SW4220301_Application Form_20220524

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 WQ M mt 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 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.):
Woodhaven Subdivision
2. Location of Project (street address),
Stanleyville Drive (SR 1920)
City:
County:Forsyth County Zip:27045
3. Directions to project (from nearest major intersection):
Head south from the intersection of NC 8 and NC 65 onto NC 8 (Gernianton 1�oad). _Drive approximately 2.2
miles and mace a rigli tt Unto Stanleyville Drive. Drive south on Stanleyyille Drive to the intersection of
Stanleyville Drive & Montlieu Drive. Site is on the left, across from Montlieu Drive.
4. Latitude:36° 13' 26.7" N Longitude:80° 15' 21.3" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tReneznals zoith modifications also requires SWU-102 — ReneWal Application Form
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 known). and the status of
construction: ❑Not Started ❑Partially Completed* ❑ Completed* *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
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: 6.2 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 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:
Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http.:8portal.iicdetir.crt-Wµfeb/l,•/rLil_es-�snd-regiilrit.ions
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 owns the project):
Applicant/Organization: Randall Dunston
Signing Official & Title:PropeM Owner
b. Contact information for person listed in item 1a above:
Street Address:386 Rock House Road
City -Winston Salem
Mailing Address (if applicable):same as above
City:.
State:NC
State:
Phone: (719 ) 619-0536 Fax:
Email:[e-mail]
Lip:27127
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy 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/Organ
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):
City:
Phone: ( )
Email:
State:
State:
Fax:
rA
Zip:
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: Ravindra Bissram, PE
Signing Official & Title:Professional Engineer
b. Contact information for person listed in item 3a above:
Mailing Address:8518 Triad Drive
City:Cnlfax State:NC Zip:27235
Phone: (336 ) 544-6426 Fax:
Email _rbissram0feicoiisulting.com
4. Local jurisdiction for building permits: Winston Salem Forsyth Count
Point of Contact:Desmond Corley Phone #: „(336 ) 747-7065
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

lru rervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
suvl-' calks, gravel areias. ctc.
'Rt,port only flint amormt of ea'isting BUA that will remain after development. Do rrol report atnl existing; BLIA that
is to be removed and which will be replaced bil new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. Existing GIS
to o ra. h was used to determine how much drainage area Flowed to the site
Projects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (Q&M.) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from hap; I/portal.ncdennorg/►,,,el)wq../ws/su/binp-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
http:Il�r#al.nedenr.nrgl►+�el�l►�'gl►vs/stiff/states►v/fnrnns_docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at hap://maps.)
Please indicate that the following req aired 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 littp://poi,tii.ncdenr.or4/iNeb/wq/ws/"sti`/­stateswZfoi-iii--i docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. RB
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants NA
Form. (if required as per Part V11 below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated and O&M NA
agreement(s) for each BMP.
4. Permit application processing fee of $505 pailable to NCDENR. (For an Express review, refer to RB
Iittp:llwww.envhelp.or&ZpagtsIonestopexpress.html 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 for RB
6. A USGS map identifying the site location. If the receiving stream is reported as.class SA or the RB
receiving stream drains to class SA waters within ?/ mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). RB
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: RB
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 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 control measures.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

