SW6230104_Application Form_20230126

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: D Coastal SW -1995 ❑ Coastal SW - 2008 0 Ph II - Post Construction
(select all that apply) 0 Non -Coastal SW- HQW/ORW Waters 0 Universal Stormwater Management Plan
11 O Other WQ M t 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
L 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.):
Dunn NC - Petco
2. Location of Project (street address):
City:Dunn CountrHarnett Zip:28334
3. Directions to project (from nearest major intersection):
0.60 miles west of the intersection of W Cumberland Street (HWY 421) and N. Powell Avenue.
4. Latitude:350 19' 22" N Longitude:780 38` 24" W of the main entrance to the project.
1. a. Specify whether project is (check one): ®New OModification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SW -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: MNot Started OPartially Completed" ❑ Completed* 'Epromde a designer's certification
2. Specify the type of project (check one):
QLow Density ®High Density E]Drains to an Offsite Stormwater System QOther
3. 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):
OCAMA Major
QNPDES Industrial Stormwater
®Sedimentation/Erosion Control:1.60 ac of Disturbed Area
[1404/401 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 QYes
If yes, see S.L. 2012 200, Part VI: bttp://12oTtal.ncdenT.org/-i-yebllr/`rules-andzlg&Mlgh=
Form SWU-101 Version OcL 31, 2013 Page 1 of 6

Ell. 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
Applicant/
Signing Official & 1, ntle.-Tommy Waters -Vice President of Real Estate
b. Contact information for person listed in item la, above:
Street Addrew.4747 Williams Drive
City.Georggtown State -TX Zip:78633
Mailing Address (if applicable):
City: State: Zip:
Phone: [phone] Fax:
Email:[e-mail]
c. Please check the appropriate box. The applicant listed above is:
M The property owner (Slap to Contact Information, item 3a)
F1 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:Sorrell lackson, LLC
Signing Official & Title Hop
e Lupton,
Member Manager
b. Contact information for person listed in item 2a above:
Street Address:1507 Arendell Str
City:Morehead QIX State:NC Zip:28557
Mailing Address (if applicable):
City: State: Zip:
Phone: [phone] Fax:
[e-mail]
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/Organization:
Signing Official & Title:
b. Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: (
Email:
Fax: (
4. Local jurisdiction for building permits: C& of Dunn
Point of Contact:G 1g1&LL.—A-d-11r— Phone*: (910 766m0983
FormSWU-101 Version Oct. 31,2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, bri � summarize how the stormwater runoff will be treated.
Stormwater will be directed to a bioretnetion pond and ultimately to a ditch on HWY 421 which drains to
the Black— River.
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 lack- Cape Fear River basin.
4. Total Property Area:1.67 acres 5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:1.67 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 Hi h Water (NW line or Mean High Water
(MHM line, and coastal wetlands landwardfrom the NHW (or Ma line. The resultant project area is used to
calculate overall percent built upon area (BLIA). Non -coastal wetlands landward of the NHW (orMHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 66 %
9. How many drainage areas does the project have f(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
Drains a Area 3
Drainage Area 4
Receiving Stream Name
Black River
Black River
Stream Class *
C
C
Stream Index Number *
18-68-21-1
16-68-12-1
Total Drainage Area (sf)
34084
15425
On -site Drainage Area (so
34084
15425
Off -site Drainage Area (sf)
0
0
0
0
Pro osed Ln ervious Area"* (so
31925
14342
Impervious Area** (total)
94
93
]m ous" Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area 3
Drainage Area 4
On -site Buildings/Lots (so
5952
4791
0
On -site streets (sf)
0
0
0
0
On -site Parkin (sf)
21921
7892
0
On -site Sidewalks (sf)
4051
1658
Other on -site (sf)
0
0
0
0
Future (so
0
0
0
0
Off -site (sf)
0
0
0
0
Existin BUA— (so
0
0
0
0
Total (sf):
31924
14341
Stream Class and Index Number can be determined at: http Ypor-tal.ncderir.orgivebltt!,jlpslcsulclassif.cations
" Impervious area is defined as the built upon area includin& but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

'Report only that amount of existing BUA that will remain after development. Do not report any existing BL A 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. Im ervious areas
were determined in CAD.
Proiects in Union Countv: ContactDEMLR Central Offlce stafflYo check ifthe project is located within aThreatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 1 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 ham_/ 1portat.ncdanr.or;lwebtwq ws jsul bmp-manual.
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
hn:%/gortal.ncdenr.org/weblwg/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at http:l/portal.ncdenr.org web/wgLws/su/maps.)
Please indicate that the following squired 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 hitp:llportal.ncdeiu.org jweblwg/ws/su/stateswjforms does.
Ini
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
h=://www.gmLhe—In.orcr/paires/"""`Qng=ge=ess 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 for _
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 Y2 mile of the site boundary, include the Y2
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.
IL Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the 11t HW 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.
L 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.
L Details of roads, drainage features, collection systems, and stormwater control measures.
in. 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.
Form SWU-101 Version Oct 31, 2013 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 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"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration SMPS, 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 vmfij the SH6VT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 2456 Page No: 76
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 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.
httv://www.secretary stat,.nc.us/CoMorations/­CSearckaspx
VI% 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 significay-Ay or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowabl�bu)It upds�i aria mint be
provided as an attachment to the completed and notarized deed restriction form. The a�propi�ate deed.
restrictions and protective covenants forms can be downloaded from h•//Mortal ncden7'or
ttp�k6eb/lt7state-
stormwater-forms does. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the respgnsfbthty of the property
owner to sign the deed restrictions and protective covenants form while the applicant istesponsible 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.
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:Brian Kemp
Consulting Firm: McClure EnWp erm Compare
Mailing Address:1700 Swift Avenue Suite 100 -
City -North Kansas City
Phone: (785 ) 393.9241
Emaii:bkemvC�mcclurevision.com
State -MO Zip:64116
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) Hope Lupton certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
Iisted in Contact information, item 1a) 6ab, id hfiz, tinerTommy Waterswith (print or type name of organization listed in
Contact Information, item la) PC -Dunn, NC-1-11 T, LLC; By: Embree Development Group 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.
l~orm 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: �1 .y '�,��.` Date: 9/i Y %z
I,' gn' - OA e?) Ohnrm a Notary Public for the State of County of
l.af 46e , do hereby certify that personally appeared
before me this day of an cknowled a the due ex tion of the application for
a stormwater permit. Witness my hand and official seal,
% Jf��
�0 Ors
���tfjft„NC,''��`���
X. APPLICANT'S CERTIFICATION
JA
My commission expires I
I, (print or type name of person listed in Contact Information, item 1a) Tommy Waters
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 N�CAC 2H .1000 and any other applicable state stormwater requirements.
Signature: Lr/�. Date:
L J VYl VYMX M Ad L a Notary Public for the State of TelyAf . County of
I OYA do hereby certify that ::JjAn-1 tN1 H I&A,+C rS personally appeared
before me this r6lay of Noaryy , 12-� 2crL2, and acynowledge the due exe lion of the application for
a stormwater permit. Witness my hand and official seal,
EMMA L. MUNIZ
_'£°LL Notary Public, State of Texas
[JXOM t°f; Comm. Expires06.17.2026
;,; ;'�Notary ID 13382013-2
SEAL
My commission expires LP — 1-7 Zv2— uo
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6