20090189 Ver 1_401 Application_20090209

Stocks Engineering, P.A.
DesLoo.iwg the Future, Today.
© 1
February 23, 2009
Mr. Ian McMillan
401 Oversight/Express Review Permitting Unit
NCDENR Raleigh Office
2321 Crabtree Boulevard, Suite 250
Raleigh, NC 27604
Re: Proposed Autumn Corporation Cape Fear
Assisted Living/Nursing Home
PCN Application
Dear Mr. McMillan:
This letter is in response to your letter dated January 2, 2009, requesting additional information in order to
process a PCN Application for the above referenced project.
The layout enclosed is a result of recent coordination with Annette Lucas of your office in an effort to meet the
low-density requirements for this site. The enclosed design addresses these concerns by documenting <24%
impervious drainage areas, minimal inlets and pipe, and vegetated conveyance.
Thank you in advance for your review of this information. Feel free to contact me with any questions or
comments.
Sincerely,
Stocks Engineering, P.A. - Raleigh
Donald L. Curry, Jr., P.E.
Associate
Encl: Completed PCN Application
Agent Authorization
Site Narrative
NCDENR SWU 101 Form
NCDENR Low Density Supplemental Form
Review Fee
Calculations
J. Michael Stocks, PE
1100 Eastem Ave.
PO Box 1108
Nashville, NC 27856
252.459.8196 (voice)
252.459.8197 (fax)
252.903.6891 (mobile)
[e-mail]
Paul D. Smith, PE
3344 Hillsborough Street
Suite 250
Raleigh, NC 27607
919.821.2440 (voice)
919.821.2210 (fax)
919.880.5886 (mobile)
[e-mail]
Autumn Care Cape Fear
Fayetteville, NC
Site Location Narrative
Proiect Narrative
This project lies on 71St School Road in Fayetteville, Cumberland County, NC. The
19.98 acre site is located on the south side of town, approximately 0.65 miles north of the
intersection of 71St School Road and Raeford Road. The site is currently undeveloped
with grass and wooded vegetation. The site drains to the south and west into an existing
wetland and into unnamed tributaries to Beaver Creek which is part of the Cape Fear
river basin.
The proposed development consists of a 47,000 sf, 90 bed nursing facility with associated
parking lots and infrastructure. Seventeen percent of the site is proposed impervious with
the remainder of the site either landscaped or left undisturbed. The proposed runoff will
consist of a combination of sheet flow, ditch/vegetated conveyance and piped flow,
draining to an existing wetland along the east property line. The proposed development
consists of 3 drainage areas as documented in the calculations and applications forms.
All drainage areas drain to unnamed tributaries of Beaver Creek to the south, which are
classified as type C.
1. General Information
a. Name of Project
Autumn Care Cape Fear
b. Street Address, City, County
This site is located in Fayetteville, Cumberland County, approx. 0.65 miles north
of the intersection of 71". School Rd and Raeford Rd
c. Acres in Tract
19.9& ac
d. Acres Being Disturbed
10.3 ac
e. Acres in Wetlands
1. Wetlands Must Be Delineated & Sign-Off Obtained From The Corps
2. Proposed Wetland Impacts Require Permits From Corps & DWQ
There are approximately 3.27 ac of wetlands on site.
L Ownership Information
Current Owner:
Autumn Corporation
451 North Winstead Ave.
Rocky Mount, NC 27804
Deed Book 7895, Page 0325
Parcel ID #9497-72-8307
g. Description of Development Proposal
1. Previous or Existing Permits
None.
2. Tax parcel ID Number
Parcel ID #9497-72-8307
h. Pre-1988 Built Upon Area, If Applicable
The site has no history of development. It has always been a vacant site.
i. Discuss Phasing of the Project & Stormwater Facilities When Applicable
N/A
j. Discuss Proposed Waste Water Treatment & Water Supply
Proposed sanitary and water connections will be extended to the site as part of
the Fayetteville PWC utility system.
k. Identify Historic Sites & Projects Being Funded With Public Monies
There are no historic sites on this property. Public money is not being used for
this development.
1. Disclose Any/All Non-Compliance Issues with DENR Agencies
Not applicable.for this site.
