SW6230807_permit application with updated calcs_20230830 (2)

DEN4LR USE ONLY
Date ReceivLcl
Fee Paid
Permit Number
Applicable Rules: 1-1 Coastal SW - 1995 11 Coastal SW - 2008 D Ph I[ - Post Construction
(select 1711 that apply) 11 Non -Coastal SW- HQW/ORW Waters E:1 Universal Storm water Management Plan
El Other WQ Mgrnt Plan:
.. . ...... .... --
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
Thisforin Way be pbotocopiedfor use as an original
1. 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.):
Travel Stm) (Store 412
2. Location of Project (street address):
39481 Iodges..Chs1peI..Road
City: Dum-i County: Harnett Zip:28334
3. Directions to project (from nearest major intersection):
Northbomid on 1-95 take exit 77, stay right, then turn south (right) onto Hod es Chapel Rd, site on immediate
Southboud on 1-95 take exist 77, stay left, then turn soot (left) onto I loftes Chapel Rd, site will be on right
after intersection of northbound on/ off rarn-os and I loc[L-es Chanel Road.
4. Latitude:35'20'24.70" N — Longitude:78'33'25.64" W of the main entrance to the project.
11, PERMIT INFORMATION:
1. a. Specify whether project is (check one): New [Modification E] Renewal w/ Modifica tion I
I RMC711171S Witil iiiodifications also rctyiires SWU 702 - Renewal Applicatioti Feria
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: 7Not Started RPartially Completed* F-1 Completed* *provide ri designer's certificatioii
2. Specify the type of project (check one):
RLow Density ZI-ligh Density FlDrains to an Off'site Storm ester System E]Other
1 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 blaffl<s; ft-iformation on required state permits can be
obtained by contacting the Customer Service Center at 1.-877-623-6748):
E]CAMA Major ZSedirnentation/Erosion Control: 10.94. ac of Disturbed Area
FINPDE,S Industrial StormwateT n404/401 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: E&SC plan project no. HARNE-2023-122
Certificate of Coverate - NCC231728 issued 6.6.23 permit NCGO80162
5. Is the project located within 5 mites of a public airport? MNO F]Yes
If yes, see S.L 2012-200, Part VI: htti)://iDortal.iicdenr.org/Web/]rZrtiles-and-regulations
ForinSWU-101 Version Oct. 31, 2013 Page 1 of 6

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/Organizat Hart: Love's Travel Stop and. Country Stores
Signing Official & Title: 'Sane Wharton -President
b. Contact information for person listed in item 1a above:
Street Address: 10601 N. Pennsylvania .Ave
City: Oklahoma City State: OK Zip: 73126
Mailing Address (if applicable):
City: State: Zip:
Phone: f 405 8 4 7- 5 4 5 2 Fax: f
Email:
c. Please check the appropriate box. The applicant listed above. is:
N The property owner (Skip to Contact Information, item 3a)
F� Lessee* (,Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
E] 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/ Orgaruzation:1 oye's Travel Story and Country Stores
Signing Official&Title: Shang Wharton -President
b. Contact information for person listed in item 2a above:
StreetAddress:: 1.0601 N • Pennsylvania Ave.
City: Oklahoma City
Mailing Address (if applicable):
City:
State: OK
State:
Phone: ( 405 ) 847-5452 Tax:
Email: construction utilities ioermits@lcves . tear
Zip: 73126
Zip:
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 Leave's `l'ra;vel Stop and Country Stores
Signing Official &Title: Tyler Gill, Field Constrlaction Manager
b. Contact information for person listed in item 3,1 above:
lvtailingAddress: 1060'1 N. Pennsylvania Ave.
City: Oklahoma City State: OEM Zip: 73"1.26
Phone: 1405 i 847-5452 Fax:
Email: construction uti 1..i.ti_es Dermits@loves . tarn
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

