SW5240402_LD Permit_20240627

Mx STATE w
ROY COOPER - c°
Governor 7 =
ELIZABETH S.BISER `
Secretary
WILLIAM E.TOBY VINSON,JR NqORTHrf�CpAROLINA
Intertm Director EJUne Lbtal,Ql(q(!ty
David Bradley Walker J LO aLv02
1125 Walker Field Drive
Rougemont,NC 27572
Subject: State Stormwater Management Permit No. SW5240402
Highland Place Subdivision
Low Density Subdivision Project
Person County
Dear Mr. Walker:
The Washington Regional Office received a complete, State Stormwater Management Permit
Application package for the subject project on April 15, 2024. Staff review of the plans and
specifications has determined that the pproject, as pproposed, complies with the Stormwater
Regulations set forth in 15A NCAC 2H.1000. We are hereby forwarding Permit No.
SW5240402 dated June 26, 2024, for the construction of the built-upon areas (BUA) and
vegetated conveyances associated with the subject project.
This permit shall be effective from the date of issuance until rescinded and the project shall be
subject to the conditions and limitations as specified therein and does not supersede any other
agency permit that may be required. Failure to comply with these requirements will result in
future compliance problems. Please note that this permit is not transferable except after notice to
and approval by the Division.
This cover letter, attachments, and all documents on file with DEMLR shall be considered part
of this permit and is herein incorporated by reference.
If any parts,requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatorryy 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 filed with the OAH within thirty (30) da s of
receipt of this permit. You should contact the OAH with all questions regarding the f ling fee (if
a filing fee is required) and/or the details of the filing process at 6714 Marl 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.
If you have any questions concerning this permit, please contact me in the Washington Regional
Office, at [phone] or ro eg nthorpe(c . eq.nc.gov.
Sincerely,
l�
Roger K. Thorpe
Enviromnentar Engineer
Washington Regional Office
Division of Energy, Mineral and Land Resources
Enclosures: Attachment A—Designer's Certification Form
Application Documents
cc: Jesse W. Wilson,PE—Wilson Engineering Group(sudstrivApmail com)
Person County Inspections(dtillmangDersoncountvnc gov)
Raleigh Regional Office([e-mail])
401DWE05� North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
—' Washington Regional Office 1 943 Washington Square Mall I Washington,North Carolina 27889
252.946.6481

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
LOW DENSITY SUBDIVISION DEVELOPMENT
In compliance with the provisions of Article 21 of Chapter 143, General Statutes of North
Carolina as amended, and other applicable Laws, Rules, and Regulations promulgated and
adopted by the North Carolina Environmental Management Commission, including 15A
NCAC 02H.1000 amended on January 1, 2017 (2017 Rules),the "stormwater rules"),
PERMISSION IS HEREBY GRANTED TO
David Bradley Walker
for
Highland Place Subdivision
Allie Clay Road, Roxboro, NC, Person County
FOR THE
construction, management, operation and maintenance of built-upon area (BUA) for a 24%
low density subdivision project (the "low density area') discharging to Class C waters as
outlined in the application, approved stormwater management plans, supplements,
calculations, operation and maintenance agreement, recorded documents, specifications,
and other supporting data (the "approved plans and specifications") as attached and/or on
file with and approved by t e Division of Energy, Mineral and Land Resources (the
"Division" or"DEMLR"). The project shall be constructed, operated and maintained in
accordance with these approved plans and specifications. The approved plans and
specifications are incorporated by reference and are enforceable parts of this permit.
This permit shall be effective from the date of issuance until rescinded and shall be subject
to the following specified conditions and limitations. The permit issued shall continue in
force and effect until the permittee files a request with the Division for a permit
modification, transfer, or rescission; however, these actions do not stay any condition.The
issuance of this permit does not prohibit the Director from reopening and modifying the
permit, revoking and reissuing the permit, or terminating the permit for cause as allowed
by the laws, rules, and regulations contained in 15A NCAC 2H.1000 and NCGS 143-215.1
et.al.
1. BUA REQUIREMENTS. The maximum amount of BUA allowed for the entire project is
262,781.19 square feet. The BUA requirements and allocations for this project are as
follows:
North Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
��� Washington Regional Office i 943 Washington Square Mall I Washington,North Carolina 27889
om emu wwain '� O" 252.9466d8t

