SW6121004_Application_20121214

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 ❑ I'll 11 - 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 forte ?nay be photocopied for use as rut 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.):
McDonald's #32-1588
2, Location of Project (street address):
rhills Road and Ra
City:Spring Lake County:Harnett Zip:28405
3. Directions to project (from nearest major intersection):
"fake a right on to Ray Road from Overhills Elemetry School and head north, the property is the east corner
property at the intersection of Overhills Road and Rau Road, next to Anderson Creek Shopping Center.
4. Latitude:35° 15' 23,20" N Longitude:78° 58' 2.87" W of the main entrance to the project.
11. PERMITINFORMA"LION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRerreimris eoith rtroriifications also regnires SWLI-102 - Rent,torrl Application F(>rm
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 certiFcatiorr
2. Specify the type of project (check one):
❑I..ow Density ®High Density ❑Drains to an Offsite Stornirvater 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/Erosion Control: 2.27 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
5. is the project located within 5 miles of a public airport? ®No El
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr-org/web/k+,cl/v
c�
U MIR
4
ales laws
Form SWU-101 Version 06Aug20i2 Page 1 of

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:McDonald's USA, LLC
Signing Official & Title:lames M. Kurtz, Development Director
b.Contact information for person listed in item I above:
Street Address:4601 Six Forks Road, Suite 200
City:Raleigh State; NC Zip:27609
Mailing Address (if applicable):4601 Six Forks Road, Suite 200
City: Rale
Sta te: NC Z i p:27609
Phone: (919 ) 559-3677 Fax: (919 ) 326-4215
Email: I im.Kurtz®us.mcd.com
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. ("]'his is the
person who owns the property that the project is located on):
Property Owner/Organization:Anderson Creek Capital, LLC _
Signing Official & Title:H. David Swain, Owner
b.Contact information for person listed in item 2a above:
Street Address:1.121- P Military Cutoff Road
City:Wilmington
Sta te: NC Z i p:28405
Mailing Address (if applicable):1121-11 Military Cutoff Road
City: Wilmington State:NC Zip:28405
Phone: (910 ) 256-2211 Fax: (910 ) 256-2171
Erna il:iasonOswai nassocia tes.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:
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: Harnett Countv inspection Department
Point of Contact: Ken Slattum Phone #:.(910 _) 893-7525
Form SWU-101 Version 06Aug2012 Page 2 of

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
ill be u
rvrous area.
SOU
site to treat the total ne
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 laver basin.
4. "Total Property Area: 1.59 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) -Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area*:1.59 acres
Total project area shall be calculated to exclude thefollowing: the normal pool of irtrporrrrded strucinr•es, the area
between the hanks of strcaurs and rivers, the area below the Normal High Water- (NNW) litre or Meau Nigh Water
(MHV\W line, and coastal 7vetlands landward from the NHW (or MHW) litre. The restrliatrt project area is user[ to
calculate overall percent built upon area (BUA). Non -coastal Wetlands larululard of the NNW (or MN[N) litre may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 62A %
9. Flow many drainage areas does the project have?2 (For high density, count I for each proposed engineered
stortrtrvater BMP. For lore density and other projects, use 1 for the Whole properly 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
Drainage Area 2
Draina Te Area _
Drainage Area _
Receiving Stream Name
Tributary to
Pistol Branch
Tributary to
Pistol Branch
Stream Class
C
C
Stream Index Number *
18-23-29-4
18-23-29-4
Total Drainage Area (so
37,331
35,937
On -site Drainage Area (so
34,216
35,937
Off -site Drainage Area (so
3,115
0
Proposed Impervious Area s
23,434
20,952
% Impervious Area** total
62.77%
58.3%
Impervious** Surface Arca:e "'
Drainage Area 1
braina e Area 2'
Drainage Area _
Drainage Area
On -site Buildings/Lots (so
0
5,300
On -site Streets (so
16,776
7,286
On -site Parking (so
2,736
7,190
On -site Sidewalks (so
474
1,176
Other on -site (so
1,205
0
Future (so
0
0
Off -site (so
3,115
0
Existing BUA*** (so
0
0
Total (so:
1 24,306
20,952
* Stream Class and Index Number can be determined at: ldtt p;//poYtal.11CdL'rf r".o1"��/ztteh/rtrrj[Jrs/csrr/classihcntious
Form SWU-101 Version 06Aug2012 Page i ol'6

