SW8980729_Historical File_20121107

AT,
NCDETIR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E. Dee Freeman
Governor Director Secretary
November 7, 2012
Dennis Coffey, CFO
Dosher Memoral Hospital
924 Howe Street
Southport, NC 28461
Subject: Approved Plan Revision
J.A. Dosher Memorial Hospital Patient Rooms Expansion and Renovation
Stormwater Project No. SW8 980729
Brunswick County
Dear Mr. Coffey:
On October 16, 2012, the Wilmington Regional Office received a plan revision for
Stormwater Management Permit Number SW8 980729. The revisions include the
demolition and removal of a portion of an existing drive and the construction of two
building additions and roundabout resulting in a net increase of 2,719 square feet of
impervious surface. A future allocation of of 5,662 square feet of impervious is reduced
to 2,943 square feet future allocation due to these improvements. It has been
determined that a formal permit modification is not required for the proposed changes.
We are forwarding you an approved copy of the revised plans for your files. Please add
the attached plans to the previously approved plan sheet.
Please be aware that all terms and conditions of the permit issued on January 31,
2002, remain in full force and effect. Please also understand that the approval of this
revision to the approved plans for the subject State Stormwater Permit is done on a
case-by-case basis. Any other changes to this project must be submitted to and
approved through the Division of Water Quality prior to construction. The issuance of
this plan revision does not preclude the permittee from complying with all other
applicable statutes, rules, regulations or ordinances which may have jurisdiction over
the proposed activity, and obtaining a permit or approval prior to construction.
If you have any questions concerning this matter, please do not hesitate to call me at
[phone].
Sincerely,
C"\f\AA-,' r>c-S
Chris Baker
Environmental Engineer II
GDS/csb: S:1WQS1Stormwater1Permits&Projects119981980729 HD1201211 permit pr 980729
cc: Roy Paul Lorenzen, P. E., Stewart
Brunswick County Building Inspections
Wilmington Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension,Wilmington,North Carolina 28405 One
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6748 Northcar'ohna
Internet:www.newaterquality.org Naturally
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DWQ USE ONLY
Date Received ee Paid P-
e / l 5/e mil
Applicable Rules: El Coastal SW-1995 ❑Coastal SW-2008 ❑Ph II-Post Construction
(select all that apply) El Non-Coastal SW-HQW/ORW Waters ❑Universal Stormwater Management Plan
❑Other WQ Mgmt Plan:
State of North Carolina /ea/3 /1 6d/5 /2)
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. 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.):
T.A.Dosher Memorial Hospital Patient Rooms Expansion and Renovation
2. Location of Project(street address):
924 Howe Street
City:Southport County:Brunswick Zip:28461
3. Directions to project(from nearest major intersection):
Take 211 south.Hospital is just south of 211/N Howe Street and intersection of Foldale Ave in downtown
Southport.
4. Latitude:33°55'44" N Longitude:78°01'16"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 SWLI 102-Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit,list the existing
permit numberSW8 980729 ,its issue date(if known)11/10/2011 ,and the status of
construction: ZNot Started ❑Partially Completed* ❑Completed* *provide a designer's certification
2. Specify the type of project(check one):
❑Low Density ii High Density ❑Drains to an Offsite Stormwater System Daher
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
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):
ECAMA Major ❑Sedimentation/Erosion Control: ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 Permit:Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name,Project/Permit ,
issue date and the type of each permit:
.4 .1\
1.
5. Is the project located within 5 miles of a public airport? No ❑Yes 1�
If yes,see S.L.2012-20D,Part VI:http://portal.ncdenr.org/web/wq/ws t'aestutSles laws
Form SWU-101 Version 06Aug2012 Page 1 of 6 y.

