SW6131002_CURRENT PERMIT_20131121

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE�%j
YYYYMMDD

A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Tracy E. Davis, PE, CPM Pat McCrory, Governor
Director John E. Skvarla, III, Secretary
November 21, 2013
Mr. Brian Canfield, COO
First Ilealth of the Carolinas
155 Memorial Drive
Pinehurst, North Carolina 28374
Subject: Stormwater Permit No. SW6131002 NOV 2 1 2013
First Health of the Carolinas
Hoke Community Hospital
Dear Mr. Canfield
The Stormwater Program under the Division of Energy, Mineral, and Land Resources (DELMR),
received a complete Stormwater Management Permit Application for the subject project. Staff
review of the plans and specifications has determined that the project, as proposed, will comply
with the Stormwater Regulations set forth in Title 15A NCAC 21-1.1000 and Session Law 2006-246.
We are forwarding Permit No. SW61.31002, dated November 21, 2013, for the construction,
operation and maintenance of the subject project and the stormwater BMPs. This permit shall be
effective from the date of issuance until November 20, 2021, and shall be subject to the conditions
and limitations as specified therein, and does not supersede any other agency permit that may be
required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing by filing a written petition with the Office of Administrative
Hearings (OAH). The written petition must conform to Chapter 150B of the North Carolina General
Statutes. Per NCGS 1.43-215(e) the petition must be filed with the OAH within thirty (30) days of
receipt of this permit. You should contact the OAH with all questions regarding the filing fee (if a
filing fee is required) and/or the details of the filing process at 6714 Mail Service Center, Raleigh,
NC 27699-6714, or via telephone at 919-431-3000, or visit their website at www.NCOAH.com.
Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Fayettesville Regional Office. If you have any questions, or
need additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely,
—)for T�avis, PEZCPM�, Director
cc: SW6131002 File, Fayetteville Regional Office
ec: Cindy Hetzler, Project Manager First Health of the Carolinas
Billy J. Roark, P.E., McGill Associates
Geological Survey Section • Land Quality Section
1112 Mail Service Center, Raleigh, Noll Carolina 11111-1111 , 111-111"11111 1AX:111-1151111
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: hfo://portal.ncdenr.org/web/Ir/
An Equal Opportunity 1 Affirmative Action Employer- 50% Recycled 110% Post Consumer Paper

State Stormwater Permit
Permit No. SW6131002
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
First Health of the Carolinas
Hoke Community Hospital
6408 Fayetteville Road, Raeford, North Carolina in Hoke County
FOR THE
construction, operation and maintenance of Dry Detention/Infiltration Basin in
compliance with the provisions of Session Law 2006-246 and 15A NCAC 2H .1000
(hereafter referred to as the "stormwater rules') and the approved stormwater
management plans and specifications and other supporting data as attached and on file
with and approved by the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until November 20, 2021, and
shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
The Water Quality Treatment Volume, 43623 cubic feet, is based on a Drainage
Area of 25.9 acres, 1 inch design storm, and Built upon area (BUA) of 11.9
acres. Volume in excess of the Water Quality Treatment Volume, as determined
from the design storm, may bypass the detention/infiltration basin. The Water
Quality Treatment Volume must completely draw down within 5 days.
3. The bottom the detention/infiltration basin shall be a minimum of 2 feet above
any underlying impervious soil horizon or bedrock.
4. Before conversion, all accumulated sediment must be removed and properly
disposed of, then the appropriate modifications to the basin depth, geometry,
and hydrology, as well as inlet and outlet structures, must be made. A
minimum of 6 inches of bottom material (below the design bottom of the original
sediment and erosion control device) must be removed prior to conversion to a
detention/infiltration basin.
5. The bottom of detention/infiltration basin must be lined with a layer of clean sand
with a depth of 4 inches or greater, unless the native soil is suitable for
infiltration. .
6. The Dry Detention/Infiltration Basin is approved for the management of
stormwater runoff as described in the application documents and as shown on
the approved plans.
Page 1 of 4

