SW4091101_Renewal Application_20240611

UEMLK USE ONLY
Date Received Fee Paid Permit Number
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER,
PERMIT
L APPLICATION FORM
In accordance with 15A NCAC 2H.1045(3), the current permit holder shall renew their high density permit 180 days
prior to its expiration. Renewed permits are valid for a period of 8 years per Session Law 2011-398(SB 781)
Section 60.(c). This application form is for permit renewals only.
A. PROJECT INFORMATION
1. State Stormwater Permit Number: SW4091101
2. Project name: Hospice of Randolph
3. Project street address: 416 Vision Dr
City: Asheboro County: Randolph ZIP
: 27203
4. What, if any, changes have been made to the project as permitted? None
If the project has changed from the original approved plans, please complete SWU-101 for a Major
Modification or Minor Modification Application form available at. httDs://deb,.nc.aov/about/divisions/energy-
mineral land resources/energy-mineral-land-rules/stormwater-program/post-construction.
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either the Permit Update form
or the Permit Transfer form available at. https://deg nc aov/about/divisions/energy-mineral-land-
resources/energy-minerai-land-rules/stormwater-program/post-construction. State Stormwater Permits do not
automatically transfer with the sale of the property.
1. Current Permit Holder's Company Name/Organization: Hospice of the Piedmont
2. Signing Official's Name: William T Cockerham
3. Signing Official's Title: Chief Executive Officer
4. Mailing Address: 1801 Westchester Dr
City: High Point State: NC ZIP : 27262
5. Street Address: 1801 Westchester Dr
City: High Point State: NC ZIP : 27262
6. Phone: [phone] Email: tcockerham ho nc.or
-�r C whme hOS�ic¢,o�-Nn 2 one OY°�
Stormwater Permit Renewal Fora) Page 1 of 3 May 11,2018

G. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non-Coastal HQW/ORM. Only applications packages that
include all required items listed below will be accepted and reviewed.
_.__.Initial_eachitem-below to indicate that the required information is provided in the application package:
1. A permit application processing fee of$505.00 payable to NCDEQ.
2. One original signed hard copy and one electronic copy of this completed form. The signing official
nVmed on this application to represent the current permittee must meet one of the following:
a. Corporation—a principle executive officer of at least the level of vice-president;
b. Limited Liability Company (LLC)—a manager or company official as those terms are defined
in G.S. 57D "North Carolina Limited Liability Company Act;"
c. Public Entity—a principal executive officer, ranking official, or other duly authorized employee;
d. Partnership or limited partnership—the general partner;
e. Sole proprietor; or
f. Letter of authorization signed by one of the signatories noted in a—e above authorizing the
signature of another entity.
3. One hard copy and one electronic copy of recorded documents required by the original permit that
have not yet been received by DEMLR, including: deed restrictions, protective covenants,
J condominium/planned community declaration and easements. If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has not been exceeded. If
the project has not been built, include a signed agreement that the final recorded deed restrictions
and protective covenants will be submitted at a later date.
y, 4. O&M Agreements, Please select one:
❑ I have a copy of the current recorded O&M Agreement for all SCMs, and I will continue to
keep this on file with the permit; or
1 do not have a copy of the current recorded O&M Agreement for all SCMs and am
requesting a copy be sent to me. I agree to keep this on file with the permit.
5. Designer Certifications, Please select one:
J A copy of the certification(s) confirming that the project was built in accordance with the
approved plans have been previously provided to the Division; or
❑ A copy of the certification(s) confirming that the project was built in accordance with the
approved plans are enclosed; or
❑ The project has not yet been built.
6. [IF APPLICABLE] If the project has been built, one original hard copy and one electronic copy of a
signed, sealed, and dated letter from a licensed professional stating that the SCMs have been
inspected, and that they have been built and maintained in accordance with the permit.
7. [IF APPLICABLE] When the permittee is a corporation or a limited liability corporation (LLC):
Provide one hard copy and one electronic copy of documentation from the NC Secretary of State,
or other official documentation, which supports the titles and positions held by the persons listed in
Section C.2 per 15A NCAC 2H. 1043(3)(b).
https://www.sosnc.aov/online services/search/by title/ Business Registration
Stormwater Permit Renewal Application Form Page 2 of 3 May 11,2018

