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HomeMy WebLinkAboutSW4240907_Application Form_20241015 DEMLR USE ONLY Date Received Fee Paid Permit Number Applicable Rules: ❑Coastal SW- 1995 CI Coastal SW- 2008 Ph post (select all that apply) ❑Non-Coastal SW-HQW/p W Waters 0 Universa❑l Stormwater Management n ❑Other WQ M.►n t Plan: agement Plan State of North Carolina Department of Environmental Quality Division of Energy, Mineral and Land Resources POST-CONSTRUCTION STORMWATER MANAGEMENT PERMIT APPLIC This form may be photocopied for use as an original. ATION FORM 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.). Design Master Dis la s Buildin Ex ansion 2. Location of Project(street address): — 5657 Pros ect Street City:Archdale ---- C 3. Directions to project(from nearest major intersection):oRandolph Zip:27263 0.95 miles South from intersection of US Hw 29 and Pro est Street SR1625 4 Latitude:35° 54' 16" N Longitude:80e 02' 07" W of the main entrance to the project. II. PERMIT INFORMATION: 1.a.Specify whether project is (check one): ZNew tRenewals with modifications a sodreq►a es SWU-10 n RRenewa Application enewal w/ aFor b.If this application is being submitted as the result of a modification to an existingForm permit number its issue date (if known) permit. list the existing construction: ❑Not Started , and the status of certification ❑Partially Completed" ❑ Completed` *provide a designer's 2. Specify the type of project: ❑Low Density NHigh Density Drains to an Offsite Stormwater System 3. If this application is being submitted as the result of a previously returned application❑ her orta letter DEMLR requesting a state stormwater management permit application, list the stormwater project number, if assigned, from proposed, and the previous name of the project, if different than currently 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): ❑CAMA Major LZSedimentation/Erosion Control: 6.65 ac of Disturbed Area ❑NPDES Industrial Stormwater N 4 0 4/4 0 1 Permit: Proposed Impacts Tem Crossin an b.If any of these permits have already been acquired please provide the Project Name, Project/Permit d Pipe 1t/Permit Number, issue date and the type of each permit: 5. Is the project located within 5 miles of a public airport? ZN If yes, see S.L. 2012-200, Part VI:http.//portalmcdenror /web/lr/ru es and ❑Yes requlationc Form SWU-101 Version July 26,2024 Page 1 of 6 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:Jerry Hardy Signing Official & Title:Jerry Hardy, Managing Member, H2PRO, LLC b.Contact information for person listed in item la above: Street Address:4001 Brambletye Court City:Greensboro State:NC Zip:27407 Mailing Address (if applicable):Same as above City. State Zip. Phone: ( ) Fax: Email: c.Please check (one) 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:H2PRO,LLC Signing Official & Title:Jerry Hardy. Managing Member b.Contact information for person listed in item 2a above Street Address:4001 Brambletye Court City:Greensboro State:NC Zip:27407 Mailing Address (if applicable):Same as above 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:Andrew Christ, PE / FEI Civil Engineers and Land Surveyors Signing Official &Title:Andrew Christ, PE/ Senior Project Manager b.Contact information for person listed in item 3a above: Mailing Address 5818 Traid Drive City:Colfax State NC Zip:27235 Phone: (336 ) 544-6438 Fax: ( Email achrist(a�feiconsulting.corn 4. Local jurisdiction for building permits City of Trinity/ Randolph County Point of Contact: Phone#: l Email Form SWU-101 Version July 26,2024 Page 2 of 8 IV. PROJECT INFORMATION 1. In the space provided below, briefly summarize how the stormwater runoff will be treated Stormwater pond will be used to ca ture and treat runoff from the BUA. 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 PP ❑ Valid Building Permit Approval Date ❑ Other: Issued Date: Date: b.If claiming vested rights, identify the regulation(s) the project has been designed in accordanc ❑ Coastal SW— 1995 El Ph II — Post Construction e with: 3. Stormwater runoff from this project drains to the Yadkin Pee-Dee 4. Total Property Area: 18.73 River basin. acres 5. Total Coastal Wetlands Area: 0 6. Total Surface Water Area- 0.23 acres acres 7. Total Property Area (4)—Total Coastal Wetlands Area (5)—Total Surface Water Area (6) = jct Total Proe Area+- 18.50 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 avers, the area below the Normal High Water(NNW)line or Mean High Water(MHVIq line, and coastal wetlands landward from the NHW(or MHW)line The resultant project area is used to calculate overall percent built upon area(BUA). Non- coastal wetlands landward of the NHW(or MH144 line may be included in the total project area. 8. Project percent of impervious area: (Total Impervious Area/Total Project Area)X 100 = 28 0 9. How many drainage areas does the project have?1 (For high density, count 1 for each proposedSCM. For /o low density and other projects, use 1 for the whole property area. If there are multiple receiving streams provide the drainage areas within the project area to each stream.) 