State Stormwater Permit
Permit No. SW6131002
7. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
8. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
9. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
II. -SCHEDULE OF COMPLIANCE
1. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
2. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted Dry Detention/Infiltration Basin functions at optimum
efficiency. The approved Operation and Maintenance Plan must be followed in
its entirety and maintenance must occur at the scheduled intervals including, but
not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowin.9 and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
3. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
4. The permittee shall submit an annual summary report of the maintenance and
inspection records for the Dry Detention/Infiltration Basin. The report shall
summarize the inspection dates, results of the inspections, and the maintenance
work performed at each inspection.
5. The Dry Detention/Infiltration Basin shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
supporting data.
6. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the Dry Detention/Infiltration Basin certifying
that the permitted facility has been installed in accordance with this permit, the
approved plans and specifications, and other supporting documentation. Any
deviations from the approved plans and specifications must be noted on the
Certification. A modification may be required for those deviations.
7. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
Page 2 of 4

State Stormwater Permit
Permit No. SW6131002
8. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
9. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of eight years from the date of the completion of
construction.
10. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, to the
Division of Water Quality, accompanied by the supporting documentation. The
approval of this request will be considered on its merits and may or may not be
approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
Page 3 of 4

State Stormwater Permit
Permit No. SW6131002
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 21 day of November, 2013.
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW6131002
Hoke Community Hospital
6408 Fayetteville Road, Raeford, North Carolina
Hoke County
Designer's Certification
i, ____, as a duly registered in the
State of North Carolina, having been authorized to observe (periodically; weekly/
full time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
cc: NCDENR-DEMLR Regional Office
Page 1 of 1

-1�b M"A £ R&-NdA- //
Application Completeness Review
m- First Submittal ❑ Re -submittal Date Received: a 3i /3 Date Reviewed:
Development/Project Name: Ae ra e.
Receiving stream name RAAVAV ,e' Classifi
tiverBasin: CT0, F,
L
By Bill Diugu
11
For post-constl'uction requirements, a program will be deemed compliant for the areas where it is
implementing any of the following programs: WS-I, WS-II, WS-III, WS-IV, HOW, ORW, Neuse River Basin
NSW, Tar -Pamlico River Basin NSW, and the Randleman Lake Water Supply Watershed Nutrient
Management Strategy.
High Density Projects that require a 401/404 within an NSW require 85% TSS, 30% TN and 30% TP removal.
T&E Species (Goose Creek, Waxhaw Creek or Six Mile Creek Water Sheds):
Latitude and Longitude: S S Z
Project Address: fa v�0, 3 nVezw;_ Y/(.a, u,t » CG OR 6
Engineer name and firm: tom, ir, m, G 11 k
PhnneWo —2 9S-3i a;- 4 Finail- k., ii v�rnt�l.5..nnati,
Is the project confirmed to be in the State MSI Stormwater Permit jurisdiction? 'Yes' or ❑ No
❑ Low Density (no curb and gutter) ❑ Low Density with curb and gutter outlets 5119igh Density ❑Other
,k / —a— 401/404i.mpacts to surface waters, wetlands, and buffers (add language to cover letter and/or add info letter)
IJA
1.
Check for $505.00 included NOV 2 1 2013
Original signature (not opy) on application
r!' Legal signature ( orporationPP/higher, Partnership -General Partner/higher, LLC-member/manager, Agent).
SKI i�G ill _i GLD C O 0
Check spelling, capitalization, punctuation: http://www.secretary.state.nc.us/corporations/thepage.aspx
If an agent signs the application, a signed letter of authorization from the applicant must be provided which
includes the name, title, mailing address and phone number of the person signing the letter.
Copy of property deed showing ownership or control
AA---a—For subdivided projects, a signed and notarized deed restriction statement
Sealed, signed & dated calculations
/(..❑ Correct supplement and O&M provided for each BMP on site (check all that were provided & number of each)
❑ Bioretention
Dry Detention Basin
❑ Filter Strip
❑/Grass
Swale
Er
Infiltration Basin
❑
Infiltration Trench
❑
Level Spreader
o
Permeable Pavement
❑
Restored Riparian Buffer
❑ Rooftop Runoff Management
❑ Sand Filter
❑ Stormwater Wetland
❑ Wet Detention Basin
❑ Low Density
❑ Curb Outlet
❑ Off -Site
❑ NCDOT Linear Road
[9' ,Ywo sets of sealed, signed & dated layout & finish grading plans with appropriate details
esc ' of stormwater management provided
d/ oils repor geotec information provided
ddd s de i ed or a note on the plans or in the accompanying documents that none exist on site and/or
djacent property
Details for the roads, parking area, cul-de-sac radii, sidewalk widths, curb and gutter;
mensions & slopes provided
rainage areas delineated ❑ Pervious and impervious reported for each ❑ Areas of high density
BMP operation and maintenance reements provided
�❑ Application complete Application Incomplete Returned: (Date)
Comments_ .47ra�.� s� 4o JI A%,li/&') 00 C- f� (/1 h� z�A2_k A-
l"'
April 26, 2013 Revision, Bill Diuguitl