4. Local jurisdiction for building permits: Cify_ o f Dunn
Point of Contact:George Adler _ Phone #:.(910 ) 766--0983
IV, PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
For the proposed project we have designed and provided a detention pond. The pond was sized to handle
up to the 17. chance storm (100-yr) in accordance with the NCDEQ Drainage Manual
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 11- Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 10.94 acres 5. Total Coastal Wetlands Area: 0.00 acres
6. Total Surface Water Area: 0.00 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+: 10.94 acres
+ Total project area shall be calculated to exclude the following: the normal p(NWol of impounded structures, the area
between the banks of streams and rivers, the area below the Normal Hi h Water (Nline or Mean High Water
(MFIW) line, and coastal wetlands landward from the NHW (or MHVM line. The resultant roject area rs used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NH (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 = 58.88
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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 7

Basin Information
Drainage Area 1
Draina e Area _
Drainage Area
Drainage Area
Receiving Stream Name
Mingo Swamp
Stream. Class *
C; S
StrearIY Index Number
18-68-12-2
Total Drainage Area (sf)
450,410.40
On -site Drainage Area (sf)
41.5,998
Off -site Draina,Re Area (so
34,412.40
Proposed lin pervious Area"*(sD
28,0090.80
% Impervious Area** totai
58.88
lLn ervrous** :Surface Area
On -site Buildings/Lots (sf)
Drama e Area 1
24,568.07
Drainage Area
Drainage Area
Drarraa e Area. —
On -site Streets (sf)
0.00
On. site Parking (st)
220,291
On -site Sidewalks (sf)
8,222.07
Other on -site (so
21,181.57
Future (sf)
0.00
Off -site (sf)
4,500
Existing BUA*** (so
227,81.3.1.5
Total (sf):
278,763
Stream Class and Index lNumber cra r be adeterraained at: htt�; �xor tahracdertr,drr' zveb rtr as esit classi¢catiorrs
1rn 7erot.ous area is defined as the builtupon area inchiding, but not limited to, buildings, roads, parking areas,
si nuallrs, gravel areas, etc,
'" Repor l orrly that rrrrrortrrt of e misting BUA that avid reamin after development. Do riot report any existing BUA that
is to be rentoved and urltrch u7ill be replaced by nezo BUA.
1.1.. Howe was the off -site impervious area listed above determined? Provide documentation. N?A
Projects in 1lraiotYCounty: Coratcrct I71liIL1i Cew.ral f?ffice stcrf/tn check rf'theproject is focaledivithin a Threurenecd&
EndangeredSpecies ivatershed that tray be subject to more stringent s°torinower regrrirenrents as per 15�11 NC I C 02B .0600
V. SUPPLEMENT AND O&M FORMS
The applicable state storn7water 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 httL):/ /L)ortal.i-tcdent'.orLa/web/wA7Li/ws/su /bmt)-manual.
VI. SUBMIT'T'AL 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
htt p: ortal.ncdem•.or web wqZws/sul statesw forms docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may he foru-id by locating project on the
interactive online map at httl2://Vortal.ncdeiir.org/web/""wq/``ws/"`su/```mal2s.)
Please indicate that the following required information have been provided by initialing in the space provided.
for each item. All original docu nents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from htt )ort11.ncdenr.or vveb we ws su statesw foriYYs docs..
1 tials
1. Original and one copy of the Stormwvater Management Permit Application Fortin.
2. Original and one coin/ of the signed and notarized Deed Restrictions & Protective Covenants N/A
Form.. (if regWred as per Part VII below)
3. Original of the applicable Stipplernent Forna(s) (sealed, sinned and dated) and O&M
agreernent(s) for each BMP.
4. Permit application processing fee of 505 pia/able to NCDENR. (For an Express review, refer to
h.ttp://w w.envliel.L).org/pages/onestopexpi'ess.litti-I for ia-dormation 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,)
Fortin SWU-101 Version Oct. 31, 2013 Page 4 of

