SW6220802_Application Form_20230217 (2)

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW -- 2008 ❑ Ph lI - Post Construction
(select 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 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.):
Chamos Convenience Store
2. Location of Project (street address):
8920 U.S. 1Lwy 401 N
City:Fuguay- Varina County:Harnett Zip:27526
3. Directions to project (from nearest major intersection):
Project is located in Southeast quadrant at intersection of U.S. H 401 N. and SR 1441 Chal beate Springs
4. Latitude:35° 30' 40" N Longitude:-78° 48' 36" 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 T02 — Renewal Application Forth
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
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: 4.18 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑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 Dyes
If yes, see S.L. 2012-200, Part VI: http:012ortal.ncdenr.org/­Web/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

III. CONTACT INFORMATION
1. a. Pratt Applicant / Signing OfficiaPs name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: Jay Ambe Shakti LLC
Signing Official & Title:Ankit K Patel / Member
b. Contact information for person listed in item la above:
Street Address:2100 Weaver Forest Way
City:Morrisville State:N.C. Zip:27560
Mailing Address (if applicable):2100 Weaver Forest Way
City: Morrisville State:N.C. Zip:27560
Phone: [phone] _ Fax:
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/Organiza
Signing Official & Title:_
b. Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):
City:
State: Zip:
State:
Phone: ( _ 1 Fax:
Email:
Zip:
3. a. (Optional) Print the name and title of another contact such as the projecf s construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:Glenn Tew / ECLS Glottal Inc.
Signing Official & Title:Glenn Tew Engineer
b. Contact information for person listed in item 3a above:
Mailing Address:19 North Mckinley Street
City:Coats State:N.C. Zip:27521
Phone: [phone] Ext. 105 Fax: [phone]
Exit.ail:TohnnyT®eclsglobaiinc.com_
4. Local jurisdiction for building permits: Harnett Coun
Point of Contact:Ly Sikes Phone #: [phone]
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below, b1k ft summarize how the stormwater runoff will be treated.
The stormwater will be collected into catch basins and then transported to a system of underground
stormwater chambers for infiltration and for peak flow attenuation before being released into an existing -Load
ditch at the low end of the site.
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: 3.46 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+:3.46 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
(MHW) line, and coastal wetlands landward from the NHW (or MHM line. The resultant project area is used to
calculate overall percent built upon area (BUA). 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 = 50.42
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 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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of

Basin Information
Drainage Area
Drainage Area
Drainage Area
Drainage Area
Receiving Stream Name
UT to Hector
Creek
Stream CIass *
WS-IV: HQW
Stream Index Number *
18-15-(0.7)
Total Drainage Area (so
155,509.20
On -site Drainage Area (so
150,717.60
Off -site Drainage Area (so
4,791.60
Proposed Impervious Area** (sq
78,408,00
% Impervious Area** total
50.42
Impervious' Surface Area
Drains e Area _
Drainage Area
Drains e Area _
Drainage Area
On -site Buildings/Lots (sf)
6,600.00
On -site Streets (so
48,027.00
On -site Parking (so
8,086.00
On -site Sidewalks (so
10,271,00
Other on -site (so
5,424.00
Future (so
0
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
78,408.00
* Stream Class and Index Number can be determined at: http:/&ortal.ncdenr.org/web/wq&s/csy c_lassi ications
* Impervious 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 BUA that will remain after development. Do not report any existing BUA 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. NA
Projects in Union County: Contact DEMLR Central Office staff ff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 75A 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 http: / / portal.ncdenr,org/web/ wq[ws/ su / bmp-manual.
VI. SUBMITTAL REQUIREMENTS
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
h ortal.ncde-nr.org/web/­`­3yq/ws/su/statesw/forms..docs. 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 athttp://portal.ncdenr.org/web/wq/ws/su/maps.)
Please indicate that the following re wired information have been provided by initialin 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 ht!p://portal.ncdenr.or&/web/­IvA/ws/su/statesw/forms docs.
Initials
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 _ 4
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
htW:Z/www.envhelp.org/pnes/onestopexl2ress.htm for information on the Express program
Form SWU-101 Version Oct. 3I, 2013 Page 4 of 7

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 _ a.
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 1/2 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.
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"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 verifij the SHVVT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 4011 Page No: 326 7-
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC W_
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.secretaiy.state.nc.us/Corporatio-ns/­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 Iisting 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 httl2:ZZj2ortal.ncdenr.org/web/Ir/state-
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 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.
Form SWU-101 Version Oct. 31, 2013 Page 5 of 7

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 .Tohnny Glenn Tew
Consulting Firm: ECLS Global Inc.
Mailing Address:19 North McUE e Street
City:Coats State:N.C. Zip:27521
Phone: [phone] Ext.105 Fax: (910 ) 897-2329
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (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.
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.
I,
a Notary Public for the State of
do hereby certify that
before me this _ day of
Date:
County 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
Form SWIU-101 Version Oct. 31, 2013 Page 6 of 7

" X. APPLICANT'S CERTIFICATION
I, (print or type name of person Iisted in Contact Information, item Ia) Ankit K Patel
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 ZH .1000 and any other applicable state stormwater requirements.
Signature: J�' `i "�— Date: C t 13 1 ZL
I, ,Cf ✓tQ ff, , _ [� )ers a Notary Public for the State of J Ord CMO Ititd-, County of
t CAen e 4 , do hereby certify that A t K t d personally appeared
before me this `day of J�tAe 2622 , and acknowle ge the du execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires q-130 -2022.
Form SWU-101 Version Oct. 31, 2013
Page 7 of 7