a. LOW DENSITY AREA BUA LIMITS. The low-density area, in the approved plans
and specifications, must not exceed 24% per the requirements of the stormwater
rules. Within this low-density area,this permit approves a percent BUA of 24.0%
are and the construction of a total of 262,781 19 squ feet of BUA. This permit does
not provide any allocation of BUA for future development within this low-density
area.
b. BUA FOR INDIVIDUAL LOTS. Each of the sixty-four (64) lots are limited to a
maximum of 2905.01 square feet of BUA, as indicated in the approved plans and
specifications. The maximum BUA assigned to each lot via this permit and the
recorded deed restrictions and protective covenants may not be increased
or decreased by either the individual lot owner or the permittee unless and
until the permittee notifies the Division and obtains written approval from
the Division.
2. PERVIOUS AREA IMPROVEMENTS. At this time, none of the pervious area
improvements listed in G.S. 143-214.7(b2) or the Stormwater Design Manual have
been proposed for this project. Pervious area improvements will be allowed in this
project if documentation is provided demonstrating those improvements meet the
requirements of the stormwater rule.
3. LOW DENSITY AREA REQUIREMENTS.The low-density area requirements for this
project are as follows:
a. LOW DENSITY AND CONVEYANCE DESIGN. The low-density area is permitted
based on the design criteria presented in the sealed, signed and dated supplement
and as shown in the approved plans and specifications. This low-density area and
conveyances must be provided and maintained at the design condition.
b. PIPING. Other than the piping shown on the approved plans, only minimal
amounts of piping under driveways and roads is allowed within the low-density
area when it cannot be avoided. No additional piping is allowed.
c. DISPERSED FLOW. The low-density area has maximized dispersed flow of
stormwater runoff through vegetated areas and minimized the channelization of
flow.
d. VEGETATED CONVEYANCES. Stormwater runoff that could not be released as
dispersed flow may be transported by vegetated conveyances with minimum side
slopes of 3:1 (H:V) designed to not erode during the peak flow from the 10-year
storm event as defined in the stormwater rules and approved by the Division
4. VEGETATED SETBACKS. A 30-foot wide vegetative setback must be provided and
maintained in grass or other vegetation adjacent to all surface waters as shown on the
approved plans. The setback is measured horizontally from the normal pool elevation
of impounded structures, from the top of bank of each side of streams or rivers, and
from the mean high waterline of tidal waters, perpendicular to the shoreline.
a. RELEASE OF STORMWATER NOT TREATED IN A STORMWATER CONTROL
MEASURE (SCM). Stormwater that is not treated in an SCM, such as in the low-
density area (including roof drains), must be released at the edge of the vegetated
setback and allowed to flow through the setback as dispersed flow.
S. RECORDED DOCUMENT REQUIREMENTS. The stormwater rules require the
following documents to be recorded with the Office of the Register of Deeds prior to
the sale of individual lots or groups of lots:
t� North Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
Washington Regional Office 1 943 Washington Square Mall I Washington,North Carolina 27889
o�• .�..,naain !F�"""" 252.9gb b481

