SW6221102_Application Form_20221128

DWQ USE ONLY
Date Received
Fee Paid Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph 11- Post Construction
(Mect all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This fonn 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.):
Utility Improvements to Serve Ashley Heizhts
2. Location of Project (street address):
Reservation Road
City: A ber deep County:Hoke Zip:28315
3_ Directions to project (from nearest major intersection):
The project is located approximately 1915 ft. from the intersection of Aberdeen Road and Reservation Road
going east towards Railroad Lane.
4. Latitude:35° 5' 32.79" N Longitude:79° 21' 49.52" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modification,
tReneenals rt)ith mndif cations also requires 51'VU-102 — Reneval Application Foml
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):
❑CAMA Major ®Sedimentation/Erosion Control: 49.42 ac of Disturbed Area
❑NPDES Industrial Storm water 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:
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http:L/ 2ortal.ncdenr.org/web/wq/ws/su/statesw/rules laws
Form SWU-101 Version 06Aug2012 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:Ashley Heights, LLC
Signing Official & Title: David Upchurch - Mana&g_Partner
b. Contact information for person listed in item 1a above:
Street Address:150 S. Page Street
City:Southern Pines State:NC Zip:28387
Mailing Address (if applicable):
City: State: Zip:
Phone: (910 ) 684-8646 Fax:
Email: du [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 & 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:
Signing Official & Title:
b. Contact information for person listed in item 3a above:
Mailing Address:
City:
Phone: ( )
Email:
State: Zip:
Fax: ( ) ^
4. Local jurisdiction for building permits: Hoke County P!anniLn&Z Zoning
Point of Contact:Robert Farrell Phone #: (910 ) 875-8407
Form SWU-l01 Version 06Aug2012 Page 2 of

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Stormwater runoff from the developed areas of the site will be captured and treated in two wet ponds and 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 regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ❑ Ph II - Post Construction
Stormwater runoff from this project drains to the Lumber
4. Total Property Area: 91.286 acres
River basin.
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':91.286 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 MHIO 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 = 19.32
9. How many drainage areas does the project have?3 (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 2
Drainage Area 3
Drainage Area _
Receiving Stream Name
Quewhiffle
Creek
Quewhiffle
Creek
Quewhiffle
Creek
Stream Class
C
C
C
Stream Index Number *
14-2-14
14-2-14
14-2-14
Total Drainage Area (sf)
519,352
590,407
2,729,441
On -site Drainage Area (sf)
519,052
590,407
2,619,583
Off -site Drainage Area (sf)
300
109,858
Pro osed Impervious Area** (sf)
102,967
133,829
641,574
Im ervious Area** (total)
19.84
22.67
23.51
Impervious- Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area 3
Drainage Area _
On -site Buildings/Lots (sf)
68,000
92,000
368,000
On -site Streets (sf)
29,771
36,007
140,016
On -site Parking (sf)
On -site Sidewalks (sf)
4,896
5,822
23,700
Other on -site (sf)
Future (sf)
Off -site (sf)
300
109,858
Existing BUA*** (sf)
Total (sf):
102,967
133,829
641,574
* Stream Class and Index Number can be determined at: http.i&ortal.ncdenr.or web/wg&s/csu/classi{ications
Form SWU-101 Version 06Aug2012 Page 3 of 6

** Irra ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
st�iezvalks, gravel areas, etc.
*** Report only that amount of existing BUA that will remain after development. Do not report any existing 13UA that
is to be rennoved and which will be replaced by new B UA.
11, How was the off -site impervious area listed above determined? Provide documentation Survey CAD file
Proiects in Union County: Contact DWQ Central Qlice staff to check if the project h located within a Threatened &
Endangered Species watershed that n:ay be subject to more stringent stormwater requirements as per I SA 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 httn://t)ortal.ncdenr.ore/web/wo/ws/su/bmv-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 hqp://12ortal,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.ncdenr.org/web/wq/w5/su/ma5.)
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/wq/ws/su/statesw/forms_docs.
nitials
1. Original and one copy of the Stormwater Management Permit Application Form. M0
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants rJTV
Form. (i f required as per Part V1I 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 pa�iIable to NCDENR. (For an Express review, refer to
http://www.envhelp.OTR/pages/onestopexpress.htnl for information on the Express program
and the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/management
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 1h mile of the site boundary, include the 1/2
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.
f. Scale_
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
Oro
Oru
for Qrd
,pro
Ord
oru
Form SWiJ-101 Version 06Aug2012 Page 4 of 6

o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated S14WT elevations (Please identify bill
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"xl1" copy of the MRCS 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.
(In€iltration Devices submitted to WiRO: Schedule a site visit far DWQ to verify tl►e SHWT prior
to suh►nittal, [phone].)
10. A copy of the most current property deed. Deed book: 1448 Page No: 0700 Dr.)
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC or 1)
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-. /www.secretarv.state.nc.us/Corporations/CSearch.asl2x
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/wsIsu/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.
Vill. 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. -Carlo Pardo, PE
Consulting Firm: Bowman North Carolina, Ltd.
Mailing Address:4006 Barrett Drive Suite 104
City:Raleigh _
State:NC
Phone: f 919 ) 553-6570 Fax:
Ernail:[e-mail] _
Zip:27609
IX, PROPERTY OWNER AUTHORIZATION (if Con tart 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 I►►)vrnratim, item 1a) with (print or hfpe nanre of organization listed in
Contact Inforniation, 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 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 Norm 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 1.43-215,6.
Signature:
Date: //' 4p -.�
1, Vl'- a Notary Public for the State of blAn [gy4,+fay , County of
do here y certify that b"!A -T. ULV-A- A..Ylh personally appeared
La
before me this r day ofand ackno e ge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
q7��firi L na~ 11
t333 Notary + • (llll
1�l
MontgonlBrY COullty`ll
ll North 1
X. APPLICANT'S CERTIFICATION
6"Ur.11
My commission expires
1, (print or hjpe nante of person listed in Contact Inf mnation, item In) David Upchurch
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 2-H .1000 and any other applicable state stormwater requirements.
Signature:
Date: fl ' " Z- ,
1, it ,' !'V� JN -a a Notary Public for the State o€ ,No" [,oty l iIl- . Countyof
do hereby certify that personally appeared
before me is Lfay of i`bY_r►JXK and acknow e ge the due execution of the application for
a stormwater permit. Witness my hand and official seal,'
C6 istina Ray
Notary Public
Montgomery County
North Carolina—
Sl Al
My commission expiresI fl;Pa `f
Form SWU-101 Version O6Aug2012 Pagc 6 of