r
DWQ USE ONLY
Date Received
Fee Paid
Permit Number
io 31 113
SInJ6/S ooa
Applicable Rules:
(select all that apply)
❑ Coastal SW -1995 ❑ Coastal SW - 2008 0?15-h II - Post Construction
❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgrnt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This farm may be photocopied for use as an original G ��n�t1(lrj D I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name -should be consistWittt trojgt1ia7Vn plans,
specifications, letters, operation and maintenance agreements, etc.): U .�M .
,70
2. Location of Project (street address):
6408 Fayetteville Road
City:Raeford County:NC Zip:28376
3. Directions to project (from nearest major intersection):
3430 LF Northeast on US 401 (Fayetteville Road) from the intersection of iohnson Mill Road
4. Latitude:35* 01' 15.279" N Longitude:79° 08' 59.449" 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 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):
❑Loco 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 DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, hoke08142013 and the previous name of the project, if different than currently
proposed, Intial site package -Hoke County Hospital Site
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):
❑LAMA Major ®Sedimentation/Erosion Control: 24.8 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts None
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:Site improvements, Hoke County Hospital Site Poject ID Hoke 2012-
056, Additional Acerage Approved 5-1-13
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part Vl: httR:/Iportal.ncdenr.orgzweb/wq/ws/­su/statesw/rules laws
Form SWU-101 Version 06Aug2012 Page I 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:FirstHealth of the Carolinas
Signing Official & Title:Brian Canfield, COO
b. Contact information for person listed in item 1a above:
Street Address:155 Memorial Drive
City:Pinehurst State:NC Zip:28374
Mailing Address (if applicable):Post Office Box 3000
City:Pinehurst State:NC Zip:28374
Phone: (910 ) 715-1543 Fax: (910 ) 715-1537
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 &
b.Contact information for person listed in item 2a above:
Street Address:
Mailing Address
Phone:
State:
Fax: ( )
3. a. (Optional) Print the name and title of another contact such as the projects construction supervisor or other
person who can answer questions about the project:
Other Contact Person/ Organiza tion:Cindy Hetzler Project Manager FirstHealth of the Carolinas
Signing Official &
b.Contact information for person listed in item 3a above:
Mailing Address:Post Office Box 3000
City:Pinehurst State:NC Zip:28374
Phone: (910 ) 715-1525 or [phone] Fax: (910 ) 715-1537
ETnail:[e-mail]
Form S WU-101 Version 06Aug2012 Page 2 of 7

" 4. Local jurisdiction for building permits: Hoke County
Point of Contact:Danny Paschal
IV. PROJECT INFORMATION
Phone #: (910 ) 875-8407
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
A series of Storm drainage inlet structures and pig to o carry storm water from streets parking buildings
concrete pads and site to a permanent storm water pond and inflitration bed on the southwest side of site
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: 30 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+:30 acres
Total project area shall be calculated to exclude the following the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHV1d line or Mean High Water
(MHVV) line, and coastal wetlands landward fi•mn the NHW (or MHVV) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Nor -coastal wetlands landward of the NHW (or MHM line may
be included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 45.8
9. How many drainage areas does the project have?2 (For high density, count 1 for each proposed engineered
stormwater BMP. For low densihj and other 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.
Form SWU-101 Version 06Aug2012 Page 3 of 7

Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
Receiving Stream Name
Beaver Creek
Beaver Creek
Stream Class *
C
C
Stream Index Number *
18-31-1951
18-31-1951
Total Drainage Area (so
1,128,923
187,230
On -site Drainage Area (so
1,128,923
133,333
Off -site Drainage Area (so
0
53897
Proposed Impervious Area** (so
521,160
39,120
Impervious Area** total
46.16
20.89
;I T ervious" Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
86,847
0
On -site Streets (so
179,555
39,120
On -site Parking (so
117,470
0
On -site Sidewalks (so
25,051
0
Other on -site (so
18,822
0
Future (sf)
93,415
0
Off -site (so
0
0
Existing BUA*** (so
0
0
Total (so:
521,160
39,120
Stream Class and Index Number can be determined at: http://Portal.ncdenr.org/webfwq&slcsu/classications
* Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Report only that amount of existing BUA that will retrain 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. Off -site area is
adjacent NCDOT roadway with area determined based on ground survey.
Proiects in Union County: Contact DlVQ Central Office staff to check if the project is located within a Th eatened &
Endangered Species watershed that may be subject to more stringent stornnvater requirements as per 15A NCAC 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 hn://portal ncdenr.org/web/wq/ws/su/bmp-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 http: Z I Rortal.ncdenr.org/ web/ wq / ws / su/ statesw/ forms does. 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.nedenr.org/web/wq/ws/su/maps.)
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://portal.ncdenr.org/web/wg/ws/su/statesw/forms does.
1pitials
1. Original and one copy of the Stormwater Management Permit Application Form. „i!1/
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants AV4
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. y
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http / /www envhelp 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.)
Form SWU-101 Version 06Aug2012 Page 4 of 7

5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor i k,�
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 1/2 mile of the site boundary, include the lh
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.
I. 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.
Is. 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). t'
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify Af k►
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"x ll" 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 verifij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1012 Page No: 693 _Ut
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC _ k4e
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:/Zwww.secretary.state.nc.us/CorporatioiisICSearch.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
hn://portal.ncdenr org/web/wg/ws/su/statesw/forms dots. 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.
Form SWU-101 Version 06Aug2012 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:Billy 1. Roark, P.E.
Consulting Firm: McGill Associates
Mailing Address:5 Regional Circle, Suite A
City:Pinehurst
Phone: [phone]
Email:bill.roarkQmc illengineers.conr
State:NC Zip:28374
Pax: (910 ) 295-3647
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (print or type mmne 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 type 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.
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
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
Form SWU-101 Version 06Aug2012 Page 6 of 7

X. APPLICANT'S CERTIFICATION (�
I, (print or hype name of person listed in Contact Information, item 1a) Brian �O-- e JC
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 tha proposed project complies with the requirements of the
applicable stormw er rules u etea 15 NCAC 21 .10 0 and any other applicable state stormwater re wrements.
Signature: c Date:
1, fin. [ ( H ` �a� �5 a Notary Public for the State of I C- County of
MDod^! do hereby certify that I✓1 (Qn Car1%el c1 personally appeared
before me thisZ Hay of �iC..�. e Z and ac nowled the dupe e ution of the application for
a stormwater permit. Witness my hand and official seal, ��� L�
H
SEAL
My commission expires 4- ID - Z O 1S
Fomi SWU-101 Version 06Aug2012 Page 7 of 7

Permit
(to be provided by DM)
04 OVA Tfq
f 0
�► STORMWATER MANAGEMENT PERMIT APPLICATION FORM a
NCDENR 401 CERTIFICATION APPLICATION FORM
INFILTRATION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Pad lit) must be printed, filled out and submitted along with all of the required information,
Contact Person
Phone Number
Date
Drainage Area Number
v �-5
Slte Characteristics
- ---- -
Drainage area
.................... .
:'I(1;128,923.00;.P f�
Impervious area
;'521,160.00 -'ftz
Percent impervious
46.16 %
Design rainfall depth
'- 1 00'(In
Peak Flow Calculations
1-yr, 24-hr rainfall depth
3.09 ''an
1-yr,24-hrintensity
;._423 "%In/hr
Pre -development 1-yr, 24-hr discharge
. : 38 36.. _.:.� ft°/sec
Post -development 1-yr, 24-hr discharge
65.77 -:S' ftaisec
Pre/Post 1-yr. 24-hr peak flow control
27.41 ft°/sec
Storage Volume: Non -SA Waters
Nov 2 7 2013
Minimum design volume required
,'2265100 's.ita
Design volume provided
40953600 .ft° OK for non -SA waters
Storage Volume: SA Waters
1.5' runoff volume
Pre -development 1-yr, 24-hr runoff volume
Post -development 1-yr, 24-hr runoff volume
Minimum required volume
Volume provided
Solis Report Summary
Soil type
Infiltration rate
SHWT elevation
Basin Design Parameters
Drawdown time
Basin side slopes
Basin bottom elevation
Storage elevation
Storage Surface Area
Top elevation
Basin Bottom Dimensions
Basin length
Basin width
Bottom Surface Area
fl°
fta
(t°
:`. fta
0 80 Nhr
22200 '-fmsl
001
days
OK
OK :)K
04.00
- Imsl
OK
.'23600
Amsl
24,356.00
' �244 00
:'- fmsl
.........................
672 00
.
':1t
85 W
1t
21,606.00
-If?
aK 3;l ga��5�olny.p
r
r r�,�f3 pi, G-1o2,
A,rrir 2;
l S b(�i2ecC w'i N rur
h
Form SW401-Infl tra0on BaslnRev.5 11Apr2011 Parts I. B II. Design Summary, Pago 1 of 2

