SW8940805_CURRENT PERMIT_20150623

STORMWATER DIVISION CODING SHEET
POST-CONSTRUCTION PERMITS
PERMIT NO. SW8 '�Li L)V O 5
DOC TYPE Q CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE 2-o1157O %Q23
YYYYMMDD

A'�A
�p
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald van der Vaart
Governor Secretary
June 23, 2015
Mr. Richard C.Andrews,Jr., President
Andrews Properties, Inc.
PO Box 1319
Wilmington, NC 28402
Subject: Notice of Compliant Inspection and
Certification of Compliance Modification
Andrews Mortuary—Hampstead Chapel
Stormwater Permit No.SW8 940805
Pender County
Dear Mr.Andrews:
The Wilmington Regional Office inspected the subject project on December 10, 2014 and identified three items that
needed to be resolved. The project was transferred to the new owner on May 7, 2015 while some of the inspection items
remained unresolved. The site has now been maintained and brought into compliance. A permit modification has been
issued to reflect the constructed condition.
Notice of Inspection:
On June 10, 2015,the Wilmington Regional Office of the Division of Energy, Mineral and Land Resources (DEMLR) re-
inspected Andrews Mortuary—Hampstead Chapel, located in Pander County to determine the status of compliance with
the State Stormwater Management Permit Number SW8 940805 issued most recently on May 7,2015. The previous
inspection from December 10, 2014 required a Designer's Certification, a modification to correct impervious surfaces, and
maintenance. These items have been addressed. DEMLR file review and site inspection revealed that the site is in
compliance with the terms and conditions of this permit. Please find a copy of the completed form entitled "Compliance
Inspection Report" attached to this letter, which summarizes the findings of the recent inspection. Please be advised that
you are required to comply with the terms, conditions and limitations of the Stormwater Management Permit under Title
15A North Carolina Administrative Code 2H .1003 and North Carolina General Statute 143-214.7, including operation and
maintenance of the permitted stormwater system. Violations of your Stormwater Management Permit may be subject to
the assessment of civil penalties of up to$25,000 per day per violation.
Certification of Compliance:
The Wilmington Regional Office received a complete, modified State Stormwater Management Permit Application for
Andrew's Mortuary—Hampstead Chapel on June 22, 2015. Staff review of the plans and specifications has determined
that the project, as proposed,will comply with the Stormwater Regulations set forth in Title 15A NCAC 2H.1003(a)(3),
effective January 1, 1988. This letter constitutes your new modified Certification of Compliance/Permit. The permit
requirements are provided below. We are forwarding Permit No. SW8 940805 dated June 23, 2015,for the construction,
operation and maintenance of the BMP's and built-upon area associated with the subject project.
1. Impervious Area Requirements:
a. Receiving Stream: The 1994 application shows that this site drains to an unnamed stream, and was
permitted with a maximum impervious area of 30%. In 2015,the Division learned that the site drained to
and unnamed tributary of Old Topsail Creek(stream index number 18-87-12)which is classified as SA;
HOW, and that the site may be within a half mile and draining to that stream which would have given the
project a maximum of 25% impervious under the regulations in place at the time. But,since the permit
was previously issued to allow impervious area of up to 30%,this site will continue to be permitted at
30% maximum impervious area.
Division of Energy, Mineral,and Land Resources
Land Quality Section—Wilmington Regional Office
127 Cardinal Drive Extension,Wilmington, North Carolina 28405•[phone]/Fax: [phone]