2. Stormwater Information
a. Provide River Basin, Stream Classification & Index Number for All water
Bodies On or Adjacent To The Project or Closest to The Project Area
The site drains to a tributary to Beaver Creek which then drains into the Cape
Fear River. Beaver Creek has a surface water classification of C.
b. Identify Whether the Stormwater Design is High Density or Low Density,
Commercial or Residential, State Stormwater or NPDES Phase II, Address
Vested Rights When Applicable; Identify Pockets of High Density
The site is designated Low Density Commercial, with a maximum allowable
impervious of 24% Actual proposed impervious is 17%.
c. Proposed Total % Impervious Surface
3.40 acres or 17% Impervious
d. Number of Proposed Treatment Measures, Type(s) of Collection System
This meets the requirements of a Low Density development, which includes
vegetated conveyances. Additional BMP measures are not applicable for this
density.
e. Will All Built Upon Area Be Collected
No.
E Identify Whether or Not the Project Has Buffer Requirements & Whether or
Not Development Is Proposed Within A Buffer
There are no buffer requirements and the proposed development is not within a
buffer.
g. Disclose Whether or Not Off-Site Runoff Is Coming Onto The Site or Into
The Proposed BMP
There is a small amount of off site runoff from the eastern part of the site. Also,
the wetland drains approximately 400 acres through this site.
h. Discuss Whether Road Construction Across Other property Is Necessary To
Access This Project
An access easement has been acquired to access this site. A driveway is proposed
to access 71" School Rd
End of Narrative

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Ditch Flow
Project Name:
Ditch # :
Station Range/Description:
Favetteville Autumn Care
1
Ditch for DA #1
Peak Discharge Calculation:
Drainage Area = 126383 sf
2.90 acres
Q1o=CxIxA
C= 0.35
I10 = 7.08 in/hr
A = 2.90 acres
Qio = 7.19 cfs
Determine Ditch Flow Depth (d) and Velocity (v) Check for Permanent Condition:
Apply Manning's Equation: V= 1.49/n * R2'*Sln , Q=A/V
Ditch Characteristics:
n = 0.03 grass
Base Width (B) = 2 ft
M = 3 M:1
Ditch Slope (S) = 8.00% ?--??
Permissible Max Velocity (Vp) 5.00 fps FBI
Apply the Following Analysis to Determine Actual "d" and "V"
d = flow depth = 0.39 ft
Area (A) = B*d + M*d2 - 1.22
Perimeter (P) = b + 2d*(M2+1)'5 4.44
R = AT = 0.27
VpR = V Permiss * R = 1.37
V = Flow Velocity = 5.90 fps
Q = design flow = 7.19 cfs
Check Ditch Velocity for Lining:
VP = 5.00 fps
Vactual = 5.90 fps
Vactual>Vallow, Find Perm Lining
check Q: OK
Page 1
Ditch Flow
Find Permanent Lining: Ditch #1
Recalculate with Liner:
Liner Material = 10" Stone (NCDOT Cl.1)
n = 0.078 10" Stone (NCDOT Cl. I)
Base Width (B) = 2 ft
M= 3
Ditch Slope (S) = 8.00%
T allow (Td) 4.00 10" Stone (NCDOT Cl. l)
Apply the Following Analysis to Determine Actual "d" and "V"
d = flow depth = 0.63
Area (A) = B*d + M*d2 = 2.43
Perimeter (P) = b + 2d*(M2+45 - 5.96
R = AT = 0.41
V = Flow Velocity = 2.96 fps
Q = design flow = 7.19 -- cfs check Q: OK
shear stress - -y *d *s
Y 62.4 lb/ft3
d= 0.63 ft
S = 8.00%
Tshear stress = 3.13
Compare Tshear stress to Td:
T allow (Tp) 4.00
Tshear stress = 3.13
Tshear stress = Td => OK
Page 2
Ditch Flow
Project Name: Fayetteville Autumn Care
Ditch # : 2
Station Range/Description: Ditch for DA #2
Peak Discharge Calculation:
Drainage Area = 185062 sf
4.25 acres
Qio=CxIxA
C = 0.44
110 = 7.08 in/hr
A = 4.25 acres
Qio = 13.23 cfs
Determine Ditch Flow Depth (d) and Velocity (v) Check for Permanent Condition:
Apply Manning's Equation: V=1.49/n * R2'*S", Q=AN
Ditch Characteristics:
n = 0.03 4" stone
Base Width (B) = 2 ft --THI
M = 3 M:1
Ditch Slope (S) = 8.00% ?--?
