SW6221102_Annual Certification Review (2024)_20240116

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 1/12/2024 2:59:51 PM (Annual Certification Submittal)
Approve by Kaitlin Peck 1/16/2024 2:31:09 PM (Annual Certification Submittal Review)
• The task was assigned to Kaitlin Peck 1/12/2024 2:59:53 PM

Post-
Construction StormwaterProgram
OVERVIEW
Please read the following as it contains useful information that will help you better understand and complete this form.
Before filling out this form:
• Go to our website and check the current information we have on file by running a State Stormwater Permit Summary Report.
• Get a copy of the most recently issued post-construction stormwater permit and plans for the project. Hard copies of these items should
have been sent to the Applicant once the permit was issued.The post-construction stormwater permit will have a permit number(on the
cover letter and at the top of each page of the permit)in the form"SW#######"(where the V"symbols are usually numbers but can
also be letters). If you do not have a copy of the permit or plans,they can either be found in our online repository or by contacting
the DEMLR office that issued the permit. For additional assistance,send an email to [e-mail]
• Ensure that the correct person is filling out this form.This certification form must be completed by the Permittee(listed on the permit)or
by a Designee of the Permittee.This form does not need to be completed by an engineer or other licensed professional.
• NOTE: For permits that have multiple Permittees,only one Annual Certification per permit needs to be submitted. Each separate
Permittee is not required to submit their own Annual Certification.
Why is an annual certification required?
• The annual permit certification on conformance with permitting conditions is required per G.S. 143-214.7(b4): "New stormwater permits
and stormwater permits that are reissued due to transfer, modification,or renewal shall require the permittee to submit an annual
certification on the project's conformance with permit conditions.The annual certification shall be completed by the permit holder or their
designee.The Department shall not require the annual certification to be completed by another party besides the permit holder or their
designee.The Department shall provide an electronic means of submittal for the permit holder or their designee to satisfy the annual
certification requirement.The addition of annual certification requirements to an existing permit or certification shall not be considered to
be a new or increased stormwater control."-G.S. 143-214.7(b4)
• The annual certification supports the Permittee by ensuring that they are aware of and are meeting all of the permitting conditions that
are required per the permit.
An annual certification must be completed each year on or before the day of the year on which the permit was issued.
For example, if a permit was issued on April 15,2022,the first annual certification for that permit would be due on or before April 15,2023;
the second annual certification would be due on or before April 15,2024;and each subsequent annual certification would be due on or
before April 15th of that year until the permit is reissued(at which point the day of the year that the permit was reissued would become the
new annual certification date).
About Saving Drafts of this Form:
If you are unable to complete the entire Annual Certification Form in one sitting,the form can be saved by clicking the"Save as Draft"
button at the bottom of any section and resuming at a later time.You will provide an email and password(set specifically for the current
project form)so you can access the form again when the link is sent to that email address. Do not upload any documents to the draft
until you are ready to submit the form,or you may encounter problems submitting it. If this happens, remove and re-upload
attachments to submit. IMPORTANT: pre-populated information that has been updated on our end since you started the draft may not
update in a saved draft. In those cases,we recommend starting a new form.

A. Permit and Project Information
Section A - Permit and Project Information:
Please enter the permit number associated with this property.
.........................................................................................................................................................................................................................................................................................................................................................................................................................
Permit Check: Reviewer must verify the permit number
The permit number entered is correct
Permit Number* Enter Permit number(in format SW#######).
SW6221102
Must begin with'SW'followed by 7 letters or numbers.ALL LETTERS MUST BE CAPITALIZED.
Project Name:* Information we have on file:
Utility Improvements to Serve Ashley Heights
The project name can be found in the permit or in the cover letter sent out with the permit.
Project County:* Information we have on file:
Hoke
This is the county the project is located in. Projects that are located in multiple counties will only list
one county as the"Project County".
Project City/Town* Information we have on file:
Aberdeen
This is the town or city the project is located in.
Date of Permit Information we have on file:
Issuance* 7/6/2023
The date that the permit was issued can be found in the permit or in the cover letter sent out with the
permit.
Issuance Month and Day July 6
(Hidden field on submission and used on the Certificate)
Project Information* Is the project name and information that we have on file for this project,as listed above,current and
correct?
Yes
No
Project Status* Construction on the project has not yet started
Construction on the project is underway
Construction on the project is completed
Sections D and E do not apply to projects that have not yet started.
Is the permit expired or No(active permit)
expiring within 180 Yes, but permittee has submitted a Renewal Application.
days?* Yes(expired already or expiring within 180 days)

B. Permittee Information
Section B - Permittee Information:
........................................................................................................................................................
Permittee Name* Information we have on file:
Ashley Heights LLC
This is the organization,government entity, individual,etc.that is currently responsible for maintaining
conformance with the permit conditions. Some permits are issued to multiple Permittees,there will be
an option to include these additional Permittees later in the form.
Current Permittee Signing Official
This is a person who represents and can sign for the permittee(for corporations,this person must be the at the level of Vice President or
higher).This person may be the same person as the permittee if the permittee is an individual.
Permittee Signing Information we have on file:
Official David T Upchurch, PE
As of: 1/1/2024
Permittee Signing Official contact information we have as of 1/1/2024:
Ashley Heights LLC
David Upchurch(Signing Official)
150 S Page St
Southern Pnes, NC 28387
Phone: [phone] Ext.
Email:[e-mail]
First Name* David
Last Name* Upchurch
Title* Engineer/Managing partner
Current Permittee Street Address
Mailing Address* 150 S Page St
Address Line 2
City State/Province/Region
Southern Pnes NC
Postal/Zip Code Country
28387 USA
Check here if the mailing address is the same as the street address.
Current Permittee Street Street Address
Address* 150 S. Page Street
Address Line 2
City State/Province/Region
Southern Pines NC
Postal/Zip Code Country
28387 USA

