SW8230507_Current Permit_20230613

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ELIZBET14 S. BISEP,
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DOUGLAS R. ANSEL
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June 13', 2023
NORTH .CARC1LlNA
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Pender County ABC Board, Owner and Applicant
Attn: Diane Q. Chadwick, Chairperson
207 Hwy 117 Bypass
Burgaw, NC, 28425
Subject: Post -Construction Stormwater Management Permit No. SW8 230507
Pender County ABC Retail & Warehouse
High Density Project
Pender County
Dear Ms. Chadwick:
The Division of Energy, Mineral and Land Resources received a complete Post -Construction Stormwater
Management Permit Application for the subject project on June 131, 2023. Staff review of the plans and
specifications has determined that the project, as proposed, complies with the Stormwater Regulations .set forth in
Title 15A NCAC 2H.1000 amended on January 1, 2017 (2017 Rules). We are hereby forwarding Permit N'o.
SW8 230507 dated June 13', 2023, for the construction, operation and maintenance of the built -upon areas
(BUA) and stormwater control measures (SCMs) associated with the subject project.
This permit shall be effective from the date of issuance until June 13', 2031 and does not supersede any other
agency permit that may be required. The project shall be subject to the conditions and limitations as specified
therein. Failure to comply with these requirements will result in future compliance problems. Please note that
this permit is not transferable except after notice to and approval by the Division.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to request
an adjudicatory hearing by filing a written petition with the Office of Administrative Hearings (OAH). The
written petition must conform to Chapter 150B of the North Carolina General Statutes and must be filed with the
O.1kH within thirty (30) days of receipt of this permit. You should contact the OAH with all questions regarding
the filing fee (if a filing fee is required) and/or the details of the filing process at 6714 Mail Seri ice Center,
Raleigh, NC 27699-6714, or via telephone at 919-431-3000, or visit their website at www.NCOAH.com. Unless
such demands are made this permit shall be final and binding.
If you have any questions concerning this permit, please contact Kellie Beth Norris in the Wilmington Regional
Office, at [phone] or [e-mail].
Sincerely,
L� Douglas R. Ansel, Interim Director
Division of Energy, Mineral and Land Resources
Enclosures: Attachment A — Designer's Certification Form
Application Documents
DES/kbn: \\\Stormwater\Permits & Projects\2023\230507 HD\2023 06 permit 230507
co; Sean A_ Dalle, PE, Grounded Engineering
Pender County Planning Department
NCDOT District Engineer
Wilmington Regional Office Stormwater File
QA North Carolina Department 4.Envir-onmental Quality I Division of Energy, Kn'esat and Land Resources
1A%AMIngtan Regional office 1 127 Cardinal Drive Extension I Wilmington, North Carolina 28405
KKORM, . Q
m"" ""0�'0,ft 910:7%.7215

Post -Construction Stormwater Management
Permit No. SW8 230507
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
POST -CONSTRUCTION STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In compliance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations promulgated and adopted by the North
Carolina Environmental Management Commission, including 15A NCAC 02H.1000 amended on
January 1, 2017 (2017 Rules) (the "stormwater rules"),
PERMISSION IS HEREBY GRANTED TO
Pender County ABC Board
Pender County ABC Retail & Warehouse
0 HWY 117, Burgaw, Pender County
FOR THE
construction, management, operation and maintenance of built -upon area (BUA) draining to one (1)
wet pond ("stormwater control measures" or "SCMs") as outlined in the application, approved
stormwater management plans, supplement, calculations, operation and maintenance agreement,
recorded documents, specifications, and other supporting data (the "approved plans and
specifications") as attached and/or on file with and approved by the Division of Energy, Mineral and
Land Resources (the "Division" or "DEMLR"). The project shall be constructed, operated and
maintained in accordance with these approved plans and specifications. The approved plans and
specifications are incorporated by reference and are enforceable part of this permit.
This permit shall be effective from the date of issuance until June 13th, 2031 and shall be subject to
the following specified conditions and limitations. The permit issued shall continue in force and effect
until the permittee files a request with the Division for a permit modification, transfer, renewal, or
rescission; however, these actions do not stay any condition. The issuance of this permit does not
prohibit the Director from reopening and modifying the permit, revoking and reissuing the permit, or
terminating the permit for cause as allowed by the laws, rules, and regulations contained in Title 15A
NCAC 2H.1000 and NCGS 143-215.1 et.al.
BUA REQUIREMENTS. The maximum amount of BUA allowed for the entire project is 54,500
square feet. The runoff from all BUA within the permitted high density drainage area of this
project must be directed into the permitted SCM. The BUA requirements and allocations for this
project are as follows:
a. SCM BUA LIMITS. The SCM has been designed to handle the runoff from 49,640 square
feet of BUA within the delineated drainage area, also referred to as DA1. This permit does
not provide any allocation of BUA for future development within the delineated drainage
area. This permit approves 4,860 square feet of BUA that was not able to be collected and
treated in an SCM due to existing NCDOT grading to bypass the system.
b. CAMA AECs. Where a project or lot is located within CAMA's Area of Environmental
Concern (AEC), the Division of Coastal Management (DCM) may calculate a different
maximum BUA based on CAMA regulations. The more restrictive BUA limit will apply to the
project.
Page 1 of 5

