SW7990507_CURRENT PERMIT_20140310

DEMLR USE ONLY
Date Received Fee Paid Permit Number
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S orth Carolina
C— Mve�q CO, Department of Environment and Natural Resources MAR 10 2014
Division of Energy Mineral and Land Resources
(NCDENR DEMLR) #'i,�', R f' ' ;r_. .yY
STORMWATER MANAGEMENT PERMIT RENEWAL APPLICATION POR'N04iA4
This form may be photocopied for use as an original
This form is to be completed by the current permit holder pursuant to Title 15A NCAC 2H.1003(h) (2).This states
that stormwater management permits, issued for projects that require the construction of engineered stormwater
control measures (High Density Permits),shall be required to submit an application to renew the permit 180 days
prior to expiration of the permit.Renewed permits are valid for a period of 8 years per Session Law 2011-398(SB
781)Section 60.(c).
I. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the North Carolina Department of
Environment and Natural Resources (NCDENR)Division of Energy Mineral and Land Resources(DEMLR). A
complete package includes all of the items listed below. The complete application package should be
submitted to the appropriate DEMLR Regional Office. (The appropriate office may be found by clicking on the
interactive online map at http://12ortal.ncdenr.org/web/guest/regional-offices.Copies of the original permit can be
obtained from the Regional Office of the Division of Energy,Mineral and LandResources.)
This Renewal is for STORMWATER PERMIT#:SW I� 01 h SD—/
Please check which of the following permit renewal scenarios apply. Initial in the spaces provided that you have
provided the required information.
VA.Renewal Only:
$505 fee
-Renewal Form-Sign and complete all sections (send original&1 copy)
-Recorded Documents Required By Permit:Deed restrictions,covenants, condominium/planned
community declaration&easements(if not already submitted to NCDENR DEMLR). Copies are
acceptable.
-Designer's Certification(if required by permit and not already received by NCDENR DEMLR) (See the
last page of your permit for a copy of the certification form.) t/
-I Have a Copy of the Current Operation and Maintenance Agreement(O&M): Please Keep this on File
with your permit.
-I Do Not Have a Copy of the Current O&M:Initial This Line to Request a copy. (If NCDENR DEMLR
does not have a copy on file, then you will be notified to submit a new O&M form.
❑ B. Renewal and Modification:
-$505 Fee and Pages 1 &2 of this Renewal Form
-SWU-101 Application Form(httn://Xortalortal.iicdenr.ororg/webhvq/wslsulstatesw/forms docs)
-Recorded Documents Required By Permit:Deed restrictions,covenants,condominium/planned
community declaration&easements(if not already submitted to NCDENR DEMLR). Copies are
acceptable.
-Under #11.1.on SWU-101 Application Form--Check Box for Modification w/Renewal
-Designer's Certification(if required by permit and not already received by NCDENR DEMLR) (See the
last page of your permit for a copy of the certification form.)
-O&M Agreement(http://portal.ncdenr.org/web/wg/zos/su/bnip-manual)
Form SW-102 (Renewal Form) Rev.Oct.31,2013 Page I of

❑ C.Renewal and Either: 1.) Permit Transfer to a New Permittee,or 2.) Project Name Change:
Please submit all items in I.A.and:
Request a NCDENR DEMLR site inspection if transferring permit to new property owner.
Submit One of the Two Following Forms below(forms available at http://portal.ncdenr.org/web/Ir/state-
stormwater-forms does).
1. FICA Name/Ownership Change Form: For planned communities (per Chapter 47C or
Chapter 47F of the General Statutes)
2. Name/Ownership Change Form: For all other transfers
Please make sure all required information is submitted with the Name/Ownership Change form(as
stated in each of the available forms)and that all required signatures and initials are filled in properly.
Otherwise the name change or transfer can not be processed and the original owner will remain as the
permit holder.
❑ D.Renewal,Modification,and Transfer(or Name Change): Please submit pages 1 and 2 of this
Renewal form along with all items listed in I.B. and C.above (check this box and initial items in B.
&C. that you are submitting to NCDENR DEMLR).
II. APPLICANT'S CERTIFICATION
Note:The legally responsible party is the current permittee and/or the legally responsible representative until such time that the permit is
officially transferred through a request to DEMLR by the permittee.
l 1
I, (print or type name of permittee or person legally responsible for the permit) 1 L 6' t Aw K i S
certify that I have a copy of the DEMLR Approved Permit and O&M Agreement on-site(OR I have obtained a copy
from DEMLR 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. I agree to notify DEMLR of any
problems with the system and prior to any changes to the system or changes in ownership I will (or have through
this renewal application)notify NCDENR DEMLR and submit the proper forms to modify or transfer the permit.
All information provided on thismit renewal application is, to the best of my knowledge,correct and complete.
Permittee Title: I�1 C�Aok\ 1Ve`r0u0i 6-+k S vv�'-e✓tip 2n M CvM cXA
Address: 2D(p �rt`dcP �61 2 �/"� O
Phone: Z" ) o
Signature: Date: '> -
NOTARIZATION:
1, a Notary Public or the State off /
Co ty f / vr.i>� d reby certify that `
lie so ally appeared before me this day of and acknowledge the due execution of the
forgoing stormwater BMP maintenance requi•ements.Witness my hand and official seal,
My commission expires
Notary Signature: Date: 7
SEAL
JESSICA CLIFTO
NOTARY PUBLIC
CRAVEN COUNTY
�WEOFNORTH CARD NA
Form SWU-102(Renewal Form) Rev.Oct. 31,2013 Page 2 of

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MAGNOLIA INVESTORS LLC
206 BRIDGE POINTE OR
NEW BERN,NO 28561 t�
[phone] 66-67?-531
DATES 7
!� PAY
TO THE
ORDER OF ✓ � � � O
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MAR 10 2014

III. GENERAL INFORMATION (� 7
1. Stormwater Management Permit Number: SW � l 0 /
2. Permit Holder's name(specify the (name of the corporation,individual,etc.):
/
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3. Printt^Owner/Signing Official's name and title(person legally responsible for permit):
4. Mailing Address for person listed in item 2 above:
City: �j State: AJ- C/i Zip: �956 '
Phone: (Z2 ) 3�'— ( D 6 0 Fax: (,2,5
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Email: V '^SKIw$
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5. Project Name: Or. rJ Z1 , r U >I ti C P lA S
6. Location of Project(street address):
( fib Ma/Lei 5-ERe-�-
City: PVC ll9/�V / C, County: 0/0-V� Zip:
c7 �l1�Pti�
7. Directions to project(from S S E� �nearest major intersection): ((`�
% 0 EaS� Z� k l /� C �L✓n/
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Form SWU-102 (Renewal Form) Rev.Oct.31,2013 Page 3 of 4

IV. PERMIT INFORMATION:
1. Specify the type of stormwater treatment: ❑Constructed Wetland ❑Bioretention et Detention Pond
❑Dry Detention Basin❑Infiltration Basin ❑Infiltration Trench ❑Sand Filter ❑Other:
2. If any changes were made to the original DEMLR approved project list them in the space below (attach additional
pages if needed and provide "As-Built" drawings with this application). If major changes have been made to your
project please request a plan revision or modification of the permit and submit"As Built" drawings along with a
final or updated stormwater system engineer certification(if not already provided to NCDENR). DEMLR Engineer
and Designer Certification Forms are available from each NCDENR DEMLR Regional Office.
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Form SWU-102 (Renewal Form) Rev. Oct. 31,2013 Page 4 of4