SW6240701_Supplement Form - Offsite_20240716

Permit No.
(to be provided by DEMLR)
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
OFF-SITE SYSTEM SUPPLEMENT
FOR DEVELOPMENT DRAINING TO PERMITTED OFF-SITE TREATMENT SYSTEMS
This form may be photocopied for use as an original
DEMLR Stormwater Management Plan Review:
A complete stormwater management plan submittal includes a stormwater management permit application, an
off-site system supplement for each off-site stormwater treatment system, appropriate supplement forms for any
on-site stormwater treatment systems, and plans and specifications showing all stormwater conveyances and
drainage details for the project.
I. PROJECT INFORMATION
Project Name : McDonald's Hoke Landing
Contact Person: Brian Soltz Phone Number: ( 919)398-6520
Is all drainage from the project directed to the off-site system? (check one): ® Yes ❑ No
II. OFF-SITE SYSTEM INFORMATION (please complete the following information for the off-site system
that will treat runoff from your project):
Permit No. SW6190901
Project Name:Hoke Landing, Phase 2
Type of System (wet pond, infiltration basin, etc.):Off-site Wet Pond
Lot No. (if part of a subdivision):Lot 3A
How much built upon area draining to the permitted treatment system has been allocated to this
project?51,960 SF
III. REQUIRED ITEMS CHECKLIST
Prior to issuing an off-site permit, verification of the following information must be provided. Initial in the
space provided to indicate that the following requirements have been met and supporting documentation is
attached. If the applicant has designated an agent in the Stormwater Management Permit Application Form, the
agent may initial below. If a requirement has not been met, attach justification.
Form SW40 1-Off-Site System-Rev.1 Page 1 of 2

Applicants Initials
a. Deed restrictions limiting the built-upon area on the site have been recorded.
b. Engineers certification for the existing off-site system has been submitted to DEMLR.
c. There are no outstanding Notices of Violation for the off-site system.
d. Off-site system is in compliance with the issued permit.
IV. STORMWATER COLLECTION SYSTEM MAINTENANCE REQUIREMENTS
1. Mowing will be accomplished as needed according to the season. Grass height will not exceed six inches at
any time.
2. Accumulated sediment and trash will be removed from the collection system as necessary. Swales and
ditches will be reseeded or sodded following sediment removal.
3. Eroded areas of swales and ditches will be repaired and reseeded. Swales and ditches will be revegetated as
needed based on monthly inspections.
4. The collection system, including catch basins, curb cuts, velocity reduction devices, and piping, will be
inspected monthly or after every significant runoff producing rainfall event. Trash and debris will be
cleared away from grates, curb cuts, velocity reduction devices, and piping.
5. The collection system may not be altered in any way without prior approval from NCDENR Division of
Energy, Mineral and Land Resources.
I acknowledge and agree by my signature below that I am responsible for maintaining the stormwater collection
system in accordance with the five maintenance procedures listed above. I agree to notify DEMLR of any
problems with the system or prior to any changes to the system or responsible party.
Print Name and Title:McDonald's USA, LLC - Tammy Kahm - US Field Area Construction Manager
Address:101 N. Carpentar St., Chicago, IL 60607
Phone:[phone]L Date:5/1/24
Signature:
Note: The legal esponsible party should not be a homeowners association unless more than 50%of the lots have been sold and a
resident of the subdivision has been named the president.
l f 2ote44 C • 0.1 ettOL S , a Notary Public
'for
Jthe
State of PC" ,County of
pee'So1� ,do hereby certify that `Thin4 k At* i M personally appeared before me this 151
day of Yh/hi , V7 ,and acknowledge the due execution of the forgoing document including the stormwater
collection system maintenance requirements. Witness my hand and official seal,
V.„4 C
Notary Public
SEAL My commission expires /Z- 91'ZOO
Form SWU-106 Rev 8.07 Page 2 of 2