III. CONTACT INFORMATION
1.a.Print Applicant/ Signing Official's name and title(specifically the developer,property owner,lessee,
designated government official,individual,etc.who owns the project):
Applicant/Organization:Dosher Memoral Hospital
Signing Official&Title:Mr.Dennis Coffey,CFO
b.Contact information for person listed in item 1a above:
Street Address:924 Howe Street
City:Southport State:NC Zip:28461
Mailing Address(if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
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: Rodgers Builders,Inc
Signing Official&Title: Mr.Richard Broadway,Project Manager
b.Contact information for person listed in item 3a above:
Mailing Address: 5701 North Sharon Amity Road
City: Charlotte State:North Carolina Zip: 28215
Phone: (910 ) 352-1433 Fax: (910 ) 251-5693
Email: [e-mail]
4. Local jurisdiction for building permits: Cityof southport Planning and Inspections
Point of Contact Mr.Wayne Strickland Phone#: (910 ) C E IV
OCT 16 2012
BY:
Form SWU-101 Version 06Aug2012 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below,briefly summarize how the stormwater runoff will be treated.
Runoff will sheet flow to new and existing area drains located near the proposed improvments. Once
captured,runoff is piped to an existing stormwater wet pond BMP on the southeast corner of the property.
Per the existing permit impervious breakdown,the BMP has enough alotted future impervious to address
stormwater quality treatment. Please also note that 13,491 SF of impervious will be removed.
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 II-Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area:9.95 acres 5. Total Coastal Wetlands Area:0 acres
6. Total Surface Water Area: .33 acres
7. Total Property Area(4)-Total Coastal Wetlands Area(5)-Total Surface Water Area(6)=Total Project
Area+:9.62 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water(NHW)line or Mean High Water
(MHVV)line,and coastal wetlands landward from the NHW(or MHI 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 =70 %
9. How many drainage areas does the project have?1 (For high density,count 1 for each proposed engineered
Stormwater BMP. For low density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project,attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information Drainage Area 1 Drainage Area_ Drainage Area_ Drainage Area_
Receiving Stream Name Southport
Restriced A.
Stream Class * SC
Stream Index Number* 18-88-3.5
Total Drainage Area(sf) 433,422
On-site Drainage Area(sf) 433,422
Off-site Drainage Area(sf) 0
Proposed Impervious Area**(sf) 2719
% Impervious Area**(total)
Impervious**Surface Area Drainage Area_ Drainage Area_ Drainage Area_ Drainage Area_
On-site Buildings/Lots(sf) 130,828
On-site Streets (sf) 0
On-site Parking (sf) 138,821
On-site Sidewalks (sf) 30,753 FC E'���
I Other on-site (sf) 0 I
Future(sf) 2943 � I OCT 2
Off-site (sf) 0 6 0�2
Existing BUA***(sf) 0 BY._
Total (sf): 303,345
* Stream Class and Index Number can be determined at: http://portal.ncdenr.org/web/wq/ps/csu/classifications
Form SWU-101 Version 06Aug2012 Page 3 of 6

** Impervious area is defined as the built upon area including,but not limited to, buildings, roads,parking areas,
sidewalks,gravel areas,etc.
***Report only that amount of existing BUA that will 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.N/A
Projects in Union County: Contact DWQ Central Office staff to check if the 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
from http://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 Water Quality(DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at http://portal.ncdenr.org/web/wq/ws/su/maps.)
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 docs.
jIniptials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions&Protective Covenants NCI.
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed,signed and dated)and O&M N/A
agreement(s)for each BMP.
4. Permit application processing fee of$505 payable to NCDENR. (For an Express review,refer to A P
http://www.envhelp.org/pages/onestopexpress.html for information on the Express program
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 I r
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 At?
receiving stream drains to class SA waters within 1/2 mile of the site boundary,include the/
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: j4Gp
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 iv1HW or NHW lines.
Q Delineate the vegetated buffer landward from the normal pool elevation of im vundsgi,
structures,the banks of streams or rivers,and the MHW(or NHW)of tidaClyE
i. Dimensioned property/project boundary with bearings&distances.
j. Site Layout with all BUA identified and dimensioned. OCT 1 6 2012
k. Existing contours,proposed contours,spot elevations,finished floor elevatio
1. Details of roads,drainage features,collection systems,and stormwater control asures.
BY:
Form SWU-101 Version 06Aug2012 Page 4 of 6