Permissible Max Velocity (Vp) 5.00 fps FBI
Apply the Following Analysis to Determine Actual "d" and "V"
d = flow depth = 0.53 ft
Area (A) = B*d + M*d2 = 1.89
Perimeter (P) = b + 2d*(M2+1).5 - 5.33
R = A/P = 0.35
VpR = V Permiss * R = 1.77
V = Flow Velocity = 7.01 fps
Q = design flow = 13.23 cfs check Q: OK
Check Ditch Velocity for Lining:
VP = 5.00 fps
Vactual = 7.01 fps
Vactual>Vallow, Find Perm Lining
Page 3
Ditch Flow
Find Permanent Lining: Ditch #2
Recalculate with Liner:
Liner Material = 14" Stone (NCDOT Cl.11)
n = 0.078 14" Stone (NCDOT Cl. II)
Base Width (B) = 2 ft
M= 3
Ditch Slope (S) = 8.00%
T allow (Td) 5.00 14" Stone (NCDOT Cl. II)
Apply the Following Analysis to Determine Actual "d" and "V"
d = flow depth =
Area (A) = B*d + M*d2
Perimeter (P) = b + 2d*(M2+1).5
R = A/P =
V = Flow Velocity =
Q = design flow =
0.84
3.80
7.31
0.52
3.48 fps
13.21 cfs check Q: OK
- y
shear stress *d *s
y = 62.4 lb/ft3
d = 0.84 ft
S = 8.00%
Tshear stress - 4.19
Compare Tshear stress to Td:
T allow (Tp) 5.00
Tshear stress - 4.19
Tshear stress = Td => OK
Page 4
Ditch Flow
Project Name: Fayetteville Autumn Care
Ditch # : 3
Station Range/Description: Ditch for DA #3
Peak Discharge Calculation:
Drainage Area = 356874 sf
8.19 acres
Qio=CxIxA
C = 0.44
110 = 7.08 in/hr
A = 8.19 acres
Qio = 25.52 cfs
Determine Ditch Flow Depth (d) and Velocity (v) Check for Permanent Condition:
Apply Manning's Equation: V=1.49/n * R"*S", Q=A/V
Ditch Characteristics:
n = 0.03 grass
Base Width (B) = 2 ft
M = 3 M:1
Ditch Slope (S) = 8.00% ?--?
Permissible Max Velocity (Vp) 5.00 fps FBI
Apply the Following Analysis to Determine Actual "d" and "V"
d = flow depth = 0.73 ft
Area (A) = B*d + M*dZ = 3.05
Perimeter (P) = b + 2d*(M2+1).5 - 6.61
R = AT = 0.46
VpR = V Permiss * R = 2.31
V = Flow Velocity = 8.37 fps
Q = design flow = 25.52 cfs check Q: OK
Check Ditch Velocity for Lining:
VP = 5.00 fps
Vactual = 8.37 fps
Vactual>Vatlow, Find Perm Lining
Page 5
Ditch Flow
Find Permanent Lining: Ditch #3
Recalculate with Liner:
Liner Material = 18" Stone
n= 0.085 18" Stone
Base Width (B) = 2 ft
M= 3
Ditch Slope (S) = 8.00%
T allow (Td) 6.00 18" Stone
Apply the Following Analysis to Determine Actual "d" and "V"
d = flow depth = 1.18
Area (A) = B*d + M*d2 = 6.58
Perimeter (P) = b + 2d*(M2+1).5 - 9.49
R = A/P = 0.69
V = Flow Velocity = 3.88 fps
Q = design flow = 25.52 cfs check Q: OK
Tshear stress - -'*d*s
y 62.4 lb/ft3
d = 1.18 ft
S = 8.00%
Tshear stress - 5.91
Compare Tshear stress to Td:
T allow (Tp) 6.00
Tshear stress - 5.91
Tshear stress = Td => OK
Page 6
:
LETTER OF TRANSMITTAL
J. Michael Stocks, PE:, . Paul D. Smith, PE
PO Box 1108 3344 Hillsborough Street
Nashville, NC 27856 F; B 2 2009 Suite 250, Raleigh, NC 27607
252.459.8196 (0) 919.821.2440 (0)
252.903.6891 (C) D r?R w?r?? ??!c.
