwater requirements as per 1 5A 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 http://�►ortal.rtcdennor web w ws su'bm 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
h �: partal.ncdenr.or Iweb; w� w's'su �`st�ikesGv.'farms does. The complete application package should be
ffice nzay be found by locating project on the
submitted to the appropriate DEMLR Office. (The appropriate o
interactive online map at h ortaI-ncdenr.or web '%vq t
Please indicate that the follawin re uired information have been -Zr
ovided b initialin 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 htt ,orta l.ncdenr.or w eb t w'c ws su sta testy i for In ais s
1. Origival and axle copy of the Storm water Mai agement Permit Applica don Form-
2. Ur igr.'rr.rrl rrruf vnc copy of the. signed and notarized Deed restrictions & Protective Covenants
Form_ (if rv'70)-eai I's �?c:r Part .Vf l l eloc")
3. Original of the applicable Supplement Form(s) (sealed, signed and d a tedl and O&M
agreement(s) .for each BMP.
4. Permit application processing fee of 5505 pmlable to NCDENR. (For an Express review, refer to
ht www.envhel :)Eg/12ages/oncNstbpexi2ress.htniI for information on the Express program
anti 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/ in anagementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
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 1/2
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.
& 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. 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 controt 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 calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
;wm
Fonn SWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers {where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs_ Include an 6.�'x1I" copy of the NRCS County Sails 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: Schecirrle a site visit for DEMLR to veriff the 5HWT prior -
to submittal, [phone].)
10. A copy of the most current property deed. Dees! book: 0� Page No: 'Vrf
11. 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 Information, item Ia, ?a, and/or 3a per 15A NCAC 1H.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 retumed.
htt www.secret,r - state.nc.0 CCor orations CSearch.as �x
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparceis, and Future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the safe of any lot. If lot sizes vary significantly or the proposed
BU.A 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 htt `lr
:" �trtal.ncdenr.or wel� 'state-stormrvater-
forms 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: 1.3 J'iL- A• S' -f —/ �� 1�
Consulting Firm-.— L A 6e ���` -�� r et'�e-s' Mailing Address: 3c'
City:
n 5 g1,1 — /0 -'41 State: C— Zip:
Phone: 5 1: . / 4/- Fax: ( i
EmaiL P s -I1 w /a 6e //A- C ,
IX. PROPERTY OWNER AUTHORIZATION (if Contact Inforr?.zation, item 2 has been filled out, complete this
section)
EE I, (print or hjpe trame of person listed ill Contact Information, i.tenr 2a) certify that I
own the property identified in this permit application, and thus give permission to (print or hIjle narrrz of persOrr
listed in Contact Information, item la) with (Inint or hIpe name of organL�ahou listed in
Contact Informations, item, 10) 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 designatvd
agent (entity listed in Contact I-n#orrmation, 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 DEMLA immediately and
n
submit a completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid perms 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 $75,0ao per day, pursuant to NCGS 143-215.6.
Date:
Signature:
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 j� a
I, (�.
rrult F7r' h Jf ''
+triad cr s rson ii'4ea 41 confact 111ftrination, LL)n In) .J_ �i S � r Lei"— _
Certify that the infaTmation included on this permit application Farm is, to the best of my kntnr�riedge. Come and
that the project will be constructed in conforniance with the approved plans, that the required deed restrictions
alld protective covena ats will be recorded, and riiat the proposed project COMplirg with the requirements of e
n r �A NCAC ?H .1000 and any other appticab[e state stormwater requ lrements.
applicable st water rules
Hate.
Signature:
ti' a Notary Public for the State of
C Y YA County of
L 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,
OORIS ONOTARY PIUBLICNE AO�SOI�J
Forsyth County
North Carolina
My Commission Expires March 14, 2023
SEAL
My commission expires
Fnrm qWr i_I01 VP.r inn Oil 11 201 )
Page 6 of 6