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 N/A
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 DWQ to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed.Deed book:0871 Page No:1033 ALP
11. For corporations and limited liability corporations(LLC):Provide documentation from the NC AO
Secretary of State or other official documentation,which supports the titles and positions held
by the persons listed in Contact Information,item la,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.
http://www.secretary.state.nc.us/Corporations/CSearch.aspx
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
http://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs.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 DWQ 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:Roy Lorenzen
Consulting Firm:Stewart Engineering,Inc
Mailing Address:421 Fayetteville Street Suite 400
City:Raleigh State:NC Zip:27601
Phone: (919 ) 380 8750 _ Fax: (919 ) 380 8752
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information,item 2 has been filled out, complete this
section)
I, (print or type 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 type name of person
listed in Contact Information,item la) with(print or type ham' • or:anization listed in
Contact Information,item la) to develop the project as cure . ' .'EWE
the lease agreement or pending property sales contract has been provided with the sub r i al,which indicates
party responsible for the operation and maintenance of the stormwater system. OCT f 6 2012
Form SWU-101 Version 06Aug2012 Page 5 of 6 BY:

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 DWQ Stormwater permit reverts back to
me,the property owner.As the property owner,it is my responsibility to notify DWQ 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$25,000 per day,pursuant to NCGS 143-215.6.
Signature: Date:
I, ,a Notary Public for the State of ,County of
,do hereby certify that personally appeared
before me this_day of ,and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information,item la) Dennis Coffey ,
certify that the information included on this permit application form is,to the best of my knowledge,correct and
that the project will be constructed in conformance with the approved plans,that the required deed restrictions
and protective covenants will be recorded,and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2I I.1000 and any other applicable state stormwater requirements.
Signature: ^-- Date: /t `3 JoL,
I, �KATH LEA of f (GEo,V ,a Notary Public for the State of grill�^a 1;etc ,County of
&tuV5wtC.K ,do hereby certify that —Dean t S .f. C o-t y personally appeared
before me this 3 day of 0c40 6 e r , aOf a. ,and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, z14-/-tA44—) l D
SEAL
r-.3.s;•-s-+-a.Ir le ,41i ti,ra-r_ri s-tom
KATHLEEN PIGEON
NOTARY PUBLIC
BRUNSWICK COUNTY,NC
MY COMMISSION EXPIRES 4 .of
.vrrsar-a-r,rs-r-em-It- a JrAr a S.s-sa--r tl My commission expires kriam$ 7, a°17
iiflECEIVE
OCT 16 2012
BY:
Form SWU-101 Version 06Aug2012 Page 6 of 6

Johnson, Kelly
From: Johnson, Kelly
Sent: Wednesday, October 17, 2012 10:54 AM
To: 'Adam Pike'
Subject: RE: SW8 980729, Dosher Memorial Hospital (Stormwater)
OK. I will get it logged in and the check returned.
Thanks,
KJ
From: Adam Pike [mailto:APike( stewartinc.com]
Sent: Wednesday, October 17, 2012 10:52 AM
To: Johnson, Kelly
Cc: Roy Lorenzen
Subject: RE: SW8 980729, Dosher Memorial Hospital (Stormwater)
Kelly,
We intend to do a the regular review process.
Thanks
Adam Pike, PE, LEED AP Civil Project Engineer
Direct 919.866.4805
STEWART
STRONGER BY DESIGN
Visit us at www.stewartinc.com
Please note my new email address:aoikeabstewartinc.com
From: Johnson, Kelly [mailto:kelly.p.johnsonlTncdenr.gov]
Sent: Wednesday, October 17, 2012 10:49 AM
To: Adam Pike
Cc: Roy Lorenzen
Subject: RE: SW8 980729, Dosher Memorial Hospital (Stormwater)
Adam,
This is a confusing topic. Plan Revisions in the Express Program are$500, but they are$0 in the Regular program. I
didn't see any note about going Express. Is that your intention,or did you intend to go Regular?
KJ
From: Adam Pike [mailto:APikecastewartinc.com]
Sent: Wednesday, October 17, 2012 10:32 AM
To: Johnson, Kelly
Cc: Roy Lorenzen
Subject: RE: SW8 980729, Dosher Memorial Hospital (Stormwater)
Kelly,
You are correct. The project involves a slight increase in the impervious area by about 2,000 SF. We were going to
address the additional area with the previously approved wet pond's future area. We are not going to redesign the
pond and are not modifying the drainage area to the pond. It seems that per your comments below that it does fall
under a permit revision.
1