WETLANDS AND SCDRSai?WER ?R gRANGl! 919.880.5886 (C)
To: Mr. Ian McMillan
401 Oversight/Permitting Unit
NCDENR Raleigh Office
2321 Crabtree Blvd., Suite 250
Raleigh, NC 27699-1650

Phone: [phone]
I
Overnight No x
Yes
Job No. Z-2007-016
Job Name: Cape Fear Valley Site

Date: 02-23-09

Sent By. Don Curry, PE
We are sending you the following:
? EC Plans x Prints/Plans ? Construction Plat ? Site Plan Drawings ? Computer Disk
? Contracts x Permit Applications ? Site Work Calculations ?
These are transmitted as checked below:
x For Approval ? As Discussed ? For Your File ? As Requested ? For Your Use
? For Review and Comment ? For Your Signature, then return to:
Copies Date Description
2 Permit Plans Full Size
3 Permit Plans 11x17
1 $240 Application Fee
5 PCN Application, Agent Auth Form, SWU-101 Form, Low Density Supplemental
(1 Orig, 4 Copies)
1 Narrative
1 Letter
Remarks
Enclosed are applications and plans for permit review. Feel free to contact me with any questions
Thanks.
Don (Ra/eiah Office
Copies To: file
of wArF9 !± , r
a? FFB s ? 2009
? r
a Y DENR-WgERQQA01Y
VgETLP.NDS ikND STOR'ft""TER 8RANCH

Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps:
®Section 404 Permit E:1 Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 39 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ® Yes ? No
1d. Type(s) of approval sought from the DWQ (check all that apply):
® 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required?
YES For the record only for DWQ 401
Certification:
® Yes ? No For the record only for Corps Permit:

® Yes ? No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in-lieu
fee program. ? Yes ® No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: Autumn Care Cape Fear Nursing Home
2b. County: Cumberland
2c. Nearest municipality / town: Fayetteville
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: N/A
3. Owner Information
3a. Name(s) on Recorded Deed: Autumn Corporation
3b. Deed Book and Page No. 7895/8307
3c. Responsible Party (for LLC if
applicable): Gerald Cox
3d. Street address: 451 N. Winstead Ave.
3e. City, state, zip: Rocky Mount, NC 27804
3f. Telephone no.: 252-443-6265
3g. Fax no.: 252-443-2703
3h. Email address: [e-mail]
Page 1 of 10
PCN Form - Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: ® Agent ? Other, specify:
4b. Name: Donald L. Curry, Jr., PE
4c. Business name
(if applicable): Stocks Engineering, PA
4d. Street address: 3344 Hillsborough St., Suite 250
4e. City, state, zip: Raleigh, NC 27607
4f. Telephone no.: 919-821-2440
4g. Fax no.: 919-821-2210
4h. Email address: [e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): 9497-72-8307
1b. Site coordinates (in decimal degrees): Latitude: 35.04736 Longitude: - 79.00567
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size: 19.98 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: Beaver Creek
2b. Water Quality Classification of nearest receiving water: "C"
2c. River basin: Cape Fear
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
Mostly wooded around wetland area, partially cleared with stockpiled logging material on site.
