SW3241004_Application Form_20241118

DEMLR USE ONLY
Date Received Fee Paid Permit Number
Applicable Rules: ❑Coastal SW-1995 0 Coastal SW-2008 El Ph II-Post Construction
(select all that apply) ❑Non-Coastal SW-HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑Other WQ Mgmt Plan:
State of North Carolina
Department of Environmental Quality
Division of Energy, Mineral and Land Resources
POST-CONSTRUCTION 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.):
Central Cowboy Church
2. Location of Project(street address):
11777 US-601
City:Midland County:Cabarrus Zip:28107
3. Directions to project(from nearest major intersection):
From the intersection of NC-27 and US-601, head north 0.3 Miles and turn right onto Central Station Cowboy
Church across from Cordell Ct.
Note: Lat-Long for Item 4 is based on EC Construction entrance locaiton, not main entrance of church.
4. Latitude:35° 15' 19.3" N Longitude:80° 29' 56.6"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 SWU-102-Renewal Application Form
b.lf this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: [Not Started Partially Completed* ❑ Completed* `provide a designer's
certification
2. Specify the type of project:
®Low Density ❑High Density ❑Drains to an Offsite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR 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):
❑CAMA Major ®Sedimentation/Erosion Control: 5.53 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 Permit: Proposed Impacts
b.lf any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport? No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr.orq/web/Ir/rules-and-regulations
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:Central Station Cowboy Church Inc.
Signing Official &Title: '. C SAA ?kOroe
b.Contact information for person listed in item 1a above:
Street Address:11777 US-601
City:Midland State:NC Zip:28107
Mailing Address (if applicable):
City: State: Zip:
Phone: (980 ) 521-6371 Fax: (
Email•smith.freedom.ranch( gmail.com
c.Please check(one)the appropriate box. The applicant listed above is:
E 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:
Signing Official &Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ( ) Fax: (
Email:
4, Local jurisdiction for building permits: Town of Midland
Point of Contact:Craig Thomas (Planning Admin) Phone#: 704 ) 888-2232 ext. 17
Email:cthomas cnr midlandnc.us
Form S WU-10l 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.
Site is low density, no SCM required. The Site used to be a farmland, the site will seed/qrass the area
disturbed to provide a more permanent stable ground than farmland.
2.a.lf 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 Yadkin Pee-Dee River basin.
4. Total Property Area: 10.45 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4)—Total Coastal Wetlands Area (5)—Total Surface Water Area (6) = Total Project
Area': 10.45 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(MHW)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 MHW)line may be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area/Total Project Area)X 100 = 22.5
9. How many drainage areas does the project have?2 (For high density, count 1 for each proposed SCM. For
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 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 2 Drainage Area ,Drainage Area—
Receiving Stream Name Anderson Creek
Stream Class * C
Stream Index Number* 13-17-13
Total Drainage Area (sf) ±9,164,588
On-site Drainage Area (sf) ±455,638
Off-site Drainage Area (sf) ±8,708,951
Proposed Impervious Area** (sf) ±61,710
% Impervious Area** (total) 13.5%
Impervious**Surface Area Drainage Area 1 Drainage Area 2 Drainage Area 3 Drainage Area
On-site Buildings/Lots (sf) 0
On-site Streets (sf) 31,847
On-site Parking (sf) 29,862
On-site Sidewalks (sf) 0
Other on-site (sf) 0
Future (sf) 0
Off-site (sf) ±1,516,193
Existing BUA***(sf) ±40,731
Total (sf): ±1,618,634
*Stream Class and Index Number can be determined at:https://www.deq.nc.gov/about/divisions/water-resources/water-
plannin q/cla ssification-standards/classification s
** 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 SWU-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.
Aerial images and Cabarrus County 2FT LiDAR.
