SW5221101_Application Form_20231120

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Standard Permitting Program — No Fee for Minor Modification
Express Permitting Program— See If;'xlpirpss Il'ee Schedule
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: /�°d f:r y � Jt :r.t(w? j + t+ rnal offit Ps
This form is to only to be used by the current permittee to notify the Division of a minor
modification. Pursuant to Roki 11 A t o"(.�„021 j_ 100,2 a minor modification is a change to the project that:
1) does not increase the net built -upon area; and/or
2) does not change the size or design of the SCM(s).
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1. State Stormwater Permit Number: SW52211101
2. Current Permit Holder's Company Name/Organization: lout Llm"mITIT_IT ..........
.....
3. Signing Official's Name: Michael Hurt_..._...
4. Signing Official's Title: Managing Member
5. Mailing Address: PO BoxIT9038
City; Rocky Mount _ State: NC ZIP: 27804
6. Street Address (if different): : 201 N Winstead Ave — Suite D
City: Rockv Mount ._...... IT mmmm — _mState: NC ZIP: 27804
7. Phone: [phone]_ IT_ ITIT,m Email: michaelihurtahurtorg com
8, Describe the minor modifications that you are requesting, including any revised BUA allocations (attach
additional pages or supporting tables similar to Section IV.10 of the original application, if needed):
Thy poN 1 Ascha�� rr s rotated o ..N "r�ened No giL@ c nth L. g�ci c lctdldtloils wele
required" Tk e and discharge upq��et to a new a trapezoidal, swwe,with a two foot bottorn n
3:1 side
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Please mark "Y' to confirm the items are included with this form. Please mark `X' if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. Two hard copies (with original signatures) and one electronic copy of this completed form.
Y„IT, __ 2. Two hard copies and one electronic copy of the revised plan sheets (must be a revision of the
originally approved plan sheets).
NA 3. If there is reallocation of lot BUA, a copy of the revised recorded deed restrictions and protective
covenants OR the proposed recorded deed restrictions and protective covenants documenting
the changes and a signed agreement to provide the final recorded document.
4, If applicable, the appropriate Express review fee.
C, CON "'t°'ACT INF::V: 11W TIIIOIN
Stormwater Permit Form 7: Minor Modification Page 1 of 2 July 14, 2017

1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name.Phill .....
Consulting Firm: Mack Gay Assocites, PA
Mailing Address:1667 .1 horrias a l etts..P.kV
City -Rocky Mount State:NC Zip:27804
Phone: [phone] Fax:
Email: hilli mack a a.com
[OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization,
Mailing Address:
City: .. .................. _ State: Zip:
Phone:
Email:
D, CERTIII::11C "'IIFI N OF Il::1ERl11t 111"'ll"""II 6l::;;;'
I, '".1,,""shown
_, the current permittee, certify that I have authorized the minor modifications listed in
Section ttached revised plan sheets. I further attest that this information is accurate and complete
to the be _
41
a Notary Public for the State of
County f„ c 1. ....... do hereby certify that
personally appeared before me this the /2 day of S-e20,21, and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
ANOELA M CLARK
(Nc 7wy W)NOTARY PUSUC
NASH COUNTY NORTH CAROUKA
My COMMISSION F_XP1RFS "" ' "
Notary Signature�____�_
My commission expires C)
f,lonrivvnlci ainriif 1, onin 7: A41noi I'',J r{ificnirrrr I1r9go 2 of )2017