D. PERMITTEE'S CERTIFICATION
I, will Am T CoCICIFCZmi-f the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on site (or I will obtain a copy and it will be kept on site), that I am
responsible for the performance of the maintenance procedures, and the site has been and will be maintained
according to the O&M Agreement and approved plans. I agree to notify DEMLR of any problems with the SCMs
or built-upon area and to submit the proper forms to modify or transfer the permit prior to any changes to the
project, SCMs, or ownership. All information provided on this permit renewal application is, to the best of my
knowledge, correct and complete. -
Signature: A%7ut— Date:
NOTARIZATION:
I, A, V'1t5f)r a Notary Public for the State of
Q , OV)01 , County of do hereby certify
that T iiWi 1 Ain personally appeared before me
this the 1 �h ,,++++++++++day of KAU( 'Irl 20 and acknowledge the due
execution of the f� trt�i i" fy.YNitness my hand and official seal,
4 p'TA %-P
(Notary Seal)
Gam: AVBL\ 2
Notary Signature
My commission expires,�,_T�
Stormwater Permit Renewal Application Form Page 3 of 3 May 11,2018

3/11/24, a0:59 AM North Carolina Secretary of State Search Results
• Upload a PDF Filing • Order a Document Online •Add Entity to My Email Notification List • View Filings
Non-Profit Corporation
Legal Name
Hospice of the Piedmont, Inc.
Prev Legal Name
Hospice at High Point, Inc.
Information
Sosid: 0071370
Status: Current-Active O
Date Formed: 9/25/1980
Citizenship: Domestic
Annual Report Due Date:
Registered Agent: Cockerham, William T. (Trent)
Addresses
Mailing Principal Office Reg Office
1801 Westchester Drive 1801 Westchester Drive 1801 Westchester Drive
High Point, NC 27262 High Point, NC 27262 High Point, NC 27262
Reg Mailing
1801 Westchester Drive
High Point, NC 27262
fficers
https://www.sosnc.gov/onIine_services/search/Business_Registration_ResuIts 1/1

PAT McCRORY
Governor
DONALD R. VAN DER VAART
N Secretary
Energy,Mineral& TRACY DAVIS
Land Resources
Director
ENVIRONMENTAL QUALITY
December 12,2016
Todd B
Hospice of Randolph County
416 Vision Drive
Asheboro,NC 27203
Subject: Compliance Inspection
Permit No. SW 4091101
Hospice of Randolph County
Randolph County
Dear Mr.B
On December 9,2016 Glen White of the North Carolina Department of Environmental Quality—
Department of Energy, Minerals & Land Resources visited the subject facility, located at 416
Vision Drive in Asheboro, to conduct a compliance inspection for the facilities Post-
Construction Stormwater Permit. This inspection was conducted at your request to verify that
recent maintenance activities left the facilities in compliance with the engineered design.
Permit:
This facility holds Past-Construction Stormwater Permit SW 4091101 approved on March 23,
2010 and in compliance with Title 15A NCAC 2H.1000 and Session Law 2006-246, for the
construction,operation and maintenance of the facilities storm water system and BMPs (Best
Management Practices).
Facility Site Review:
Inspector walked the grounds of the facility and reviewed each of the stormwater inlets that drain
to the bio-cell. All inlets appear to be in good condition, free of any debris and are well
maintained. The bio-cell itself appears to be have been recently cleaned of any debris. New
mulch has been installed and plant materials pruned as necessary. Rip-rap stone aprons are clean
and managed. No trash or debris was seen anywhere in the system. The bio-cell and stormwater
system appear to significantly represent the initial engineered design and are being maintained in
accordance with the maintenance plan.
State of North Carolina I Environmental Quality I Energy.4lineral and Land Resources
Winston-Salcm Regional Office i 4501-lanes Mill Road,Suite 300 1 Winston-Salem.NC 27103
336 776 9800

This facility was found to be compliant with its Post-Construction Stormwater Permit. If you
have any questions or concerns,please contact Glen White at 336-964-8218 or at
[e-mail].
Sincerely,
Matthew E. Gantt,P.E.
Regional Engineer
Land Quality Section
Winston-Salem Regional Office
Enclosures:
Inspection Report
cc: Division of Mineral and Land Resources (WSRO)
State of North Carolina I Environmental Quality I Energy.Mineral and Land Resources
Winston-Salem Regional Office 1 450 Hanes Mill Road.Suite 300 1 Winston-Salem.NC 27103
3307769800