Post -Construction Stormwater Management
Permit No. SW8 230507
2. PERVIOUS AREA IMPROVEMENTS. At this time, none of the pervious area improvements
listed in G.S. 143-214.7(b2) or the Stormwater Design Manual have been proposed for this
project. Pervious area improvements will be allowed in this project if documentation is provided
demonstrating those improvements meet the requirements of the stormwater rule.
3. SCM REQUIREMENTS. The SCM requirements for this project are as follows:
a. SCM DESIGN. The SCM is permitted based on the design criteria presented in the sealed,
signed and dated supplement and as shown in the approved plans and specifications. This
SCM must be provided and maintained at the design condition.
b. PLANTING PLAN. The SCM landscape planting plan shown in the approved plans shall be
followed in its entirety during construction. After the plants are established, the operation
and maintenance agreement must be followed.
c. FOUNTAINS. At this time, a decorative spray fountain has not been proposed within the wet
pond. Decorative spray fountains will be allowed in the wet pond if documentation is
provided demonstrating that the proposed fountain will not cause resuspension of sediment
within the pond or cause erosion of the pond side slopes.
d. IRRIGATION. If the wet pond is to be used for irrigation, it is recommended that some water
be maintained in the permanent pool, the vegetated shelf is planted with appropriate species
that can handle fluctuating conditions, and human health issues are addressed.
4. STORMWATER OUTLETS. The peak flow from the 10-year storm event shall not cause
erosion downslope of the discharge point.
5. VEGETATED SETBACKS. A 50-foot wide vegetative setback must be provided and maintained
in grass or other vegetation adjacent to all surface waters as shown on the approved plans. The
setback is measured horizontally from the normal pool elevation of impounded structures, from
the top of bank of each side of streams or rivers, and from the mean high waterline of tidal
waters, perpendicular to the shoreline.
a. BUA IN THE VEGETATED SETBACK. BUA may not be added to the vegetated setback
except as shown on the approved plans.
b. RELEASE OF STORMWATER NOT TREATED IN AN SCM. Stormwater that is not treated
in an SCM must be released at the edge of the vegetated setback and allowed to flow
through the setback as dispersed flow.
6. RECORDED DOCUMENT REQUIREMENTS. The stormwater rules require the following
documents to be recorded with the Office of the Register of Deeds:
a. EASEMENTS. All SCMs, stormwater collection systems, vegetated conveyances, and
maintenance access located on property owned by other persons or entities must be located
in permanent recorded easements or drainage easements as shown on the approved plans.
b. OPERATION AND MAINTENANCE AGREEMENT. The operation and maintenance
agreement must be recorded with the Office of the Register of Deeds.
c. FINAL PLATS. If a final plat is recorded, it must reference the operation and maintenance
agreement and must also show all public rights -of -way, dedicated common areas, and/or
permanent drainage easements, in accordance with the approved plans.
d. DEED RESTRICTIONS AND PROTECTIVE COVENANTS. The permittee shall incorporate
specific restrictions and conditions into a facility management plan or another legal
instrument in lieu of deed restrictions and protective covenants.
7. CONSTRUCTION. During construction, erosion shall be kept to a minimum and any eroded
areas of the on -site stormwater system will be repaired immediately.
Page 2 of 5

Post -Construction Stormwater Management
Permit No. SW8 230507
a. PROJECT CONSTRUCTION, OPERATION AND MAINTENANCE. During construction, all
operation and maintenance for the project shall follow the Erosion Control Plan requirements
until the Sediment -Erosion Control devices are converted to SCMs or no longer needed.
Once the device is converted to a SCM, the permittee shall provide and perform the
operation and maintenance as outlined in the applicable section below.
b. SCM RESTORATION. If one or more of the SCMs are used as an Erosion Control device
and/or removed or destroyed during construction, it must be restored to the approved design
condition prior to close-out of the erosion control plan and/or project completion and/or
transfer of the permit. Upon restoration, a new or updated certification will be required for the
SCM(s) and a copy must be submitted to the appropriate DEQ regional office.
8. MODIFICATIONS. No person or entity, including the permittee, shall alter any component
shown in the approved plans and specifications. Prior to the construction of any modification to
the approved plans, the permittee shall submit to the Director, and shall have received approval
for modified plans, specifications, and calculations including, but not limited to, those listed
below. For changes to the project or SCM that impact the certifications, a new or updated
certification(s), as applicable, will be required and a copy must be submitted to the appropriate
DEQ regional office upon completion of the modification.
a. Any modification to the approved plans and specifications, regardless of size including the
SCM(s), BUA, details, etc.
b. Redesign or addition to the approved amount of BUA or to the drainage area.
c. Further development, subdivision, acquisition, lease or sale of any, all or part of the project
and/or property area as reported in the approved plans and specifications.
d. Altering, modifying, removing, relocating, redirecting, regrading, or resizing of any
component of the approved SCM(s), stormwater collection system and/or vegetative
conveyance shown on the approved plan.
e. The construction of any allocated future BUA.
f. The construction of any infiltrating permeable pavement, #57 stone area, public trails, or
landscaping material to be considered a pervious surface that were not included in the
approved plans and specifications.
g. Other modifications as determined by the Director.
9. DESIGNER'S CERTIFICATION. Upon completion of the project, the permittee shall determine if
the project is in compliance with the approved plans and take the necessary following actions:
a. If the permittee determines that the project is in compliance with the approved plans, then
within 45 days of completion, the permittee shall submit to the Division one hard copy and
one electronic copy of the following:
i. The completed and signed Designer's Certification provided in Attachment A
noting any deviations from the approved plans and specifications. Deviations
may require approval from the Division;
ii. A copy of the recorded operation and maintenance agreement;
iii. Unless already provided, a copy of the recorded deed restrictions and
protective covenants; and
iv. A copy of the recorded plat delineating the public rights -of -way, dedicated
common areas and/or permanent recorded easements, when applicable.
b. If the permittee determines that the project is not in compliance with the approved plans, the
permittee shall submit an application to modify the permit within 30 days of completion of the
project or provide a plan of action, with a timeline, to bring the site into compliance.
10. OPERATION AND MAINTENANCE. The permittee shall provide and perform the operation and
maintenance necessary, as listed in the signed operation and maintenance agreement, to
assure that all components of the permitted on -site stormwater system are maintained at the
approved design condition. The approved operation and maintenance agreement must be
followed in its entirety and maintenance must occur at the scheduled intervals.
a. CORRECTIVE ACTIONS REQUIRED. If the facilities fail to perform satisfactorily, the
permittee shall take immediate corrective actions. This includes actions required by the
Division and the stormwater rules such as the construction of additional or replacement on -
site stormwater systems. These additional or replacement measures shall receive a permit
frori the Division prior to construction.
Page 3 of 5

