SWA000166_Application Form_20221005

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
SW Program(s): ❑ Coastal SA-HQW ❑ Coastal SA-ORW ❑ Coastal FW-ORW ❑ Coastal Other
❑ Non -coastal HQW ❑ Non -coastal ORW ❑ Urbanizing Areas ❑ USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to R olication Instructions
A. ELIGIBILITY FOR FAST -TRACK PERMITTING
To be considered for a Fast Track ATC Permit, all of the items below must be checked. If any item cannot
be checked, then the project must apply under the Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project) will meet all applicable
requirements of 15A NCAC 02H .1000 - .1062, including the Minimum Design Criteria (MDC), upon project
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Director's
Certification.
® The project is not out of compliance with an existing stormwater permit or any other environmental permit.
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined in 15A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seal of a professional licensed pursuant to either Chapter 89A
or 89C of the NC General Statutes.
® I understand that at project completion, an application with the as -built stormwater plans (as described in 15A
NCAC 02H .1044 must be submitted, and DEQ will review the as -built stormwater plans to confirm
compliance with the MDC. Approval of the as -built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1 Project Name- North Carolina State Laborato of Public Health Addition
2. Previous Project Name (if applicable):
3. Location of Project (street address): 4312 District Dr_
City:Raleigh County:Wake Zip:27607
4. Directions to project (from nearest major intersection):
Just North of intersection at Blue Ridge Road and Wade Avenue. Turn onto District Dr and follow to end of
road.
5. Latitude:350 48' 29.2" N Longitude:780 43' 08.3" W
C. PERMIT INFORMATION
1. Specify whether project is (check one):
of the main entrance to the project.
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: SWA
Stormwater Fast Track ATC Application Form Page 1 of 11 Feb. 10. 2018

By choosing this option, you are also requesting that DEQ rescind the previous Fast Track ATC Permit
upon issuance of the new Fast Track ATC Permit.
Stormwater Fast Track ATC Application Form Page 2 of 11 Feb. 10, 2018

Stormwater will be captured with roof drains, foundation drains, and natural grade.11owing into an existing
SCM bioretention basin that is being up graded and enlar ed for the building addition.
3. Stormwater runoff from this project drains to the Neuse River basin(s).
4. Receivin4 water information (if more than 3 receiving waters, provide additional information on an attached sheet);
Receiving
Water 1
Receiving
Water 2
Receiving
Water 3
Receiving Stream Name
Richlands Creek
Stream Classification
C;NSW
Stream Index Number
27-33-11
Stormwater Fast Track ATC Application Form Page 5 of 11 Feb. 10, 2018

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQW/ORW). Only application packages that include
all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
Initial
1. Two original signed hard copies and one electronic copy of this State Stormwater Fast Track
Process "Authorization to Construct" (ATC) Permit Application Form.
2. Permit application processing fee of $505 payable to NCDEQ.
3. Two hard copies and one electronic copy of a USGS map identifying the project location
and GPS coordinates for the project. If the receiving water is Class SA or the receiving water
drains to Class SA waters within '/z mile of the project boundary, include the '/z mile radius
on the map. If the project is within 575 feet of Class SA-ORW waters, include the 575-foot
/ radius on the map.
(� 4. Two original signed hard copies and one electronic copy of a site plan depicting the boundary
of the project or project phase currently being permitted, including the locations of SCMs,
streams, wetlands, and buffers.
5. Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased.
6. A copy of the most current property deed. Deed book: 017183 Page No: 02086
7. [IF APPLICABLE] When the applicant is a corporation or a limited liability corporation (LLC): Provide
two hard copies and one electronic copy of documentation from the NC Secretary of State, or other
official documentation, which supports the titles and positions held by the persons listed
in Section C.2 per 15A NCAC 2H. 1043(3)(b). The corporation or LLC must be listed as an active
corporation in good standing with the NC Department of the Secretary of State; otherwise, the
application will be returned. https://www.sosnc.clov/search/index/corp
8. [IF APPLICABLE] When the applicant is a Partnership or other person engaging in business under
an assumed name, attach a copy of the Certificate of Assumed Name.
9. [IF APPLICABLE] When the applicant is not the property owner: Provide two hard copies and one
electronic copy of lease agreements, affidavits, pending sales agreement, development agreement,
or other documents showing that the applicant has obtained legal rights to submit a stormwater
permit application within the proposed project area.
10. [IF APPLICABLE] If modifying an existing permit for completed or partially completed projects, a copy
of the designer's certification.
Stormwater Fast Track ATC Application Form Page 7 of 11 Feb. 10. 2018

