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SW6120301_Application_20120323
w DWQ USE ONLY Date Received Fee Paid Permit Number *-IC)51ct 0 141 31 0301 Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction (select all that apply) ❑ Non -Coastal SW- I-IQW/ORW Waters ❑ Universal Storrwater 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 forth may be photocopied for rise as air 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.): CVS Pha rm acy Store #10157 2. Location of Project (street address): Northeastern Ouadrant of the interesection of NC HWY 24/87 and HM Cagle Drive - City: County: Harnett Lip: 28326 3. Directions to project (from nearest major intersection): I -lead South on Hwy 24 87 from the intersection of NC 24 and NC 87 in Southwestern Harnett County about 1 mile until you reach H M Cagle Drive. The site is at the Northeastern quadrant of the intersection of HWY 24/87 and HM Cagle Drive. 4. Latitude: 350 15' 40.83" N 11. PERMIT INFORMATION: Longitude: 790 02' 43.80" W of the main entrance to the project. 1. a. Specify whether project is (check one): ®New ❑Modification b.If this application is being submitted as the result of a modification to an existing permit, list the existing permit number , its issue date (if known) , and the status of construction: ❑Not Started ❑Partially Completed* ❑ Completed* *provide a designer's certification 2. Specify the type of project (check one): ❑Low Density ®I -sigh 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 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/Eros ion Control: 2.1 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: N/A Form SWU-101 Version 07Jun2010 Page I of E 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: Hart Redd, LLC Signing Official & Title:Tim Register, Registered Agent _ b.Contact information for person listed in item la above: Street Address:116 Wilson Pike Circle, Suite 103 City:Brentwood State:TN Zip:37027 Mailing Address (ifapplicable):INIA City: Phone: (910 385-5194 Email: timregister©intrstar.net State: Zi Pax: 615 591-5868 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 aril 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:HM's Kids Inc. Signing Official & Title:Mr. Mike Cagle b.Contact information for person listed in item 2a above: Street Address:3035 NC H 1 iva ruii Mailing Address (if applicable):3035 NC Hwy 87 S State:NC Zip:28326 City:Cameron State:NC Zip:28326 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: lonTho Signing Official & Title: Redd Reality Construction Manager b.Contact information for person listed in item 3a above: Mailing Address:116 Wilson Pike Circle, Suite 103 City:Brentwood State:TN Zip:37027 Phone: (615 ) 591-5525 x 230 Fax: ( ) Email: jon@hartredd.com 4. Local jurisdiction for building permits: Harnett County Inspections Department _ Point of Contact: Ken Slattum Phone #: (910 ) 893-7525 Form SWU-101 Version 07Jun2010 Page 2 of 6 IV. PROJECT INFORMATION 1. In the space provided below, tELefly summarize how the stormwater runoff will be treated. Two infiltration basins with be utilitized on the north and south sides of the site to treat the total new impervious area. 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: 2.016 acres 5. Total Coastal Wetlands Area: 0 acres 6. TotaI Surface Water Area: 0 acres 7. Total Property Area (4) -Total Coastal Wetlands Area (5) -Total Surface Water Area (6) = Total Project Area`:2.016 acres + Total project area shall be calculated to exclude the following the normal pool of imppounded structures, the area between flee banks of streams and rivers, the area below the Normal Hi Water (MM line or Mean High Water (MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area es used to calculate overall percent built upon area (BUA). Non -coastal wetlatds landward of tlee NHW (or MHW) line pray be included in the total project area. 8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 68.4 % 9. How many drainage areas does the project have?2 (For high density, count 1 for each proposed engineered storinwater BMP. For low densihj and other projects, use I for the whole property area) 10. Complete the following information for each drainage area identified in Project Information item 9. If there are more than four drainage areas in the project, attach an additional sheet with the information for each area provided in the same format as below. Basm Information `''•s; '' "� €, : ; ` Drama e'AieaP1 ;Drama e,Area 2 Dr`aina e'Area _ Draina e Area°. Receiving Stream Name Tributary to Mill Branch Tributary to Mill Branch Stream Class * C C Stream Index Number * 18-23-29-2-4 18-23-29-24 Total Drainage Area (so 55,327 23,981 On -site Drainage Area (so 55,327 20,794 Off -site Drainage Area (sf) 0 3,197 Proposed Impervious Area** (so 41,167 12,654 % Impervious Area** total 74.4% 65.0% Im" "eryious `Siirface=A'rea, o : 1. I7raina e Area 1 Dr°aina e "Pii 6a;2 ;Drama "e Area ': .Draina 6: Aiea ' On -site Buildings/Lots (so 13,225 0 On -site Streets (so 0 0 On -site Parking (so 24,000 11,711 On -site Sidewalks (so 1,168 943 Other on -site (so 2,774 0 Future (so 0 0 Off -site (sf) 0 0 Existing BUA*** (so 0 2,941 Total (so: 41,167 15,595 Stream Class and Index Number can be determined at: littp.aortal.ncdeter.oty eb/wq&s/csu/classi icatioris bnperoious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks, gravel areas, etc. Form SWU-101 Version 07Jun2010 Page 3 of 6 *** Rel7ort only that amount of existing BUA that will remain after development. Do not report any existing BLIA that is to he reproved and zrrhich will be replaced by new BLIA. 11. How was the off -site impervious area listed above determined? Provide documentation. Survey Prooects in Union County: Contact DWQ Central Office staff to check if the project is located within a 'Threatened d'- Endangered Species watershed that may be subject to more stringent stormwater requirements as per NCAC 02B .0600. V. SUPPLEMENT AND O&M FORMS The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded from http://portal.ncdennorg/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 http://portal.nciietir.orb;/4veb/tivq/ws/su/statesw/forms_clocs. 