Additional Information
Maximum runoff to each Inlet to the basin?
Length of vegetative filter for overflow
Distance to structure
Distance from surface waters
Distance from water supply well(s)
Separation from impervious soil layer
Naturally occuring sail above shwt
Bottom covered with 4-in of clean sand?
Proposed drainage easement provided?
Capures all runoff at ultimate build -out?
Bypass provided for larger stones?
Pretreatment device provided
Permit No.
(to be provided by DWO)
In OK
OK
OK
OK
OK
OK
OK
or N) OK
or N) Need a recorded drainage easement`
or N) OK
or N) OK
7ff%"A_ S;'191 —OWN tt eJ " 0Li"ta� 6 �7
r'fS{'«eti�iev JF' +L 4'^(fir,, kcy, /�._ prol,r.rF7 ; s GPe✓•.i'e..,C,
AS el boy a(,YA I s ori. 4L) f-t,G pu Lli'e r, r C
a�ail�,Sft �� rhspe��-ru�15.
Foen SW401-In6ara0on ReslmRev.e Mp2011 Parts 1. a II. Design Summary, Page 2 of 2

Permit
(to be provided by DWQ)
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An Incomplete submittal package will
result In a request for additional Information. This will delay final review and approval of the project. Initial In the space provided to
indicate the following design requirements have been met. If the applicant has designated an agent, the agent may initial below. If a
requirement has not been met, attach justification.
Pagel Plan
r
Initials
41_4 —
Sheet No.
G_I6 Z
Gd
1. Plans (1" -/or larger) of the entire site shoving:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficlenl per basin),
Basin dimensions,
Pretreatment system,
High flow bypass system,
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Overflow device, and
C _ IoZ
Boundaries of drainage easement.
2. Partial plan (1" = 30' or larger) and details for the Infiltration basin showing:
- Bypass structure,
- Maintenance access,
- Basin bottom dimensions,
- Basin cross-section with benchmark for sediment cleanout,
• Flaw distribution detail for Inflow,
-Vegetated filter, and
- Pretreatment device.
�(�
p v"�
e-S62
3. Section view of the infiltration basin (1" = 20' or larger) shoving:
- Pretreatment and treatment areas, and
- Inlet and outlet structures.
4. A table of elevations, areas, incremental volumes & accumulated volumes to verify the volume provided.
/5AC
5. A soils report that is based upon an actual field Investigation, soil borings, and Infiltration tests. The
results of the soils report must be verified in the field by DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
�i/
6 v---#
6. A construction sequence that shows how the infiltration basin will be protected from sediment until the
entire drainage area is stabilized.
7. The supporting calculations.
8. A copy of the signed and notarized operation and maintenance (0&M) agreement.
9. A copy of the deed restrictions (if required). /V�/nt
Form SW4014rifiltration Basin-Rev.4 Page i of t Part III. Required Items Checklist, Page 1 of i

