SW6120802_Application_20120822

DWQ USE ONLY
` D to eceived
Fee Paid
Permit Number
W6/209-t)Z
Applicable les: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 P I'h II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may he 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.):
2. Location of Project (street address):
5750 Corporation Drive, Hope Mills, NC 28348 [north side of Chicken Foot Road (SR 2252)between
Corporation Drive (SR 2333) and 1-95N on -ramp]
City:Hope Mills County:Cumberland
3. Directions to project (from nearest major intersection):
Zip:
located on the north corner of Chicken Foot Road (SR 2252)_ and Corporation Drive (SR 2333)
4. Latitude:34° 56' 12.499" N
U. PERMIT INFORMATION:
Longitude:-78° 55' 16.009" W
1. a. Specify whether project is (check one): ®New ❑Modification
of the main entrance to the project.
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
If this application is being submitted as the result of a previously returned application or a letter from DWQ
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: 2.75 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:
Fonn SWU-101 Version 07Jun2010 Page 1 of

Ill, 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 :Bojangles' Restaurants, Inc.
Signing Official & 'Title: Claude Clark (Director of Engineering & Construction)
b.Contact information for person listed in item I above:
Street Address:9432 Southern Pine Blvd.
City:Charlotte
Mailing Address (if applicable):
City:
Phone: (704 ) 527-2675
Email:[e-mail] ^
State:NC
State:
Zip:28273
Zip:
Fax: (704 ) 522-8677
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: Bojangles' Restaurants, Inc.
Signing Official & Title: Claude Clark (Director of Engineering and Construction)
b. Contact information for person listed in item 2a above:
Street Address:9432 Southern Pine Blvd
City:Charlotte State:NC Zip:28273
Mailing Address (if applicable):
City: State: Zip:
Phone: (704 ) 527-2675 Fax: (704 } 522-8677
Email:cclark®bojangles.com
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: Bojangles' Restaurants, Inc.
Signing Official & Title:Claude Clark (Director of Engineering & Construction)
b.Contact information for person fisted in item 3a above:
Mailing Address:9432 Southern Pine Blvd.
City:Charlotte State:NC Zip:28273
Phone: (704 ) 527-2675 Fax: (704 ) 522-8677
Email:cclark@boja ngles.com
4. Local jurisdiction for building permits: Cumberland County
Point of Contact:Edward Byrne Phone #: (910 } 678-7609
Form SWU-101 Version 07Jun2010 Page 2 of 6

IV% PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Runoff from impervious surfaces will be collected in catch basins and pipe to an above ground infiltration
basin.
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 I1- Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 1.32 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
Total Property Area (4) - Total Coastal Wetlands Area (5) -Total Surface Water Area (6) = Total Project
ArW:1.32 acres
` Total project area shall be calculated to exclude thefollowing: the normal pool of impounded structures, the area
between the banks of strcazzzs and rivers, the area below the N
ormal High Water (NNW) line or Mean High Water
(MHVO line, and coastal wetlands landward from the NHW (or MHW) litre. The resultant project area is used to
calculate overall percent built upon area (BLIA). Non -coastal wetlands landward of tiee NHW (or MHW) line znay
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 62 %
9. I -low many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low densihj and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
Drainage Area 1
Draina e Area
Drainage Area _
Drainage Area
Receiving Stream Name
Rockfish Creek
Stream Class *
C
Stream Index Number *
18-31-(23)
Total Drainage Area (so
45,239
On -site Drainage Area (so
44,200
Off -site Drainage Area (sf)
1,039
Proposed Impervious Area** (so
35,409
% Impervious Area** total
78
Impervious— Surface Area
Drainage Area
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (sf)
3,808
On -site Streets (so
0
On -site Parking (so
28,860
On -site Sidewalks (so
I,702
Other on -site (so
Future (so
0
Off -site (so
1,039
Existing BUA*** (so
0
Total (so:
35,409
* Stream CIass and Index Number can be determined at. http.•//portal.ncdenr_or&,�2eb/ivq[ps/csu/clnssifuations
*` Izneppervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sir walks, gravel areas, etc.
�**Report only that amount of existing BUA that will remain after developtnent. Do not report any existing BUA that
is to be rennoved and which will be replaced by new BUA.
Form SWU-101 Version 07Jun2010 Paae 3 of

11.. How was the off -site impervious area listed above determined? Provide documentation. topographic survey
Projects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species v>>atershed that may he subject to more stringent storrnvt,ater requirements as per NCAC 028 .06i00.
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 hqp://portal.nedenr.org/web/wq/ws/su/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from hgp://portal.ncdenr.org/web/­wq/"­ws/su/­statesw/­forms docs. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at http://portal.ncdenr.org/web/wq/ws/su/mals.)
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 hqp://portal.ncdenr.org/web/wq/ws/su/statesw/forms_docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form,
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part V11 beloiv)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4, Permit application processing fee of $505 payable to NCDENR, (For an Express review, refer to
http://www.envhelp.org/pages/otiestopexpress.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/ managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations.
S. Two sets of plans folded to $.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MI-1W or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/ project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
Form SWU-101 Version 07Jun2010 Page 4 of 6

9. .Copy of any applicable soils report with the associated SHVVT elevations (Please identify
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verifif the SHWT prior
to submittal, [phone].)
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 State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per NCAC 21-1,1003(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.
httE.Z/www.secretary.state.iic.us/Corporatiotis/CSearch,aspx
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table 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/wq/ws/su/statesw/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 forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer: Brian 1'. Upton, PE
Consulting Firm: The Isaacs Group, PC
Mailing Address:8720 Red Oak Blvd., Ste. 420
City:Charlotte State:NC Zip:28217
Phone: (704 ) 527-3440 Fax: (704 } 527-8335
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 huts been filled ottt, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) I ' certify that 1
oven the property identified in this permit application, and thus givepermission to (print or type name of person
listed in Contact Information, item 1a) Clatide Clark with (print or type name of organization listen in
Contact Information, item 1a) Boiangles' Restaterattts, lac. 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.
Form SWU-101 Version 07.1un2010 Page 5 of'6

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 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/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 ci lties of up t 5 00 er day, pursuant to NCGS 143-215.6,
Signature: Date:
1, ._. _ 2_�e.n) !T �OGN�,_r"_ _ a Notary Public for the State of _W rt.k G&ro1'^Uc- , County of
„me-04:� k)bm re, , do hereby certify that ��1� IjjAr I( personally appeared
before me this ay of U } and zacowledge the due ecution of the application for
a stormwater permit. Witness my hand and official seal, Cat
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X. APPLICANT'S CERTIFICATION
SEAL
My commission expires_f�is l'"v`A K ,
1, (print or type name of person listed in Contact Infortirntion, itern 7a) 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 storm wajqplunder 15A NCl�H00, SL 2006-246 (Ph. it -Post Construction) or SL 2008-211.
Signatu
Date: d -16 _
I, ."') 1,c'ke- r- a Notary Public for the State of or--h (' .�r!__r. o/ �4 , County of
Yn /- _, do hereby certify that UI-ud,e Q,IA-r' personally appeared
before me this �L day of AIt9, S t- , -,im-2,and ac nowledge the Lipp execution of the application for
a stormwater permit. Witness my hand and official seal,
PSttlIiltlriifrrfrl
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SEAL
My commission expires
l&24. 20 14
Form SWU-101 Version 07.1un2010 Page 6 of