I spoke with someone a few months ago in regards to this and I thought that a review fee was still needed. I might
have just misunderstood the person. Sorry for the confusion.
Thanks
Adam Pike, PE, LEED AP I Civil Project Engineer
Direct 919.866.4805
STEWART
STRONGER BY DESIGN
Visit us at www.stewartinc.com
Please note my new email address:[e-mail]
From: Roy Lorenzen
Sent: Wednesday, October 17, 2012 10:26 AM
To: Adam Pike
Subject: FW: SW8 980729, Dosher Memorial Hospital (Stormwater)
Can you respond to Kelly?
Roy P. Lorenzen, PE I Land Planning & Design Senior Project Manager
Associate Vice President
Direct 919.866.4813
STEWART
STRONGER BY DESIGN
Visit us at www.stewartinc.com
Please note my new email address: rlorenzene stewartinc.com
From: Johnson, Kelly [mailto:kelly.p.johnsonancdenr.gov]
Sent: Wednesday, October 17, 2012 10:23 AM
To: Roy Lorenzen
Subject: SW8 980729, Dosher Memorial Hospital (Stormwater)
Roy,
We received this application today. It looks like this may be a Plan Revision ($0) rather than a permit modification
($505).
Are you just re-allocating impervious area that has already been permitted and "using"some of the future impervious
that you have already designed the pond for? I think you are because both the 2002 permit(and the associated 2011
renewal) and the current proposal show 303,345sf BUA. It also does not look like you are redesigning any part of the
pond,correct? It also doesn't look like you are changing the drainage area of the pond, or subdividing the project,
correct? Are there any other significant changes other than re-allocating already-permitted impervious?
If so,then this is a Plan Revision and I will return the check. Please let me know if there is anything"bigger"going on
here that I am missing. I go through all of the applications briefly when they come in to check for this type of thing, but I
have not gone through it very carefully.
Thanks,
Kelly
*** My email has changed to [e-mail]
KeLLW VLsow
Kelly Johnson
Environmental Engineer
Division of Water Quality
2

Stormwater Permitting
127 Cardinal Drive Extension
Wilmington,NC 28405-3845
Office: 910.796.7331
Fax: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
3

C mpleteness view Checklist
Project Name: Ha. itosPcifiG Received Date: 6 Icy --aok"),
Project Location: Accepted Date: ®®
Rule(s) 02008 Coastal 01995 Coastal ElPhase II (WiRO) DUniversal 01988 Coastal
Type of Permit: New or or PR Existing Permit#6Mo4or PR): no') ?q nPE Cert on File?
Density: HD or LD Type: Co mercia or Residential ENCG:
%: _ ` 11(%OK?) Stream Class: ®SA Map EOffsite to SW8
Subdivided?: Subdivision or Sinsle Lot 11ORW Map I ElExempt 1
Paperwork Emailed Enginee 1V 11 t
®Supplement(s) (1 original per BMP) BMP Type(s): law [C
Jr—
®O&M with correct/original signatures(1 original per BMP except LS/VFS and swales)
[application with correct/original signatures C*C) 9-rc Ode sN-%
OCErp or LLC: Sig.Auth. per SoS or letter Note to Reviewer:
505 (within 6mo) `�70 11 : aP2M.INUOI
Soils Report with SHWT good a 1100
Calculations (signed/sealed) ,DtC, lqq a ' OIG‘roAk,
ONo obvious errors A ` n
6 rife ncity includes common areas, etc `�* ,\` \al
l' _
Deed Restrictions, if subdivided: d), n11/4 (�
Si ned& Notarized ` �• g
� �
Correct Template (Comm/Res& HD LD or c. Covenants& Rest.
Plans ��G�a'
02 Sets o iDetails(roads,cul-de-sacs,curbs, sidewalks, BMPs, Buildings;et'c) -.-'—_" _-- —
DGradfieg Ljvvetidnl15: Deliiieatei or No Wetlands
®Vicinity Map U Layout (proposed BUA dimensions)
®Legend ODA Maps Project Boundaries
Infiltration Wet Pond Offsite
Soils Report ®Soils Report ®PE Cert for Master Lot#:
®SHWT: EISHWT: ®Deed Rest for Master [JLot#Matches Master
Bottom: PP: BUA Permitted (Master): sf
Visited: BUA Proposed (Offsite): sf
Additional Information:
Permitted Proposed: Proposed: Proposed:
BUA(st) I I
DA(sf)
PP(el)
SHWT(el)
Depth (ft)
SA(sf)

