SW3170803 - Reafield

SUPPLEMENT—EZ FORM COVER PAGE
Please indicate the types, quantities and locations of SCMs that will be used on this project
Quantity
Location(s)
Infiltration System
Street address
Bioretention Cell
Wet Pond
Stormwater Wetland
City, State, Zip
ICharlotte, NC 28205
Permeable Pavement
Sand Filter 1
Middle of property, behind parking lot
Rainwater Harvesting
Email.
Green Roof
_
Level Spreader -Filter Strip
l
Disconnected Impervious Surface
Treatment Swale
Dry Pond 1
Middle of property, behind parking lot
Designer information for this project:
Name and Title:
(Brian Smith, PE
Urban Design Partners, LLC - T
Organization
Street address
1318-E6 Central Avenue
City, State, Zip
ICharlotte, NC 28205
Phone number(s)
Email:
704-334-3303
lbrian@urbandesignpartners com
DeSi_4ner
111111111/1l//�
O.. FESS/p���29
SEAL -
027890
5o�.1'��
Applicant:
Project Name:
Reafield
Address
F- Rea Road
City / Town
Union County, NC
C.IrmI.
ir
IWn
Q„abfy ,
Company.
Reafield, LLC
Contact
George Macon J
Mailing Address:
2400 South Blvd, Suite #300
City, State, Zip:
Charlotte, NC 28203_
Phone number(s):
704-561-5308
Email.
Igmacon@mpvre com
Certification Statement
I certify, under penalty of law. that this Supplement -EZ form and all supporting
information were prepared under my direction or supervision;
- that the information provided in the form is, to the best of my knowledge
and belief, true, accurate, and complete, and
Signatu a of Desig - that the engineering plans, specifications, operation and maintenance
agreements and other supporting information are consistent with
the information provided here
I am aware that there are significant penalties for submitting false
�1 1 information including the possibility of fines and imprisonment for knowing
Date violations as well as a report being made to my professional board.
Cover Page 1 4 09 PM 8/21/2017

SAND FILTER
Reafield
THE DRAINAGE AREA
q
Drainage area number
1
Break down of BUA in the drainage area (both new and existing).
Total coastal wetlands area (sq ft)
sf
Parking / driveway (sq ft)
61753 sf
Total surface water area (sq ft)
sf
Sidewalk (sq ft)
13044 sf
Total drainage area (sq ft)
4 sf
Roof (sq ft)
22750"sf
BUA associated with existing development (sq ft)
134130 sf
Roadway (sq ft)
-
Proposed new BUA (sq ft)
134130 sf
Other, please specify in the comment box below (sq ft)
36584 sf
Percent BUA of drainage area
.72%
ITotal BUA (sq ft)
134131 sf "
COMPLIANCE WITH THE APPLICABLE STORMWATER PROGRAM
Slormwater program(s) that apply (please specify)
Design rainfall depth (in)
2.6 in
n/a
Minimum volume required (cu ft)
10841 cf
Design volume of SCM (cu ft)
50773 cf
GENERAL MDC FROM 02H.1050
#1 Is the SCM sized to treat the SW from all surfaces at build -out?
Yes
#7 If applicable, with the SCM be cleaned out after construction?
Yes
#2 Is the SCM located on or near contaminated soils?
No
#8 Does the mainetenance access comply with General MDC (6)?
Yes
#3 What are the side slopes of the SCM (H.V)?
3.1
#9 Does the drainage easement comply with General MDC (9)?
Yes
#3 Does the SCM have retaining walls, gabion walls or other engineered side slopes
No
#10 If the SCM is on a single family lot, does the plat comply with General MDC (10)9
#4 Are the inlets, outlets, and receiving stream protected from erosion (10 -year storm)?
Yes
#11 Is there an 08M Agreement that complies with General MDC (11)?
Yes
#5 Is there a a bypass for flows in excess of the design flow?
Yes
#12 Is there an O&M Plan that complies with General MDC (12)?
Nc
#6 What is the method for dewatering the SCM for maintenances
Drawdown Orifice 1#13
Was the SCM designed by an NC licensed professional?
Yes
SAND FILTER MDC FROM 52H.1056
#1 SHWT elevation (fmsl)
n/a
#3 Volume of stormwater from drainage area during design storm (cubic feet)
32646.cf
#1 Type of sand filter (open or closed)
Open
#3 Total volume that can be stored above the sediment and sand chambers (cubic feet)
50773 cf
#1 If closed, describe if the filter will be pre -cast or pour -in-place
#3 Is this sand filter designed to attenuate peak flows?
Yes
#3 Elevation of the bypass device (fmsl)
588 It
#1 If closed, top of grate elevation (fmsl)
n/a
#3 Descnbe the bypass device
42 Volume that can be retained in the sediment chamber (cubic feet)
#2 Will there be a permanent pool in the sediment chamber?
9266 cf
No
20' emergency spillway lined with rip -rap
#2 Bottom of the sediment chamber (fmsl)
585 ft
#4 Ponding depth from the top of the sand to the bypass device (ft)
3 It
#2 Area of the sediment chamber (square feet)
5899 sf
#5 Describe the mechanism for distributing flow over the sand surface
#2 Physical depth of the sediment chamber (inches)
24 in
Slope bottom of pond towards sand bed
#2 Ponding depth in the sediment chamber, above any permanent pool (inches)
24 in
#6 Sand specification for sand chamber
#2 Elevation of top of weir between chambers (fmsl)
#2 Volume that can be retained in the sand chamber (cubic feet)
587 ft
11014 cf
clean washed concrete sand
#2 Bottom of the sand chamber (fmsl)
585 ft
#7 Depth above underdrain pipe (inches)
21 in
#2 Area of the sand chamber (square feet)
6766 sf
#8 Will the media be maintained to drain at least two inches per hour at the sand surface?
Yes
#2 Physical depth of the sand chamber (inches)
24 in
#9 Is at least one clean-out pipe provided at the low point of each underdram line?
Yes
#2 Ponding depth in the sand chamber, above any permanent pool (inches)
24 in 1#9
Will clean-out pipes be capped?
Yes
ADDITIONAL INFORMATION
Please use this space to provide any additional information about this sand filter that you think is relevant to the review.
SHWT has not yet been determined, will provide answer when available;,'Other' impervious area is allocated for future development of another building and parking lot
Sand Filter 2 4 09 PM 8/21/2017