IV. PROJECT INFORMATION
1_ In the space provided below, briefly summarize how the stormwater runoff will be treated.
Offsite water ua hill a pstream of the proerty)will be pi ed through the ro )cart . On -site stormwater will
pass through swales running dowel the property lines to the ditclilines aiang the roadway. Inlets have been
minimized to maximize use of swales for water quality. Roadway will be ribbon pavement to.maximize
contact with
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
Stormwater runoff from this project drains to the Roanoke
4. Total Property Area: 16.9 acres
River basin.
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:16.9 acres
} T'otal projeet area shall be calcrdated to exclnde Nrc follorl,bF 77: tare normal ppol of•int 7orrnded strrrctrrres, the area
between the barks of'st-rcanis and rivers, Me area l��°l��t€ tlr� N��rr�rrrl High Watcf- (NI�IM line or Mean HVi Water
(MHM. line, and coastal wetlands landmird i-orn the NHW (orMHW) line. the re s".11.11nt t area is r.tsed to
crticrr2ate €rt�€ rall percent built npon area (BLIA). Nnn-c[�astal zcetl�urds I.arlalzt�artl of tlrc NN1 V (crr MHW} lira rrrrrll
be included in Elie total project flivar.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 145,460 sf/737,950 sf
=19.7% %
9. How many drainage areas does the project have?1 (For high densihj, count 1 for each proposed engineered
stormwater BMP. For low densihj and otlier projects, use 1 for the whole properhj area)
10. 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, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area _
Drainage Area _
Drainage Area
Drainage Area _
Receivin Stream Name
Trick -Um Creek
Stream Class *
C
Stream Index Number *
22-25-5-1
Total Drainage Area (so
sf
On -site Drainage Area (sf)
737,950 sf
Off -site Drainage Area (sf)
779,692 sf
Proposed Impervious Area** (so
145,460 sf
% Impervious Area** total
19.7%
Impervious— Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area
On -site Buildings/Lots (so
3,500 sf
On -site Streets (so
45,160 sf
On -site Parking (so
0 sf
On -site Sidewalks (so
9,300 sf
Other on -site (so
0 sf
Future (so
0 sf
Off -site sf)
0 sf
Existing BUA*** (so
0 sf
Total (so:
145,460 sf
* Stream Class and Index Number can be determined at: lrtll?//l�r�r'lal.nc�l� rrr.crrtirt l�fteacrs�sar/t'laa sr ic':r[ir�rtti
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

M. Wetlands delineated, or a note on the plans that bonne 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).
p. Vegetated buffers (where required).
Copy of any applicable soils report with the associated SHWT elevations (Please identify proposedM devices
elevations in addition to depths) as weII as a map of the baring locations with the existing
elevations and boring togs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMI's, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices suhmitted to WiRO: Schedule a site visit for DEMLR to verify the SHWl prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 3606 Paige No: 4245 RB
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC NA
Secretary of State or other official dOCUmentation, which supports the titles and positions held
by the persons fisted in Contact Information, item la, 2a, and/or 3a per 15A NCAC 2I1.1003(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.
111W Zwww.sec-retar .state.ne.us Coy porations /CSearch.asl2x
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
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 Iot. 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 litt��}7nrt��l.ilydeiZr'.nr'glwe6llrltit-tte-
stormw11cr-fornns dU�'s. 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 tine 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 wiII 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).
�'nncttlh+^w �7nu+•+�F^'•T�^-,."r�,•�rq'Ri^--rr rr^; PF
Consulting Firm: Fleming Engineering, Incorporated
Mailing Address:8518 Triad Drive
City:Colfax
State:NC
Phone: (336 ) 544-6426 Fax:
Email: rbissram@feiconsulting. tom
Zip`27235
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or tnjpe name of person listed in Contact Information, item 2a) certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item 1a) with (print or hjpe name of organization listed in
Contact Information, item 1a) 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 S WU-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 designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
Iease agreement, or pending sale, responsibility for compliance with the DEMLR 5tormwate.r 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. 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 assess+nPnt of Civil nenalties-of-up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
I,
a Notary Public for the State of
do hereby certify that
before me this _ day of
Date:��.
County of
personally appeared
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
I, (print or type nallic of Ilerson listed in Confacf In fnf' natiblr, ifent 1a) Randall ;coft Du"'.14011
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 or-1�NCAC 2H •1000 and any other applicable state stormwater requirements.
Signature:
Date: 2 Z
I %Aa.l e •l L�a Notary Public for the State of C'x lc r� C7 . County of
do hereby certify that Q,ndaI n 5 Ifs -- _ net sonally appeared
before me this day of Ve'04A CA-1U 022 , and ac wledge tit ue execution of the application for
a stormwater permit. Witness my hand and official seal,
HALEY MORGAN DRAPER
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 20214049215
MY COMMISSION EXPIRES DECEMBER 21, 2425
SEAL
My commission expires Z/ VzC e I ` e f ZO [iZ
Form SWU-101 Version Oct. 31, 2013 Page 6 of