LETTER OF TRANSMITTAL
s
STEWART TO FROM
1 Adam Pike I
NCDENR DWQ Section Project Engineer
127 Cardinal Drive Ext. [phone]
Wilmington, NC 28405
DATE SENT VIA
10/15/12 UPS Ground
PROJECT NUMBER PROJECT NAME
C10035 Dosher Hospital Addition
COPIES DATE DESCRIPTION
2 10/15/12 Plans
2 10/15/12 Calculations, Application,
1 10/15/12 Deed, $505 check, signing authority form
z For approval 0 For review &comment L Returned for corrections
g For your use ❑ Approved as submitted E Returned after review
E As requested ❑ Approved as noted E Resubmit copies for approval
COMMENTS
Please find included the necessary items for the DWQ state stormwater review
submittal. If you have any questions please feel free to call or email me at
apike@stewartinc.(Alt
WON flECEIVE Thanks
li OCT 162012 1))
BY:_
SIGNED COPIED TO
file
Adam Pike, PE
ENGINEERING.INNOVATION.SOLUTIONS.TM 421 FAYETTEVILLE STREET RALEIGH,NC T 919.380.8750
SUITE 400 27601 F 919.380.8752

Stormwater Impact Analysis - NCDENR
Permit Submittal
For the proposed
J.A. Dosher Memorial Hospital Patient Rooms
Expansion and Renovation
Southport, North Carolina
Prepared for
Peterson Associates
Prepared By
Stewart Inc.
S
E , R
October 15, 2012
EGEIVE
OCT 16 2012

Stormwater Impact Analysis
For
S.A. ©usher Memorial Hospital Patient Rooms Expansion and
Renovation
Southport, North Carolina
Prepared for:
Peterson Associates
Prepared by:
Stewart Inc.
Firm License No. 1051
421 Fayetteville St.
Raleigh, NC 27601
919.380.8750
....u1 nu,h,
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SEAL
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FOR REVIEW ONLY
Stewart Project No. C10035
October 15, 2012

Table of Contents
1. Table of Contents & Narrative
2. Site Information
a. QUAD Map
b. FEMA Map
c. Soils Map
3. Quantity Calculations
a. Stormwater Permit and Renewal letter
b. Impervious Area Breakdown
c. Existing Wet Pond BMP Impervious Area "Bank"

