SW6120802_Application_20120806

DWQ USE ONLY
ate Received
Feo Paid
Permit Numbor
6I I,?
JsO5 1$- kick t 2'
i n
Applic ble Rufes: Coastal SW —1995 ❑Coastal SW -- 2008 13:fh II - Post Construction
(select all that apply) 94on-Coastal SW- HQWIORW Waters F-Universal Slormwater Management Plan
DOther WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
]'his form may be phowepled for use as an original
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.):
2.
3.
4. Latitude:* 66' f2: 6" N Longitude:=7E° of the main entrance to the project.
ll. PERMIT IN ORMATION:
1. a. Specify whether project Is (check one): New ClModification
b.If this application is being submitted as the result of a modifleadon to an existing permit, list the existing permit
numbar21 , its issue date (if known)`, � , and the status of construction: C]Not Started
(]Partially Completed" 0 Completed` -provide a deslgner's cedillcallon
2. Specify the type of prro0ct (chock one): - F Vf
ElLow Density l;fi high Density []Drains to an Offsile Slormwater System (]Other
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
requeating a state stormwater management permit application, list the storrAwater project number, if
and the previous name of the project, If different than currently
assigned, t p
proposed, =y
4.a.Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Se Ice Center at 1-877-S23-6748): t
EICAMA Major SodimentationlErosion Control: 2A ac of Disturbed Area
CINPDES Industrial Stormwater 0404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, ProjectlPermit Number,
Issue date and the type of each permit:
III. CONTACT INFORMATION
Forum s1YU-101 Version 07Am2010 Page X oFG

I.e. Print Applicant/ Signing official's name and title (specifically the developer, properly owner, lessee,
designated government official, Individual, etc. who owns the prQJeQt):
Signing Official &
b.Contact Information for person listed In item la above:
Street Address-,
Clty:cji (6(6 State:NQ
Mailing Address
City:...
Phone-,
Emall.
ZIP=.
State: zip
1. - 7- J
773
Fax: (W 5224677
c. Please check the appropriate box. The applicant listed above Is:
The properly owner (Skip to Contact Information, Item 3a)
Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
EJ Purchaser* (Atta6h a copy of the pending sales agreement and complete Contact Information, Item 2a and
2b below)
Cl Developer* (Complete Contact Information, Item 2a and 2b below.)
2. a. Print Properly Owners name and title below, If you are the lessee, purchaser or developer. (This isthe
person who owns the properly that the project Is located on):
Property Owner/Organization:41 W1 ek"
Signing Official &.Title-._;
b. Contact Information for person listed In item 2a above:
Street Address.
City: State:NQ dip:
a�k
Mailing Address
zlp:Lajl
city.
State:L
Phone-
Emall:2Fix:
—1
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/O anizationa
Signing Official & Title ";k- hi f :61 rzi;A0�!
b. Contact Information
far person fisted
In Item 3a above:
Mailing AddresS:R4'39!§"` 169".81idl
'aii
City
State
Phone: Fax:
-FPX1 X
-044. . . . . . . . . . . .
Emall:99 .
4. Local
jurisdiction
, for bulldin permits: ba6&0d.
Point of Contact:gd Phone 678-16Q9
Form SW U- 10 1 Version 07.lun10 . Page 2 of 7
far person fisted
In Item 3a above:
Mailing AddresS:R4'39!§"` 169".81idl
'aii
City
State
Phone: Fax:
-FPX1 X
-044. . . . . . . . . . . .
Emall:99 .
4. Local
jurisdiction
, for bulldin permits: ba6&0d.
Point of Contact:gd Phone 678-16Q9
Form SW U- 10 1 Version 07.lun10 . Page 2 of 7