Post -Construction Stormwater Management
Permit No. SW8 230507
b. MAINTENANCE RECORDS. Records of maintenance activities must be kept and made
available upon request to authorized personnel of the Division. The records will indicate the
date, activity, name of person performing the work and what actions were taken.
11, PERMIT RENEWAL. A permit renewal request must be submitted at least 180 days prior to the
expiration date of this permit. The renewal request must include the appropriate application,
documentation and the processing fee as outlined in 15A NCAC 02H.1045(3).
12. CHANGES TO THE PROJECT NAME, PERMITTEE NAME OR CONTACT INFORMATION.
The permittee shall submit a completed Permit Information Update Application Form to the
Division within 30 days to making any one of these changes.
13. TRANSFER. This permit is not transferable to any person or entity except after notice to and
approval by the Director. Neither the sale of the project and/or property, in whole or in part, nor
the conveyance of common area to a third party constitutes an approved transfer of the permit.
a. TRANSFER REQUEST. The transfer request must include the appropriate application,
documentation and the processing fee as outlined in 15A NCAC 02H.1045(2). This request
must be submitted within 90 days of the permit holder meeting one or more of the following:
i. A natural person who is deceased;
ii. A partnership, limited liability corporation, corporation, or any other business
association that has been dissolved;
iii. A person or entity who has been lawfully and finally divested of title to the property
on which the permitted activity is occurring or will occur through foreclosure,
bankruptcy, or other legal proceeding.
iv. A person or entity who has sold the property, in whole or in part, on which the
permitted activity is occurring or will occur;
V. The assignment of declarant rights to another individual or entity;
vi. The sale or conveyance of the common areas to a Homeowner's or Property
Owner's Association, subject to the requirements of NCGS 143-214.7(c2);
b. TRANSFER INSPECTION. Prior to transfer of the permit, a file review and site inspection
will be conducted by Division personnel to ensure the permit conditions have been met and
that the project and the on -site stormwater system complies with the permit conditions.
Records of maintenance activities performed to date may be requested. Projects not in
compliance with the permit will not be transferred until all permit and/or general statute
conditions are met.
14. COMPLIANCE. The permittee is responsible for complying with the terms and conditions of this
permit and the approved plans and specifications until the Division approves the transfer
request.
a. REVIEWING AND MONITORING FOR COMPLIANCE. The permittee is responsible for
verifying that the proposed BUA within each drainage area and for the entire project does
not exceed the maximum amount allowed by this permit. The permittee shall review and
routinely monitor the project to ensure continued compliance with the conditions of the
permit, the approved plans and specifications.
b. APPROVED PLANS AND SPECIFICATIONS. A copy of this permit, approved plans,
application, supplement, operation and maintenance agreement, all applicable recorded
documents, and specifications shall be maintained on file by the permittee at all times.
c. MAINTENANCE ACCESS. SCMs, stormwater collection systems, and vegetated
conveyances must be accessible for inspection, operation, maintenance and repair as
shown on the approved plans.
d. DIVISION ACCESS. The permittee grants Division Staff permission to enter the property
during normal business hours to inspect all components of the permitted project.
e. ENFORCEMENT. Any individual or entity found to be in noncompliance with the provisions
of a stormwater management permit or the requirements of the stormwater rules is subject to
enforcement procedures as set forth in NCGS 143 Article 21.
Page 4 of 5

Post -Construction Stormwater Management
Permit No. SW8 230507
f. ANNUAL CERTIFICATION. The permittee shall electronically submit to the Division an
annual certification completed by either the permittee or their designee confirming the
projects conformance with permit conditions.
g. OBTAINING COMPLIANCE. The Director may notify the permittee when the permitted site
does not meet one or more of the minimum requirements of the permit. Within the time
frame specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee shall provide
copies of modified plans and certification in writing to the Director that the changes have
been made.
h. OTHER PERMITS. The issuance of this permit does not preclude the permittee from
obtaining and complying with any and all other permits or approvals that are required for this
development to take place, as required by any statutes, rules, regulations, or ordinances,
which are imposed by any other Local, State or Federal government agency having
jurisdiction. Any activities undertaken at this site that cause a water quality violation or
undertaken prior to receipt of the necessary permits or approvals to do so are considered
violations of NCGS 143-215.1, and subject to enforcement procedures pursuant to NCGS
143-215.6.
Permit issued this the 13th day of June 2023.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
cymk. --y' A 14
or Douglas R. Ansel, Interim Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Permit Number SW8 230507
Page 5 of 5