5. A detailed narrative (one to two pages) describing the storniwater treatinciit/i-iianageiti.e.iitfoi�
the project. This is required in addition to the brief summary provided in the Project
Information, item I.
G. 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 Ih mile of the site boundary, include the 1/2
mile radius on the map.
T 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.
I. 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 NI-IW lilies.
• Del ineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or .NTJ.W) 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 (includirig off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate docurnent).
p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWTelevations (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 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 SITWT prior
to sitbinittal, [phone].)
10. A copy of the most current property deed. Deed book: 2764 Page No: 8 8 9
11. For corporations and lirnited liability corporations (11..,C): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions hold
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15.A NCAC 2H.1 003(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.
httl2://www.secretarv.state,.i,ic.usZCorporations/CSeaj:ch.asL)x
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future developilierit, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sites 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. 'Fhe appropriate deed restrictions and
protective covenants forms can be downloaded from hLtp:4,ortal.ncdei-ir.org/wel)/Ir/­statc,-stormwatei-
forms flocs. 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 websiLe, 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

VI L CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual an.cl/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 Fngirneer:Chr�stopher° Wall
Consulting Firm: Harrison French & Associates
Mailing Adclress:1705 S Walton Blvd Suite
City: Bentonville State: AID Li p:72712
Phone: (479 ) 273-778i1x453
Email:[e-mail]
Fax:
YIG X� Ip p U p ( � 9 IV �.... �. h INN°C8 u I w
IX. �(af Contact Iarfba-rrantkrra, item 2 has begin filled out, cornpalete this
sectacr)'1)
I, (prrarat or ti/pie naraae of paerson lasted Ira Contact dnfomiatlon, item 2n,1 Shane Wharton , certify that I
Own the property identified in this permit application, and thus give permission to (paint or type naraze cif persorr
listen in Contact Infarnrration, ¢tent 1ra) Love' s Travel- Stops with (paraut or, type ract)rae c ftrganization listen in
Con tact Infoyrnatiorr, itel)i Ira) Love's Travel Stops to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the subriittal, 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 DEML,R Stormwater permit reverts back
to me, the property owner, As the property owner, it is rnr.y responsibility to notify DEMLR immediately and
submit a completed Flame/Ownership Change Form within 30 days, otherwise I will be operating a storrnwvater
treatment facility without a apid permit. I runderstand that the operation of a stormwater treatment facility
without a valid hermit ' Z born of NC General Statue 143-215.1 and may result in appropriate enforcement
action. including tl��ne ass"n of civil penalties of up to $25,000 per day, pursuant to �TCGS 143-215.d.
Signature:
Date: -2,1 2,?)
I, Jessica Daley a Notary Public for the State of Oklahoma , Comity of
Oklahoma _do hereby certify that, Shane Wharton personally appeared
before me this 211 clay of August .............m, 202 3 ., and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,,,~. ....._......::: ._.... . _._._......_
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My commissiorn expires 1 15.2 4
1'or°rn SW(J-101 Version Oct, 31, 2013 Page 6 of 7

X.
1, (prirrtOr° type rralrle gfperfsarr listen irr Cct)ttaCI Irrfcarrtration, it'erra :1a) Shane Wharton
certify that the rrlftlrmation hicluded on this permit application form is, to the best of lily knowledge, correct and
that the project will he constr€rcted in conforina:nce with the approved }Mans, that the required deed restrictions
l d protective will b co -led, and that the proposed project complies with the repuirernents of the
at7��l c ale s c mwater covenants utes et NCAC 2H ,1.000 and any other applicable state stormwater requirements.
Signature:
f, Jessica. Dale
Date: g 2,
a Notary Public for the State of Oklahoma
Oklahoma , do hereby certify that Shane Wharton
County of
personally appeared.
before me this 21 day of Auc�tsm ._.. _., m2 02_3._..., and acknowledge the due execution of the application for
a stormwater permit. Witness army hand and official seaTL
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My eomraussion expires 1 . 15 . 2 4
Foini SWWU-101 Versiotr Oct. _ 1, 2013 Page 7 of7