a. ACCESS AND/OR EASEMENTS. The entire stormwater conveyance system and
maintenance accesses must be located in public rights-of-way, dedicated common
areas that extend to the nearest public right-of-way, and/or permanent recorded
easements that extend to the nearest public right-of-way for the purpose of
inspection, operation, maintenance, and repair.
b. OPERATION AND MAINTENANCE AGREEMENT. The operation and maintenance
agreement must be recorded with the Office of the Register of Deeds.
c. FINAL PLATS. The final recorded plats_must reference the operation and
maintenance agreement and must also show all public rights-of-way, dedicated
common areas, and/or permanent drainage easements, in accordance with the
approved plans.
d. DEED RESTRICTIONS AND PROTECTIVE COVENANTS. Recorded deed restrictions
and protective covenants must include, at a minimum,the following statements
related to stormwater management:
i. The following covenants are intended to ensure ongoingg compliance with
State Stormwater Management Permit Number SW5240402, as issued by
the Division of Energy, Mineral and Land Resources (the "Division")
under 15A NCAC 02H.1000, effective January 1, 2017.
ii. The State of North Carolina is made a beneficiary of these covenants to
the extent necessary to maintain compliance with the Stormwater
Management Permit.
iii. These covenants are to run with the land and be binding on all persons
and parties claiming under them.
iv. The covenants pertaining to stormwater may not be altered or rescinded
without the express written consent of the Division.
V. Alteration of the drainage as shown on the approved plans may not take
place without the concurrence of the Division.
vi. The maximum built-upon area (BUA) per lot is 2,905.01 square feet. This
allotted amount includes any BUA constructed within the lot property
boundaries, and that portion of the right-of-way between the front lot line
and the edge of the pavement not shown on the approved plans. BUA has
the same meaning as G.S. 143-214.7, as amended.
vii. The maximum allowable BUA shall not be exceeded on any lot until the
permit is modified to ensure compliance with the stormwater rules,
permit, and the approved plans and specifications.
viii. Filling in, piping or altering any vegetated conveyances (ditches, swales,
etc.) associated with the development, except for average driveway
crossings, is prohibited by any persons.
ix. A 30-foot wide vegetative setback must be provided and maintained
adjacent to all surface waters in accordance with 15A NCAC 02H.1003(4)
and the approved plans.
X. All roof drains shall be released no closer than at the edge of the 30-foot
wide vegetated setback and allowed to flow through the setback as
dispersed flow. At no time shall stormwater runoff be piped into or
through the setback.
xi. Any individual or entity found to be in noncompliance with the provisions
of a stormwater management permit or the requirements of the
stormwater rules is subject to enforcement procedures as set forth in
NCGS 143,Article 21.
North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources
M Q Washington Regional Office 1943 Washington Square Mall I Washington,North Carolina 27889
v nr •��..,.�vi waN./00�'
252.986 b48t

e. DEEDS FOR INDIVIDUAL LOTS. The permittee shall record deed restrictions and
protective covenants prior to the issuance of a certificate of occupancy to ensure
the permit conditions and the approved plans and specifications are maintained in
perpetuity.
6. CONSTRUCTION. During construction, erosion shall be kept to a minimum and any
eroded areas of the on-site stormwater system will be repaired immediately.
a. PROJECT CONSTRUTION, OPERATION AND MAINTNEANCE. During construction,
all operation and maintenance for the project and stormwater system shall follow
the Erosion Control Plan requirements until the Sediment-Erosion Control devices
are no longer needed.
b. FINAL GRADING. The vegetated areas and vegetated conveyances shall be entirely
constructed and vegetated. Once the final grading is completed and the site is
stabilized, the permittee shall provide and perform the operation and
maintenance as outlined in the applicable section below.
7. MODIFICATIONS. No person or entity, including the permittee, shall alter any
component shown in the approved plans and specifications, except for minimum
driveway crossings. Prior to the construction of any modification to the approved
plans, the permittee shall submit to the Director, and shall have received approval for
modified plans, specifications, and calculations including, but not limited to, those
listed below. For Chan es to the proJ'ect that impact the certifications, anew or
updated certification(s�, as applicable,will be required and a copy must be submitted
to the appropriate DEQ
regional office upon completion of the modification.
a. Any modification to the approved plans and specifications, regardless of size
including the BUA, details, etc.
b. Redesign or addition to the approved amount of BUA.
c. Further development, subdivision, acquisition, lease or sale of any, all or part of
the project and/or property area as reported in the approved plans and
specifications.
d. The construction of any permeable pavement, #57 stone area, public trails, or
landscaping material within the common areas to be considered a permeable
surface that were not included in the approved plans and specifications.
e. Altering, modifying, removing, relocating, redirecting, regradin , or resizing of any
component of the approved stormwater collection system and/or vegetative
conveyance shown on the approved plan, except for minimum driveway crossings
within the low-density area.
f. The construction of any allocated future BUA.
g. Adding the option to use permeable pavement or #57 stone within the lots as a
permeable surface. The request may require a proposed amendment to the deed
restrictions and protective covenants for the subdivision to be submitted and
recorded.
h. Other modifications as determined by the Director.
oft I" North Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
Washington Regional Office i 943 Washington Square Mill I Washington,North Carolina 27889
v.o.nm ma�� 252946.6481

