SW6110802_HISTORICAL FILE_20110812

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
�i HISTORICAL FILE
[i❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
n-&Z&/n
YYYYMMDD

Lawyer, Mike '
From: Lawyer, Mike
Sent: Friday, August 12, 2011 10:20 AM
To: [e-mail]'; 'Sam Powers'
Subject: Nazareth Missionary Baptist Church
Wesley & Sam,
This e-mail is to acknowledge receipt of the Stormwater Management Permit application by our office on August 11,
2011 for the subject project. The application package appears to be complete. I will contact you if I have any questions
or need additional information.
Thanks for your assistance in this matter.
Mike
Michael Lawyer, CPSWQ
Environmental Specialist
NCDENR-Division of Water Quality
Surface Water Protection Section
Fayetteville Regional Office
Direct: [phone]
Main: [phone]
Fax: [phone]
e-mail: [e-mail]
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed
to third parties unless the content is exempt by statute or other regulation.

Anderson E
P.O. Box 1736
305 North Chippewa
Lumberton, N.C. 28359
Licensure No.: C-0793
August 10, 2011
Fneerinm & Assoc., P.A.
NCDENR - Division of Water Quality
Attention: Mike Lawyer
225 Green Street — Suite 714
Fayetteville, NC 28301
Ref: Nazareth Missionary:Baptistt burchVr
Stormwater Manage ent�+P-ackage n �,
Mr. Lawyer, f
Larry Anderson, P.E.
President
DLNa-FRO
DWQ
Please find enclosed',the�f 116wing information -on the above referenced?project for your review:
• Completed StOnii)e Ater Management "Pi it`Application Form (one original, one copy)
• Application•Fee ($505.00) '44 `,
•
Stormwater Management s & Details (two copies) b
• Completed W f D'etentiori sin Operation Agr ent
Vi .9 a /rplement --_ a
• Wet Detention Basin Supplement Form
• Soils Report f T the�ppr jbct site
Copy of the Deed}for the property
• Copy of the Erosion Control PIan:Approval °
vmn�°
I trust that the information providedlxwill-be sufficient for your --review. If you have any questions
or require additional information, please d"onat•hesitate to contact me.
Thanks,
Powers, P.
& ASSOCIATES, P.A.
SJP/jib
National Society of
Enclosures Professional Engineers®
ntsveue.�sed,�enmer '
Phone: [phone] Fax: [phone] • Email: [e-mail]

:`DWQ.UBFxONLY;",';
Date Received
Fee Paid
Permit Number
6- ft- 1 /
_2r525
1SWIo 0g02__
Applicable Rules:
❑ Coastal SW -1995 ❑ Coastal SW
- 2008 ❑ Ph I1- 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 ®�J�a d—u'p�i0
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FOR
rM II 1 2u1�
This form may be photocopied for use as an original
I. GENERAL INFORMATION
r v�
1. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Nazareth Missionary Baptist Church
2. Location of Project (street address):
US HWY 401
City:Wagram County:Scotland Zip:28369
3. Directions to project (from nearest major intersection):
Heading East on US 401 out of Wagram toward Raeford the site is on the left side of the road approximately
300 feet E of the intersection of Howard St. and US 401.
4. Latitude: 34 * 53' 47.039" N Longitude:79* 21' 31.68" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ENew []Modification
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 EHigh 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 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 ESedimentation/Erosion Control: 5.0 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
issue date and the tvoe of each oermit:Proiect Name: Nazareth Missionary Bz
Number,
Form SWU-101 Version 07July2009 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:Nazareth Missionary Baptist Church
Signing Official & Title: Pastor Darrel Gibson Jr.
b.Contact information for person listed in item la above:
Street Address: 25020 Nazareth Church St
City: Wagram State:NC Zip:28369
Mailing Address (if applicable):PO Box 481
City:Wagram State:NC Zip:28369
Phone: (910 ) 369.2790
Email: pastorgibsonQyahoo.com
Fax: (910 ) 369.2216
c. Please check the appropriate box. The applicant listed above is:
One 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
Signing Official &
b.Contact information for person listed in item 2a above:
Street Address:
Mailing Address (if
City:
Phone: ( )
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:United Builders of Lumberton
Signing Official & Title: Timmy Tim Lewis. Owner
b.Contact information for person listed in item 3a above:
Mailing Address: 615 East 5' Street
City: Lumberton State:NC Zip:28358
Phone: (910 ) 738-6243 Fax: (910 ) 738-5327
4. Local jurisdiction for building permits: Scotland County
Point of Contact:Eamest Stephens Phone #: (910 ) 277-2420
Form SWU-101 Version 07July2009 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, bnefly summarize how the stormwater runoff will be treated.
Wet Detention Pond
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:
ElValid Building Permit Issued Date:
❑ Other: Date:
b.Identify the regulation(s) thepprolect has been designed in accordance with:
❑ Coastal SW —1995 ❑ Ph II — Post Construction
3. Stormwater runoff from this project drains to the Lumber River basin.
4. Total Property Area: 5.6 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*:
5.6 acres
Total project area shall be calculated to exclude the following the normal pool of imppounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may be
included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 34.11 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density and other projects, use 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.
;Basinlriformahon <;
Draina e Area ='
;Dfdina esArea=_j
iDraina e;Areai&.;.'
Receiving Stream Name
Lumber River
Stream Class
WS-IV,B;
Sw,H W
Stream Index Number *
14-(3)
Total Drainage Area (so
243,936
On -site Drainage Area (sf)
243,936
Off -site Drainage Area (sf)
0
Proposed Impervious Area** (sf)
83,199.6
% Impervious Area** (total)
34.11
rlin ervrods".'-Surface"*A ea t'rt
Drairia"cAreaYKC
Dfaina e,Area5---f
Draiha ewArea=i;DPaina
e%rea;_.
On -site Buildings/Lots (sf)
20,037.6
On -site Streets (sf)
0
On -site Parking (sf)
58,370.4
On -site Sidewalks (sf)
4,791.6
Other on -site (sf)
0
Future (so
0
Off -site (so
0
Existing BUA*** (st)
0
Total (sf):
83,199.6
* Stream Class and Index Number can be determined at: http://`h2o.enr.state.nc.uslbinislreporLsLreportsWB.html
** Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
si etualks, gravel areas, etc.
'Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that is
to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
Form SWU-101 Version 07Ju1y2009 Page 3 of 6

