SW4231001_Application Form_20240111

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:Bruce S.Henry,Sr.
Signing Official&Title:Bruce S.Henry,Sr.,Owner
b.Contact information for person listed in item la above:
Street Address:2048 Bethania Rural Hall Road
City:Winston-Salem State:NC Zip:27106
Mailing Address (if applicable):
City: State: Zip:
Phone: (336 ) 922-3422 Fax: ( )
Email:[e-mail]
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)
n 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:
Signing Official&Title:
b.Contact information for person listed in item 2a above:
Street Address:
City: State: Zip:
Mailing Address (if applicable):
City: State: Zip:
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:
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: City of Winston-Salem Inspections Division
Point of Contact:Chris Murphy Phone#: (336 ) 727-8016
Form SWU-101 Version Oct. 31,2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below,briefly summarize how the stormwater runoff will be treated.
Stormwater runoff will be treated by a bio retention cell located in the Western portion of the parcel.The bio
cell will be used for quality treatment for the stormwater runoff.
2.a.If claiming vested rights,identify the supporting documents provided and the date they were approved:
n 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 Yadkin Pee-Dee River basin.
4. Total Property Area:3.243 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+:3.243 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water(NHW)line or Mean High Water
(MI-ITN)line,and coastal wetlands landward from the NHW(or MHVV)line. The resultant project area is used to
calculate overall percent built upon area(BUA). Non-coastal wetlands landward of the NHW(or MHVV)line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area/ Total Project Area)X 100 =27.84 %
9. How many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
stormwater BMP. For low density 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 Drainage Area_ Drainage Area_ Drainage Area
Receiving Stream Name Hunters Creek
Stream Class * C
Stream Index Number* 12-81-1
Total Drainage Area(sf) 63,598
On-site Drainage Area(sf) 63,598
Off-site Drainage Area(sf) 0
Proposed Impervious Area**(sf) 38300
% Impervious Area**(total) 60
Impervious**Surface Area Drainage Area 1 Drainage Area_ Drainage Area_ Drainage Area
On-site Buildings/Lots(sf) 7566
On-site Streets (sf) 0
On-site Parking (sf) 28262
On-site Sidewalks (sf) 2472
Other on-site (sf) 0
Future(sf) 0
Off-site (sf) 0
Existing BUA*** (sf) 0
Total (sf): 38300
* Stream Class and Index Number can be determined at: http//portal.ncdenr.org/web/wq/ps/csu/classifications
** Impervious 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 Oct. 31,2013 Page 3 of 6