Permit: SW4091101 Owner-Project: Hospice of Randolph
Inspection Date: 1 2/0 912 0 1 6 Inspection Type Compliance Evaluation Reason for Visit: Routine.
Built Upon Area Yes Na NA N€
Is the site BUA constructed as per the permit and approval plans? M ❑ ❑❑
Is the drainage area as per the permit and approved plans? M ❑ ❑El
Is the BUA(as permitted)graded such that the runoff drains to the system? M ❑ ❑E
Comment: Appears to match design.
aE
SW Measures vat No NA
t
Are the SW measures constructed as per the approved plans? ❑ 0 ❑
Are the inlets located per the approved plans? ❑ ❑ ❑
Are the outlet structures located per the approved plans? M ❑ ❑ ❑
Comment: No deficiencies,noted.
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? M ❑ ❑ ❑
Are the SW BMP inspection and maintenance records complete and available for review or provided to ❑ ❑ ❑
IM
t7WQ upon request?
Comment: Bio-cell and all stormwater structures draining to the system aDDear to be in very good working order
and are well maintained. No issues found.
page: 2

Compliance Inspection Report
Permit: SW4091101 Effective:03123/10 Expiration: 12/31/21
Project: Hospice of Randolph
Owner: Hospice of Randolph
County: Randolph Adress: 416 Vision Dr
Region: Winston-Salem
City/State/Zip:Asheboro NC 27203
Contact Person: Rhonda Moffitt Title: Phone: [phone]
Directions to Project:
Type of Project: State Stormwater-HD-Bioretention
Drain Areas: 001-(Haskett Creek) (03-06-09){C)
On-Site Re presentative(s):
Related Permits:
Inspection Date: 12/09/2016 Entry Time: 11:OOAM Exit Time: 12:00PM
Primary inspector: Glen White Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit inspection Type: State Stormwater
Facility Status: El Compliant ❑ Not Compliant
Question Areas:
IS State Stormwater
(See attachment summary)
page: 1

BK 2907 PG 1499 (4)
This document presented and filed:
04/26/2024 02:11:53 PM
AGREEMENT
Fee$26.00 Excise Tax: $0.00
IIIIIIIIIIIII IIIIIII Illlllllll
20181608
Randolph County North Carolina
Krista M. Lowe, Register of Deeds
C ; V
MAY 10 202�
CVE PAGE
Type of Document: hleekl-e-le-JI
Grantor:
Grantee:
Prepared by:
V/R rn ctu to.����
Address: )6-6 1 Z-n 6 2-

operation ° aintenance Agreement
Project Name: 6jQ �
Project Location: q q �,, , ,,,a P�
"7 ,; Cover Page_;
Maintenance records shall be kept on the following SCM(s). This maintenance record shall be kept in a log in a known set location.
Any deficient SCM elements noted in the inspection will be corrected, repaired, or replaced immediately. These deficiencies can
affect the integrity of structures, safety of the public, and the pollutant removal efficiency of the SCM(s).
The SCM(s) on this project include (check all that apply&corresponding O&M sheets will be added automatically):
Infiltration Basin Quantity: 0 Location(s):
Infiltration Trench Quantity: 0 Location(s):
Bioretention Cell Quantity: 1 Location(s):
Wet Pond Quantity: 0 Location(s):
Stormwater Wetland Quantity: 0 Location(s):
Permeable Pavement Quantity: 0 Location(s):
Sand Filter Quantity: 0 Location(s):
Rainwater Harvesting Quantity: 0 Location(s):
Green Roof Quantity: 0 Location(s):
Level Spreader- Filter Strip Quantity: 0 Location(s):
Proprietary System Quantity: 0 Location(s):
Treatment Swale Quantity: 0 Location(s):
Dry Pond Quantity: 0 Location(s):
Disconnected Impervious Surface Present: No Location(s):
User Defined SCM Present: No Location(s).
Low Density Present: No Type:
I acknowledge and agree by my signature below that I am responsible for the performance of the maintenance procedures listed for
each SCM above, and attached O&M tables. I agree to notify NCDEQ of any problems with the system or prior to any changes to
the system or responsible party.
Responsible Party: °
Title & Organization:
Street address:
City, state, zip:
Phone number(s):
Email: vt
Signature: Date: t
t�t ( a Notary Public for the State of JJI?r k fl
County of t �� ►�` _, do hereby certify that17
�
personally appeared before me this (Q day of v 2 �i and
acknowledge the due execution of the Operations and Maintenance Agreement.
Witness my hand and official seal, � !
%0 pO.
s®®�;�
•( Y
e0
rUe s
PUB0
01
Oq
Seal ' My commission expires 4/19/2024
STORM-EZ Page 1 of 3
Version 1.5 O&M Agreement 9