IV. PROJECT INFORMATION
I. In the space provided below, bi
summarize how the stormwater runoff will be treated.
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 PUDApproval Date:
Valid Building Permit Issued Date:
0 Other. s.j Date..
b. If claiming vested rights, Identify the regulation(s) the project has been designed In accordance with:
0 coastal SW - 1996 El Ph 11 - Post Construction i
3. Stormwater runoff from this project drains totheRiver basin.
4. Total Property Area: j acres 6. Total Coastal Wetlands Area: acres
6. Total Surface Water Area--Q acres
7. Total Property Ar6a (4) -Total Coastal Wellands Area (6) -Total Surface Water Area (6) -Total Project
Area": 4 acres
+ Total project area shall be calculated to exclude ffie following., the normal pool of lInpounded structures,
the area between tho'banks of streams and river Ilia area below the filoanat High Water (A(HW) line or
Mean HIgh Water (MHW) line, and coastal wetlands landward from the NHW(or MHW) 1117e. 7-17a resullant
project area Is used to calculate overallpelventbuIll upon ama (RUA). Non -coastal wetlands landward oI
the NHW(or MHW)line maybe Included lnthe lofatproject area.
8. Project percent of Impervious area: (Total Impervious Area Total Project Area) X 100 a _QQ %
9. How many drainage areas does the project have?j (For high dansily, count I for each proposed engineered
stormwater BMP. For low density and otherpmJects, use I for the whole property area)
10. Complete the following Information for each drainage area Idenfiflod 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 formal as below.
Basin Information
Drainage Area
Drainao Area .'�
Drainage Area
Drainage Area
Receiving Stream Name
Stream Class
Stream Index Number
Total Drainage Area Lso
On-sIte Drainage Area (sA
Off -site Drainage Area (st)
Proposed Impervious Area (S_Q
I% Impervious Area" qqlaQ_ j
Im2ervious" Surface Area
/brainage Area t'
D lnage Area
'�q
Drainage Area
Drainage Area
On -site Bultdings/Lots (sf)
On -site Streets (Sq
On -site Parking (sq
On -site Sidewalks -
Other on -site tsq
Future(so
Off -site (89
I ExIstingWA111" (sQ
Total (sK
Stream Class end Index ftmbeh�nfnedql- ldfpJodal nedenn Mlw&LA�qlcsyl
classifications
Form SWU-101 VcrsIon07Atn20I0 I'age 3 of 7

** Impervious area Is deltned as the ,built upon area Moluding, bul not limited to, bulldings, roads, p8rking
areas, sidewalks, gravel areas, etc.
*'*Report only that amount Ofexisting BUA that w111rem8in alter development. Do notmportany 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 dalermined7 Provide documentation. io o "ra `i?I urve `
J!rajec(A fit Union Cormfg. Cotttoci Dll'Q CenArtl Ojflce strito the ek if the project !s located willihr a Threatened &
Endangered Species watershed that may be subjecl to more stringent storrinvater requirements as per NCAC Oil] , 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 e o web w Iws sul
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the DIvision of Water Quality (DWQ).
A cumppfete package Includes all of the items listed below. A detailed application Instruction sheet and BMP
checklists are available from btll2ftortal.ncdenr.efg/weber! g1Ws U stateswlforms docs. The complete
appllcation package should be submitted to the appropriate DWQ Office. (The appropriate office may be found by
locating project on the interactive online map athtlp:Upgdal.nrdanr.ora(webiq/ws/sulmaps.)
Please kWJgQW hat the -following mqulmd Informatiall hm heen provided by lnitfal[M 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 httpw;llp�#al ncde .orc y�ebl � suls�lesw forms .do_gg.
Initials
1. Original and one copyof the Stormwater Management Permit Application Form.
2. Original and one copyof the signed and notarized Dead Restrictions & Protective Covenants
Form. (Yret
3. Originalof.the applicable Supplement Form(s) (sealed sinned and dated MW O&M
agreemont(s
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
fit xffi and
5. A detailed narrative (one to two pages) describing the stormwater treatment./management for
the project. '
6. A USGS map Identifying the site location. If the receiving stream Is reported as class $A or the
receiving strt
7. Seated, signed and dated calculations.
$. Two sets of plans felded.t4 8.Kx 14" (sealed, signed, & dated), Including:
a. DevelopmentlProject 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 dales.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
Impounde
Delineate the vegetated buffer landward from the normal pool elevation of Impounded
strr.
i. Dimensioned propertylproject boundary with bearings & distances.
J. Site Layout with all BUA Identifled and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none oxlst. (Must be delineated by a
qualified I
n. Existing drainage (including off -site), drainage easements, pipe sixes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
0. Copy of any applicable solls report with the associated SHWT eleyallons (Please Identify
elevations Ii
10. A copy of the most current property deed. Deed book: Page No:
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
_Secretary of
VIE. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
Fonu SWIJ-101 Version 07Jmi20I0 Paget of'7