Post -Construction Stormwater Management
Permit No. SW8 230507
Attachment A
Certification Forms
The following blank Designer Certification forms are included and specific for this project:
• As -Built Permittee Certification
• As -Built Designer's Certification General MDC
• As -Built Designer's Certification for Wet Detention Pond Project
A separate certification is required for each SCM. These blank certification forms may be copied and
used, as needed, for each SCM and/or as a partial certification to address a section or phase of the
project.
Page 1 of 1

Post -Construction Stormwater Management
Permit No. SW8 230507
AS -BUILT PERMITTEE CERTIFICATION
I hereby state that I am the current permittee for the project named above, and I certify by my
signature below, that the project meets the below listed Final Submittal Requirements found in NCAC
02H.1042(4) and the terms, conditions and provisions listed in the permit documents, plans and
specifications on file with or provided to the Division.
H
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this is part of a Fast Track As -built Package Submittal.
Printed Name
County of
personally appeared before me this
Signature
a Notary Public in the State of
do hereby certify that
day of
and acknowledge the due execution of this as -built certification. (SEAL)
Witness my hand and official seal
My commission expires
20
Pemmittee's Certification NCAC-1042(4)
Ccmplel� Provided
N/A
A. CiFfii RFSTRUITICINS / BUA RECORDS
1. The deed restrictions and protective covenants have been recorded
_
Y or N
and contain the necessary language to ensure that the project is
maintained consistent with the stormwater regulations and with the
permit conditions.
2. A copy of the recorded deed restrictions and protective covenants
Y or N
has been provided to the Division.
3. Records which track the BUA on each lot are being kept. (See Note
Y or N
B. MAINTENAW-F ACCESS-
1. The SCMs are accessible for inspection, maintenance and repair.
Y or N
2. The access is a minimum of 10 feet wide.
Y or N
3. The access extends to the nearest public right-of-way.
Y or N
C. EASEMENTS
1. The SCMs and the components of the runoff collection / conveyance
Y N
system are located in recorded drainage easements.
or
2. A copy of the recorded plat(s) is provided.
Y or N
i D. SINGLE FAMILY RESIDENTIAL LOTS - Pia;s for residential lots that
Y or ;
have an SCM include the folk�:
1
1. The specific location of the SCM on the lot.
Y or N
2. A typical detail for the SCM.
Y or N
3. A note that the SCM is required to meet stormwater regulations and
that the lot owner is subject to enforcement action as set forth in
Y N
NCGS 143 Article 21 if the SCM is removed, relocated or altered
or
_ without prior approval.
F nPIFReTit_);ti ►o►N�-pIpTENhN4E AGREEMENT!'
I Y or N
_ _
1. The O&M Agreement is referenced on the final recorded plat.
_ Y or N
2. The O&M Agreement is recorded with the Register of Deeds and
Y N
appears in the chain of tittle.
or
.—O ERAVON AND MAINTENANC N —maintenance records we
being kept in -a known set location for each SCM and are available for
review.
� Y or N
Page 1 of 6

Post -Construction Stormwater Management
Permit No. SW8 230507
Completed' { NIA
Provided !
G. DESIGNER'S CERTIFICADON FORM — has been provided to the Y or N
Division.
Note 1- Acceptable records include ARC approvals, as -built surveys, and county tax records.
Provide an explanation for every requirement that was not met, and for every "NIA" below. Attach
additional sheets as needed.
Page 2 of 6

Post -Construction Stormwater Management
Permit No. SW8 230507
AS -BUILT DESIGNER'S CERTIFICATION GENERAL MDC
hereby state that I am a licensed professional and I certify by my signature and seal below, that I
have observed the construction of the project named above to the best of my abilities with all due care
and diligence, and that the project meets the below listed General MDC found in NCAC 02H.1050 in
accordance with the permit documents, plans and specifications on file with or provided to the
Division, except as noted on the "AS -BUILT' drawings, such that the intent of the storrnwater rules
and statutes has been preserved.
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this is a part of a Fast -Track As -Built Package Submittal per. 1044(3).
Check here if the designer did not observe the construction, but is certifying the project.
Check here if pictures of the SCM are provided.
Printed
Name
NC Registration
Number Date
SEAL:
Signature
Consultant's Mailing Address:
City/State/ZIP
Phone Number
Consultant's Email address:
0 Circle N if the as -built value differs from the Plan. If N is circled, provide an explanation on Page 2.
ON/E = not evaluated (provide explanation on page 2) OO N/A = not applicable to this SCM or project.
C onsuifant's Certification NCAC:
.1050
L TREATMAEAT REQUVRE TENTS
1003((3) & Generai MDO. i WAs-built ®NIE I ONIA
1. The SCM achieves runoff treatment.
-
Y or -N
2. The SCM achieves runoff volume match.
Y or N
3. Runoff from offsite areas and/or existing BUA is
Y or N
bypassed.
4. Runoff from offsite areas and/or existing BUA is directed
Y or N
into the permitted SCM and is accounted for at the full
build -out potential.
5. The project controls runoff through an offsite permitted
Y or N
SCM that meets the requirements of the MDC.
6. The net area of new BUA increase for an existing project
Y or N
has been accounted for at the appropriate design storm
level.
7. The SCM(s) meets all the specific minimum design
Y or N
_criteria.
B. VEGETATED SETBACKS I Milk
1 The width of the vegetated setback has been measured
_
Y or N
from the normal pool of impounded waters, the MHW
line of tidal waters, or the top of bank of each side of
rivers or streams.
2. The vegetated setback is maintained in grass or other
Y or N
vegetation.
3. BUA that meets the requirements of NCGS 143-214.7
Y or N
b2 2 is located in the setback.
Page 3 of 6