STORMWATER IMPACT ANALYSIS
3.A. DOSHER MEMORIAL HOSPITAL PATIENT ROOMS EXPANSION AND
RENOVATION
SOUTHPORT, NORTH CAROLINA
EXECUTIVE SUMMARY
This Stormwater Impact Analysis has been prepared specifically to address
the requirements of the NCDENR coastal county stormwater treatment
requirements, in order to quantify the impact of the proposed development upon
downstream systems. Per the coastal county requirements, the improvements to
the site will require the control of the first inch and half of stormwater runoff for the
site
As is detailed below, the proposed improvements will be treated by the
existing wet pond BMP on site. This BMP was permitted under permit SW8980729
and renewed on November 11, 2011.
Site Information
J.A. Dosher Memorial Hospital is located at intersection of Fodale Avenue and
North Howe Street in Southport, North Carolina. The site currently is developed
with buildings, sidewalks, and parking lots for the hospital.
The site lies within the Dutchman Creek Basin and is outside of any
floodplains, wetlands. The latest version of the United States Department of
Agriculture Soil Conservation Service Soil Survey of Brunswick County, North
Carolina map indicates that the on-site soils are mostly made up of Pactolus fine
sand, with the rest of the soils made up of Kureb fine sand and Wando fine sand
which is classified as Hydrologic Soil Group A. Per FEMA Flood Insurance Rate Map
3720209600J, dated June 2, 2006, no 100-yr Floodplain is present within the
project site.
Existing hospital development is generally situated on or near a high point
where runoff breaks either west or east. The highest elevation within the site is
toward the north.
Proposed Improvements
The proposed improvements associated with this project include two small
building additions at the south/southeast corner of the existing building along with
a building addition for the central utility plant. The existing drive at the southern
portion of the main building will also be removed and a roundabout drop off area
will be created at southeast entrance to the main building.

Design Requirements
BMP Design Requirements
There is an existing wet pond BMP that was permitted back in January 31,
2002. The wet pond was designed to handle 9.95 acres of runoff. Per the existing
permit impervious breakdown (see appendix 3) the existing wet pond has available
future impervious area. This project will use a portion of the available future
impervious area to handle the new impervious associated with the addition.
Further explanation and breakdown is described in appendix 3.
Overall Results / Summary
BMP/Impervious Area Summary
The table below shows the pre development/post development impervious
area associated with this project.
Pre Development/Post Development Impervious Area
Pre-development
Impervious Area: 297,683 sf
Post-development
Impervious Area: 300,402 sf
Area Difference: 2,719 sf
Wet Pond Impervious Area Bank
Pre-development Impervious Area: 297,683 sf
Post-development Impervious Area: 300,402 sf
Area Difference: 2,719 sf
Future Imp. Area (Pre Development): 5,662 sf
Future Imp. Area (Post Development): 2,943 sf
Conclusions
Based on the results, the requirements of the NCDENR have been met with
no additional structural measures. Please see the attached appendices for
additional calculations.

Appendix 2
2. Site Information
a. QUAD Map
b. FEMA Map
c. Soils Map

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iir Conservation Service National Cooperative Soil Survey Page 1 of 3

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Map Unit Legend
Brunswick County,North Carolina(NC019)
Map Unit Symbol Map Unit Name Acres in AOi Percent of AOi
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-4' Natural Resources Web Soil Survey 10/15/2012
Conservation Service National Cooperative Soil Survey Page 3 of 3

Appendix 3
3. BMP Calculations
a. Stormwater Permit and Renewal letter
b. Impervious Area Breakdown
c. Existing Wet Pond BMP Impervious Area "Bank"

A
T E WAT
Impervious Cover Anlaysis
Project: Dosher Hospital Addition
Number: C10035
Date: 15-Aug-12
433,422 sf
9.95 ac
Pre-development Impervious*
Total Impervious - 297,683 sf = 6.834 ac
Total Pervious - 135,739 sf = 3.116 ac
Percent Impervious - 68.68%
Existing Impervious Remaining
- Buildings 123,980 sf
- Parking/Drives 143,232 sf
- Sidewalk/Concrete 30,471 sf
TOTAL 297,683 sf
Existing Impervious Removed '
- Buildings 158 sf
- Parking/Drives 10,131 sf
- Sidewalk/Concrete 3,202 sf
TOTAL 13,491 sf
Impervious Area Added
- Buildings 7,006 sf
- Parking/Drives 5,720 sf
- Sidewalk/Concrete 3,484 sf
TOTAL 16,210 sf
Total Impervious Area
- Buildings 130,828 sf
- Parking/Drives 138,821 sf
- Sidewalk/Concrete 30,753 sf
TOTAL 300,402 sf
Pre Development/Post Development Impervious Area
Pre-development Impervious Area: 297,683 sf
Post-development Impervious Area: 300,402 sf
Area Difference: 2,719 sf
Total Post-Development Impervious
Total Impervious - 300,402 sf = 6.896 ac
Total Pervious - 133,020 sf = 3.054 ac
Percent Impervious - 69.31%
421 Fayetteville Street, Suite 400, Raleigh, NC 27601 Tel [phone] Fax [phone] www.stewart-eng.com

