SW6120801_Application_20120822

DWQ USE ONLY
D to Received
Fee Paid Permit Nunlber
M/Z
1 4So5 -# ti I 3 i.a13.DgD1
Applicable ules: ❑ Coastal SW - -1995 ❑ Coastal SW - 2008 F1 Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- I-1QW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M 7mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This f rm may be photocopied fir rise as air 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.):
Lot 1 A Averitt Prol2erties
2. Location of Project (street address):
-185 Airport Road
City: Fayetteville County: Cumberland Zip: 28306
3. Directions to project (from nearest major intersection):
Approximately 0.50 miles southeast along Airport Road from the intersection of U.S. Hwy 301 and Airport
Road.
4. Latitude:34° 59' 51" N 1_ongitude: 78' 53' 3-1" W of the main entrance to the project.
H. PERMIT INFORMATION:
-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" *1?J'0V du rr cerlifrcrrtiou
Specify the type of project (check one):
❑Low Density ®I-ligh Density ❑Drains to an Offsite Stormwater Systerii ❑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-b23-6748):
❑CAMA Major
❑NPDES Industrial Stormwater
®SediiiierltatiOn/Erosion Control: 4.35 ac of Disturbed Area
❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Pr me, Project/Permit Number,
issue date and the type of each permit: n/a T� i� ril�r
4UG - 7 2012
Form S W U-101 Version 07Jun2010 1'agc l of G

❑I. 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: Fullblock LLC
Signing Official &'Title: William B. Fuller, Jr., Managing Member
b.Contact information for person listed in item I above:
Street Address: 32"1 N. Front Street
City: Wilmington _ _ State: NC Zip: 28401
Mailing Address (if applicalde):
City: State:
Phone: ( 910 ) 763-0380 _ _ Fax:()l0
Email: [e-mail]
— Zip:-
777-2929
c. ['lease check the appropriate box. The applicant fisted 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. ('Phis is the
person who owns the property that the project is located on):
Property Owner/Organization:
Signing Official & "Title:
b.Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):
State:
Zip:
City: State: "Gip:
Phone: ( ) Fax: {
t�mail:
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 fisted in item 3a above:
Mailing Address:
City:
Phone: L
I -mail:
4. Local jurisdiction for building permits:
Point of Contact:
State:
Fax:
Phone #:
lip:
Form SWU-101 Version 0TIun2010 llziue 2 of6

Phone:
Fax:
Email:
4. Local jurisdiction for building permits:
Point of Contact:
IV. PROJECT INFORMATION
Phone #: ( }
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
All stormwater runoff will be conveyed by a storm drainage system to a wet detention pond.
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: 4.49 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,:4.49 acres
' Total project area shall be calculated to exclude the following: the norwal pool of impounded structures, the area
between the batiks of streams and rivers, fire area below the Normal High Water (NHW) litre or Mean Higli Water
(MHW) litre, and coastal wetlands landward from the NHW (or MHW) brie. The resultant project area rs used to
calculate overall percent built upon area (BUA). Nori-coastal wetlands latidre)ard of the NNW (or MHW) line tumy
be included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 55.9
9. How many drainage areas does the project have?7 (For higli density, count T for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for fire ?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 07Jun2010 Page 3 of 7

Basin Information
Draina e Areal
Draina e Area _
Draina e Area _
Drainage Area _
Receiving Stream Name
Big Sandy Run
Stream Class *
C
Stream Index Number *
18-31-25
Total Drainage Area (so
195,584
On -site Drainage Area (so
195,584
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
109,250
% Impervious Area** total
55.9
Impervious** Surface Area
Drainage Area 1
Drainage Area _
Drainage Area
Drainage Area _
On -site Buildings/Dots (sf)
"12,120
On -site Streets (so
0
On -site Parking (so
34,697
On -site Sidewalks (so
543
Other on -site (so
0
Future (sf)
61,890
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
109,250
Stream Class and Index Number can be determined at: httn://portal.rtcdcrtr.org%zuebAilg pti/csiilclassrficatiotis
Irtt 7Lrviaus area is defined as file built upon area including, bill not limited to, buildings, roads, parking areas,
si ezoalks, gravel areas, etc.
Report only that aniount of existing BUA that will rentain after development. Do not report any existing BUA that
is to be reproved and Which will be replaced by neztr BL1A.
11. How was the off -site impervious area listed above determined? Provide documentation
Projects in Union County: Contact D6i1Q Central Of slafflo check ifthe project is located �r,ilhin a Threatened h
Endangered Species watershed that maY he 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 littp://portal.ncdenr.org/sveb/wq/ws/su/bmp-manual.
V1. 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.ncdenr.orglweb/wq/ws/su/statesw/forms does. 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 httLi:%/portal.ncdenr.oi-g/web/wq/ws/su/maw.)
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 does.
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 below)
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 $505 payable to NCDENR. (For an Express review, refer to _ �$
htt www.envhelp.org/ pages onesto pen ress.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.)
Form SWU-101 Version 071un2010 Page 4 of 7

5.
A detailed narrative (one to two pages) describing the storm water treatment/man igementfor
the project. 'I'll is 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" (seaied, 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 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.
in. 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).
9.
Copy of any applicable soils report with the associated SFIWT 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 BMI's, 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 verify [lie SNWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 8905 Page No; 169 lope)
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 1a, 2a, and/or 3a per NCAC 2FI.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.
htt www.secretar .state,nC.us Cor ora tionsZ CSearch.as px
VI1. 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 forth. The appropriate deed restrictions and
protective covenants forms can be downloaded from
http://L)ortal.ticdeni-.org/webZwq/ws/su/-,tatesw/forrns 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 Iot.
Form SWU-101 Version 07Jun2010 Page 5 of 7

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:_ Robert P. Balland, P.E.
Consulting firm: Paramounte Engineering, Inc.
Mailing Address: 5911 Oleander Drive, Suite 201
City: Wilmington State: NC Zip: 28403
Phone: (910 ) 791-6707
Email: rballa,nd©12aramounte-eng.com
Fax: (910 ) 79"I-6760
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information., item 2 lias been filled out, complete this
section)
I, (print or type name of person listed in. Con fact Information, item 2a) , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item In) with (print or type name of organization listed in
Contact Information, item 1n) 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 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 civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
Date: —I --zr, b IZ
roa 5, a Notary Public for the Stategy� of _�11N O-A 3i ina, County of
do hrr
ereby certify that V ttOA-M " -I� A(U' t L, personally appeared
before me this O�J­dav of , s a no�vledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, 0_0
SEAL_
My commission expires 1-12- ED12-6 I
Form SWU-101 Version 07Jun2010 Page 6 of 7

X. APPLICANT'S CERTIFICATION
I, (print or type name of person listen in Contact Information, iferu 1a) William B. Faller, Jr., Managing Member
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 wilt be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules tinder 15A NCAC 2I-1 .1000, SL 2006-246 (Ph. 11 - Post Construction) or SL 2008-21"1,
Signature: Date:
I, �I } 1 �-- L a Notary Public for the State of N(ID(4-k 00Ay (nCounty of
do hereby certify that -W(0LJ \ -- - personally appeared
before me this day of l��, and_a knowledge the d exec lion of the application for
a stormwater permit. Witness my hand and official seal, �Y
SEAL
My commission expires 2D(
Form SWU-101 Version 07Jun2010 Page 7 of 7