Post -Construction Stormwater Management
Permit No. SW8 230507
- ,-�
(!)As -built
ON/E
l ON/A--
4. BUA that does not meet the requirements of NCGS 143-
Y or N
214.7 (b2)(2) is located within the setback and is limited
to:
a. Publicly funded linear projects (road, greenway
sidewalk)
b. Water -dependent structures
c. Minimal footprint uses (utility poles, signs, security
lighting and appurtenances)
5. Stormwater that is not treated in an SCM is released at
Y or N
the edge of the setback and allowed to flow through the
setback as dispersed flow.
!!
. •3w a %jRtKWATER OUTS- the outlet handles the peak
flow from the 10 year storm with no downslo e erosion.
Y or N
t_C_�. VARIATIONS
I i
1. A variation (alternative) from the stormwater rule
Y N
provisions has been implemented.
or
2. The variation provides equal or better stormwater control
Y N
and equal or better rp otection of surface waters.
or
E. COMPLIANCE WITH OTHER REGULATORY PROGRAMg I
Y ��
has been met.-
-
F. SIZING -the volume of the SCM takes the runoff from all I
surfaces into account and is sufficient to handle the required
Y or N
f
I
storm depth . I
Q CONTAMINATED SOILS - infiltrating SCM's are not
Y or N
�
located in or on areas with contaminated soils.
H. SIDE SLOPES
1. Vegetated side slopes are no steeper than 3HA V.
Y or N
2. Side slopes include retaining walls, gabion walls, or
Y or N
other surfaces that are steeper than 3H:1 V.
3. Vegetated side slopes are steeper than 3H:1 V (provide
Y or N
supportin documents for soils and vegetation).
'
1. EROSION EROSION PROTECTION
_ _
1. The inlets do not cause erosion in the SCM.
Y or N
2. The outlet does not cause erosion downslope of the
Y or N
discharge point during the peak flow from the 10 year
storm.
_
J.EXCESS FLaVft -An overflow 1 bypass has been
Y
provided. +
DEWATERIWG -- A method to drawdown standing water has
or N
Y or N
�~ i
been provided to facilitate maintenance and inspection.
L. CLEANOUT AFTER CONSTRUCTION - the SCM has been
Y or N
i
cleaned out and converted to its approved design state.
M, MAINTENANCE ACCESS
—
l
Y or N
1 The SCM is accessible for maintenance and repair.
2- The access does not include lateral or incline slopes
Y or N
>3:1.
119-.115ESIG"NERQUALIFICATIONS
(FAST -TRACK PERMIT) - i
The designer is licensed under Chapters 89A, 89G, 89E, or
Y or N
89F of the General Statutes.
Provide an explanation for every MDC that was not met, and for every item marked "N/A" or "WE",
below. Attach additional pages as needed:
Page 4 of 6

Post -Construction Stormwater Management
Permit No. SWS 230507
AS -BUILT DESIGNER'S CERTIFICATION FOR WET DETENTION POND PROJECT
hereby state that I am a licensed professional and I certify by my signature and seal below, that
have observed the construction of the project named above to the best of my abilities with all due care
and diligence, and that the project meets all of the MDC found in NCAC 02H.1053, in accordance with
the permit documents, plans and specifications on file with or provided to the Division, except as
noted on the "AS -BUILT" drawings, such that the intent of the stormwater rules and the general
statutes has been preserved.
Check here if this is a partial certification. Section/phase/SCM #?
Check here if this is part of a Fast -Track As -Built Package Submittal per .1044(3).
Check here if the Designer did not observe the construction, but is certifying the project.
Check here if pictures of the SCM are provided.
Printed
NC Registration Number
Signature
Date
Consultant's Mailing Address:
City/State/ZIP
Phone Number
Consultant's Email address
CO Circle N if the as -built value differs from the Plan/permit. If N is circled, provide an explanation on page 2
©N/E = not evaluated (provide explanation on page 2) ®N/A = not applicable to this project or SCM.
This Certification must be completed in conjunction with the General MDC certification under NCAC 02H.1050
— Consultant's Certification NDC .1053)
i QAs-built
E ON/E
©NIA
A. Forebay I Dwths ! Fountain
1. The available Sediment storage is consistent with the
Y N
approved plan and is a minimum of 6 in.
or
2. Water flow over the forebay berm into the main pond
Y N
occurs at a non -erosive velocity.
or
3. The provided Forebay Volume is 15%-20% of the main
Y N
pool volume.
or
4. The Forebay entrance elevation is deeper than the exit
Y N
elevation into the pond.
or
5. The Average Design Depth of the main pond below the
permanent pool elevation is consistent with the permitted
Y or N
value?
6. Fountain documentation is provided.
Y or N
BuSli- a siopes i ioriks i Vewtated Shelf�-
1. The width of the Vegetated Shelf is consistent with the
Y N
approved plans and is a minimum of 6 feet.
or
2. The slope of the Vegetated Shelf is consistent with the
Y N
approved plans and is no steeper than 6:1.
or
C._ As -built Main Pool 1 Areas ! Volumes i Elevations
1 The permanent pool surface area provided is consistent
Y N
with the permitted value.
or
2. The Temporary Pool Volume provided is consistent with
Y N
the permitted vaiue.
or
3. The permanent pool elevation is consistent with the
Y N
permitted value.
or
Page 5 of 6