3b. List the total estimated acreage of all existing wetlands on the property:
3.27 AC
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
1,670
3d. Explain the purpose of the proposed project:
Nursing Home
3e. Describe the overall project in detail, including the type of equipment to be used:
Heavy equipment for grading and building erection operations.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Comments:

? Yes ? No Unknown
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
? Preliminary ? Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ? Yes ? No Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
Page 3 of 10
PCN Form - Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
® Wetlands ? Streams - tributaries ? Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary T
W1 ®P ? T FILL ® Yes
? No ? Corps
? DWQ 0.05
W2 ? P ®T TEMP CLEARING ® Yes
? No ? Corps
? DWQ 0.01
W3 ? P ? T ? Yes ? Corps
? No ? DWQ
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes ? Corps
? No ? DWQ
2g. Total wetland impacts 0.06
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ - non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)
S1 ? P ? T ? PER ? Corps
? INT ? DWQ
S2 ? P ? T ? PER ? Corps
? INT ? DWQ
S3 ? P ? T ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T ? PER ? Corps
? INT ? DWQ
S6 ? P ? T ? PER ? Corps
? INT ? DWQ
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form - Version 1.3 December 10, 2008 Version
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual) list all open water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number - (if applicable) Type of impact Waterbody type Area of impact (acres)
Permanent (P) or
Temporary T
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
0. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed, then complete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose (acres)
number of pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then you MUST fill out Section D of this form.
6a.
? Neuse ? Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number - Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) or for Stream name mitigation (square feet) (square feet)
Temporary T impact required?
B1 ?P?T ?Yes
? No
B2 ?P?T ?Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts
6i. Comments:
Page 5 of 10
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Proposed alignment minimizes wetland impact and 2:1 slopes over impacted area minimize fill footprint.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Contractor is to take extra care to keep equipment within affected area and stabilize crossing as initial phase of work.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ® No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, w hich mitigation option will be used for this
project? ? Mitigation bank
? Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form - Version 1.3 December 10, 2008 Version
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ? Yes ® No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified ? Yes ® No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
El Yes No
?
Comments:
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 17%
2b. Does this project require a Stormwater Management Plan? ? Yes ® No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: Not Required per City of Fayetteville
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project? City of Fayetteville
? Phase II
3b. Which of the following locally-implemented stormwater management programs ? NSW
? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No
attached?
4. DWQ Stormwater Program Review
? Coastal counties

4a. Which of the following state-implemented stormwater management programs apply ? HQW
? ORW
(check all that apply):
? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes ? No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 8 of 10
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the ? Yes ® No
use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ? Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ? Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes ® No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ? Yes ® No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ? Yes ® No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Enclosed system via existing WWTF per PWC/City of Fayetteville.
Page 9 of 10
PCN Form - Version 1.3 December 10, 2008 Version
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ? Yes ® No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ? Yes ® No
impacts?
El Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
Phase I Study
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
Phase I Study
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation ? Yes ® No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
Phase I Study
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ® No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
Donald L. Curry, Jr., PE
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nted Name Applicant/Agent's S g ture Date
(Agent's signature is valid only if an authoriz ion letter from the applicant
is provided.)
Page 10 of 10
JAN 2 2009
SAMPLE AGENT AUTHORIZATION FORM
WAFER QUALITY
PROPERTY LEGAL DESCRIPTION: NIE?LANU?ANDS70RMW??SEFtBRfW?
LOT NO.
PLAN NO. PARCEL ID: g141t7 - 7 Z - 8 3c:,7
STREET ADDRESS: -11 s r 5c.w-vot- ?-D
Please print:
Property Owner: C-?"? fox , cS rD .?
Property Owner:

? v .J lZ?a?2,Ec?ce.s 445-1 f/. W t-j S ? AV
90C-Y-y vJ.-tr, rJ C- Z '780`1
The undersigned, registered property owners of the above noted property, do hereby authorize
?vr tA.r. u . Cog" i?lZ Q? , of ?S ?,1C?r t't rZc &I R4
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
AV U.MlJ CO(LPOP-ATca J q5'1 N• W(J5ry32W Ash-= Pxr`t itao ?..1 c '1 c z? 8044
Telephone: ZSZ -1443 -b2-4.S
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
.- i
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thorized ignature - f r Authorized Signature
Date: ?? Q Date:
4,
DWQ USE ONLY
Date Received Fee Paid Permit Number
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Applicants name (specify the name of the corporation, individual, etc. who owns the project):
Autumn Care Cape Fear of Fayetteville
2. Print Owner/ Signing Official's name and title (person legally responsible for facility and compliance):
Gerald Cox President
3. Mailing Address for person listed in item 2 above:
P.O. Box 7728
City:Rocky Mount State:NC Zip:27804
Phone: (252 ) 443-6265 Fax: (252 ) 443-2703
Email:[e-mail]
4. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Autumn Care Cane Fear of Favetteville
5. Location of Project (street address):
71s' School Rd (Parcel ID 9497-72-8307)
City:Fayetteville County:Cumberland
Zip:28314
6. Directions to project (from nearest major intersection):
Approx. 3,400' north of the intersection of US 401/Raeford Rd and 71St School Rd.
