SW6140201_HISTORICAL FILE_20140309 (2)

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
HISTORICAL FILE
COMPLIANCE EVALUATION INSPECTION
DOC DATE
Jozz_ d&22
YYYYMMDD

NCDENR - Stormwater Permitting Map Viewer Page 1 of I
NC Department of Environment and Natural Resources
Energy Mineral and Land Resources - Stormwater Permitting Map Viewer
4Back to Stormwater Permitting (http://partal.ncdenr.org/web/ir/ w aps)
Stormwater Permitting Map Viewer
Enter Address' iFind Address l Reset
Latitude (decimal degrees, N) 35.2639 Longitude (decimal degrees, W):79.0428 Find Location
Need to mmort degre tes, zecondA to dec'maI form t? Ih P: r m,um I f r bl.mr. Cla I Wn.W.6 aac-I nunp
Or, just enter coordinates in the ADDRESS field like this: (deg min sec) ( deg min sec), and than click Find Address'.
Need help with this mom? Contact Belhany Georgoulias at (o 9) 807 6372 or hethLv. eorgoulias@niAy r.Wv
Click on the map to see permitting information.
Please check with the local government to verify current boundaries and specific stormwater requirements.
Powered LV Gbal Mess JaveSnlpt An V3,Inm,rcmr,& en d Gogle rinse Title, eup n—ir, a nenuelnl
NW: Mew.. —I ereee 1—u,e 1.10 us censur we rM41ed In, prm bee.IMwnunon.
. lot 2.— ter nanwe NU.'/ wam. lot upGYd 0.waLw N I
N.C, neperm e,t of Envonment and Natural Pe.nnrms
lion Anil Service Cren, Raleigh, NC 27699.160,
nr ,dN pa"T4ri
.h,nL PCI:J.na 512 if --I-Sl. iRd
VV 9 �tlw
41
http://portal.ncdenr.org/web/Ir/sw-permitting-map 1 2/14/2014

DWQ USE ONLY
Dale Received
Fee Paid
Permit Number
Applicable Rides: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M >mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as no 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.):
2. Location of Project (street address): tloz 9 ON
City:Cameron Coimty:NC 0At SSA la Zip:28326
3. Directions to project (from nearest major intersection):
Approximately 0.25 miles north along HM Cagle Drive from its intersection with NC Hwy 87 in Harnett
County. The site is behind the Cagle Furniture Store.
I L
4. Latitude:35° 15' 50" N P6 • Longitude:79° 02' 34" W t of the main entrance to the project.
/
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): . ®New ❑Modification ❑ Renewal w/ Modificationt
tReuetunls with modifications also requires SWU-102 - Renaval Application Fonn
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 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): -
❑LAMA Major
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 4.0 ac of Disturbed Area
❑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 VI: htt�//12ortal.ncdenr.org/web/wq/ws/su/statesw/rules laws
Form SWU-101 Version06Aug2012 Page I of6

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 oroiect):
Applicant/Organization:David E. Looper & Company, Inc.
Signing Official & Title:Clark Rowe, Project Manager
b.Contact information for person listed in item la above:
Street Address:320 15°h Street SE
City:Hickory State:NC Zip:28602
Mailing Address (ifapplicable):PO Box 3224
Phone: (828 ) 324-1284
Email:[e-mail]
State:NC Zip:28603
Fax: [phone]
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/Organiza
Signing Official & Title:_
b.Contact information for person listed in item 2a above:
Street Address:3035 NC 87 South
City:Cameron State:NC Zip:28326
Mailing Address (ifapplicable):Same
Phone: (919 ) 606-4696
Email:[e-mail]
gmail.com
Zip:
Fax: [phone]
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: Chandler Engineering PA
Signing Official & Title:lim Chandler. PE - President
b. Contact information for person listed in item 3a above:
Mailing Address:309 S. Fuquay Avenue
City:Fuquay-Varina State:NC Zip:27526
Phone: (919 ) 390-4227
Email:[e-mail]
Fax: (919 ) 552-6962
4. Local jurisdiction for building permits: Harnett County
Point ofContactAmandaBader Phone#: [phone]
Form SWU-101 Version 06Aug2012 Page 2 of