Post -Construction Stormwater Management
Permit No. SW8 230507
--
-
OAS -built
QN/E
®N/A 1
4.
__
The temporary pool elevation is consistent _ with the
or
N
permitted value.
_
D. Inlets ! Outlell I Onrwdmn
i
1.
The design volume draws down in 2-5 days.
Y
or
N
2.
The size of the Orifice is consistent with the permitted
Y
N
value.
or
3.
A trash rack is provided on the outlet structure.
Y
or
N
4.
Hydrologic impacts to the receiving channel are minimized
Y
N
from the 1 yr 24 hr storm discharge?
or
5.
The inlets and the outlet location are situated per the
Y
N
Errog. apved plan and avoid short-circuiting.
-- - --
or
-
E. Ye�getab
f
1.
- ---
The vegetated shelf has been planted with a minimum of 3
-
Y
- -
-
N
- —
diverse species.
or
2.
The vegetated shelf plant density is consistent with the
approved plans and is no less than 50 plants per 200 sf or
Y
or
N
no less than 24 inches on center.
Provide an explanation for every MDC that was not met, and for every item marked "N/A" or "N/E"
below. Attach additional pages as needed:
Page 6 of 6

Operation & Maintenance Agreement
Project Name:
Project Location:
Pender County ABC Retail & Warehouse 3L--ry 7
0 Hwy 117, Burgaw, NC 28425
Cover Page
Maintenance records shall be kept on the following SCM(s). This maintenance record shall be kept in a log in a known set location.
Any deficient SCM elements noted in the inspection will be corrected, repaired, or replaced immediately. These deficiencies can
affect the integrity of, structures, safety of the public, and the pollutant removal efiiiciency of the SCM(s).
The SCM(s) on this project include (check all that apply & co
Infiltration Basin
Quantity:
Infiltration Trench
Quantity:
Bioretention Cell
Quantity:
Wet Pond
Quantity:
Stormwater Wetland
Quantity:
Permeable Pavement
Quantity:
Sand Filter
Quantity:
Rainwater Harvesting
Quantity:
Green Roof
Quantity:
Level Spreader - Filter Strip
Quantity:
Proprietary System
Quantity:
Treatment Swale
Quantity:
Dry Pond
Quantity:
Disconnected Impervious Surface
Present:
User Defined SCM
Present:
Low Density
Present:
ng O&M sheets will
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Location(s):
Type:
De aaaea a
I acknowledge and agree by my signature below that I am responsible for the performance of the maintenance procedures listed for
each SCM above, and attached O&M tables. I agree to notify NCDEQ of any problems with the system or prior to any changes to
the system or responsible party.
Responsible Party:
Title & Organization:
Street address:
City, state, zip:
Phone number(s):
Email:
Diane Q. Chadwick
Chairperson, Ponder County ABC Board
207 Hwy 117 Bypass
Burgaw, NC 28425
910.259.2672
[e-mail]
Signat f.-t� GdO r.ai.�cyv� Date:
a Notary Public for the f�aCountyof , do hereby c 'fy that
personally appeare before me this day of and
acknowledge the due execution of the ra ' ns and Maintenance Agreement.
Witness my hand and official seal,
an i
��d L
0 co
ZEM
STORM-FZ
Version 1.5
f
RIB --- �.... wpp • wow-
�yV=M V W.
MAY 12 2M
Q n 2By.
My commission expires (�� L.- -
O&M Agreement
4/24/2023
Page 1 of 5