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
13UA 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 farm. The appropriate deed restrictions and
protective covenants forms can be downloaded from hltp:Nporial.iicdenr.orglwebly{q[wp(sulgtateswlformsdvcs.
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 properly
'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 ail the Items required in the permit and listed on the
forms available on the webalte, that the covenants will be binding on all parties and persons claiming under them,
that they will run with the land, -that the required covenants cannot be changed or deleted without concurrence
from the NC DWQ, and that they will be recorded prior to the sale of any lot.
Vill. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section If you wish to designsto authority to another individual and/or firm (such as a
consulting engineer andlor firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional Information).
Consulting Engineer:13rian T. Upton, PE
Consulting Firm: The Isaacs Group. PC
Matting Address:8720 Red Oak Blvd., Ste, 420
City:CharloltZip:28217
Phone: )_ 527-3440 Fax: UM 527-U335
Emall:
IX. PROPERTY OWNER AUTHORIZATION (If Contact Informatlon, Item 2 has been tilled ou4 complete Ib&
sactlon)
I, (print or type name ofperson Astedin Contact Information, Rom 29) rAOe- A4 ert y l at 1
own the properly Identified in this permit application, and thus give permission to (print ortype name ofparson
listed In Contact Information, Item la) Clawith (print or type name oforgenlzallon listed in
Contact Information, item fat s' e u s 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 1 acknowledge, understand, and agree by my signature below, that If my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwaler permit reverts back
to me, Ahe property owner. As the property owner, it Is my responsibility to notify DWQ Immedlately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permll. 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: a.Yt,r- c.��n.� �? �"" l ' Date:
I,Judee C , a Notary Public for the Slate ohq c i� NI County of
�
Ca IJ r , do hereby certify that n 1 �t I lOf rff _ IW W' Y) - m personally appeared
before me this Cray of , and ac owledge the due xecut on of th applicatio r or .
a stormwaler.permit. Witness my hand and official seal,
I SORDANA LEIGH LEGGETT
NOTARY PtkOl-1C
CUMBERNC
Forni StiW-101 Version 07Jua201O Page 5 of 7 WcommLANt) pMO-COUNTY, 16
Nfy Commtsstan Exp►res 8-28•x416

For all subdivisions, outparcels, and future development, the appropriate properly restrictions and protective
covenants are required to be recorded prior to the sale of any lot. if lot sixes 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 hU:llpQrtaLncd=.org/w�glws/su/statesw/forms-dors.
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 aval[able on the webslte, that the covenants will be binding on all parties and persons dalming under them,
that they wlli run with the land, that the required covenants cannot be changed or deleted without concurrence
from the NC DWQ, and that they will be recorded prior to the safe of any lot.
Vill, CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section If you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer:rfan7 11nlon: l?
Consulting Firm: 7j;isa c,Gror�1�;' F?0
Mailing AddressU 20'Red 0a 131yd: Ste:- 420
Cily:eha/♦eeiyyypJJJ��i6
Staler;
ZIp..: ,
Phone:
Fax:
Email:
IX PROPERTY OWNER AUTHORIZATION (If Coalact Informallon, item 2 has been >rlled out, complete this
sectlon)
1, (print or type name ofperson Ilsled in Contact In(ormallon, Item 28) = p A/c S , u WNI , certify that I
own the property identified in this permit application, and thus give permission to (print or type name ofperson
Ilsled in Confect Informallon, ltem fe) : "`C a with (print or type name of organization !!sled In
Contact lnfermallon, item fa)Mie e ti ! 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 DWQ Stormwaler permit reverts back
to me, the property owner, As the property owner, It is my responsibility to notify DWG( 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 penaltle§ of up to $25,000 per day, pursuant to NCGS 143-215:6.
3ignaturc1J&,11 fate: � -f �,c L-
iL
1,} , a Notary Public for the State of `�i h �L(�d�� County of
f t. mWi` l ncl _, do hereby certify that chxleS L1 • rMer personally appeared
before me this q ivay of `� h _., and a�cAnowledge the d fuja execution of j e a/pplic,,al for
van nlr,rill .T f'rn,1.... 1 d l f�U [Jf,
a stormwater, permit. Witness my hand and official seal,
Form SWU-101 Version 07Jun2olo 1 Page 5 of 7
JORDANA LEIGH LEGGETT
NoTARY PUBLIC
CUM13ERLAND COUNly, NC
My Commis*n Expires 6.26-20%