lur rctviotrs area is defined as the built upon area including, but trot liniifed to, buildings, roads, parking areas,
si erualks, gravel areas, etc.
'Report only that amount of existing BUA that Will rentaitr after development. Do not report any existing BUA that
is to be removed and which will be replaced by neul BUA.
I1. How was the off -site impervious area listed above determined? Provide documentation. Survey
Projects in Union Count: Contact D11•'Q Central Offce slgyto check if the project is located milhirt a Thruuleirecl �l'
Endangered Species ivalershed that may be subject to move stringent slormivuler requirements as per 15A rVC 4 C 0213 .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&]vt) forms
must be submitted for each BMP specified for this project. The latest versions of the farms can be downloaded
from http://portal.ncdennorg/web/%vq/ws/su/bnip-rllanual.
Vl. 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 http1/Vortal,ncciem-.org/web/wgj,<vs/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.ncclenr.org/4veb/wq/ws/su/maps,)
Please indicate that the following re wired 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 hap:/1portal.ncdennorg/web/wq/ws/su/statesw/forms does.
Ini ials
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 VII below)
3. Original of the applicable Supplement Forms) (sealed, signed and dated) and O&M
agreement(s) for each 13MP.
t. Permit application processing fee of $505 payable to NCDENR. (For an I-xpress review, refer to
htt www,envlieII2.org/12ages/onestopexpress.fitml 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/managetnentfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 'I.
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 tile'/a
mile radius on the map.
7. 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.
f. Scale.
& 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 -I W or NI-J W 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 MI-IW (or NHLN) 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.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
Form SIVU-l01 Version 06Aug2012 Page 4 of 6

m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated) by a
qualifies{ 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).
V t td b ff s wh re e i ed)
F. ege a c u er e r qu r
9. Copy of any applicabll e soils report with the associated Sl-[LN'I' 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"xl1" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the reportshould 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 verrfi/ the SHVVI' prior
to stcbruittal, (91Q) 796-7378Ni, -
.)
10
11
A copy of the most current property deed. Deed book: 2107 & 1836 Page No: 730 & 649
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 15A 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
VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
I�or 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://portai.ncdenr.org/web/H,g/ws/su/states%,,,/formsdocs. 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: Cornplete 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: ohn Holcomb
Consulting Firm: Kimley-l-lorn and Associates, Inc.
Mailing Address:333 Fayetteville Street, Suite 600
City: Raleigh
Phone: (919 ) 653-5872
f;mai 1: ioh n, hol corn b'Jkim ley -horn. com
State:NC Zip:27601
Fax: (919 ) 653-5847
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, iterir 2 has been filled orrt, coinplete this
section)
1, (print or hyllc rratrre of person listed in Contact Information, iterir 2a) H. David Stuairr , certify that I
own the property identified in this permit application, and thus give permission to (print or tylic rratne of person
listed in Contact Information, item in) fatties M. Kurtz with (print or tt/pe name of organization lister! in
Contact Information, iterir 1a) McDonald's LISA, 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.
Forin SWU-101 Version 06Aug2012 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 anti/or cancels or defaults on their
lease agreement, or pen ' g sale, resp st ' 'ty for compliance with the DWQ Stormwater permit reverts rack to
me, the property owne . roe y ow r, it is my responsibility to notify DWQ immediately and submit a
completed Name/O 1 rs 1' C a e 'orm within 30 days; otherwise I will be operating a stornnvater treatment
facility without a va d e it. 1 c tand that the operation of a stormwater treatment facility w'Ithout a valid
permit is a violatio of C ener St t e 143-21$.1 and may result in appropriate enforcement action including
the assessment of vil na ies up f25,000 per day, pursuant to NCGS 143-215.6.
Signatu
Date: 1012 Z- /z 012�
I, 00;mn R 5i1Lrt1VwV-\ a Notary Public for the State of Ivor h C(2rQI(rVrCnuntV of
j�eLO 1 VIOD YP' do hereby certify that H RAD O Gy,) A-E ro personally appeared
before me this % day of CSC AMA F , and ackn ledge the due ex cution of the application for
a stormwater permit. Witness n1y hand and official seal, /;7/1-- (CI � ll/l!/t'1D✓L
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X. APPLICANT'S CERTIFICATION
SEAL
My commission expires
I, (print or type traine of person listed in Contact Information, ifeua In) ]mires M. Kurtz
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 stormwater rules under 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Signature:
/� � _ Date: 1 �•,� z51 t�
a Notary Public for the State of !.1 County of
do hereby certify that�T 422 M, 41k-/--/7 personally appeared
before me thi day of —.PgO1 Z, and acknowledge the due executioy ff the zpplication for
a stormwater permit. Witness my hand and official seal, / tihl C /--
SEAL
My commission expires
Form SWU-101 Version 06Aug2012 Page 6 of 6