Wet Pond Maintenance Requirements
Important operation and maintenance procedures:
Immediately after the wet detention basin is established, the plants on the vegetated shelf and
- perimeter of the basin should be watered twice weekly if needed, until the plants become
established (commonly six weeks).
_ No portion of the wet pond should be fertilized after the initial fertilization that is required to establish
the plants on the vegetated shelf.
_ Stable groundcover will be maintained in the drainage area to reduce the sediment load to the wet
pond.
_ If the pond must be drained for an emergency or to perform maintenance, the flushing of sediment
through the emergency drain will be minimized as much as possible.
_ At least once annually, a dam safety expert will inspect the embankment. Any problems that are
found will be repaired immediately.
The measuring device used to determine the sediment elevation shall be such that it will give an
accurate depth reading and not readily penetrate into accumulated sediments.
After the wet pond is established, it will be inspected quarterly and within 24 hours after every storm event greater
than 1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance shall be kept in a
known set location and shall be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately.
SCM element:
Potential problem:
How to remediate the problem:
The entire wet pond
Trash/debris is present.
Remove the trash/debris.
The perimeter of the wet
Areas of bare soil and/or
Regrade the soil if necessary to remove the gully, plant ground
pond
erosive gullies have
cover and water until it is established. Provide lime and a one -
formed.
time fertilizer application.
The inlet pipe is clogged (if
applicable).
Unclog the pipe. Dispose of the sediment off -site.
The inlet pipe is cracked
The inlet device
or otherwise damaged (if
Repair or replace the pipe.
applicable).
Erosion is occurring in the
Regrade the swale if necessary and provide erosion control
swale (if applicable).
devices such as reinforced turf matting or riprap to avoid future
problems with erosion.
Sediment has
accumulated to a depth
Search for the source of the sediment and remedy the problem
greater than the original
if possible. Remove the sediment and dispose of it in a location
design depth for sediment
where it will not cause impacts to streams or the SCM.
'
storage.
The forebay
Erosion has occurred.
Provide additional erosion protection such as reinforced turf
matting or riprap if needed to prevent future erosion problems.
lWeeds
are present.
Remove the weeds, preferably by hand. If pesticide is used, i
I
wipe it on the plants rather than spraying.
friv
MAY 12 2023
BY

Wet Pond Maintenance Reautrements (Continued)
SCM element:
Potential problem:
How to remediate the problem:
Sediment has
accumulated to a depth
Search for the source of the sediment and remedy the problem
greater than the original
if possible. Remove the sediment and dispose of it in a location
design sediment storage
where it will not cause impacts to streams or the SCM.
depth.
The main treatment area
Algal growth covers over
Consult a professional to remove and control the algal growth.
50 /o of the area.
Cattails, phragmites or
other invasive plants covers
Remove the plants by wiping them with pesticide (do not
50% of the basin surface.
spray).
p y)'
Best professional
practices show that
pruning is needed to
Prune according to best professional practices.
maintain optimal plant
health.
The vegetated shelf
Determine the source of the problem: soils, hydrology, disease,
Plants are dead, diseased
etc. Remedy the problem and replace plants. Provide a one -
or dying.
time fertilizer application to establish the ground cover if a soil
test indicates it is necessary.
Weeds are present.
Remove the weeds, preferably by hand. If pesticide is used,
wipe it on the plants rather than spraying.
Shrubs have started to
Remove shrubs immediately
yiuw un ine embankment.
-
Evidence of muskrat or
Consult a professional to remove muskrats or beavers and
beaver activity is present.
repair any holes or erosion.
The embankment
A tree has started to grow
on the embankment.
Consult a dam safety specialist to remove the tree.
An annual inspection by
an appropriate
professional shows that
Make all needed repairs immediately.
the embankment needs
repair.
Clogging has occurred.
gg g
Clean out the outlet device and dispose of any sediment in a
The outlet device
location where it will not cause impacts to streams or the SCM.
The outlet device is
damaged.
Repair or replace the outlet device.
Weeds or volunteer trees
Remove the weeds or trees.
are growing on the mat.
Floating wetland island
(if applicable)
The anchor cable is
damaged, disconnected or
Restore the anchor cable to its design state.
missing. I
= Lr ll.;: IIR W �..
MAY 12 2023
BY-

Wet Pond Maintenance Reauirenents (Continued)
SCM element:
Potential problem:
How to remediate the problem:
Erosion or other signs of
damage have occurred at
Repair the damage and improve the flow dissipation structure.
the outlet.
The receiving water
Discharges from the wet
pond are causing erosion
or sedimentation in the
Contact the local NCDEQ Regional Office.
receiving water.
MAY 12 2023
BY: .

W.W.Detention Pond Del* SUMMwY
Wet Pond [Xagram
WET POND ID
#1
Pretreatment No
other than
Has Veg. Filter? No
FOREBAY
Permanent Pool El.Hfl
Temporary Pool El:
Clean Out Depth:
Sediment Removal
Bottom Elevation:
ATTACH ADDITIONAL SHEETS IF NECESSARY
Permanent Pool El.DE
Temporary Pool El:
Clean Out Depth:
Sediment Removal
Bottom Elev ation:
MAY 0 8 T!Q3
MAY 12 2023
13Y.-

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
2. 2
i �?- BE-
I 230S -1
Applicable R es: O Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ 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
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.):
Pender Countv ABC Retail & Warehouse
2. Location of Project (street address):
0 Hwy 117
City:Burgaw County:Pender Zip:28425
3. Directions to project (from nearest major intersection):
The subject site is located at the northeast corner of the intersection of Hwy 117 and E. Fremont Street in
Burgaw, NC
4. Latitude:34° 33' 11.14" N Longitude:77* 54' 47.93" W of the main entrance to the project.
II. PERMIT INFORMATION:
I. a. Specify whether project is (check one): nNew ❑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
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: 3.2 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:Erosion Control - PENDE-2023-012, aRRroved 21 Ayri12023
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: hW2:1/2ortal.ncdenr.org/web/lr/rules-and-regulations E C E IVE
JUN 0 120
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6 9
BY:

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:Pender County ABC Board
Signing Official & Title:Diane O. Chadwick, Chairperson ---------
b. Contact information for person listed in item 1a above:
Street Address:207 Hwv 117 Bvvass
City:Burgaw State:NC Zip:28425
Mailing Address (if applicable):P.O. Box 804
City:Bureaw State•NC Zip:28425
Phone: (910 ) 259.2672 Fax: (N/A )
Email:[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: State: Zip:
Phone: ( ) Fax: ( )
Email:
4. Local jurisdiction for building permits: Town of Bur aw
Point of Contact:Ie_ssica Gray Phone #: 910 6 a �-
MAY 12 2023
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6 8 :

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The BUA for the Mroposed project has been calculated to be 33.8%and therefore qualifies as a high --density
development. A wet pond has been provided at the rear of the site to provide water quality treatment
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: 3.71 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. TotaI Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:3.71 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 (N11M line or Mean High Water
(MHK9 line, and coastal wetlands landward from the NHW (or MHI line. The resultant project area :s used to
calculate overall percent built upon area (BLIA). Non -coastal wetlands landward of the NHW (or MHM line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 33.8 %
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. SCM NCDOT ROW
Basin Information
Drainage Area I
Drains .Area 2
Drainage Area _
Drainage Area
Receiv#jg Stream Name
Bur aw Creek
Bur aw Creek
Stream Class *
QSW
CSW
Stream Index Number *
18-74-39
18-74-39
Total Drains Area (sf)
78,480 sf
15,779 sf
On -site Drainage Areas
78,480 sf
0 sf
Off -site Drains Area (sf)
0 sf
15,779 sf
Proposed Impervious Area**
49,640 sf
4,282 sf
% Impervious Area** total
63.3%
27.1%
hn 'ous"* Surface Area
Drainage Area 1
Drainage Area
Dra�iita Area _
Drains Area _
Can -site Buildings/Lots s
18,285 sf
0
On -site Streets (sf)
0
0
On -site Parking (sf)
26,577 sf
0
On -site Sidewalks (sf)
4,778 sf
0
Other on -site (sf)
0
0
Futures
0
0
Off -site (sf)
0
4,282 sf
Existing BUA*** (so
0
0
Total (sf):
49,640 sf
4,282 sf
Stream Uass and Index Number can be determined at:
Impervious area is defined as the built upon area includ
sidewalks, gravel areas, etc.
Form SVVU-101 Version Oct. 31, 2013 Page 3
ht : orta1.ncdenr.or eb wrVE
ing, but not Iimited to, buildings, M3
of 6 BY.

*''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. This area consist
of the driveways and sidewalks located in the public right-of-way
Proiects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&]VI) forms
must be submitted for each BUT specified for this project. The latest versions of the forms can be downloaded
from http://]2ortal.ncdenr.org/web/iyq/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
http://Portal.ncdenr.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 at http://Rortal.ncdenr.org/web/wq/ws/su/maps.)
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 htW://Rortal.ncdenr.org/web/Wg/ws/su/statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. SAD
2. OriginaI and one copy of the signed and notarized Deed Restrictions & Protective Covenants N/A
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M SAD
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to SAD
hn://www.envhelp.org/pages/onestopexpress.html 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 SAD
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the SAD
receiving stream drains to class SA waters within'h mile of the site boundary, include the Yi
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). SAD
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: SAD
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 water
i. Dimensioned property/project boundary with bearings & distances. iz
j. Site Layout with all BLTA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control meas s. MAY 12 2023
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by
qualified person. Provide documentation of qualifications and identify the person
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).
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify N/A
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 SHVVT prior
to submittal; [phone].)
10. A copy of the most current property deed. Deed book: 4787 Page No:1241-1243 SAD
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC N/A
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.
httv://www.secreLml.state.nc.us/Coi2orations/CSearch.asRx
VIL 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/lr/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 formes 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:Sean A Dolle
Consulting Firm: Grounded Engineering
Mailing Address:4909 Liles Road
City:Raleigh State:NC Zip:27606
Phone: (919 ) 438.3694 Fax: (N/A 1
Email:sean®grounded-engineering.com
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 la) 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.
MAY 12 2023
BYE
Form SWU-141 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:
I, a Notary Public for the State of . County of
do hereby certify that
personally appeared
before me this _ day of 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 type name of person listed in Contact Information, item Ia) !�) iarot Q • GSA -,NhGyc
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 requirement . of the
applicable stormwater rules under 15A NCAC 2H .1000 and any other applicable state sto m e re m s
Signature: � �'.%� �`��;'"` �� (��Z .�r�— Date: _ _ '
before me
a stormwater permit.
'W'I
Public
do hereb certify that I FkrAbnally appeared
1
r of W.dac owledge the due executi n of the application for
Witness my hand and official seal,
n y
0
Form SWU-101 Version Oct. 31, 2013
SEAL
M commission expires
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MAY 12 2023
Page 6 of 6
BY.

OMPLAIMFIT4M CAR PAGE
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QvUf ation Ststametst:
runder persetty of law that ♦firs Supplamerit-FZ form and all su;pporang informabon were prepared under my dkreCtion or supervision; that
rma4lon prarided in the farm m. to the hest of my knowledge and belief, true, accurms. and aemplste-, and that the engineering plans•
ations, operation and mamlenanca agreements and other supporting information are Consistent with the mformatlon prvvKfed here.
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JUN 13 2023

DRAINAGE AREAS
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Is thro a ho densily project?
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Does ft MW have low denaky areas? ' We
4
If ea amber of love qMft dWrmW area8:
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Is aWpatt of 1* project Wbject to previous rule -
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JUN 13 2023
BY
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