SW8 940805
June 23, 2015
b. Maximum Impervious Area Data:
17.1 ac
Project Area
743,730 ft2
Max Percent Impervious 30%
Allocated Impervious;Total: 223,119 ft2
Onsite Buildings: 1,650 ft2
Onsite Streets: 6,366 ft2
Onsite Parking: 0 ft2
Onsite Sidewalk: 625 ftZ
Existing: 88,522 ft2
Future: 125,956 ft2
2. Collection System: Due to the presence of a collection system, the runoff will be treated in an innovative system
consisting of three (3)existing wet ponds located on the site as was previously permitted on November 28, 1994.
3. Engineer's Certification: An Engineers Certification was received on February 18, 2015 verifying that the
stormwater controls, general layout of the project and the amount of impervious area are in substantial
compliance with the approved Stormwater Plan. If changes to the approved plan issued are made,then a revised
Engineers Certification will be required.
4. Operation and Maintenance: This site is subject to the monitoring requirements as set forth in the approved
Operation and Maintenance Plan, enclosed.
5. Deed Restrictions: Deed restrictions are not required because the three tracts included in this-17.1ac tract are
owned by the same owner,Andrews Properties, Inc., which is also the permittee.
6. Future Modifications: Any modification of the plans submitted to and approved by this Office or further
development of this site regardless of the fact that the modification may be less than 1 acre, will require an
additional Stormwater Submittal/Modification and approval prior to initiation of construction. Modifications include
but are not limited to; project name changes,transfer of ownership, redesign of built-upon surfaces, addition of
built-upon surfaces, redesign or further subdivision of the project area as shown on the approved plans.
7. Permits: The project shall be constructed and maintained in accordance with the plans and specifications
approved by the Wilmington Regional Office. This Certification does not supersede any other permit or approval.
The developer is responsible for obtaining any and all permits and approvals necessary for the development of
this project. This could include the Division of Coastal Management under CAMA requirements, the Division of
Environmental Management under Wetland 401 Water Quality Certification and/or a Dredge and Fill Permit
and/or a Sewer Extension/Collection Permit, U.S.Army Corps of Engineers 404 Wetland Permit, NPDES
stormwater permit if disturbing five acres or more, local County or Town Agency permits under their local
ordinances,or others that may be required.
8. Expiration Date: This Certification shall be effective from the date of issuance until rescinded.
If any parts, requirements, or limitations contained in this permit are unacceptable,you have the right to request an
adjudicatory hearing by filing a written petition with the Office of Administrative Hearings(OAH). The written petition must
conform to Chapter 150B of the North Carolina General Statutes, and must be fled with the OAH within thirty(30)days of
receipt of this permit. You should contact the OAH with all questions regarding the filing fee(if a filing fee is required)
and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714,or via telephone at 919-431-
3000, or visit their website at www,NCOAH.com. Unless such demands are made this permit shall be final and binding.
Page 2 of 3

-SW8 940805
Juae 23, 2015
If you have any questions,or need additional information concerning this matter, please contact Kelly Johnson in the
Wilmington Regional Office, at(910)796-7215.
57 cy Davis, P.E., Director
Division of Energy, Mineral and Land Resources
GDS/kpj: %StormwaterTermits& Projects119941940805 LD12015 06 permit 940805
enc: Application, June 22, 2015
Operation and Maintenance Agreement, November 28, 1994
Inspection Report, June 10, 2015
cc: Denise Freund, PE, WK Dickson
Inspector, Fender County Inspections
County Engineering
Division of Coastal Management
Wilmington Regional Office Stormwater File
Page 3 of 3

STORMWATER OPERATION AND MAINTENANCE PLAN
FOR
ANDREWS MORTUARY - HAMPSTEAD CHAPEL AND
ACCESS ROAD FOR SEA LAWN MEMORIAL PARK
HAMPSTEAD, NORTH CAROLINA
1 . The owner will be responsible for the proper operation and
maintenance of the stormwater collection and treatment
facilities.
2 . Monthly, or after every runoff producing rainfall event,
which ever comes first, the pond side slopes and grassed
inlet swales will be inspected, trash will be removed, and
eroded areas will be repaired before the next rainfall.
3 . Quarterly, the collection system will be inspected for proper
functioning. Accumulated trash will be cleared from catch
basin grates, basin bottoms, and piping will be checked for
obstructions and cleared as required. Pond inlet pipes will
be checked for undercutting, riprap or other energy
dissipation structures will be replaced and broken pipes will
be repaired.
4 . Semi-annually, accumulated sediment from the bottom of the
outlet structure will be removed. The pond depth will be
checked at various points. If depth is reduced to 75% of the
original design depth, 3 feet, or whichever is greater,
sediment will be removed to at least the original design
depth. Grassed swales, including the vegetated filter if
applicable, will be reseeded twice a year as necessary.
5. Mowing of the side slopes will be accomplished according to
the season. Maximum grass height will be 6" .
6. All components of the detention pond system will be kept in
good working order. Repair or replacement components will
meet the original design specifications as per the approved
stormwater plan.
7 . Every six months after the site construction is finished and
the site is stabilized, beginning in April or October, samples
will be collected from the ponds at the locations noted on the
enclosed sketch. If there is no data to be collected at
collection point 3 due to insufficient rainfall, the sample at
this location will not be taken until the next collection
period. The following monitoring tests will be ,performedby; -a-i, -
certified lab: ;
r mov + 6 1994
7 AYE i cl¢
PROJ Sw 8 a
� 4630S

f .
TEST METHOD NUMBER
Hydrocarbons(Oil & Grease) SM17th Ed 5520F
NO3-N SM17th Ed 353 . 1
NO2-N SM17th ED 354 . 1
NH3-N SM17th Ed 350.2
Total Phosphorous SM17th Ed 365 .2
Fertilizer (TKN+PO4+K) EPA 600/4-79-020.
Results of the tests will be forwarded to the Division of
Environmental Management, Water Quality Section, within 30
days of the month the samples are due. After monitoring the
water quality for one year, the owner may request termination
of the testing.
Andrews Mortuary, Inc.
P.O. Box 13
/� /I /� Wilmington, NC 28402
I, Lai,ra A jd aw L N � , a Notary Public for the State
of !U, +� cu, i; a , Countyof do
hereby certify that 2 :Cjaj (_, Pjd,-e<,r personally
appeared before me this ) to* day of Nove� 19qq , and
acknowledges the due execution of the foregoing instrument.
Witness my band and Jofficial seal,
MyTcommmfission expires „� zi i 499
�� r JQ���i A P
vo"