8. DESIGNER'S CERTIFICATION. Upon completion of the project, the permittee shall
determine if the project is in compliance with the approved plans and take the
necessary following actions:
a. If the permittee determines that the project is in compliance with the approved
plans, then within 45 days of completion,the permittee shall submit to the
Division one hard copy and one electronic copy of the following:
i. The completed and signed Designer's Certification provided in
Attachment A noting any deviations from the approved plans and
specifications. Deviations may require approval from the Division;
ii. A copy of the recorded operation and maintenance agreement;
iii. Unless already provided, a copy of the recorded deed restrictions and
protective covenants; and
iv. A copy of the recorded plat delineating the public rights-of-way,
dedicated common areas and/or permanent recorded easements,
when applicable.
b. If the permittee determines that the project is not in compliance with the
approved plans,the permittee shall submit an application to modify the permit
within 30 days of completion of the project or provide a plan of action,with a
timeline, to bring the site into compliance.
9. OPERATION AND MAINTENANCE. The permittee shall provide and perform the
operation and maintenance necessary, as listed in the signed operation and
maintenance agreement to assure that all components of the permitted on-site
stormwater system are maintained at the approved design condition. The approved
operation and maintenance agreement must be followed in its entirety and
maintenance must occur at the scheduled intervals.
a. CORRECTIVE ACTIONS REQUIRED. In the event that the low-density area fails to
meet the requirements of low density, the permittee shall take immediate
corrective actions. This includes actions required by the Division and the
stormwater rules such as the construction of additional or replacement on-site
stormwater systems. These additional or replacement measures shall receive a
permit from the Division prior to construction.
b. MAINTENANCE RECORDS. Records of maintenance activities must be kept and
made available upon request to authorized personnel of the Division. The records
will indicate the date, activity, name of person performing the work and what
actions were taken.
10. CURRENT PERMITTEE NAME OR ADDRESS CHANGES. The permittee shall submit a
completed Permit Information U date A lication Form to the Division within 30
days to making any one or more of the fo owing changes:
a. A name change of the current permittee;
b. A name change of the project;
c. A mailing address change of the permittee.
11. TRANSFER. This permit is not transferable to any person or entity except after notice
to and approval by the Director. Neither the sale of the project and/or property, in
whole or in part, nor the conveyance of common area to a third party constitutes an
approved transfer of the permit.
North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources
Washington Regional Office 1 943 Washington Square Mall I Washington,North Carolina 27889
v r`�=+wmam11� �//" 2529 Wb4fll

a. TRANSFER REQUEST. The transfer request must include the appropriate
appplication, documentation and the processing fee as outlined in 15A NCAC
02H.1045(2) and must be submitted upon occurrence of any one or more of the
following events:
i. The sale or conveyance of the project and/or property area in whole or in
part, except in the case of an individual residential lot sale that is made
subject to the recorded deed restrictions and protective covenants;
ii. The assignment of declarant rights to another individual or entity;
iii. The sale or conveyance of the common areas to a Homeowner's or
Property Owner's Association, subject to the requirements of NCGS 143-
214.7(c2);
iv. Dissolution of the partnership, corporate, or LLC entity, subject to NCGS
55-14-05 or NCGS 57D-6-07 and 08;
V. Bankruptcy;
vi. Foreclosure, subject to the requirements of Session Law 2013-121;
b. TRANSFER INSPECTION. Prior to transfer of the permit, a file review and site
inspection will be conducted by Division personnel to ensure the permit
conditions have been met and that the project and the on-site stormwater system
complies with the permit conditions. Records of maintenance activities performed
to date may be requested. Projects not in compliance with the permit will not be
transferred until all permit and/or general statute conditions are met.
12. COMPLIANCE. The permittee is responsible for complying with the terms and
conditions of this permit and the approved plans and specifications until the Division
approves the transfer request.
a. REVIEWING AND MONITORING EACH LOT FOR COMPLIANCE. The permittee is
responsible for verifying that the proposed BUA on each individual lot, within each
drainage area and for the entire project does not exceed the maximum amount
allowed by this permit. The permittee shall review all individual lot plans for new
construction and all subsequent modifications and additions for compliance. The
plans reviewed must include all proposed BUA,grading, and driveway pipe
placement.The permittee shall not approve any lot plans where the maximum
allowed BUA limit has been exceeded or where modifications are proposed to the
grading and/or to the stormwater collection system and/or to the vegetated
conveyance unless and until a permit modification has been approved by the
Division. The permittee shall review and routinely monitor the project and each
lot to ensure continued compliance with the conditions of the permit,the
approved plans and specifications, and the recorded deed restrictions and
protective covenants. The permittee shall notify any lot owner that is found to be
in noncompliance with the conditions of this permit in writing and shall require
timely resolution.
b. ARCHITECTURAL REVIEW BOARD (ARB) OR COMMITTEE (ARC). The permittee
may establish an ARB or ARC to conduct individual lot reviews. However, any
approval given by the ARB or ARC on behalf of the permittee does not relieve the
permittee of the responsibility to maintain compliance with the conditions of the
permit and the approved plans and specifications.
c. APPROVED PLANS AND SPECIFICATIONS. A copy of this permit, approved plans,
application, supplements, operation and maintenance agreement, all applicable
recorded documents, and specifications shall be maintained on file by the
permittee at all times.
North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources
Washington Regional Office i 943 Washinyton Square Stall I Washington.North Carolina 27889
wwn �..m a,.n� 252946.6481