G. CERTIFICATION OF APPLICANT/ FINANCIALLY RESPONSIBLE PARTY
The Applicant, who is also the Financially Responsible Party, identified in Section D of this form must sign and have
notarized the following guaranty:
1, (print or type name of Applicant/Financially Responsible Party) s
certify that the information included on this permit application form is, to thebest of my know edge, correct and
that:
1. the design has been or will be completed in accordance with the MDC as set forth in Rules 15A NCAC
02H .1050 through .1062, to the best of my knowledge;
2. the completed design meets or will meet the MDC and that the percentage BUA that is the basis for the
design shall not be exceeded, to the best of my knowledge; and
3. As the applicant, I shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as -built package. If I retain another licensed
professional before the project is complete, then I shall provide an updated
guaranty with the current licensed professional's seal. A licensed professional shall inform
the Division if he is no longer associated with this project.
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath I
agree to provide corrected information should there be any change in the information provided herein.
Type or print name � _ � � Title or Authority r✓ �i�.s�e hAt42
5lgnature
Date
a Notary Public for the State of ' 10 r' - 1 &Kp l PLC
County of Q rLL , do hereby certify that �lJt-K �.O
personally appeared before me this � day of SI,L ( L_, and acknowledge the
due execution of the application for a stormwater permit. Witnes y hand and official seal,
LASHUN HART
NOTARY PUBLIC
FRANKLIN COUNTY, NC
my M-A0arl
SEAL
My commission expires +I f (k /a LA 7
Stormwater Fast Track ATC Application Form Page 8 of 11 Feb. 10, 2018

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be co pleted b the Design Professional identified in Section D.5.
I, , attest to the following:
1. is application has been reviewed by me and is accurate and complete, to the best of my knowledge;
2. The design has been completed in accordance with the MDC as set forth in Rules 15A NCAC 02H
.1050 through .1062, as applicable;
3. The percentage built -upon area that is the basis for the design will not be exceeded; and
4. 1 have the expertise, education, and experience required to design the SCMs proposed in this
application in accordance with the MDC as set forth in Rules 15A NCAC 02H .1050 through .1062.
5. 1 will provide all documents and certified as -built plans in hard copy and electronic format related to
this permit to a new Applicant/Property Owner and to DEMLR upon transfer of this permit to a new
Applicant/Property Owner.
Note: In accordance with N.C.G.S. 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. In addition, any person
who knowingly makes any false statement, representation, or certification in any application may be reported to
the appropriate NC professional licensing board.
Signature:
CAR
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SEA3
584
❑1
SEAL
Date: 7 -, Z
Stormwater Fast Track ATC Application Form Page 9 of 11 Feb. 10, 2018

I. PROPERTY OWNER'S AUTHORIZATION (IF APPLICANT IS NOT THE PROPERTY OWNER)
1, (print or type name of the Property Owner) , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of Applicant)
_ with (print or type name of Applicant's
organization)_ 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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and submit
a completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
I,
County of
a Notary Public for the State of
do hereby certify that
personally appeared before me this day of
Date:
, and acknowledge the
due execution of the application for a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Stormwater Fast Track ATC Application Form Page 10 of 11 Feb. 10, 2018

J. CERTIFICATION OF CURRENT PERMITTEE (COMPLETE ONLYIF PERMIT TRANSFER IS
REQUESTED)
1, (print or type name of the Current Permittee) am submitting
this request for a transfer of Fast Track ATC permit # SWA With the
submission of this transfer request I am providing a copy of the most recent permit, all related documents and as -
built plans certified by my design professional in hard copy and electroniq format to the Proposed
Permittee/Applicant identified in Section G of this application and to DEMLR . I further attest that this request for
a permit transfer is accurate and complete to the best of my knowledge. I assign all rights and obligations as
permittee to the proposed permittee named in Section G of this form.
Signature:
County of
personally appeared before me this
Date:
_, a Notary Public for the State of
, do hereby certify that
day of , and acknowledge the
due execution of the application for a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Stormwater Fast Track ATC Application Form Page 11 of 11 Feb. 10, 2018