DEMLR USE ONLY
�. Date ceiv Fee Paid p Permit Number
7
Appricable Rules: ❑ Coastal SW-1945 ❑Coastal SW- 2008 ❑ Ph II-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 Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
L 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.):
Hampstead Chapel
2. Location of Project(street address):
17750 US Hwy 17
City: Hampstead County: Pender Zip: 28443
3. Directions to project(from nearest major intersection):
Project is located on the southeast corner of the intersection of US Hwy 17 and Transfer Station Road (SR-
1695).
4. Latitude: 34'23' 52.26" N Longitude: 77'40' 20.56" W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): []New ®Modification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SVVU-102-Renezoal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number SW8 940805 its issue date(if known) 11/28/94 and the status of
construction: ❑Not Started ❑Partially Completed* ®Completed* *provide a designer's certification
2. Specify the type of project(check one):
®Low Density []High Density ❑Drains to an Offsite Stormwater System []Other
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR 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: 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:
5. Is the project located within 5 miles of a public airport? ®No s
If yes, see S.L. 2012-200, Part VI:ht ortal.ncdenr.or web Ir rules-and-re lati JUN JA'2015
2 z1-
FormSWU-101 Version Oct. 31,2013 Page I of BY.

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 proiect):
Applicant/Organization: Andrews Properties, Inc.
Signing Official &Title: 1.Scot Andrews,Vice President
b.Contact information for person listed in item I above:
Street Address: 1617 Market Street
City: Wilmington State: NC Zip: 28401
Mailing Address (if applicable): PO Box 1319
City: Wilmington State: NC Zip: 28402
Phone: (910 ) 762.7788 Fax: (910 ) 762.0631
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)
❑ 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: Z
Mailing Address: BY'
City: State: Zip:
Phone: ( ) Fax:
Email:
4. Local jurisdiction for building permits: Pender County
Point of Contact: Kenneth Morrison Phone#: (910 ) 270.5008
Form SWU-101 Version Oct. 31,2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below,briefly summarize how the stormwater runoff will be treated.
The area around the mortuary drains to a series of three interconnected existing wet detention ponds and
leaves the owner's property through two 24" culverts at the rear of the site. The runoff from the new
maintenance building proposed in this area will drain by sheet flow through vegetated areas prior to leaving
the project site. Stormwater runoff from the cemetery and access road area drains through approximately 300
feet of grassed swale before leaving the owner's propert}_.approximately 10 feet in width.
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 1I-Post Construction
3. Stormwater runoff from this project drains to the White Oak River basin.
4. Total Property Area: 17.07 acres 5. Total Coastal Wetlands Area: 0.0 acres
6. Total Surface Water Area: 0.0 acres
7. Total Property Area(4) -Total Coastal Wetlands Area (5) -Total Surface Water Area (6) =Total Project
Area': 17.07 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(NM line or Mean High Water
(MHIM line, and coastal wetlands landward from the NHW(or MHM line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non-coastal wetlands landward of the NHW(or MHW)line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area)X 100 = 30 %
9. How many drainage areas does the project have?1 (For high densihj, count I for each proposed engineered
stormwater BMP. For law 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.
EGEIVEA
JUN JA0015
Z-Z'
BY:---
Form SWU-101 Version Oct. 31,2013 Page 3 of 7

