SW6220505_Application Form_20220607

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph Il - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters !] Universal Stormwater Management Plan
❑ Other WQ M gnit Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This fo"n tuay be photocopied for use as aii original
1. 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.):
Utility Improvements to Serve Shahbain Reserve - Phase 1 _
2. Location of Project (street address):
Rockfish Road
City:Raeford County:Hoke Zip:28376
3. Directions to project (from nearest major intersection):
The roiect is located approximately 970 ft. from the intersection of Rockfish Road and Koonce Road goin
west towards Mossv Oak Circle.
4. Latitude:34° 59' 33.34" N Longitude:79� 05' 23.9l." W of the main entrance to the project_
Il. PERMIT INFORMATION:
1 _ a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
#Renewals with modifications also requires 51,VU-302 - Reneuoal 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):
❑Law Density ®High Density ❑Drains to an Offsite Storm -water System ❑Other
3. if this application is being submitted as the result of a previously returned application or a letter from DWQ
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 ®Sedimentati on/ Erosion Control: 17.50 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:
5. is the project located within 5 miles of a public airport? ®No ❑Yes
if yes, see S.L. 2012-200, Part V1: http://portal.ncdenr,org/web/wq/ws/su/statesw/rules laws
Form SY U-101 Version HAug2012 Page I of

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:1& K General Contractor Inc_
Signing Official & Title:Mubarak Shahbain - President
b. Contact information for person listed in item I above:
Street Address:1184 Fayetteville Road
City:Raeford
Mailing Address (if applicable):
City:
Phone: (910 ) 777-7778
Email: amalgiandkbuilders.com
State:
Zip:28376
State: Zip:
Fax:
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.)
22 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: State: Zip:
Mailing Address (if applicable):
City:.
Phone: ( }
Email:
Sta
Fax: ( )-
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: Hoke County Planning/Zoning,
Point of Contact: Robert Farrell Phone #: (910 } 875-8407
Form SWU-101 Version 06Aug2012 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff from the developed areas of the site will be cal2tLLred and treated in three wet ponds and
an infiltration basin
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 Cape Fear _ River basin.
4. Total Property Area: 115.32 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area*:115.32 acres
+ TotaI project area shall be calculated to exclude the following the normal pool of intpo�u�nded strictures, the area
between the Ranks of streams and rivers, the area below the Normal Hi Th Water (fin w1 line or Mean High Water
(MHW) line; and coastal wetlands landward frotn. the NHW (or MHV�Ij lime. 77ze resultant project area zs used to
calculate overall percent built upon area (RUA). Non -coastal wetlands landward of the NNW (or MHi9 litre tray
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =19.52
9. How many drainage areas does the project have?4 (For high density, count 1 for each proposed engineered
storznwater BMP. For low densihl and other projects, rise 1 for the whole property 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 1
_
Drains a Area 2
Drainage Area 3
Y
Drainage Area 4
Receiving Stream Name
Gull Branch
Gully Branch
Gully Branch
Gully Branch
Stream Class *
B
B
B
B
Stream Index Number *
18-31-20.7
18-31-20.7
18-31-20.7
18-31-20.7
Total Drainage Area (so
883,772
394,402
176,822
874,858
On -site Drainage Area (so
883,772
394,402
176,822
874,858
Off -site Drainage Area (sf)
Proposed Trnpervious Area** (sfl
371AM
171,155
86,745
350,959
% Impervious Area** total
Impervious- Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area 3
Drainage Area 4
On -site Buildings/Dots (st)
272,000
112,000
641000
232,000
On -site Streets (so
71,993
43,779
17,073
82,159
On -site Parking (so
On -site Sidewalks (so
27,645
15,376
5,672
26,880
Other on -site (so
91920
Future(so
Off -site (s
Existing BUA*** (so
Total (sf):
371,638
171,155
86,745
350,959
Strewn Class and Index Number can he determined fit: 1ttt t:/Ipc�rtrtl.r�rilenr.argl`rueb/zuzlfps csti/c[cis&tftc tions
Im pervious area is defined as the built upon area including, but not [united to, buildings, roads, parking areas,
sidewalks, grave[ areas, etc.
Corm SWU-101 Version 06Aug2012 Page 3 of

