NCC221307_FRO Submitted_20220405

For TOWF Use Only Application #:
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
TOWN of
WAKE FOREST
LAND DISTURBING (E&SC)
PERMIT APPLICATION, PLAN CHECKLIST, &
FINANCIALLY RESPONSIBLE OWNER (FRO) FORM
NO PERSON MAY INITIATE ANY LAND -DISTURBING ACTIVITY ON 1/2 ACRE OR MORE BEFORE THESE FORMS, FEES, AND AN
EROSION AND SEDIMENTATION CONTROL PLAN SEALED BY A NORTH CAROLINA REGISTERED PROFESSIONAL ENGINEER OR
LANDSCAPE ARCHITECT HAVE BEEN COMPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN Y2 ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW. SEE THE UNIFIED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NOTE: THE APPLICATION FEE OF $500.0 PER ACRE ROUNDED UP TO THE NEXT ACRE I.E.: 1.1 ACRES = 2 ACRES*
$500 = $1,000) IS DUE AT TIME OF SUBMITTAL. IF FEES ARE NOT SUBMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCLAIMER: TOWN OF WAKE FOREST FEES AND CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE CALL 919-435-9443 TO CONFIRM CURRENT FEES AND CHARGES.
PART A: PROJECT INFORMATION
PROJECT NAME Crenshaw Corners Mavis Tire
1. TAX PIN NUMBER
2. ZONING NB
1830-18-8708
3. LOCATION/ADDRESS OF TRACT 111 Crenshaw Corners Drive, Wake Forest, NC 27587

4. SUBDIVISION N/A LOT# N/A
5. DEED BOOK 16713 PAGE 1101
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Auto Service Shop
7. TOTAL NUMBER OF UNITS 1 Building
8. PERCENT IMPERVIOUS SURFACE 52%
9. TOTAL TRACT ACREAGE: 0.93 AC
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK: 0.86 AC
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE * $500/ACRE _ $
CHECK NUMBER
DATE PAID
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call 919-435-
9443 to confirm current fees and charges.
12. PROPERTY OWNER(S) (PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME Food Lion LLC E-MAIL
ADDRESS 2110 Executive Drive Salisbury, NC 28147
PHONE
CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME Will Swaringen E-MAIL [e-mail]
ADDRESS 4130 Parklake Ave., Suite 130, Raleigh, NC 27612
PHONE [phone] CELL 919-578-9000

14. PLANS PREPARED BY Bohler Engineering
ADDRESS 4130 Parklake Ave., Suite 130, Raleigh, NC 27612
EMAIL [e-mail]
PHONE [phone] CELL 919-578-9000
15. DOCUMENTS SUBMITTED (SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon 1st review)
FINANCIAL RESPONSIBILITY OWNER FORM
COMPLETED PLAN CHECKLIST
PLANS (to be submitted with construction set)
E&SC CALCULATIONS (1 copy)
STORMWATER CALCULATIONS (1 copy)
MAINTENANCE AND OPERATION AGREEMENT
NCDOT Encroachment/Driveway Permit
DWQ 401 Permit
USACOE 404 Permit
NCGO10000 Permit COC
EROSION & SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND -DISTURBING ACTIVITY WILL COMMENCE: 6-1 -22
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN, supporting documents, maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion & Sedimentation Control Ordinance outlined in
the UDO.
Assistant Project Manager
8-19-21
SIGNATURE TITLE DATE

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S) OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND -DISTURBING ACTIVITY PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET:
Mavis Southeast LLC [e-mail]
NAME EMAIL
2626 Glenwood Ave, Suite 550
ADDRESS
Raleigh NC 27608
CITY STATE ZIP CODE
914-984-2500 914-984-2500
PHONE CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
NAME
ADDRESS
CITY
PHONE
STATE
CELL
EMAIL
ZIP CODE
IF THE FINANCIALLY RESPONSIBLE PARTY IS A PARTNERSHIP OR OTHER PERSON ENGAGING IN BUSINESS UNDER AN
ASSUMED NAME, ATTACH A COPY OF THE CERTIFICATE OF ASSUMED NAME. IF THE FINANCIALLY
RESPONSIBLE PARTY IS A CORPORATION, GIVE NAME AND STREET ADDRESS OF THE REGISTERED AGENT:
NAME OF REGISTERED AGENT
ADDRESS
CITY STATE ZIP
E-MAIL ADDRESS