7. Latitude:35° 02' 50.44" N Longitude:79° 00' 18.90" W of project
8. Contact person who can answer questions about the project:
Name:Donald L. Curry, Jr., PE Telephone Number: (919 ) 821-2440
Email: [e-mail]
II. PERMIT INFORMATION:
1. Specify whether project is (check one): ®New ?Renewal ?Modification
Form SWU-101 Version 03.27.08
Page 1 of 4
' 2. If this application is being submitted as the result of a renewal or modification to an existing permit, list the
existing permit number N/A and its issue date (if known)
3. Specify the type of project (check one):
®Low Density ?High Density ?Redevelop ?General Permit ?Universal SMP ?Other
4. 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 ®404/401 Permit ?NPDES Stormwater
III. PROJECT INFORMATION
1. In the space provided below, summarize how stormwater will be treated. Also attach a detailed narrative (one
to two pages) describing stormwater management for the project.
Low Density - vegetated conveyance into existing wetland
2. Stormwater runoff from this project drains to the Cape Fear River basin.
3. Total Property Area: 19.98
acres 4. Total Wetlands Area: 3.27 acres
5. 100' Wide Strip of Wetland Area: N/A acres (not applicable if no wetlands exist on site)
6. Total Project Area**:19.98
acres 7. Project Built Upon Area:17 %
8. How many drainage areas does the project have?3
9. Complete the following information for each drainage area. If there are more than two drainage areas in the
project, attach an additional sheet with the information for each area provided in the same format as below.
For high density projects, com lete the table with one drainage area for each engineered stormwater device.
Basin Information Drainage Area 1 Drainage Area '2
Receiving Stream Name Unnamed Trib to Beaver Creek Unnamed Trib to Beaver Creek
Stream Class & Index No. C C
Total Drainage Area (so 126,383 185,062
On-site Drainage Area (so 77,484 180,051
Off-site Drainage Area (sf) 48,899 5,011
Existing Impervious* Area (so 0 0
Proposed Impervious*Area (so 11,977 44,014
% Impervious* Area (total) 9.5% 23.8%
Impervious* Surface Area Drainage Area 1 Drainage Areal
On-site Buildings (so 0 11,015
On-site Streets (so 0 0
On-site Parking (so 11,218 27,713
On-site Sidewalks (so 759 5,286
Other on-site (so 0 0
Off-site (sf) 0 0
Total (so 11,977 44,014
* Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks,
gravel areas, etc.
**Total project area shall be calculated based on the current policy regarding inclusion of wetlands in the built upon area
percentage calculation. This is the area used to calculate percent project built upon area (BUA).
Form SWU-101 Version 03.27.08 Page 2 of 4
Basin Infprination Drainage Area I
Receiving Stream Name Unnamed Trib. To Beaver Creek
Stream Class & Index No. C
Total Drainage Area (sf) 356,874
On-Site Drainage Area (sf) 291,600
Off-Site Drainage Area (sf) 65,274
Existing Impervious Area (sf) 0
Proposed Impervious Area (sf) 84,735
% Impervious Area (total) 23.7%
linpervioua Surface Area Drainage Area I
On-site Buildings (sf) 41,446
On-site Streets (sf) 0
On-site Parking (sf) 39,398
On-site Sidewalks (sf) 3,891
Other on-site (sf) 0
Off-site (sf) 0
Total (sf): 84,735
SWU-101 Supplemental Area Table
Autumn Care Cape Fear Fayetteville
10. How was the off-site impervious area listed above derived? Measured in ACAD program
IV. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
One of the following deed restrictions and protective covenants are required to be recorded for all subdivisions,
outparcels and future development prior to the sale of any lot. If lot sizes vary significantly, a table listing each lot
number, size and the allowable built-upon area for each lot must be provided as an attachment. Forms can be
downloaded from http://h2o.enr.state.nc.us/su/bmp forms.htm - deed restrictions.