, BiurelenionIV�aintenanceRequirements
Important operation and maintenance procedures:
Immediately after the bioretention cell is established, the plants will be watered twice weekly if
needed until the plants become established (commonly six weeks).
- Snow, mulch or any other material will NEVER be piled on the surface of the bioretention cell.
- Heavy equipment will NEVER be driven over the bioretention cell. -
- Special care will be taken to prevent sediment from entering the bioretention cell.
- Once a year, a soil test of the soil media will be conducted.
Remove top layer of fill media when the pool does not drain quickly. Based on the media
specification, the pool should drain within 24 hours.
After the bioretention cell is established, it will be inspected quarterly and within 24 hours after every storm event
greater than 1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance shall be
kept in a known set location and shall be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired immediately.
SCM element: Potential problem: How to remediate the problem:
The entire bioretention Trash/debris is present. Remove the trash/debris.
cell
The perimeter of the Areas of bare soil and/or Regrade the soil if necessary to remove the gully, plant
bioretention cell erosive gullies have ground cover and water until it is established. Provide lime
formed. and a one-time fertilizer application.
The flow diversion
The structure is clogged. Unclog the structure and dispose of any sediment off-site.
'
structure (if applicable) The structure is damaged. Make any necessary repairs or replace if the damage is too
much for repair.
The inlet pipe is clogged Unclog the pipe and dispose of any sediment in a location
(if applicable). where it will not cause impacts to streams or the SCM.
The inlet pipe is cracked
or otherwise damaged (if Repair or replace the pipe.
applicable).
The inlet device Regrade the swale if necessary and provide erosion control
Erosion is occurring in the devices such as reinforced turf matting or riprap to avoid
swale (if applicable). future erosion problems.
Stone verge is clogged or Remove sediment and clogged stone and replace with clean
covered in sediment (if stone.
applicable).
Flow is bypassing Regrade if necessary to route all flow to the pretreatment
pretreatment area and/or area. Restabilize the area after grading.
gullies have formed.
Sediment has Search for the source of the sediment and remedy the
accumulated to a depth problem if possible. Remove the sediment and dispose of it in
rester than three inches. a location where it will not cause impacts to streams or the
The pretreatment area g SCM.
Erosion has occurred. Provide additional erosion protection such as reinforced turf
matting or riprap if needed to prevent future erosion problems.
Weeds are present. Remove the weeds, preferably by hand. If pesticide is used,
wipe it on the plants rather than spraying.

Bioretention Maintenance Requirements (continued)
SCM element: Potential problem: How to remediate the problem:
Best professional
practices show that Prune according to best professional practices. Maintain lines
pruning is needed to of sight between Z-61
.
maintain optimal plant
health.
Determine the source of the problem: soils, hydrology,
disease, etc. Remedy the problem and replace plants.
Bioretention cell Plants are dead, diseased Provide a one-time fertilizer application to establish the ground
vegetation or dying. cover if a soil test indicates it is necessary. If sod was used,
check to see that it was not grown on clay or impermeable
soils. Replace sod if necessary.
Weeds are present. Remove the weeds, preferably by hand. If pesticide is used,
wipe it on the plants rather than spraying.
Tree stakes/wires are Remove tree stake/wires (which can kill the tree if not
present six months after removed).
planting.
Spot mulch if there are only random void areas. Replace
Mulch is breaking down or whole mulch layer if necessary. Remove the remaining mulch
has floated away. and replace with triple shredded hard wood mulch at a
maximum depth of four inches.
Determine the extent of the clogging - remove and replace
either just the top layers or the entire media as needed.
Bioretention cell mulch Soils and/or mulch are Dispose of the spoil in an appropriate off-site location. Use
and media clogged with sediment. triple shredded hard wood mulch at a maximum depth of four
inches. Search for the source of the sediment and remedy the
problem if possible.
An annual soil test shows
that pH has dropped or Dolomitic lime shall be applied as recommended per the soil
heavy metals have test and toxic soils shall be removed, disposed of properly and
accumulated in the soil replaced with new planting media.
media.
Clogging has occurred. Wash out the underdrain system.
The underdrain, filter Clean out the drop inlet. Dispose of the sediment in a location
fabric element, and Clogging has occurred. where it will not cause impacts to streams or the SCM..
outlet system
The drop inlet is damaged Repair or replace the drop inlet.
Erosion or other signs of
damage have occurred at Repair the damage and improve the flow dissipation structure.
the outlet.
The receiving water Discharges from the
bioretention cell are
causing erosion or Contact the local NCDEQ Regional Office.
sedimentation in the
receiving water.