PHONE
FAX
The above information is true and correct to the best of my knowledge and belief and was
provided by me under oath (This form must be signed by the Financially Responsible Person if an
individual or his attorney -in -fact, or if not an individual, by an officer, director, partner, or
registered agent with the authority to execute instruments for the Financially Responsible
Person). I agree to provide corrected information should there be any change in the information
provided herein.
Qzpb� 54P 9W. 65TAT6
NAME TITLE OR AUTHORITY
7
8 j-zo 1-11
SIGNATURE DATE
I, Uarlbd a Notary Public of the County of
wee `4brfL
State of North G&relima, hereby certify that
, �effiru c Co(-<4(:) rA appeared personally before me this day and being
duly sworn cknowledged that the above form was executed by him.
Witness my hand and notarial seal, this aC) day of _kgLASt , 20-?- t
1-4
WVAl
Ra
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Notary
My commission expires t n j
CLARIBEL JEREZ
Notary PWft Sale of New York
No. OIJE538t M
Quawwd in Wesbc� County
Cowm*ekfn EVMr wI12MINIM1

TOWN of
WAKE FOREST
LAND DISTURBING (E&SC) PERMIT PLAN SUBMITTAL CHECKLIST
(SUBMITTER TO PLACE A CHECK MARK NEXT TO EACH ITEM)
mll" .
�VLOCATION/VICINITY MAP
2. EXISTING AND PROPOSED COUNTOURS, INCLUDING OFFSITE
V3. CLEARLY DELINEATED BOUNDARIES OF LAND DISTURBANCE WITH ACREAGE
V4. SOILS AREA MAP
V5. DRAINAGE AREA MAP
V06.EXISTING UTILITY EASEMENTS, STORM DRAINAGE, BASINS, LEVEL SPREADERS
7, EXISTING LOT LINES, LOT NUMBERS, SURROUNDING PROPERTY OWNERS
&�rg, STREAM CENTERLINES, STREAM BUFFERS, WETLANDS, FLOODPLAINS
v9 TEMPORARY EROSION CONTROLS TO BE SHOWN ON PLANS:
1. EROSION CONTROL CALCULATIONS (SEDIMENT BASIN, SEDIMENT TRAP,
SKIMMER, DITCH, ETC...)
2. SKIMMER BASINS REQUIRED FOR DRAINAGE AREA OVER 5 ACRES
3. IF PAM IS TO BE USED ONSITE FOR ANY APPLICATIONS, CALCULATIONS FOR
APPLICATION RATES AND SPECIFICATIONS MUST BE SHOWN. IN ADDITION,
SOIL TESTS MUST BE TAKEN TO DETERMINE CORRECT SOIL CHARGE AND
PRODUCT TYPE PRIOR TO USE.
�4. CONSTRUCTION ENTRANCE 50 FOOT MINIMUM WITH WOVEN 20 #
TENSILE STRENGTH FABRIC UNDERNEITH
V5. SILT FENCE - METAL POSTS WITH WIRE SPACED AT 6 FEET
W6. HARDWARE CLOTH OUTLETS (SPECIAL SEDIMENT CONTROL FENCE)
V7. TREE PROTETION FENCE WITH "DO NOT ENTER TREE PROTECTION AREA"
SIGN IN ENGLISH AND SPANISH
i. REQUIRED AROUND PERIMETER OF
PROPERTY