10. Complete the following information for each drainage area directed to an SCM or low density area identified 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. in Basin Information Draina•e Area 1 Draina.a Area 2 Draina•e Area Draina•e Area Receiving Stream Name Hunts Fork Hunts Fork 11.11111111.11111.111111111 Stream Index Number DrIndexe NuArember r*sf) 12-119-7-3 12-119-7-3 Totalsite Drainage (sf)Area641,964 173,718 11111111111111111111111111111 641,964 173,718 1111111111111111111111111111 Off-site Drainage Area (sf) 0 11111111111111111111111111111 Pro.osed Impervious Area** sf 0 0 96,576 11111111111111111111111111.1 Impervious Area** total 10.7% 0 55.6/o 11111111111111111111111111111 Impervious" Surface Area Drainage Area 1 Drainage Area 2 Drainage Area Drainage Area On-site Buildings/Lots (sf) 0 On-site Streets (sf) 22,000 On-site Parking0 (sf) 0 74,576 On site Sidewalks (sf) 0 IIIIIIIIIIIMIIIIIIIIIIIIIM 11111.11111111111.111111111111111111111111 Other on-site (sf) 0 IMIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIII IIMICE Off-site (sf) 0 1111111111111111.111111111111.11.111111 11111111.11111111111111111111111111111111111 Existing BUA*** (sf) 68,961 41,071 111111111111111111111111111.1 Total (sf): 68,961 137,647 111.11111111111.11111111111 Stream Class and Index Number can be detemuned at.htt s.//www_de .nc. ov/about/divisions/water-resources/water- tannin /classification-standards/classifications 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. See definition 15A NCAC 02H 1002(17). Form S WU-101 Version July 26,2024 Page 3 of 8 11. How was the off-site impervious area listed the Section IV, 10 Tables determined? Provide documentation GIS-Public Information Projects in Union County: Contact DEMLR 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 SCM specified for this project. The latest versions of the forms can be downloaded from htt s://www.de .nc. ov/about/divisions/ener -mineral-and-land-resources/stormwater/stormwater- rogram/stormwater-design manual_ For SCMs subject to older design standards or offsite projects, the archived supplement can be found from hops://www.deq.nc.gov/about/divisions/energv mineral and land suresources/stormwater/stormwater ro ram/stormwater-desi n-manual/archived-stormwater-desi n-manual- pple me ntal-forms VI. CHECKLIST OF SUBMITTAL REQUIREMENTS FOR AN ADMINISTRATIVELY COMPLETE APPLICATION PACKAGE PER 15A NCAC 02H .1042(2) Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and Land Resources (DEMLR). An administratively complete application package includes all of the items listed below. A detailed application instruction sheet and SCM checklists are available from htt s://www.de nc. ov/about/divisions/ener -mineral-and-land-resources/stormwater/ ost-construction- rroogram/new-permits-permit modifications. The complete application package should be submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating rject on the map at htt s://www.de .nc ov/about/divisions/ener -mineral-and-land-resourpes/stormwater/stormtwaternline program/post construction-program ) Please indicate that the followin re uired information have been rovided b initialin 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 https://www.deg nc qov/about/divisions/energv mineral and-land-resources/stormwater/stormwater ro ram. 1. Original and one copy of the Stormwater Management Permit Application Form. Initials 2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants Form or, for major modifications. a copy of the recorded deed restrictions and protective covenants limiting the built-upon area so that it does not exceed the capacity of the SCM(s) or the BUA thresholds. (if required as per Part VII below) Deed book: Page No: Relevant section: 3. Original of the applicable Supplement Form(s) and dated an agreement(s) for each SCM. (please refer to Section V fors more nforma on) d O&M -� 4. Appropriate permit application processing fee per NCGS 143-215.3D(e)(2)payable to NCDEQ. A full list of fee adjustments is available on the DEQ website https://www deq.nc goy/accessdeq/permit fees 2023 updates (For an Express review, refer to: htt psl/www.de .nc qov/accessdeq/express permitting for information on the Express program and the associated fees. Contact the appropriate Coastal 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/management for 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 receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2 mile radius on the map. fer-- 7 Sealed, signed, and dated calculations (one copy). Form SWU-101 Version July 26,2024 Page 4 of 8 8. Two sets of plans folded to 8.5"x 14" (sealed, signed, & dated), including: 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 MHW or NHW lines. • Delineate the vegetated setback landward from the normal pool elevation of structures, the banks of streams or rivers, and the MHW(or NHW) of tidal waters. i. Dimensioned property/project boundary with bearings & distances. impounded j. Site Layout with all BUA identified and dimensioned. k. Existing contours, proposed contours, spot elevations, finished floor elevations. I. Details of roads. drainage features. collection systems. and stormwater control measures (including any applicable SCM planting plans). m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated b a qualified person, identify the person who made the determination on the plans. y 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 . 9. Copy of any applicable soils report with the associated SHWT elev ations (Please identi ) - elevations in addition to depths) as well as a map of the boring locations with the existingf= elevations and boring logs. Include an 8.5"x11" co project area clearly delineated. For projects with infiltration SCMs, the report should also include the soil type, expected infiltration rate, and the ofy met the NRCS County Soils map with the of determining (Infiltration Devices submitted to WiRO: Schedule a s tehd voisit for DEMLR to the verify'thetSH rate. Prior to submittal. (910) 796-7378.) lNT 10. A copy of the most current property deed Deed book 2110 11. For corporations and limited liability corporations (LLC): Provide age No. n40 Secretary of State or other official documentation, which supports from ��� by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2H 10NC _ the titles and positions held 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. 