d. MAINTENANCE ACCESS. SCMs, stormwater collection systems, and vegetated
conveyances must be accessible for inspection, operation, maintenance and repair
as shown on the approved plans.
e. DIVISION ACCESS. The permittee grants Division Staff permission to enter the
property during normal business hours to inspect all components of the permitted
project.
E ENFORCEMENT. Any individual or entity found to be in noncompliance with the
provisions of a stormwater management permit or the requirements of the
stormwater rules is subject to enforcement procedures as set forth in NCGS 143
Article 21.
g. ANNUAL CERTIFICATION. The permittee shall electronically submit to the
Division an annual certification completed by either the permittee or their
designee confirming the projects conformance with permit conditions.
h. OBTAINING COMPLIANCE. The Director may notify the permittee when the
permitted site does not meet one or more of the minimum requirements of the
permit. Within the time frame specified in the notice, the permittee shall submit a
written time schedule to the Director for modifying the site to meet minimum
requirements. The permittee shall provide copies of modified plans and
certification in writing to the Director that the changes have been made.
i. OTHER PERMITS. The issuance of this permit does not preclude the permittee
from obtaining and complying with any and all other permits or approvals that are
required for this development to take place, as required by any statutes, rules,
regulations, or ordinances,which are imposed by any other Local,State or Federal
government agency having jurisdiction. Any activities undertaken at this site that
cause a water quality violation or undertaken prior to receipt of the necessary
permits or approvals to do so are considered violations of NCGS 143-215.1, and
subject to enforcement procedures pursuant to NCGS 143-215.6.
Permit issued this the 26th day of June 2024.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
For
William E. Toby Vinson, Jr., Interim Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Permit Number SW5240402
-t,� North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources
D E�"� Washington Regional Office 1943 Washington Square Mail I Washington,North Carolina 27889
.�.
niaanb 252.9466481

Attachment A
Certification Forms
The following blank Designer Certification forms are included and specific for this project:
• As-Built Permittee Certification
• As-Built Designer's Certification for Low Density Projects
A separate certification is required for each SCM. These blank certification forms maybe
copied and used, as needed,for each SCM and/or as a partial certification to address a section
or phase of the project.
/ /}QQ` North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources
V f —'D Q�l�' Washington Regional Office 1943 Washington Square Stall I Washington,North Carolina 27889
!/" 252.946.6481