ii. REQUIRED AT BUFFER ZONES
iii. REQUIRED IN TREE SAVE AREAS (AROUND
DRIP LINE)
8. DIVERSION DITCHES
v9. INLET PROTECTION
10. EROSION
11. PERMANENT EROSION/STORMWATER CONTROLS
L STORMWATER CALCULATIONS, Q PRE, Q POST, %
IMPERVIOUS
ii. PROPOSED STORMWATER EASEMENTS (RECORDED)
iii. MAINTENANCE AND OPERATION AGREEMENT
iv. PROFESSIOANLLY SURVEYED AND ENGINEER STAMPED AS-
BUILTS OF STORMWATER PONDS/BIO CELLS, LEVEL
SPREADERS, STORM DRAINAGE INVERTS, TOPS, GRATES,
SLOPES, LENGTH, SIZE, ETC...
V. PERMANENT DITCHES WITH MATTING
LJ l0. EROSION PERMIT NOTES: (please add to plans)
1. A LAND DISTURBING (E&SC) PERMIT IS REQUIRED FOR PROJECTS OVER 0.50
ACRE.
IF MULTIPLE LOTS WITH LAND DISTURBANCE OVER 0.50 ACRE TOTAL ARE
EITHER CONTIGUOUS OR NON-CONTIGUOUS IN THE SAME SUBDIVISION, BY
THE SAME BUILDER/OWNER, A LAND DISTURBING PERMIT IS REQUIRED.
THE COST OF THE PLAN REVIEW AND PERMIT IS $500/ACRE ROUNDED UP (1.1
ACRES = 2 ACRES @ $500/ACRE = $1,000). THE FEE IS DUE ATTIME OF PLAN
SUBMITTAL. DEVELOPER IS RESPONSIBLE FOR INFORMING BUILDER OF E&SC
PERMIT REQUIREMENTS ON INDIVIDUAL LOTS.
DISCLAIMER: Town of Wake Forest fees and charges are subject to change
without notice. Please call 919-435-9443 to confirm current fees and charges.
2. IF ADDITIONAL ACREAGE IS ADDED TO AN EXISTING PERMIT REVISED FORMS,
PLANS, AND ANY ADDITIONAL FEES MUST BE SUBMITTED.
3. IF OWNERSHIP OF A PROPERTY HAS CHANGED A REVISED FRO MUST BE
SUBMITTED.
4. IF A PROPERTY IS TAKEN OVER BY THE BANK, THE BANK SHALL CONTACT THE
TOWN AND REPAIR ALL EROSION CONTROL MEASURES TO TOWN/NCDENR
STANDARDS. THEY SHALL ALSO SUBMIT ANEW FRO FORM.
5. IF A PROJECT IS NOT COMPLETE WITHIN TWO YEARS, THE PLANS MUST BE
RENEWED AT $250/ACRE. A REVISED SET OF PLANS MAYBE SUBMITTED IF
ACREAGE HAS ALREADY BEEN DEVELOPED AND A CERTIFICATE OF OCCUPANY
HAS BEEN ISSUED.