L
T E WA RT
Imprevious "Bank" for Ex Wet Pond BMP
Project: Dosher Hospital Addition
Number: C10035
Date: 7-Oct-12
i3saw st rvrate r visnagatda systems
Ern INA 6. lyta 72
DIVISION OP WA `Elt QUALITY
PROJ3'd.T DESIGN DATA SHEET
Project Name: I.A.D Memorial Hospital
Pt unit Number: SW8 980725
Location: 3runswick Comfy
Applicant Mr.aim Haywood,Administrator
lUlediittp Addre. ,: LA.Dosber Memorial Hospital
924 Howe Street
Southport,NC 28461
Application Dam: January 30,20022
Name of Re cowing Stacaullndex#: Caps Fear JUT Price Crock/3-6-17
Classification of Water Body: "SC Sw"
Fond Depth,fart: 7.5
Per nanent Pool Elevation,PMSL: 14.10
Drainage Area,acres: 9.95
Total Impervious Surges,:.1': 303,345
Buildings,le: 123,980
?sitting,t' : 143,232
Sidewalks,fts: 30,411
Future, ': 5,6662
Wet Pond Impervious Area Bank
Pre-development Impervious Area: 297,683 sf
Post-development Impervious Area: 300,402 sf
Area Difference: 2,719 sf
Future Imp. Area (Pre Development): 5,662 sf
Future Imp. Area (Post Development): 2,943 sf
421 Fayetteville Street, Suite 400, Raleigh, NC 27601 Tel [phone] Fax [phone] www.stewart-eng.com

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PREPARED BY: James R.Inevatter . P.O. Box 10969, Southport,
North Carolina 25461-
edA, 0871 1033 •
-0 _ tSMATIuN'
STATE OF NORTH C •. : , ; I B NI 2:38
��Bd1NSON
COUNTY OFUlt4d NJ�O(�(�,C ITER OF OEEOS :
gneaz - E7.�NSMeg COO�IP!K
THIS DEED, Made and entered into this the J41‘ day
of .Jawuar 1992, by and between LARRY L. HENRY and wife,
LINDA S. HENRY of Brunswick County, North Carolina, parties of
the first I rt; and J. ARTHUR DOSBER MEMORIAL HOSPITAL, 924
Howe Street, jthport, North Carolkna4 tt; party of the
second part; cfq! C r��
r T�ESSg�T
n INTZFFICIAL
TAW( Baid ,i�/ � first part, for and in con-paz" "vCJ`//' �''' /;
sideration of the sum of TEN DOLtJ 1j'BER VALUABLE CON-
i
SIDERATION to them in hand paid by said party of the second
part, the receipt of which is hereby acknowledged, have bar-
gained and sold and by these presents do hereby bargain, sell 1
and conveyWo said party of the second part, its successors
and assigns, %`• that certain lot"fir" �T'! of land lying and
being in the City o n a ,T�, , 0111 - Township, Brunswick
County, r5I1JJ .nn *ore described as
follows: �l%Q
BEGINNING at an iron stake, which said iron stake is
located the following courses and distances from a C
monument identified as N.A.D. 1927 N.C.G.S.
"HOSPITAL" N=66957.5787 E=2296566.3250; from said
N.A.D. monument runs thence South 75 degrees 30 40,. C� 7�
minutes 38 seconds East 452.03 feet to an existing !6 , -3
rebareo,., uns thence North 13 degrees 02 flutes 31
seco • G .-st 146.25 feet to the '�,• point of 1
Beginning,"i om said Hegi .' q r ' thence el
North 13 •�- es 1 - .1r , _13 eL::'lest 39.84
feet to an i �;'� >' ,./ -• stake is fur-
ther `�� I 40 f •e• -es 02 minutes 31 seconds
East 5.b9 an a in the
south L.aL st—cif kl;: C;�, odale venue; from said
rebar runs thence No ` Fp-/-- -: 57 minutes 29
seconds East 6.06 feet to - f r�
'� ake set; runs
thence South 13 degrees 02 minutes seconds East
39.84 feet to an iron stake set; runs thence South
76 degrees 57 minutes 29 seconds West 6.06 feet to
rivEvis the place and point of BEGINNING containing 241.46
Psrcwse"OcwycU square feet as per survey for Dr. Larry Hamby and J.
„e.........w A. Dasher Memorial Hospital by Tide Water Engineer-
cG ing and Surveying P.A. dated December 31. 1991.
AMMO.II C
TOT ( r.. �. rmi I 7
T R'.NSACT a
CX.A za o, e kJ: 000043
rime s . .