DRY POND
Reafield
THE DRAINAGE AREA
1
Drainage area number
1
Break down of BUA in the drainage area (both new and existing).
Total coastal wetlands area (sq fl)
sf
Parking / driveway (sq ft)
61753 sf
Total surface water area (sq ft)
sf _
Sidewalk (sq ft)
13044 sf
Total drainage area (sq ft)
4 sf
Roof (sq ft)
22750 sf
BUA associated with existing development (sq ft)
134130 sf
Roadway (sq ft)
-
Proposed new BUA (sq ft)
134130 sf
Other, please specify in the comment box below (sq ft)
36584 sf
Percent BUA of drainage area
72%
Total BUA (sq ft)
134131 sf
COMPLIANCE WITH THE APPLICABLE STORMWATER PROGRAM
Stonnwater program(s) that apply (please specify)
Design rainfall depth (in)
2 6 in
n/a
Minimum volume required (cu ft)
10841-cf
Design volume of SCM (cu fl)
50773 cf
GENERAL MDC FROM 02H.1050
#1 Is the SCM sized to treat the SW from all surfaces at build -out?
Yes
#7 If applicable, with the SCM be cleaned out after construction?
Yes
#2 Is the SCM located on or near contaminated soils?
No
#8 Does the mainetenance access comply with General MDC (8)?
Yes
#3 What are the side slopes of the SCM (H•V)?
31
#9 Does the drainage easement comply with General MDC (9)?
Yes
#3 Does the SCM have retaining walls, gabion walls or other engineered side slopes?
No
#10 If the SCM is on a single family lot, does the plat comply with General MDC (10)?
#4 Are the inlets, outlets, and receiving stream protected from erosion (10 -year storm)?
Yes
#11 Is there an 08M Agreement that complies with General MDC (11)?
Yes
#5 Is there a a bypass for flows in excess of the design flow?
Yes
#12 Is there an 08M Plan that complies with General MDC (12)?
Yes
#6 What is the method for dewatenng the SCM for maintenance?
Drawdown Onfice
#13 Was the SCM designed by an NC licensed professional?
Yes
DRY POND MDC FROM 02H .1062
#1 SHWT elevation (fmsl)
n/a
#5 Describe the pretreatment that will be provided for the dry pond
#1 Elevation of the bottom of the dry pond (fmsl)
585 ft
Forebay separated by stone berm
#1 Distance from bottom to SHWT (feet)
n/a
#6 Size of drawdown onfice (in)
n/a
#2 Elevation of the temporary pool during the design storm (feet)
568 ft
#6 Drawdown time for the temporary pool (hours)
n/a
#2 Ponding depth of the design storm (feet)
3 ft
#7 Does the pond minimize impacts to the receiving channel from the 1 -yr, 24 -hr storm?
Yes
#3 Will the dry pond be uniformly graded to flow toward the outlet?
Yes
48 Is there a small permantent pool near the onfice to prevent clogging?
Yes
#3 Is a low flow channel being provided?
No
#8 Describe how the outlet will be designed to prevent clogging:
#4 Are the inlet(s) and outlet located in a manner that avoids short-circuiting?
#4 Describe any measures, such as berms or baffles, that will be taken to increase the flow path
Yes
Grated top to avoid debris from entering outlet structure
n/a
#9 Are the dam and embankment planted in non -clumping turf grass?
#9 Species of turf that will be used on the dam and embankment
#9 Will trees and shrubs be prevented from growing on the dam and embankment?
as
n/a
Yes
ADDITIONAL INFORMATION
Please use this space to provide any additional information about this dry pond that you think is relevant to the review
Other' impervious area allocated for future development of another budding & parking lot
Dry Pond 3 4 09 PM 8/21/2017