Permit No.
(to be provided Dy DM)
• oreI WAipDoy
W� STORMWATER MANAGEMENT PERMIT APPLICATION FORM c
NCDENR 401 CERTIFICATION APPLICATION FORM
DRY EXTENDED DETENTION BASIN SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 11)) must be printed, filled out and submitted along with all the required information.
Project name
Contact person
Phone number
Date
Drainage area number
(L 1MOSJGNSINFORM ION
Site Characteristics
......................._......
Drainage area ;.A,1H921bt) df�
Impervious area I$2116000 ''!f2
%Impervious 0.46
Design rainfall depth i9 100 T.
Peak Flow Calculations
1-yr, 24-hr rainfall depth
Rational C, pre -development
Rational C, post -development
Rainfall Intensity:)-yr, 24-hr slorm
Pre -development 1-yr, 24-hr peak flow
Post -development 1-yr, 24-hr peak flow
Pre/Post 1-yr, 24-hr peak control
Storage Volume: Non -SA Waters
Minimum required volume
Provided volume
Sediment storage volume provided
Storage Volume: SA Waters
1.5, runoff volume
Pre development 1-yr, 24-hr runoff volume
Post -development 1-yr, 24-hr runoff volume
Minimum required volume
Provided volume
Sediment storage volume provided
Basin Design Parameters
Drawdown lime
SHWT elevation
Basin bottom elevation
Storage elevation
Basin side slopes
Top elevation
Freeboard provided
Basin Bottom Dimensions
Basin length
Basin width
Length to width ratio
INhr
222,651.001': ft'
45,962.00 i'if OK
'-11491.00 `iry' OK
to
it
ft'
to
ff
ff
..........001
_'.,days
OK
IL�-. 22200
. 'first
i''23400-
first
OK
-23600
fmsl
..'r 3.0
d:1
OK .
';;, 244 00 '
':.Imsl
OK
$.' 800
!Pry
OK
67200 ';: fl
8500 it
790 :1 OK
7X 3;1 I� ks�o�Ps per �r�f ����w C-1o2.
Z;( sJrStlrzR.Q w;A'turf,
Form SW4D1-Dry Extended Dolonnon BaslmRev.3 Ports I. & II. Design Summary, Page 1 or 2

Additional Information
Total runoff volume captured by basin
Forebay provided
Is basin in a recorded drainage easement?
Does basin capture all runoff at ultimate build out?
Is a sediment depth indicator Included?
Does the basin Include a drain?
.`2600
.::ac-In
(Y or N)
...::: Y
;'.(YorN)
Permit No.
(to be provided by DIM])
Forebay Is required
Need to a recorded drainage easement
OK
OK
OK
)K)i- .rht i>r$rw i5 Orti r�, SrGc�la—pwt—lrc� �/�.� Ocu.,e�{ �y
,/
Qj s�,$}rlTtt� q i5 O�v1 :I Nf� hUY (I C. f1 He✓41
(ti�r�i I.. bftVJ 'iur ti7sh.4.d-u.=, s, Y
Fenn SW401-Dry Extended Detention Basin Rev.3 Pads 1. & U. Design Summary. Pago 2 or 2

Permit No.
(to be provided by DWO)
I I- REQUIR �EJV�,S G E6KLIST t
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An Incomplete submittal package will
result In a request for additional information. This will delay final review and approval of the project. Initial in the space provided to
indicate the following design requirements have been met. If the applicant has designated an agent, the agent may initial below. If a
requirement has not been met, attach justification.
Pagel Plan
Initials
L
Sheet No.
6G
1. Plans(1" j50''orlarger) ofthe entire site showing:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Basin dimensions,
Pretreatment system,
Maintenance access,
Proposed drainage easement and public right of way (ROW),
Overflow device, and
_( o Z
Boundaries of drainage easement.
C -50 2
2, Plan details (1" = 30' or larger) for the biorelention cell showing:
Basin dimensions
Pretreatment system,
Maintenance access,
Outlet structure,
Overflow device,
Flow distribution detail for basin inflow, and
Vegetation specifications.
f C 56'L 3. Section view of the basin (1" = 20' or larger) showing:
- Side slopes, 3:1 or lower,
- Pretreatment and treatment areas, and
- Inlet and outlet structures.
6/(- yO Z 6. A construction sequence that shows how the dry detention basin will be protected from sediment until the
entire drainage area is stabilized.
%Jlr 7. The supporting calculations.
6. A copy of the signed and notarized operation and maintenance (0&M) agreement.
e✓�� 9. A copy of the deed restrictions (if required). N14
10. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. County
soil maps are not an acceptable source of soils information.
Form SW401-Dry Extended Detention Basin-Rev.3 Part III. Required Items Checklist, Page 1 of 1