Form DRPC-1 High Density Commercial Subdivisions
Form DRPC-2 High Density Developments with Outparcels
Form DRPC-3 High Density Residential Subdivisions
Form DRPC-4 Low Density Commercial Subdivisions
Form DRPC-5 Low Density Residential Subdivisions
Form DRPC-6 Low Density Residential Subdivisions with Curb Outlets
By your signature below, you certify that the recorded deed restrictions and protective covenants for this
project shall include all the applicable items required in the above form, 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 State, and that they will be recorded prior to the
sale of any lot.
V. SUPPLEMENT FORMS
The applicable state stormwater management permit supplement form(s) listed below must be submitted for each
BMP specified for this project. Contact the Stormwater and General Permits Unit at [phone] for the status
and availability of these forms. Forms can be downloaded from http://h2o.enr.state.nc.us/su/bmp forms.htm.
Form SW401-Low Density
Form SW401-Curb Outlet System
Form SW401-Off-Site System
Form SW401-Wet Detention Basin
Form SW401-Infiltration Basin
Form SW401-Infiltration Trench
Form SW401-Bioretention Cell
Form SW401-Level Spreader
Form SW401-Wetland
Form SW401-Grassed Swale
Form SW401-Sand Filter
Form SW401-Permeable Pavement
Low Density Supplement
Curb Outlet System Supplement
Off-Site System Supplement
Wet Detention Basin Supplement
Infiltration Basin Supplement
Underground Infiltration Trench Supplement
Bioretention Cell Supplement
Level Spreader/Filter Strip/Restored Riparian Buffer Supplement
Constructed Wetland Supplement
Grassed Swale Supplement
Sand Filter Supplement
Permeable Pavement Supplement
Form SWU-101 Version 03.27.08 Page 3 of 4
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. The complete application package should be
submitted to the appropriate DWQ Office. (Appropriate office may be found by locating project on the
interactive online map at htt_p://h2o.enr.state.nc.us/su/msiamaps.htm)
1. Please indicate that you have provided the following required information by initialing in the space provided
next to each item.
Initials
• Original and one copy of the Stormwater Management Permit Application Form ?p-c_??.
• Original and one copy of the Deed Restrictions & Protective Covenants Form (if g
required as per Part IV above)
• Original of the applicable Supplement Form(s) and O&M agreement(s) for each BMP OJI A
• Permit application processing fee of $505 (Express: $4,000 for HD, $2,000 for LD)
payable to NCDENR q01 +?v?z.?fnrcc
• Calculations & detailed narrative description of stormwater treatment/ management
• Copy of any applicable soils report
• Two copies of plans and specifications (sealed, signed & dated), including: `??-°r?
- Development/ Project name
- Engineer and firm
-Legend
- North arrow
- Scale
- Revision number & date
- Mean high water line
- Dimensioned property/ project boundary
- Location map with named streets or NCSR numbers
- Original contours, proposed contours, spot elevations, finished floor elevations
- Details of roads, drainage features, collection systems, and stormwater control measures
- Wetlands delineated, or a note on plans that none exist
- Existing drainage (including off-site), drainage easements, pipe sizes, runoff calculations
- Drainage areas delineated
- Vegetated buffers (where required)
VII. AGENT AUTHORIZATION
If you wish to designate authority to another individual or firm so that they may provide information on your
behalf, please complete this section. (ex. designing engineer or firm)
Designated agent (individual or firm):Donald L. Curry, Jr., PE
Mailing Address:3344 Hillsborough St., Suite 250
City:Raleigh State:NC Zip:27607
Phone: (919 ) 821-2440 Fax: (919 ) 821-2210
Email: [e-mail]
VIII. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in General Information, item 2) Gerald Cox
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 15A NCAC
2H.1000.
Signature:
Form SWU-101 Version 03.27.08 Page 4 of 4
Date: ??
Permit No.
(to be provided by DWQ)
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
LOW DENSITY SUPPLEMENT
This form may be photocopied for use as an original
A low density project is one that meets the appropriate criteria for built upon area and transports stormwater
runoff primarily through vegetated conveyances. Low density projects should not have a discrete stormwater
collection system as defined by 15A NCAC 2H .1002(18). Low density requirements and density factors can be
found in 15A NCAC 2H .1005 through .1007, DWQ BMP Manual (2007), and Session Law 2006-246.