Projects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per NCAC 01B .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
fromhttp:/_/h2o.enr.state.nc.us/su/bmo forms.htm.
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 http://h2o.enr.state.nc.us/su/bmp forms htm. 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://h2o.enr.state.nc.us/su/msi maps.htm.)
Please indicate that the following required 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 http://h2o.enr.state.nc.us/su/bmp forms htm.
1. Original and one 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 VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.envhelt).org/pages/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
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' i mile of the site boundary, include the rh
mile radius on the map.
7. Sealed, signed and dated calculations.
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).
'tials
A/ 1
4
■III'
■"T
Form SWU-101 Version 07July2009 Page 4 of 6

9.. Copy of any applicable soils report with the associated SHWT elevations (Please identify 14
10.
11.
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 verify the SHWT prior
to submittal, [phone]J
N
A copy of the most current property deed. Deed book: 1229 Page No: 208-209
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 NCAC 21-1.1003(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.secretary.state.ne.us /Corporations /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
http://h2o.enr.state.nc.us/su/bmp forms htmlideed restrictions. 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:Samuel 1. Powers, PE
Consulting Firm: Anderson Engineering and Associates, PA
Mailing Address:305 North Chippewa Street
City:Lumberton State:NC Zip:28358
Phone: (910 ) 671.9530
Email:samjpowers©gmail.com
Fax: (910 ) 618.0838
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type 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 la) with (print or type name of organization listed in
Contact Information, item IN 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 07July2009 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 property owner, it is my responsibility to notify DWQ 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.
a Notary Public for the State of
do hereby certify that
before me this _ day of
stormwater permit. Witness my hand and official seal,
SEAL
County of
personally appeared
and acknowledge the due execution of the application for a
My commission
X. APPLICANTS CERTIFICATION
I, (print or type name of person listed in Contact Information, item 2) Pastor Darrel Gibson Jr.
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 stouter rule .undue 15A N(;6C 21­1.1000, �L 2006-246 (Ph. II -Post Construction) or SL 2008-211.
Date: it s //
T v
I, V 2R n Z l3y�e thg •� a Notary Public for the State of N C County of
p ob�5o do hereby certify that flVrr�\ 0-C:,bson Sr - personally appeared
before me this day of , lO l 1 . and acknowledge the cl4e execution of the application for a
stormwater permit. Witness my hand and official seal,Q zzsk� - o
SEAL
My commission expires O (� - \ `i - -�' O \ 5
Form SWU-101 Version 07July2009 Page 6 of 6