'Report only that apnouttf of existing BUA that will remain after development. Do not report any existing BUA that
is to be rennoved and Which will be replaced by tww BLIA,
11. How was the off -site impervious area listed above determined? Provide documentation. N/A
Proiects in Union County: Contact DWQ Central Qfce staff to check if'the project is located within a Threatened &
Endangered .Species itatershed that Wray° be subject to more stringent stornmater requirements as per 1 SA IYCAC 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 b_ ;.//portal.ncdenr.orz/web/wci/ws/su/bmo-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from httl2://pc)rtal.ncdonr.org/web/wy/ws/su/statesw/farms dots. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at http; / / portal.ncdenr.org/web/wq/ws/so/mans.)
Please indicate that the following required information have been provided by 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 htWp fZRortal.ncdenr.org/web/wq/­ws/suZ-5tatesw/fornis does.
Initials
1. Original and ow copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form, (if required as per Part V11 belozv)
3. Original of the applicable Supplement Form(s) (sealed si ed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of S505 payable to NCDENR, (For an Express review, refer to
httl2://www.envhelp.org/12ages/onestopexpress.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
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 wi thin 1/a 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.
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.
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).
p. Vegetated buffers (where required).
Form SWU-101 Version 06Aug2012 Page 4 of 6

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 8.5"xll" copy of the NRCS County Soils 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: Schedule a site visit for DWQ to uerifij the SHVVT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book.1391 Page No: 0720
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 la, 2a, and/or 3a per 15A NCAC 2H.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.
http: / /www.secretaiy.state,nc,us/Corporations/CSearcli.gpx
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 lot. 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
htt ortal.ncdenr.or web w ws su statesw forms does. 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 DWQ, 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: Carlo Pardo, PE
Consulting Firm: Bowman North Carolina, Ltd.
Mailing Address:4006 Barrett Drive, Suite 104
City:Raleigh State:NC Zip:27609
Phone: (919 ) 5.53-6570 Fax: ( )
Email:cnardo®bowrnan.com
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been felled out, coniplete this
section)
1, (print or type naerze of person listed in Contact Inforniation, itenz 2a) , certify that l
own the property identified in this permit application, and thus give permission to (print or type name of person
Iisted in Contact Information, item 1a) with (print or ttfpc name of organization Iisted in
Contact 111formration, 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 W LI-101 Version 06Aug2012 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
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the
completed Name/Ownership C
facility without a valid permit.
permit is a violation of NC Gen
the assessment of civil nenaltiu
Signature:
property owner, it is my responsibility to notify DWQ immediately and submit a
.hange Form within 30 days; otherwise I will be operating a stormwater treatment
I understand that the operation of a stormwater treatment facility without a valid
e tatue 143-215.1 and may result in appropriate enforcement action including
o up to $25,000 per day, pursuant to NCGS 143-215.6.
Date: )a z
:L.i':< - , a Notary Public for the State of H C_ . County of
do hereby certify that
personally appeared
before me this ]a day of and acknowledge the due exe e application for
a stormwater permit. Witness my hand and official
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
1, (print or hjpe name oj'person listed in Contact Information, item 1a) Mabarak Shaltbain _..._�,.,...—
certifv that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be construct in conformance with the approved plans, that the required deed restrictions
and protective covenants will recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules n er 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Signature: ZZ Date: ZZ Zz 2-4-
I, a Notary Public for the State of--,, �� T, County of
do hereby certify that H ()l �,�bou n personally appeared
before me this 11cl day of HCUA A04k'�i and acknowledg cu t application for
a stormwater permit. Witness my hand and official se
;U
` pvB%,G;; -;
'''•�.Q AND GQ,,�•`.
SEAT.
My commission expires Dr _ r 5 _ 0Q W
Form SWU- l0 l Version 06Aug20 E 2 Page 6 of 6