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 028.0600,
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 https://www.deq.nc.qov/about/divisions/energy-mineral-and-land-resources/stormwater/stormwater-
proqram/stormwater-desiqn-manual. For SCMs subject to older design standards or offsite projects, the archived
supplement can be found from https://www.deq.nc.qov/about/divisions/enerqy-mineral-and-land-
resources/stormwater/stormwater-program/stormwater-design-manual/archived-stormwater-design-manual-
supplemental-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
https://www.deq.nc.gov/about/divisions/energy-mineral-and-land-resources/stormwater/post-construction-
proqram/new-permits-permit-modifications. The complete application package should be submitted to the
appropriate DEMLR Office. (The appropriate office may be found by locating project on the interactive online
map at https://www.deq.nc.qov/about/divisions/energy-mineral-and-land-resources/stormwater/stormwater-
program/post-construction-program.)
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 https://www_deq_nc.qov/about/divisions/energy-mineral-
and-1 a nd-resources/stormwater/stormwater-program.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. NEW
2. Original and one copy of the signed and notarized Deed Restrictions & Protective PIA-
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) (sealed, signed and dated) and O&M NEW
agreement(s)for each SCM. (please refer to Section V for more information)
4. Appropriate permit application processing fee per NCGS 143-215.3D(e)(2)payable to �►�Ortysp„�51�
NCDEQ.
A full list of fee adjustments is available on the DEQ website:
https://www.deq.nc.gov/accessdeq/permit-fees-2023-updates
(For an Express review, refer to: https://www.deq.nc.qov/accessdeq/express-permittinq 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 N fib
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 NEW
or the receiving stream drains to class SA waters within 'A mile of the site boundary, include
the mile radius on the map.
7. Sealed, signed, and dated calculations (one copy). NEW
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: NEW
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 impounded
structures, the banks of streams or rivers, and the MHW(or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings &distances.
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 by a
qualified person; 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).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify NEW
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 SCMs,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 DEMLR to verify the SHWT
Prior to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 16968 Page No: 0109 Stink etv:ovOly
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC f.1//t
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2H.1040(1).
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
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: Relevant section:
14. If a modification to an existing 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
i. Deed restrictions and protective covenants limiting the BUA so that it
does not exceed the capacity of the SCM(s) or the BUA thresholds.
ii. Drainage easements, when applicable.
iii. 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 deed restrictions and
protective covenants forms can be downloaded from https://www.deq.nc.qov/about/divisions/enerqy-mineral-and-
land-resources/stormwater/stormwater-program/post-construction-program/post-construction-forms. 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 DEMLR, 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:Nancy Elizabeth Warlick, P.E.
Consulting Firm: CESI
Mailing Address:PO Box 268
City:Concord State:NC Zip:28026
Phone: (704 ) 648-2684 Fax: ( )
Email:lizwarlick(c cesicgs.com
Form SWU-101 Version July 26,2024 Page 6 of 8

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) e Sv1n. Th , 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 /a) with (print or type name of organization listed in
Contact Information, item la) to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
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 DEMLR Stormwater permit reverts back
to me, the property owner.As the property owner, it is my responsibility to notify DEMLR 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 assessme ' penalties of up to$25,000 per day, pursuant to NCGS 143-215.6.
Signature: J '` Date: ��
e � j
I, ) Pr-- ^r S , a Notary Public for the State of /n"
County of C , do hereby certify that -e i- Ste.M'ti
personally appeared before me this r-;--% day of 0 C1-o -- , _Abaci , and acknowledge the
due execution of the application for a stormwater permit. Witness my hand and official seal,
Tee-i /A.:51\xi,_010
ehr
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SEAL
Eff
My commission expires t f °l 1 ag
Form SWU-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) Q.'Q S Mt
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 star rules 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Signature: Date: Zagr z_
/
G Ic1.4-0--0 S , a Notary Public for the State of �ci
Coun y of ( hcwrrt.S , do hereby certify that ie ..5h1
personally appeared before me this day of f , 2b -4 , and acknowledge the
due execut'onn of the application r a itormwater permit. Witness my hand and official seal,
"1�_ � `
8' 8"""/1,,flyq •y
b ' ,oTA RA I {{
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3 „. VG & K0,
eire
SEAL
My commission expires la a q, —en AA-
Form SWU-101 Version July 26,2024 Page 8 of 8