-rA7-r�1SatV
DEMLR USE ONLY
D t Receiv
ee Paid -e
Permit Nu
,-
_)
Applicab e Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ff Ph II :_Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan: -e S (X "r1_r?_ C j2)<'.
State of North Carolina
X.vtctS-c '%r_w't Got.gz CRTC dtW" �
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form ntay 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.) -
2. Location of Project (street address):Riz
Rea Road C/vI
City: County.Union County Zip:28173r'a's a
3. Directions to project (from nearest major intersection):)";1�-1.A
OttitD I
Travel 0.4 miles northwest from the intersection of Rea Road and Tom Short Road �n7 Ar 13i1 p
4. Latitude:35° 01' 08" N Longitude:80° 48' 21" 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 ntodtftcahons also requires SINU-102 - Renezoal Application Form
b. If 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 (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System ❑Other
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: 8.68 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 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. httu:////portal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 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: Reafiel d, LLC
Signing Official & Title:George Macon, Owner
b. Contact information for person listed in item 1a above:
Street Address:2400 South Blvd, Suite 300
City:Charlotte
Mailing Address (if applicable):
City:
Phone: (704 ) 561-5308
Email: [e-mail]
State -NC Zip:28203
State: Zip:
Fax: ( 1
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: Reafield, LLC
Signing Official & Title:George Macon, Owner
b. Contact information for person listed in item 2a above:
Street Address:2400 South Blvd, Suite 300
City Charlotte
Mailing Address (if applicable):
City:
Phone: (704 ) 561-5308
Emajl:[e-mail]
State:NC Zip:28203
State: Zip:
Fax: ( 1
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:
Phone:
4. Local jurisdiction for building permits:
Point of Con
State:
Fax:
Phone #: (
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6
Zip:

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Runoff from the site will be captured in a pipe system and carried to a dry pond with a sand filter
which shall provide water quality treatment of 90% TSS removal and contro 1peak runoff rates back to
pre -developed conditions. The pond has been sized to treat some future development on site.
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 Catawba River basin
4. Total Property Area: 8.68
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+:8.68 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 fi,ont the NHW (or MHM line. The resultant project area is used to
calcidate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHW) line may
be included tit the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 72
9. How many drainage areas does the project have?1 (For high density, coatnt 1 for each proposed engineered
stortnwater 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
McBride Branch
Stream Class *
C
Stream Index Number *
11-138-3-3
Total Drainage Area (so
187,389
On-site Drainage Area (so
187,389
Off-site Drainage Area (sf)
0
Proposed Impervious Area** (so
134,130
Impervious Area** total
72
Impervious— Surface Area
Drainage Areal Drainage Area _ Drainage Area _ Drainage Area _
On-site Buildings/Lots (so
22,750
On-site Streets (so
0
On-site Parking (sf)
61,753
On-site Sidewalks (so
13,044
Other on-site (so
0
Future (so
36,584
Off-site (so
0
Existing BUA*** (so
0
Total (so:
134,130
* Stream Class and Index Number can be determined at: http://portal.ncdenr.org web/wq/ps/esn/classifications
bnpennous area is defined as the built upon area including, but not limited to, bttildings, 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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off-site impervious area listed above determined? Provide documentation.
No off-site impervious included
Proiects 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 requnrennents 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://12ortal.ncdenr.org/web/wq/ws/su/bmp-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms docs. 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 ht42:/ /12ortal.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 httl2://portal.ncdenr.org/web/wq/ws/su/statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. LAY
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants Yl a
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
hgp://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
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.
7. Sealed, signed and dated calculations (one copy).
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 buffer 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.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
in. 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).
Form SV U-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required). �/�
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify r "/�
"
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 W< < �� �c j
project area clearly delineated. For projects with infiltration BMPs, the report should also 1�
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 verifij the SHWT prior
to subnzittal, [phone].)
10. A copy of the most current property deed. Deed book: 6893 Page No: 886 L -26-r
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC Lzrx
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.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.secretaKy.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/lr/state-stormwater-
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 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:Brian D. Smith
Consulting Firm: Urban Design Partners LLC
Mailing Address:1318-E6 Central Avenue
City -Char
State:NC
Zip:28205
Phone: (704 ) 334-3303 Fax: (704 ) 334-3305
Email:[e-mail]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or hjpe name of person listed in Contact Informatton, item 2a) certify that I
own the property identified in this permit application, and thus give permission to (print or hjpe name of person
listed in Contact Information, item 1a) with (print or type name of organization listed to
Contact Ittfortnation, item 1a) 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.
Form SWU-101 Version Oct. 31, 2013 Page 5 of 6

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.
Date:
a Notary Public for the State of
do hereby certify that
County of
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, (pent or hjpe name of person listed in Contact Information, item 1a) George Macon
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 st wa er rules under 15A NCAC 21-1.1000 and any other applicable state stormwate eq'uire7nts.
Signature: Date: ��CY
I, dk6a n C , t'u r6 er a Notary Public for the State of ? �Q r 01/County of.
/ ►f do hereby certify that D f _'e `/:�QeD n personally appeared
before me this y of and ackliowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
,0 c
SEAL
My commission expires
Form SWU-101 Version 06Aug2012 Page 6 of 6