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 lnttl)://portal.ncdenr.org/web/vvgZws/,,u/mites.) 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 http:/J ortalmcdenr.org/web/wq/ws/su/statesw-/forms_docs. i is 1. Original and titre 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 VI! belotcr) 3. Original of the applicable Supplement Fornn(s) (sealed, signed and dated) and O&M agreement(s) for each SMI'. 4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to http://www.envhelp.org/pagesZonestopexpress.litml 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. `hhis 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. 8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: a. Development/Project name. b. Engineer and firm. c. Location map with named streets and NCSR numbers. d. Legend. e. North arrow. f. Scale. g. Revision number and dates. h. Identify all surface waters on the plans by delineating the normal pool elevation of impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal waters, and any coastal wetlands landward of the MHW or NHW lines. • Delineate the vegetated buffer landward from the normal pool elevation of impounded structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters. i. Dimensioned property/project boundary with bearings & distances. j. Site Layout with all 13UA 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. Form SWU-101 Version 07.1un2010 Page 4 of 6 o. Drainage areas delineated (included in the main set of plans, not as a separate document). p. Vegetated buffers (where required), rr// 9. Copy of any applicable soils report with the associated SHWT elevations (Please identify L�li 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 DWQ to verifiy fire SHWT prior to submittal, (910) 796-7378.) 10. A copy of the most current property deed. Deed book: 2000 Page No: 747 1-1. 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 1a, 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. http:// www.secretary.state.nc.us/Corporations/CSearch.aspx 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.ncdennorg/web/ivq/ws/su/statesw/forms does. Download the latest versions for each submittal. In the instances where the applicant is different than the property owner, it is the responsibility of the property owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring that the deed restrictions are recorded. By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and protective covenants for this project, if required, shall include all the items required in the permit and listed on the forms available on the website, that the covenants will be binding on all parties and persons claiming under them, that they will run with the land, that the required covenants cannot be changed or deleted without concurrence from the NC 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: Chris Bostic, PE Consulting Firm: Kimley-Horn and Associates, Inc. Mailing Address: 333 Fayetteville Street, Suite 600 City: Raleigh Phone: (919 ) 835-1494 Email chris.bostic@kimley horri.com State: NC Zip: 27601 Fax: (9119 ) 653-5847 IX. PROPERTY OWNER AUTHORIZATION (if Contact Irrforrrration, item 2 has been filled out, complete this Section) 1, (print or type name of person listed in Contact Information, item 2a) Mike Cagle certify that I own the property identified in this permit application, and thus give permission to (print or type ?nine of person listed ill Contact Information, item 1a) Tim Register with (print or type name of organization listen in Contact Information, item 1a) Hart -Redd LLC 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 07Jun2010 Page 5 of 6 As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated agent (entity fisted 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 1 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 civil wnaltie Aup to $25,OOO�er day, pursuant to NCGS 143-215.6. Signature: I, a Notary u Public for the State of V Coll of r2 (Io hereby certify that �personally appeared before me this � day of , � Z1q-, 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 1, (print or type name of person listen in Contact Information, item 1a) Tint Register 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 covenai will be recorded, and that the proposed project complies with the requirements of the applicable storm er rul s under 15A NCAC 2H .1000, SL 2006-246 (Ph. II - Post Construction) L 08-211. Signature: ` Date: I, t1 { r 66roes,a Notary Public for the State of f�c i -4n I County of 'Sar'-'P ?n do hereby certify that _ ! 1f aC2`j'r . RQG'i-! r personally appeared Y14before me this 'clay of _ I 1 aaa, and ac wled e the due e�xecu ' of the appli gtion for a stormwater permit. Witness my hand and official seal, ! ' SEAL, My commission expires f- CCU �-�(C-' j Dorm SWU-101 Version 07Jun2010 Page 6 of 6