SW6220804_Application Form_20221116

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 ❑ Ph 11- 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 Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Rebekah Evans 230kV POD
2. Location of Project (street address):
Upton Tyson Rd
City: Grays Creek
County: Cumberland
3. Directions to project (from nearest major intersection):
Zip: 28306
Travel ±5,667 ft west on Upton Tyson Rd from the intersection of Hwy 87. Project location is on the right.
4. Latitude: 34° 55' 53" N Longitude: -78' 50' 4" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals 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):
®Low Density ❑High Density ❑Drains to an Offsite Stormwater System ❑Other
If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application, list the stormwater project number,
if assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major
®Sedimentation/Erosion Control: 4.00 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 Name, Project/Permit Number,
issue date and the type of each permit:
Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://12ortal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 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: South River Electric Membership Corporation
Signing Official & Title:Chris Spears (Registered Agent, Executive Vice President & CEO)
b. Contact information for person listed in item 1a above:
Street Address:17494 US 421 S
City:Dunn
Mailing Address (if applicablc):PO Box 931
State:NC
Zip:28335
City:Dunn State:NC Zip:28335
Phone: [phone] Fax: ( 1
Email:[e-mail]
Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City: State: Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
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: Nathan Bass (Pike Engineering, LLCI
Signing Official & Title:Nathan Bass - Facilities Planning & Siting Manager
b. Contact information for person listed in item 3a above:
Mailing Address:123 N White St
City:Fort Mill State:SC Zip:29715
Phone: [phone] Fax: ( 1
Email:[e-mail]
4. Local jurisdiction for building permits: Cumberland County Planning
Point of Contact:Sabrina Greer Phone #: (910 ) 678-7609
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Low density with oil containment pit at high point of the site also being utilized as stormwater detention. All
other runoff will be unchanneled surface flow through the adjacent agricultural fields.
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: 2.73 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+:2.73 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 (NHM line or Mean High Water
(MHM line, and coastal wetlands landward from the NHW (or MH1O line. The resultant project area is used to
calculate overall percent built upon area (B UA). 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 = 20.6
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.
Basin Information
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Grays Creek
Stream Class *
C
Stream Index Number
18-35-(2)
Total Drainage Area (sf)
118,918
On -site Drainage Area (sf)
0
Off -site Drainage Area (sf)
Proposed Impervious Area** (sf)
24,535
Impervious Area** (total)
20.6
Impervious- Surface Area
Drainage Area 1
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
0
On -site Streets (sf)
0
On -site Parking (sf)
0
On -site Sidewalks (sf)
0
Other on -site (sf)
24,535
Future (sf)
0
Off -site (sf)
0
Existing BUA*** (sf)
0
Total (sf):
24,535
* Stream Class and Index Number can be determined at: http.i&ortal.ncdenr.or web/wg&s/csu/classi{ications
Im ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

Report Witty tit wamnt oferisting RUA t1fat Witt renwitt er Arrylirrrr t. rt i a
is to& aril, ar ;rhich wilt be n' tacni by new RUA,
it. How was the off -site impervious area listed Above Provide documentatim °:
the P14,ex t is kwaW w4in a A
ErdangeredSpecies uatm1wd that m
V. SUfTLEMO" D
The applicable staff stormwAter a it supplernmt and operation and tnawertance
rust be su ' ` W for each ISMp _ified for this project. 71w latest versions of the fcwnis can be downloaded
fryP-MADVA1..
ei. SUM k MAL REQUIRIEMENIS
only completeapplication pees will be accepted and rMe ed by if* Division of Energy, Mineral and
Iwa d Resources tDEML . A complete p, a includes f the items Misted below,. A defiled application,
i i€rn P checklists a t
Ott :. tal.ncderrr ,' a divs. nW coulpletelica ` package should be
submitted to the appropriate R Office. fay off ice may be f t�y locating project n tl A
utter -m o ` map at lrt c�rtal.r d gar s x
Please indicate that the following uired 1_nforwafion have ideal initiate thes ^ prow
for each item All origitut dtvuments MUST be si rued and initiated in blue Ink. Download the is versionsi
for each submitted Application from tal.r er�r.u�r ° ° � � t��s nos dt I I
initial!
L i�irtrtand twe oyN of the StarrrraterNbnagement Perrrnit ,ppl ation, Form. &k6
I OfiginalaidoneciTyof thesigned notarizxcl A
1,19
Form Of requite 'prr Part f`tt hitw�
. Originot of the applicable Supplement Formlsi AmiLed. sitz t and datedl actedMM /UY
agreement(s) for jiSh ONtt*
, Permit application processing tee of V-05 to CLIENRs (For an Express revie -, refto
hft.1 ro _er �i tni for information on, the Express program
ar the associated feeContact the Appr ate re0onal office Express Permit Coordinator for
additional information and to schedule the required Application tier -t
" A detailed narrative tonie to two pages), describing the stormwater treatment/rnanagemwent for Nt16
. A USCS map identifying the site bout.. If the v" arn, is reported as class SA or the v
receiving strew drams to class sA waters widtin t : mile of the site boundary, include the� w
mile radius on the rnap�
7. Sealed, signed and dated calculations (one cope).
S. Two sets o(plans folded 12 3' x t ' (seated, signed, dated1, ircludirr
a. =elfin �t -t na
l►" En ineer and firm.
c. Location reap with named streets and WSR numbers.
d,
e. Niirffi arrow.
f. SCAW
vRevision number and dates,
f tih All StlffaCO Waters on to plans bs- delineating normal ¢ t elevation of
%ram strua:turesf the, banks of rr and rives, the lJ or NHW line of tidal
_ tee and am coastal we%mds landward of the Mi°IW or VIV lines.
Delineate d*vegetated buffer landward from the normal pool elevation of impourded.
structures, cif strearrw or rive and the SfMV for NHW) of tidal waters,
if Dimensioned prop- r project boundarywith bearings & dicta ,
f Site LAvout with all D identifiedand4imensiorted-
elevatiewts, finite f1cor elevatitms.
i of rcaad dr ` f trrres� call i c e stormwater control rneasu v
rnL st, p tu_st be del' - a
a uali " s� I`x de dc�cu rrtatic ct lifi at identify person Who
�€ tie deter�rrati+�r� o n.
n sty ' chid' �si lE "ale a t S. pipe sizes. runoff cakulatiom,
o. Drainage areas ted (' Wed in in set of plain, not as a skate d cranwrit).