`17fr=h_ AL . . '-%'.
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087 ! 1034
—.-sz-e,,, [1:3
VCg
araoFFtCIA o the following
Itz sest
r%` UuIN
Conditions sic ��#j�
1. Party of the second d •;f 4Qor its successors or
assigns, shall neither erect nor construct any building or
other structure on the property conveyed herein.
2. Should party of the second part or its succes-
sors or as is no longer have need for the ject property ,
FFt
the property s A be reconv r the first part
:71(!:t ;
without Consi. 1014F,g tract or
DO the abed
parcel of land, together witIAgrtMes and appurtenances
thereunto belonging, unto the said party of the second part,
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DOSHER (
Memorial Hospital 11C00.1.-
924 N. Howe Street
Southport, NC 28461
[phone]
fax [phone]
May 29, 2012 www.dosher.org
Mr. Roger Barnes
Assistant Director, Finance
Division of Medical Assistance
N.C. Department of Health & Human Services
1985 Umstead Drive
Raleigh, NC 27603
Subject: FFY2011 MRI/GAP Payment Plan—Additional Uncompensated Care Certified Public Expenditures
Adjustment
Dear Mr. Barnes:
The undersigned, as an officer of and on behalf of J.Arthur Dosher Memorial Hospital ("the Hospital"), hereby
certifies that it considers itself to be a public hospital under applicable law by virtue of being owned and
operated by a governmental unit, owned by a governmental unit and operated by an instrumentality of
government, or owned and operated by a nonprofit instrumentality of government.
The undersigned previously certified to the Division of Medical Assistance ("the Division")the Hospital's
expenditures net of payments on behalf of uninsured individuals in the total amount of$1,390,510 covering the
period from October 1,2010 through September 30,2011. Covering the same time period and in addition to
the previous certification,the Hospital at this time certifies to the Division the Hospital's expenditures net of
payments on behalf of uninsured individuals in the additional amount of$78,559. This additional certification
of Uncompensated Care Costs is based on this Hospital's 2009 Fiscal Year Uninsured Costs and Uninsured
payments and is adjusted for inflation by the Division
We understand and agree that the Division will rely on this additional certification of expenditures and offsetting
payments as a statement of expenditures claimable for Federal Financial Participation for the 2011 Federal Fiscal
Year.
We further understand that expenditures claimed on the basis of this additional certification will be adjusted
based on the 2011 DSH Audit and on the final audit of the Hospital's Fiscal Year 2011 cost report and other 2011
financial reports.

Yours truly,
By: Dennis J.Coffey,Sr.Vice President of Finance
. ti,1•1/
(Signature)
Provider Number: 3401327
CFO's Telephone: [phone]
CFO's Fax: [phone]
CFO's Email: [e-mail]