40(1). htt ://www.secreta .state.nc.us/Cor orations/CSearch.as x 12. If the applicant is not the property owner, a copy of a lease agreement. affidavit, or other document showing that the applicant has obtained legal rights to submit a stormwater permit application within the proposed project area 13. If applicable, a copy of any recorded drainage, maintenance, or operation and maintenance easements demonstrating ownership interest sufficient to operate the SW system. Deed book; �� Page No 14 If a modification to an existingPaRelevant section permit: a. The applicant/permit holder will remain the same and permit has not and will not expire within the next 180 days. b_ Signed, sealed & dated Designer Certification Forms c Copies of the following documents recorded with the County Register of Deeds __&i41._ i. Deed restrictions and protective covenants limiting the BUA does not exceed the capacity of the SCM(s) or the BUA thresholds. it N ii. Drainage easements, when applicable. ni. Operation & Maintenance Agreement iv. Final subdivision plat referencing the Operation & Maintenance Agreement / - Form SWU-101 Version July 26,2024 Page 5 of 8 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 protective covenants forms can be downloaded from htt s://www_de .nc. ov/about/divisions/ener -mineral and- land-resources/stormwater/stormwater- ro ram/ ost-construction- ro ram/ ostcostru deed restrictions and the latest versions for each submittal, d cti�n-forms. Download 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 p p rty By the notarized signature(s) below, the permit holder(s) certify that the recorded property 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 a restrictionsdpersons claiming under them, that they will run with the land, that the required covenants cannot be changed deleted without concurrence from the NC DEMLR, and that they will be recorded prior to the sale of lot. g or any VIII. CONSULTANT INFORMATION AND AUTHORIZATION Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such consulting engineer and/or firm) so that they may provide information on your behalf for this project(such as addressing requests for additional information). as a Consulting Engineer:Andr�hrist. PE Consulting Firm: FEI Civil En ineers and Land Surve ors Mailing Address:8518 Triad Drive City:Colfax Phone: (336 State:NC Zip:27235 544-6438 Email:achnst(u�feiconsultinq.com — Fax: (_ Form SWU-101 Version July 26,2024 Page 6 of 8 IX. PROPERTY OWNER AUTHORIZATION (if Contact information, item 2 has been filled section) out, complete this I, (print or type name of person listed in Contact Information, item 2a) Jer Hard own the property identified in this permit application, and thus give permission toV listed in Contact information, item 9a)Jer Hard � certify that I Coed in Contact Information, itemm 9a, Jerry Hardy (print or typef o name off/person with thep projectc type name of organization copysted inf the lease agreement or pending property sales contract has been provided with the submittal, to develop as currently proposed. A of party responsible for the operation and maintenance of the stormwater system. As the legal property owner I acknowledge, understand, and agree bymy which indicates the agent(entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults lease agreement, or pending sale, responsibility for compliance with the DEMLR below, that if my designated to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediatelyan their a completed Name/Ownership Change Form within 30 days; otherwise I will be operating stormwater permit reverts back facility without a valid permit. I understand that the operation of a stormwater treatment facility and submit permit is a violatio f NC General Sta n 1 3 215.1 and may result in appropriate operating a stormwater treatment the assessment ivil penalties of up o -21per day, yle without i valid 13- enforcement action including pursuant to NCGS 143-215.6. Signature: .4/ i y„ �' 1\D'ate: 7/.,t_ s___.9 Ze)e:"7 i Count of ` , , a Notary Public for the State of I`I�� '^r f1 y ( '� do hereby certify that ,� I( I �� personally appeared before me this day of 1I�I �l( �i�C'�` r 1-4- , �. and acknowledge the due execution of the application fora stormwater permit. Witriess my y hand and official seal, ��J ' ASHTON CARTER Notary Public-North Carolina Guilford County My Comm;ssion Expires August 12,2026 SEAL My commission expires k /Li I,!C 1 Z 2(� L- ' � ,t Form S WU-101 Version July 26,2024 Page 7 of 8 X. APPLICANT'S CERTIFICATION I, (print or type name of person listed in Contact Information, item la) Jer Hard certify that the information included on this permit application form is, to the best of my knowledge, correct that the project will be constructed in nformance with the approved plans, that the required deed restrictions and protective c enants will be rec rd and that the proposed project complies with the requirementsg ect and he applicable sto ater rules under 5 CAC 2H .1000 and any other applicable state storm ater requirements. Signature, I t ' C- 1 (7 Date: GYG�Zei �% , a Notary Pic for the St to of County of I)'Th I r. do hereby certify that L LI ( t personally appeared before me this L�+ I_ day of due execution of the application for a stormwater permit. Witness r �l- and acknowledge the V1 ss myhand and official seal, C Cy`�-- ASHTON CARTER Notary Public-North Carolina Guilford County My Comrr sin Exp rr.„s,lust 12,2026 SEAL My commission expires �C Form SWU-101 Version July 26,2024 Page 8 of 8