Permit Number:
(to be provided by DWQ)
Drainage Area Number:
Infiltration Basin Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area will be carefully managed to reduce the sediment load to the
infiltration basin.
— Immediately after the infiltration basin is established, the vegetation will be
watered twice weekly if needed until the plants become established (commonly
six weeks).
— No portion of the infiltration basin will be fertilized after the initial fertilization
that is required to establish the vegetation.
— The vegetation in and around the basin will be maintained at a height of
approximately six inches.
After the infiltration basin is established, it will be inspected once a quarter and within
24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal
County). Records of operation and maintenance will be kept in a known set location
and will be available upon request. NOV 2 7 2013
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
infiltration basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
The inlet device: pipe or
The pipe is clogged (if
Unclog the pipe. Dispose of the
swale
applicable).
sediment off -site.
"rho pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
Furiu SU401-ImiInation Basin O&-ivl-Rev.;
Pa_e i of 3

l
BMP element:
The main treatment area
outlet
The receiving water
Potential problem:
Sediment has accumulated
and reduced the depth to 75%
of the original design depth.
Erosion has occurred or
riprap is displaced.
Weeds are present.
A visible layer of sediment
has accumulated.
Water is standing more than
5 days after a storm event.
Weeds and noxious plants are
growing in the main
treatment area.
Shrubs or trees have started
to grow on the embankment.
An annual inspection by an
appropriate professional
shows that the embankment
needs reoair.
has occurred.
The outlet device is damagec.
Erosion or other signs of
damage have occurred at the
outlet.
How 1 will remediate the problem:
Search for the source of the
sediment and remedy the problem if
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Remove the weeds, preferably by
hand. If pesticides are used, wipe
them on the plants rather than
spraying.
Search for the source of the
sediment and remedy the problem if
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP. Replace any media that
was removed in the process.
Revegetate disturbed areas
Replace the top few inches of filter
media and see if this corrects the
standing water problem. If so,
revegetate immediately. If not,
consult an appropriate professional
for a more extensive repair.
Remove the plants by hand or by
wiping them with pesticide (do not
Remove shrubs or trees
immediately.
Make all needed repairs.
Clean out the outlet device. Dispose
of the sediment off -site.
Repair or replace the outlet device.
Contact the NC Division of Water
Quality 401 Oversight Unit at 919-
733-1 786.
Perm SW.101-Inli I I rat ion Basin OTC iNI-Rev.3
Paec 2 of 3

Permit N
(to be provided by DINQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. 1 agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project name:Floke Community Hospital
B11P drainage area number:
Print name:Brian Canfield
Title:Chief Operating Officer
Address:P.O. Box 3000, Pinehurst, NC 28374
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
1. KMba 11 S(StUrl�U�-, a Notary Public for the State of
NOHJ) �IIr7�i rig County of Moo( -Pe do hereby certify that
Br i cqm Gnf—"C'(d personally appeared before me this ZZ
day of ©Cbbe f ?A 13 , and acknowledge the due execution of the
forgoing infiltration basin maintenance requirements. Witness m�yhand and official seal.
gp �H ft
SEAL
My commission expires 4— t o .2--o t S
Form SW-101-Int itration Basin O&&.M-Rev.3
Ptee 3 of

Permit Number:
(Io be provided by DWQ)
Drainage Area Number:
Dry Extended Detention Basin
Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set location. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
The dry extended detention basin system is defined as the dry detention basin, outlet
structure, pretreatment including forebays and the vegetated filter if one is provided.
This system (check one):
❑ does ® does not incorporate a vegetated filter at the outlet.
This system (check one):
❑ does ® does not incorporate pretreatment other than a forebay.
Important maintenance procedures: NOV 2 7 2013
— The drainage area will be managed to reduce the sediment load to the dry
extended detention basin.
— Immediately after the dry extended detention basin is established, the vegetation
will be watered twice weekly if needed until the plants become established
(commonly six weeks).
— No portion of the dry extended detention pond will be fertilized after the first
initial fertilization that is required to establish the vegetation.
— I will maintain the vegetation in and around the basin at a height of
approximately six inches.
— Once a year, a dam safety expert will inspect the embankment.
After the dry extended detention basin is established, it will be inspected once a quarter
and within 24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in
a Coastal County). Records of operation and maintenance will be kept in a known set
location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the dry
Areas of bare soil and/or
Regrade the soil if necessary to
extended detention
erosive gullies have formed.
remove the gully, and then plant a
basin
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
form SW40I-Dn Detuuikm OEM-IleV.j
Page I ol'4