Permittee Signing Please enter a telephone number that we can use to reach the Permittee Signing Official during
Official Telephone normal business hours.
Number* 910-684-8646 Ext.
Permittee Signing Please enter an email address that we can use to reach the Permittee Signing Official.
Official Email Address* [e-mail]
Permittee Information* Is the Permittee information that we have on file for this project,as listed above, current and correct?
Yes
No
Additional Permittees?* Are there additional Permittees associated with this permit?
Yes
- No
Any additional Permittees associated with the permit can be found in the permit or in the cover letter
sent out with the permit.Typical additional Permittees include Developers, Property Owners,
Purchasers,and Lessees.
Additional Permittee Has any of the Additional Permittee(s)information changed since this permit was last issued or since
Information* the last Annual Certification was submitted(whichever occurred most recently)?
No
Yes

C. Property Owner Information
Section C - Property Owner Information
..................................................................................................................................................................................
These property owners may or may not be listed as the Permittee and/or Co-permittees above.
Check here if the current Property Owner is the same as the Permittee listed in Part B.
Do not select this item if the current Property Owner is the same as one of the Additional Permittees
listed in Part B.
Check here if the project is a subdivision with each of the individual lots owned by separate
individual entities.
Property Owner Please enter the name of the Property Owner that owns the property covered under the permit.
(Primary)Name* Ashley Heights LLC
This is the organization,government entity, individual,etc.that is currently owns the property covered
under the permit.Some permits cover property owned by multiple entities,there will be an option to
include these additional Property Owners later in the form.
Property Owner Signing Official
This is a person who represents and can sign for the current Property Owner(for corporations,this person must be the at the level of Vice
President or higher).This person may be the same person as the current Property Owner if the current Property Owner is an individual.
First Name* David
Last Name* Upchurch
Title* Engineer/Managing partner
Property Owner Signing Street Address
Official Mailing 150 S Page St
Address
Address Line 2
City State/Province/Region
Southern Pnes NC
Postal/Zip Code Country
28387 USA
Check here if the mailing address is the same as the street address.
Property Owner Signing Street Address
Official Street Address* 150 S. Page Street
Address Line 2
City State/Province/Region
Southern Pines NC
Postal/Zip Code Country
28387 USA
Property Owner Signing Please enter a telephone number that we can use to reach the Property Owner Signing Official during
Official Telephone normal business hours.
Number* 910-684-8646 Ext.
Property Owner Signing Please enter an email address that we can use to reach the Property Owner Signing Official.
Official Email* [e-mail]

Property Owner Has the Property Owner information changed since this permit was last issued or since the last Annual
Information* Certification was submitted(whichever occurred most recently)?
No
Yes
Additional Property Does this permit have additional Property Owners associated with it?
Owners?* Yes
No
Any additional Property Owners associated with the permit can be found in the permit or in the cover
letter sent out with the permit. Individual lot owners in a subdivision should not be included here unless
it is specifically written into the permit.
Additional Property Has any of the Additional Property Owner(s)information changed since this permit was last issued or
Owner Information* since the last Annual Certification was submitted(whichever occurred most recently)?
No
Yes

F. Project Certifier Information
Section F - Project Certifier Information
......................................................................................................................................................................................
Please enter the following information for the Project Certifier:
The Project Certifier is:* This is the individual that is certifying if the project is in conformance with all of the permit conditions.
This individual can be either the permittee or a designee of the permittee(an engineering license is not
required to certify that the project is in conformance with the permit conditions.
The Permittee(listed in Section B)
A designee of the Permittee
Project Certifier Name and Title
First Name* David
Last Name* Upchurch
Certifier's Title* Engineer/Managing partner
Project Certifier Mailing Street Address
Address* 150 S Page St
Address Line 2
City State/Province/Region
Southern Pnes NC
Postal/Zip Code Country
28387 USA
Check here if the mailing address is the same as the street address.
Project Certifier Street Street Address
Address* 150 S. Page Street
Address Line 2
City State/Province/Region
Southern Pines NC
Postal/Zip Code Country
28387 USA
Project Certifier 910-684-8646 Ext.
Telephone Number*
Project Certifier Email* [e-mail]

G. Certification
Section G - Certification
................................................................................................................
Certifier Full Name David Upchurch
(Hidden field on submission and used on the Certificate)
Signing Official Full David Upchurch
Name (Hidden field on submission and used on the Certification Summary)
As the current(permittee/designee of the permittee), I, David Upchurch,certify under penalty of law that,to the best of my knowledge,:
* the information in this form is true,accurate,and complete.
no, I cannot certify this.
* RECORDED ANSWER BASED ON SITE CONFORMANCE RESPONSES IN SUBMISSION
the project is currently in conformance with all of the permit conditions.
no, I cannot certify this(corrective actions required).
* By checking this box and signing below:
o I agree that submission of this Annual Certification Form for the Post-Construction Stormwater Program is a"transaction"subject to
Chapter 66,Article 40 of the NC General Statutes(the"Uniform Electronic Transactions Act');
o I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the NC General Statutes(the"Uniform
Electronic Transactions Act');
o I understand that an electronic signature on this Annual Certification Form has the same legal effect and can be enforced in the same
way as a written signature;AND
o I intend to electronically sign and submit this Annual Certification Form.
Print Name:* David Upchurch
Name of person submitting this form(populated with Certifier Full Name)
Signature:
Date:* 01/12/2024
Signed Month and Day Certification Year
January 12,2024 2024