AS-BUILT PERMITTEE CERTIFICATION
1 hereby state that 1 am the current permittee for the project named above,and I certify by my signature
below,that the project meets the below listed Final Submittal Requirements found in NCAC 02H.1042(4) and
the terms,conditions and provisions listed in the permit documents,plans and specifications on file with or
provided to the Division.
❑ Check here if this is a partial certification. Section/phase/SCM #?
❑Check here if this is part of a Fast Track As-built Package Submittal.
Printed Name Signature
1, a Notary Public in the State of
County of do hereby certify that
personally appeared before me this day of 20
and acknowledge the due execution of this as-built certification. (SEAL)
Witness my hand and official seal
My commission expires
Permittee's Certification NCAC .1042 4 Completed/ N A
Provided
A. DEED RESTRICTIONS BUA RECORDS
1. The deed restrictions and protective covenants have been Y or N
recorded and contain the necessary language to ensure that the
project is maintained consistent with the stormwater regulations
and with the permit conditions.
2. A copy of the recorded deed restrictions and protective Y or N
covenants has been provided to the Division.
pp North Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
• _EJ/ Washington Regional Office 1943 Washington Squat e Mall I Washington,North Carolina 27889
ow nr i�,i wam\ 0041 "" 252.9.M16 b481

3. Records which track the BUA on each of are being kept. See Y or N
Note 1
B. MAINTENANCE ACCESS
1. The SCMs are accessible for inspection, maintenance and repair. Y or N
2. The access is a minimum of 10 feet wide. Y or N
3. The access extends to the nearest public right-of-way. Y or N
C. EASEMENTS
1. The SCMs and the components of the runoff collection y or N
conveyance system
are located in recorded drainage easements.
2. A copy of the recorded plat(s) is provided. Y or N
D. SINGLE FAMILY RESIDENTIAL LOTS - Plats for residential lots that y or N
have an SCM include the following:
1. The specific location of the SCM on the lot. Y or N
2. A typical detail for the SCM. Y or N
3. A note that the SCM is require to meet stormwater regulations
and that the lot owner is subject to enforcement action as set y or N
forth in NCGS 143 Article 21 if the SCM is removed, relocated or
altered without prior approval.
E. OPERATION AND MAINTENANCE AGREEMENT Y or N
1. The 0&M Agreement is referenced on the final recorded plat. Y or N
2. The 0&M Veement is recorded with the Register of Deeds andy or N
appears in the chain of title.
F. OPERATION AND MAINTENANCE PLAN - maintenance records are
being kept in a known set location for each SCM and are available for Y or N
review.
G.-DESIGNERS CERTIFICATION FORM -has been provided tote Y or N
Division.
Note 1-Acceptable records include ARC approvals,as-built surveys,and county tax records.
Provide an explanation for every requirement that was not met, and for every "N/A" below.
Attach additional sheets as needed.
D_E Q. North Carolina Department of Environmental Quality Division of Energy,Wer.l and Land Resources
/�lJl/� Washington Regional Office 1 943 Washington Square Mall I Washington.North Carolina 27889
f., �^'•'s='� / 252916b481

AS-BUILT DESIGNER'S CERTIFICATION FOR LOW DENSITY PROIECTS
I hereby state that I am a licensed professional and I certify by my signature and seal below,that I have
observed the construction of the project named above to the best of my abilities with all due care and
diligence,and that the project meets all of the MDC found in 15A NCAC 02H.1003,in accordance with the
permit documents,plans and specifications on file with or provided to the Division,except as noted on the
"AS-BUILT"drawings,such that the intent of the stormwater rules and the general statutes has been
preserved.
❑Check here if this is a partial certification. Section or phase
❑ Check here if this is part of a Fast-Track As-Built Package Submittal per 15A NCAC 02H.1044(3).
❑Check here if the Designer did not observe the construction but is certifying the project.
❑Check here if pictures of the project are provided.
Printed Name Signature
NC Registration Number Date
SEAL: Consultant's Mailing Address:
City: State: Zip:
Phone:l-)
Consultant's Email address:
O Circle N if the as-built value differs from the Plan/permit.If N is circled,provide an explanation on page 3.
OO N/E= Not Evaluated(provide explanation on page 2). ON/A=Not Applicable to this project/plan.
Consultant's Certification(MDC 1SA NCAC 02H.1003)
Project Density and Built-Upon Area OI As-built OO N/E ON/A
1. The project has areas of high density based on natural drainage Y or N
area boundaries,variations in land use or construction phasing.
2. The project's built-upon area does not exceed the maximum limit Y or N
specified in the permit.
Dispersed Flow OI As-built OO N/E OO N/A
1. The project maximizes dispersed flow through vegetated areas Y or N
and minimizes channelized flow.
North Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
Washington Regional Office j 943 Washington Square Mall I Washington,North Carolina 27889
152.946,6481