ti
BMP element:
Potentialproblem:
Flow 1 will remediate theproblem:
The inlet device: pipe or
The pipe is clogged (if
Unclog the pipe. Dispose of the
swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the swale if necessary to
swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
The forebay
Sediment has accumulated
Search for the source of the
and reduced the depth to 75%
sediment and remedy the problem if
of the original design depth
possible. Remove the sediment and
(see diagram below).
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Erosion has occurred or
Provide additional erosion
riprap is displaced.
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Weeds are present.
Remove the weeds, preferably by
hand. If pesticides are used, wipe
them on the plants rather than
spraying.
The main treatment area
Sediment has accumulated
Search for the source of the
and reduced the depth to 75%
sediment and remedy the problem if
of the original design depth
possible. Remove the sediment and
(see diagram below).
dispose of it in a location where it
will not cause impacts to streams or
the BMP. Revegetate disturbed
areas immediately with sod
(preferred) or seed protected with
securely staked erosion mat.
Water is standing more than
Check outlet structure for clogging.
5 days after a storm event.
If it is a design issue, consult an
appropriate rofessional.
Weeds and noxious plants are
Remove the plants by hand or by
growing in the main
wiping them with pesticide (do not
treatment area.
spray).
Forni SW401-Di D�mition O&' _3
p,_r=of4

U
BMP element:
Potentialproblem:
How I will remediate theproblem:
The embankment
Shrubs or trees have started
Remove shrubs or trees
to grow on the embankment.
immediately.
Grass cover is unhealthy or
Restore the health of the grass cover
eroding.
- consult a professional if necessary.
Signs of seepage on the
Consult a professional.
downstream face.
Evidence of muskrat or
Use traps to remove muskrats and
beaver activity is present.
consult a professional to remove
beavers.
An annual inspection by an
Make all needed repairs.
appropriate professional
shows that the embankment
needs repair.
The outlet device
Clogging has occurred.
Clean out the outlet device. Dispose
of the sediment off -site.
The outlet device is damaged
Repair or replace the outlet device.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
The measuring device used to determine the sediment elevation shall be such that it will
give an accurate depth reading and not readily penetrate into accumulated sediments.
When the basin depth reads 0_5 feet in the main pond, the sediment shall be removed.
When the basin depth reads N A feet in the forebay, the sediment shall be removed.
Sediment Removal
Bottom
FOREBAY
BASIN DIAGRAM
(fill in the blanks)
Sediment
Storage
Temporary Pool Elevation 236
Pool Temporan
Sediment Removal Elevation 234.5 Volume
---------------------------------------------
Bottom Elevation 234 1 25%
MAIN POND
Form SW401-Dry Detention O&M-Rev.3
Page 3 of 4

Permit Number:
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project nume:Site Improvements, Floke County Hospital Site
BiVfP drainage area number:
Print name:Brian Canfield
Title:Chief Operating Officer
Address:P.O. Box 3000, Pinehurst, NC 28374
Note: The legally responsible party should not be a homeowners association unless more than 50%of
the lots have been sold and a resident of the subdivision has been named the president.
�QVIdefS a Notary Public for the State of
Nfl , qy-olim , County of MQDf L do hereby certify that
&iaVt C-aVt�e(C� personally appeared before me this
day ofn'jybe(r 2013, and acknowledge the due execution of the
forgoing dry detention basin maintenance requirements. W, ne_ sspy hand and official
seal, Lt�b
pb<lpgd
r: f.7;f.
SEAL
My commission expires 4— 0— ?--OD IS
Form SW401-Dig Dcicnlion O&M-Reo. i Paec 4 of 4