Basin Information Drainage Area 1 Drainage Area_ Drainage Area_ Drainage Area_
Receiving Stream Name Old Topsail
Creek
Stream Class SA;HQW
Stream Index Number* 18-87-12
Total Drainage Area (so 743,730
On-site Drainage Area (sf) 743,730
Off-site Drainage Area(sf) 0
Proposed Impervious Area'(so 223,119
Impervious Area** total 30
Impervious—Surface Area Drainage Area 1 Drainage Area_ Drainage Area_ Drainage Area_
On-site Buildings/Lots(so 1,650
On-site Streets (so 6,366
On-site Parking (so 0
On-site Sidewalks (so 625
Other on-site (so 0
Future(sf) 125,956
Off-site (so 0
Existing BUA***(so 88,522
Total (so: 223,119
Stream Class and Index Number can be detennined at: htw.. portal.tudenr.org/web/wg[p!i esu/classifications
" Imyyervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sid�zvniks,gravel areas, etc.
***Report only that amount of existing BUA that zoill remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off-site impervious area listed above determined?Provide documentation.
Projects in Union County: Contact DEMLR Central Office staff to check ifthe project is located within a Threatened&
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A 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
fromhgp://portal.ncdenr.org/web/wq/ws/`su/­bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
h_ptt ://portal.ncdenr.org/web/wq/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map athtW://portaI.ncdenr.org/web/wq/ws/­`su/mal2s.)
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 http://portal.ncdenr.org/web/wq/ws/su/statesw/forms dots.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. IS7
2. Original and one copy of the signed and notarized Deed Restrictions&Protective Covenants �A%\.
Form. (if required as per Part VII below) ME
3. Original of the applicable Supplement Form(s) (sealed signed ate �M P
agreement(s) for each BMP. 4kZ� � T
4. Permit application processing fee of$;3payab e to NCDENR. (. r an xpress review, er to >)
http://www.envhelp.org/pages/onestopexpress.html for infoi _ tion on the Express rogram
Form SWU-101 Version Oct. 31,2013 Page 4 of 7

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/managementfor
the project. This 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 L
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 (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.
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.
I. Details of roads, drainage features,collection systems,and stormwater control measures.
m. 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 SHWT 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 BMPs, 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 DEMLR to venfij the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 0713 Page No: 0167 F
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 15A NCAC 2H.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.
htW://www.secretary.state.nc.us/Corl2orations/­CSearch.aspx
ECEIME
JUN 142015
zv
BY:
Form SWU-101 Version Oct. 31,2013 Page 5 of 7

VII. 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 form. The appropriate deed restrictions and
protective covenants forms can be downloaded from ht_pt ://12ortai.ncdenr.org/web/]r/state-stonnwater-
forms 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 DEMLR,and that they will be recorded prior to the sale of any lot.
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: Denise L. Freund,PE
Consulting Firm: WK Dickson&Co.,Inc.
Mailing Address: 909 Market Street
City: Wilmington State: NC Zip: 28409
Phone: (910 1 762.4200 Fax: (910 ) 762.4201
Email: [e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed in Contact Information, item 2a) certify that I
own the property identified in this permit application,and thus give permission to (print or hjpe nave of person
listed in Contact Infonnation, item la) with (print or hjpe name of organization listed in
Contact Information, item la) 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.
E'^IE6�/E
JUN 112015
pZ
BY:
Form SWU-101 Version Oct. 31,2013 Page 6 of 7

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 DFMLR Stormwater permit reverts back
to me, the property owner. As the property owner,it is my responsibility to notify DEMLR 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, a Notary Public for the State of ,County of
do hereby certify that personally appeared
before me this_day of and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
1, (print or hype name of person listed in Contact Information, itern la) f. Scot Andrews
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 stormwa r Yrus and 5A NCAC 21-1.1000 and any other applicable state stormwater requirements.
Signature: pp Date: / 7
1, 1eI&' TCI,Y ke✓ a Notary Public for the State of V 4A lLU"��rrttl. County of
NQW 141+1C 1W ,do heerYIYI reby certify that J. SCO I Avtdre 5 personally appeared
before me this I day of JLe. .aD { ,and ac uwlG ge due exc in of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
>�r
a �+OTARY A
PUBLIC U �{
My commission expires 11 /�/
ECEIVE
JUN 14 2015
Form SWU-101 Version Oct. 31,2013 Page 7 of 7 BY:_ 7'
�_

i
DAWSON ENGINEERING
Engineering 3177 Wrightsville Avenue
Land Planning Wilmington,N.C. 28403
Surveying [phone]
� I
June 16, 1995 FILE CEO PAY
Wilmington Industrial Development,Inc./
U.S.Small Business Administration
Post Office Box 1698
Wilmington,NC 28401
�aJ FEB 1 8 201�i. i
RE: Andrews Mortuary-Hampstead Chapel
BY:S(N8 9�U i I
To Whom It May Concern: t
I
Dawson Engineering has provided civil engineering design and periodic construction observation services for the project.
We have been requested by Andrews Mortuary to report on the status of the construction work at the new Hampstead
Chapel.
The project has been completed in substantial conformance with the project design documents and is presently occupied. j
During construction some minor modifications to the interior layout were constructed and an attached drive-through
canopy structure was added to the north end of the building.
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It has been our pleasure to work on this particular project because of the owner's patience and commitment to construct a
top quality facility to serve the long term needs of the Hampstead community.
If we can provide additional information concerning the facility please call.
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Very truly yours,
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DAWSON ENGINEERING I
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Daniel E.Dawson,P.E. O;a- y;�T ••y
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cc: Mr.Richard C.Andrews,Jr., 035
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