Vegetated Conveyances (DAs-built ©N/E GO N/A
1. Stormwater that is not released as dispersed Bow is transported Y or N
by vegetated conveyances.
2. The project has a minimal amount of non-vegetated conveyances Y or N
to reduce erosion.
3. Other than minimal piping under driveways and roads,no piping Y or N
has been added beyond what is shown on the approved plans.
4. Side slopes are no steeper than 3HAV. Y or N
S. The conveyance does not erode in response to the peak Bow from the Y or N
10-year storm.
Curb outlet systems(if applicable) IOAs-built ©N/E GO N/A
1. The swale or vegetated area can carry the peak Bow from the Y or N
10-year storm at a non-erosive velocity.
2. The longitudinal slope of the Swale or vegetated areas does not excee Y or N
S%.
3. The swale has a trapezoidal cross-section and a minimum bottom wic Y or N
of two feet.
4. The minimum length of the swale or vegetated area is 100 feet. Y or N
S. Side slopes are no steeper than 3H:lV. Y or N
6. The project utilizes treatment swales designed per Section.1061 Y or N
in lieu of the curb outlet system requirements.
Vegetated Setbacks(if applicable) OAs-built GO N/E OO N/A
1. The width of the vegetated setback is at least 30'. Y or N
2. The width of the vegetated setback has been measured from the nor
pool of impounded waters,the MHW line of tidal waters, Y or N
or the top of bank of each side of rivers or streams.
3. The vegetated setback is maintained in grass or other vegetation. Y or N
4. BUA that meets the requirements of NCGS 143-214.7(b2)(2) is locate Y or N
in the setback.
S. BUA that does NOT meet the requirements of NCGS 143-214.7(b2)(2
located within the setback and is limited to:
• Publicly-funded linear projects(road,greenway,or sidewalk) Y or N
• Water dependent structures
• Minimal footprint uses such as poles,signs,utility
appurtenances,and security lights.
6. The amount of BUA within the setback is minimized,and Y or N
channeling of the runoff from the BUA has been avoided.
J/{q� North Carolina Departmentm of Environmental Quallty Division of Enerqv.Mineral and Lund Resources
_E � �! Washington Regional Office 1943 Washinyton Square Mall I Washington,North Carolina27889
o r a� _ 22946b481

7. Stormwater is not discharged(via swale or pipe) through a
vegetated setback.Stormwater is released at the edge of the Y or N
setback and allowed to Flow through the setback as dispersed Flow.
Outlets OO As-built 02 N/E ©N/A
1. Stormwater outlets do not cause erosion downslope of the y or N
discharge point during the peak Flow from the 10-year storm.
Variations OI As-built OO N/E ©N/A
1. The project has variations from the MDC that were not previously Y or N
approved. (Modification may be required.)
Deed restrictions(if applicable) OAs-built ©N/E ON/A
1. Deed restrictions are recorded and ensure that the project and
the BUA will be maintained in perpetuity consistent with the Y or N
permit,approved plans,and specifications.
For Subdivisions Only(Residential or Commercial) OAs-built ON/E ON/A
1. The number of platted lots is consistent with the approved plans. Y or N
2. The project area is consistent with the approved plans. Y or N
3. The layout of the lots and streets is consistent with the approved Y or N
plan.
4. The width/radius of streets,paved accesses,cul-de-sacs and sidewal Y or N
is consistent with the approved plan.
S. No piping,other than those minimum amounts needed under a Y or N
driveway or under a road,has been added.
6. The lot grading,road grading,vegetated conveyances,piping, Y or N
inverts,and elevations are consistent with the approved plans.
Provide an explanation for every requirement that was not met, and for every"N/A" below.
Attach additional sheets as needed.
Worth Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
Washington Regional Office ( 943 Washington Square Mall I Washington,North Carolina 27889
ww rb �mwan� J`� 252.946.6481