- Vegetated buffers, (where requirvd).
9. Cop of any appikaMe soil report with the asacciatedWT elevations, (Meaw identifv ...ZVV6..
�att�s i addition to t s wellas a of the boring ata� it .stir
�v ati s and boringems. ImIudean 3" 01 '.. t the NkCSCounhSails it the
��t area ckart r delineated. For projectswith WittfAtiou IN, thOr��+rt tt also
inc1 Udethe Witt t -re. expected infiltration rate, and t1w, mediod of detrm ining the infiltration rate,.
of ilhoion D to W dwJu r a site vr t v VDlLR Iv Ti� ate SIANT prkw
to s ,l mitt , f 910) 7 _ , : .
10, A copy,copy,4 the mmt c unvnt property k- Page .-
lt. Forrorporations af td limited kability corporatiors LLCY Provide docuawntation troy the N
Scvretary of State or o4her off i ial dmunwntation,. :h suppprts t1w Wes and positions Wd
15A NCA - 3 (eta
ati r t t �t ti ties
tanding
ApoicAnt Complete this on if vou wish to designate auk ` ' - to another individual for firm(sucha a
consul " e ` r an d or firm) sc� that d y provide irdw tion on year behalf for this prooct Ouch a
addressing ren is for additional infortnatMl,
Consuming Engineer -Nathan Bass A
consulting Firm
itin w it t
City-
'fojjNfill State.SC" t
Phorw- t7o4 57&:i�4� a '
D PROPERTY OWNER ALITHORMA71ON tit ) tad en"alwa. item 2 IwsIvM filled it n1j to tint-
t, t yint'-'Ir h4W U40W t�f pw1kin smell in Contact 1"fonnatkift. Aim t Certify that t
propertyown the identified in this permit ar0catkin, and thus give pe=Issian to 111rrfnt or IWv now 0 pemwif
lzst .i r GnIfa-t htfO M , Ite z 10) with t rint or type t ass
Confaa ifs tion� firm tai to derelop the pri)Ooct as cur r la - ^ Ot
the lease a t or pending propertysiale-, rontract idert with the subtnittal, which indicates at
parh operation %terra stormwater sa to

p. Vegetated buffers (where required).
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 DEMLR to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 11389 Page No: 0591
11. 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 1a, 2a, and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http:/ /www.secretary.state.nc.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://portal.ncdenr.org/web/Ir/state-
stormwater-forms docs. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DEMLR, and that they will be recorded prior to the sale of any lot.
W IIW4Z6]0GY81Nr:\00rIU110]C4uKT41[6]0/:\URl:1tey10to] Nrff.'r11630I
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:Nathan Bass, PLA
Consulting Firm: Pike Engineering, LLC
Mailing Address:123 N White St
City:Fort Mill
Phone: (704 ) 576-3499
Email:[e-mail]
State:SC Zip:29715
Fax: ( )
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 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.
Form SWU-101 Version Oct. 31, 2013 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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and
submit a completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that the operation of a stormwater treatment facility
without a valid permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
a Notary Public for the State of . County of
, do hereby certify that
before me this _ day of
personally appeared
. and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or hjpe name of person listed in Contact Information, item 1a) Chris Spears
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 stormwatgr rules under 15AP�tAC 2H .1000 and any other applicable state stormwater requirements.
Signaturk��&- V Date: d A k
a Notary Public for the State of County of
do hereby certify that C�c 5 { V ` • QQQC S personally appeared
before me this day of �V. r�4- �22, and ack wledge the due exe on of the application for
a stormwater permit. Witness my hand and official seal,
Kacey W Johnson
Notary Public
Harnett County, NC
SEAL
My commission expires
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6