For all subdivisions, oulparcels, 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 It :!! octal. c w sins alesw o
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 tha 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
proteoUve covenants for this project, If required, shall Include all the Items required In the permit and listed on the
forms available on the webalte, that the covenants will be binding on all parties and persons claiming under them,
that they will run with the land, that the required covenants cannot be changed or deleted without concurrence
from the NC DWQ, and that they will be recorded prior to the sale of any lot.
Vill. CONSULTANT INFORMATION ANU AUTHORIZATION
Applicant; Complete this section If you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide Information on your behalf for this project (such as
addressing requests for additional Information).
Consulting Engineer:brian T-Uplon. eg
Consulting Firm: -The Isaacs Qpun.PC
Mailing Address; 20
Cily,CharlolStale:NQ ZIP:201i
Phone: kjQl 1627-94Q Fa)(: (M ).627-8335
Email; b�ot�gfiJ�tsaacsaru• com
IX. PROPERTY OWNER AUTHORIZATION (if contact Infomrallon, Item 2 has been filled out, complete 11r1s
section)
(pant orlype namo ofporson listed In Contact informatlort, 11e1n2a)jCg
1 /%, jC° r'n�'+�, certify that
own the property Identified In this permit application, and thus give permission to rprint ortypo name ofpereon
11sted In Contact Information item fa) Lr q's Clark with (print or type name oforpanlzallon listed in
Contact Informallon, Item 1aJ to develop the project as currently proposed. A
copy of the lease agreement or pending property sales contract has been provided with She submittal, which
indicates the party responsible for the operation and maintenance of the stormwater system.
As the legal properly owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed In Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back
to me, the property owner. As the property owner, It Is my responsibility to notify DWQ Immediately and submit a
completed Name/Ownershlp 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 NGGS 143-216.6.
k J
Slgna(ire: C 2's �y r- —� Date;
a Notary Rublic for tho State ofy►"� Cki�"fC=z- , County of
i71 cx -r A ?c=..> _ _ , do hereby certify that _•%IUCA4I I'�r�11r ►'' personally appeared
before me this 11 day of ') , and acknowledge the due execution of the application for
a sEorntwater permit. Witness m and and official seal, ' L' ' {�a r4f �f
JENNIFER J. ADERINTO
Nalsry pubiio.Ststs of Arizons
Fonn SW -t41 Version 07Juu2010 Page 5 of o Meriaope County
My Commission Expire 5
• December 11,

SEAL
My commission expires
X. APPLICANTS CERTIFICATION
1, (print or typo name of person listed in Conlect lnformalran, aem ia) Claude'Clark
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 slorrnwater rules under 15A NCAC 2hl .1000, SL 2000-246 (Ph. I — Post Construction) or SL 2008-
211.
Signature: Date:
I, V tt a. �e��► � , a Notary Public for the State of drA am Itna , County of
le
do hereby certify that C14u.d� P% r f5 p nally appeared
before me this ay of Jul , a4 R 2, and acknowi e l due executi oft a app canon for
a storrnwater permit. Witness m hand and official seal,
g���lA
kMY
�hf RY 9i M4
' LTG
Mo
SEAL
My commission expires
Form SWU-101 Vcrsion VNII12010 Page 6 of 7