SW3220305_Application Form_20220615

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ CoastaI 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 t 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.):
Rockv River Regional Wastewater Treatment Plant Phase 3 Exvansion Desien
2. Location of Project (street address):
6400 Breegy Lane
City:Concord County:Cabarrus Zip:28025
3. Directions to project (from nearest major intersection):
From the intersection of US Highway 49 and US Highway 601, head south on US Highway 601. Turn right
onto Flowes Store Road. Turn left onto Simplicity Road. Turn right onto Breezy Lane which leads into the
Rocky River Regional Wastewater Plant (RRRWWTP).
4. Latitude:35* 19' 41" N Longitude:80° 32' 31" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modifiicationt
tRenewals with modifications also requires 5WU-702 - 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: 15.88 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
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

If yes, see S.L. 2012-200, Pali VI: http:/Jportal.nrdenr.tirr web/lrlrules-and-regulations
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:Water and Sewer Authority of Cabarrus County fWSACCI
Signing Official & Title:Chad VonCannon, Engineering Director
b. Contact information for person listed in item 1a above:
Street Address:232 Davidson Highway
City:Concord State:NC Zip:28027
Mailing Address (if applicable):Same as street address
City: State: Zip:
Phone: [phone] Fax: ( )_
Email:[e-mail]
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/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: f 1
Email:
State:
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:Brown and Caldwell
Signing Official & Title:ICim Devendorf, PE
b. Contact information for person listed in item 3a above:
Mailing Address:309 E Morehead St Suite 160
City:Charlotte State:NC Zip:28202
Phone: [phone] Fax: ( )
Email:kdevendorf®BrwnCald.com
4. Local jurisdiction for building permits: Cabarrus County
Point of Contact:Matt Love Phone #: ,(704 ) 920-2131
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

5. A detailed narrative (one to two pages) describing the stormwater treatment/management for KD
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the KD
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2 see attachment 4 - atte plans
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). KD
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: KD
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 Iandward 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).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify KD
elevations in addition to depths) as well as a map of the boring locations with the existing see attexAment 4 -site plans
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the See atlachment8-peoteM report
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 DEMLR to verify the SHVVf prior
to submittal, [phone])
10. A copy of the most current property deed. Deed book: 1351 Page No: 213 KD
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC KD
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 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.
hft://www.secretary.state.nc.us/CoEporations/CSearch.aspx
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 htiR://12ortal.ncdenr.org/web/Ir/state
stormwater-forms docs. 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.
Fonn SWU-101 Version Oct. 31, 2013 Page 5 of 7

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:Kim Devendorf
Consulting Firm: Brown and Caldwell
Mailing Address:309 E Morehead St Ste 160
City:Charlotte State:NC Zip:28202
Phone: (315 ) 401-3634 Fax: j 1
Email:[e-mail]
DC PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person Iisted 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 1 a) with (print or type name of organization listed in
Contact Information, item 1a) to develop the project as currently proposed. A copy of
the Iease 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 Iegal 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. 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 $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
I, , 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
Form SWU-101 Version Oct. 31, 2013 Page 6 of 7

X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item 1 a) Chad Von Cannon
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 rule under 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Signatu e:_ n� _ Date: � % a z
I, -f l_mam 1�I e_a weirI�fQY� 4 , a Notary Publicforthe State of 4 dfi !!a 'Mn , County of
,� C2 C r W-_ do hereby certify that ��nA V Dn Co Yi n O'S\ personally appeared
before me this ' day of Cl M, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
``•,�U�Nrrn nrrrrrUl/,
kSPr9ER
-4 ` pT AR
s
SEAL
My commission expires 'furye 3. d Oa
Form SWU-101 Version Oct. 31, 2013 Page 7 of 7