6. AN EROSION PRECONSTRUCTION MEETING MUST BE HELD WITH THE TOWN OF
WAKE FOREST PRIOR TO START OF ANY WORK, INCLUDING INSTALLATION OF
EROSION CONTROL MEASURES, DEMOLITION, CUTTING TREES, AND
GRUBBING.
CALL ENGINEERING AT [phone] TO SET UP A MEETING. ALL PLANS MUST
BE SIGNED AND COPIES RETURNED TO THE TOWN 1 WEEK PRIOR TO
PRECONSTRUCTION MEETING.
7. THE OWNER, GENERAL CONTRACTOR, GRADING COMPANY, AND EROSION
CONTROL INSTALLER MSUT BE PRESENT AT THE PRECONSTRUCITON MEETING.
8. THE E&SC PERMIT WILL BE DISTRIBUTED AT THIS MEETING.
L_�CJ 11. E&SC CONSTRUCTION SEQUENCE NOTES: (please add to plans)
1. PRIOR TO SCHEDULING THE PRECONSTRUCTION MEETING, THE EROSION AND
SEDIMENT CONTROL SURETY MUST BE SUBMITTED TO THE TOWN OF WAKE
FOREST. THE NCG010000 CERTIFICATE OF COVERAGE MUST BE OBTAINIED BY
THE PERMITTEE, WHEN APPLICABLE. A COPY OF THE COC MUST BE SUBMITTED
TO THE TOWN.
2. AFTER THE PRECONSTRUCITON MEETING IS HELD, THE CONTRACTOR CAN
INSTALL INITIAL EROSION CONTROL MEASURES ONLY. THIS INCLUDES BUT IS
NOT LIMITED TO CONSTRUCTION ENTRANCE, SILT FENCE, PERIMETER
DIVERSION DITCH, CHECK DAMS (ROCK OR WADDLE TYPE), TREE PROTECTION
FENCE, EXISITNG INLET PROTECTION, SKIMMER SEDIMENT BASINS, AND
SEDIMENTTRAPS. CLEAR ONLYAS NECESSARYTO INSTALLTHESE MEASURES.
3. CONTRACTOR IS RESPONSIBLE FOR E&SC WEEKLY INSTALLATION AND
MAINTENANCE LOG INCLUDING DATES OF TEMPORARY/PERMANENT
GROUND COVER, A RAIN GAGE, COPY OF TOWF SIGNED PLANS ONSITE,
REVISED SIGNED PLANS, NPDES LOG, AND CONSTRUCTION BOX MUST BE
PRESENT AND EASILY ACCESSABLE ONSITE.
4. ONCE MEASURES ARE INSTALLED, CONTRACTOR/FRO TO CALL TOWF FOR AN
INITIAL INSPECTION. IF SITE PASSES INSPECTION, A CERTIFICATE OF
COMPLIANCE WILL BE ISSUED. CONTRACTOR CAN NOW BEING CLEARING,
GRUBBING, AND GRADING.
5. CONTRACTOR TO MAINTAIN ACCESS ROAD FOR EMERGENCIES AT ALL TIMES.
6. PHASE PROJECT TO LEAVE AS LITTLE GROUND OPEN AS POSSIBLE.
7. TEMPORARILY SEED, STRAW AND TACK OR HYDROSEED WITHIN 14 DAYS OF
ANY PHASE OF GRADING, INCLUDING SLOPES. SEED BASINS AND DITCHES
IMMEDITEALY AFTER CONSTRUCTION.
8. PRIOR TO REMOVAL OF TEMPORARY MEASURES, TOWN MUST APPROVE
REMOVAL. ALL AREAS ABOVE TEMPORARY MEASURE MUST HAVE 85%
GROUND COVER.
9. THE TOWN OF WAKE FOREST CONSTRUCTION INSPECTOR WILL EVAULATE THE
SITE ATLEAST ONCE A MONTH. A COPY OF THE INSPECTION FORM WILL BE
EMAILED TO THE FRO. THE WEEKLY EROSION LOG AND NPDES LOG MUST BE
ONSITE AND AVAILABLE FOR REVIEW.
10. IF THE SITE IS FOUND OUT OF COMPLIANCE A NOTICE OF VIOLATION WILL BE
ISSUED GIVING THE CONTRACTOR/FRO 7 WORKING DAYS TO REMEDY THE
PROBLEM. IF THE SITUATION IS NOT RESOLVED WITHIN THE TIME PERIOD A
FINE MAY BE ISSUED.
11. IF SEDIMENT LEAVESTHE SITE A FINE MAY BE ISSUED UP TO $5,000 PER DAY

PER VIOLATION. IF SEDIMENT ENTERS A BUFFER, STREAM, OR WETLAND
NCDWQ WILL BE NOTIFIED. THEY MAY ISSUE FINES UP TO $25,000 PER DAY PER
VIOLATION.
12. CALL THE TOWN UPON COMPLETION FOR A FINAL EROSION INSPECTION. A
PUNCHLIST MAY BE GENEREATED ADDRESSING ANY REMAINING ITEMS.
THERE MUST BE 85% GROUNDCOVER ON THE ENTIRE SITE PRIOR TO A
CERTIFICATE OF OCCUPANCY. IF THE SITE IS FOUND TO BE IN COMPLIANCE
AN EROSION CERTIFICATE OF COMPLETION WILL BE ISSUED. AFTER THE
COMPLETION OF THE PROJECT, SUBMIT A NOTICE OF TERMINATION TO END
COVERAGE UNDER THE NCG01000 PERMIT.