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Based on the in -situ soil type for the project site, stormwater runoff will be treated by 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 regulations) the project has been designed in accordance with:
❑ Coastal SW — 1995 ❑ Ph It — Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 1.80 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-:1.80 acres
t Total project urea shall be calculated to exclude the following: the normal pool of impounded structures, the area
bekueen the bunks of streanns and rivers, the area below the Nornwl 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 (BLIA). Non -coastal wetlands landrard of the NHW (or MHW) line nnny
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 56.1 %
9. How many drainage areas does the project have?l (For high density, count 1 for each proposed engineered
stornavater BMP. For low density and other projects, use I 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
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Reedys Swamp
Stream Class *
C
Stream Index Number *
18-23-29-2
Total Drainage Area (sf)
78408
On -site Drainage Area (sf)
78408
Off -site Drainage Area (sf)
0
Proposed Impervious Area** (sf)
43900
E. Impervious Area** (total)
56.1
Impervious** Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
7467
On -site Streets (sf)
27569
On -site Parking (so
4718
On -site Sidewalks (so
2783
Other on -site (sf)
1363
Future (so
0
Off -site (sf)
0
Existing BUA*** (sf)
0
Total (so:
43900
* Streon Class and Index Number can be determined at: litty.Ijvortal.ncdenr.org/7veb/7y46zs/Csit/­`Classiflcations
** Inn ervious 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 BLIA that will remain after development. Do not report any existing BLIA that
is to be removed and which will be replaced by neru BLIA.
Form SWU-101 Version 06Aug2012 Page 3 of

11. How was the off -site impervious area listed above determined? Provide documentation.
Projects in Union County: Contact DWQ Central Office stafflo check ifthe project is located irithin a Threatened &
Endangered Species ivalershed that moY be subject to more stringent slortmvater 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
fromhtto://Dortal.ncdenr.oriz/web/wci/ws/sLi/bmi)-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://12ortal.ncdenr.orV/web/wq/ws/su/stitesw/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:/ /12ortal.ncdenr.org/web/wq/WS/­',;LI Lmaps.)
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://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms does.
I iI Is
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.envhelp.org/pages/onestol2exl2ress.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/managementfor
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'fe mile of the site boundary, include the 11h
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.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
I. 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).
Fonn SWU-101 Version 06Aug2012 Page 4 of

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 x11 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].)
A copy of the most current property deed. Deed book: 2799 Page No: 362
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 ]a, 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.secretary.state.nc.us/­Corporatioiis/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://12ortal.ncdenr.org/web/wq/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 Engineenlim Chandler, PE
Consulting Firm: Chandler Engineering, PA
Mailing Address:309 S. Fu uay Avenue
City:Fuquay-Varina State:NC Zip:27526
Phone: (919 ) 390-4227
Email:[e-mail]
Fax: (919 ) 552-6962
IX. PROPERTY OWNER AUTHORIZATION (if Contract Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2o) HM's Kids Inc. . 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) Clark Rowe with (print or type name of organization listed in
Contact Information, item la) David E Looper & Co., Inc. 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 SWU-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 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. 1 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, NVAvJ)Y �� CI CIK A a Notary Public for three Stateof �'�+(�(. , Countyof
l- I ) AAL/ — do hereby certify that l/TVVU1-)f1,21ure t_( personally appeared
before me this day of L�OVIKin. an a ovule ge the due execution of the application for
a stormwater permit. Witness my hand and official
(�.D. Clu y
11-23-2018.
m. Exp. ° AUS4,
(]V qP
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires I) -')� ' v "` v
I, (print or type name of person listed in Contact information, item 1a) Clark Rowe
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2H .1000 and any other applicable stale stormwater requirements.
Date: February4, 2014
1, loyce A. Kessler a Notary Public for the State of North Carolina County of
Catawba do hereby certify that
Clark Rowe
personally appeared
before me this 4th day of February 2014 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, '* &�
SEAL
My commission
August 17, 2018
Form SWU-101 Version 06Aug2012 Page 6 of 6

.i !
a_- � _
. � p � : l•!
. i �� 1J k
ryYI• .: AN K��
i ':