1. PROJECT INFORMATION
Project Name : Autumn Care Cape Fear of Fayetteville
Contact Person: Gerald Cox Phone Number: (252 )443-6265
Number of Lots:I Allowable Built Upon Area Per Lot*:208,879sf (24% of 19.98ac)
*If lot sizes are not uniform, attach a table indicating the number of lots, lot sizes and allowable built upon area
for each lot. The attachment must include the project name, phase, page numbers and provide area subtotals and
totals. BUA shall be shown in units of square feet.
II. BUILT UPON AREA
See the Stormwater Management Permit Application for specific language that must be recorded in the deed
restrictions for all subdivisions.
For uniform lot sizes, complete the following calculation in the space provided below where:
• SA Site Area - the total project area above Mean High Water. Wetlands may be excluded when the
development results in high density pockets.
• DF Density Factor - the appropriate percent built upon area divided by 100.
• RA Road Area - the total impervious surface occupied by roadways.
• OA Other Area - the total area of impervious surfaces such as clubhouses, tennis courts, sidewalks, etc.
• No. Lots - the total number of lots in the subdivision.
• BUA/Lot - the computed allowable built upon area for each lot including driveways and impervious surfaces
located between the front lot line and the edge of pavement.
Form SW401-Low Density-Rev.2 Page 1 of 3
(SA x DF) - RA - OA = BUA
T No. Lots Lot
Calculation:
(SA: ft2 x DF: ) - (RA: ft2) - (OA: ft2) = BUA per Lot = ft2
(No of Lots: )
III. REQUIRED ITEMS CHECKLIST
Initial in the space provided to indicate that the following requirements have been met and supporting
documentation is provided as necessary. Indicate the page or plan sheet number where supporting documentation
can be found. If the applicant has designated an agent on the Stormwater Management Permit Application Form,
the agent may initial below.
Page/Plan
Initials Sheet No.
C-O(e a. A 30 foot vegetative buffer is provided adjacent to surface waters. Projects in the Neuse, Tar-
Pamlico, Catawba River basins, and Randleman Lake may require additional buffers.
?P b. Deed restriction language as required on form SWU-101 shall be recorded as a restrictive
covenant. A copy of the recorded document shall be provided to DWQ within 30 days of
platting and prior to sale of any lots.
APP c. Built upon area calculations are provided for the overall project and all lots.
AA d. Project conforms to low density requirements within the ORW AEC (if applicable).
[15A NCAC 2H .1007(2)(b)]
C-al, e. Side slopes of swales are no steeper than 3:1.
c-o f. Longitudinal slope of swales is no greater than 5%; calculations for shear stress and velocity
are shown if slope is greater than 5%.
?Vc c-o (O g. Swales are designed to carry, at a non-erosive velocity, at least the 10-year storm.
c-dc, h. Swale detail and permanent vegetation is specified on the plans.
Form SW401-Low Density-Rev.2 Page 2 of 3
IV. SWALE SYSTEM MAINTENANCE REQUIREMENTS
Mowing will be accomplished as needed according to the season. Grass height will not exceed six inches at
any time.
2. Swales will be inspected monthly or after every runoff producing rainfall event for sediment build-up,
erosion, and trash accumulation.
Accumulated sediment and trash will be removed as necessary. Swales will be reseeded or sodded following
sediment removal.
4. Eroded areas of the swales will be repaired and reseeded. Swales will be revegetated as needed and in a
timely manner based on the monthly inspections.
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.
6. Swales will not be altered, piped, or filled in without approval from NCDENR Division of Water Quality.
I acknowledge and agree by my signature below that I am responsible for the performance of the six maintenance
procedures listed above. I agree to notify DWQ of any problems with the system or prior to any changes to the
system or responsible party.
Print Name and Title:Gerald Cox, President
Address:451 N. Winstead Ave., Rockv Mount. NC 27804
Phone: [phone]? Date: /144 <_'O
Signature:
The- legally responsible 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.
I,__ODAY13__J? Jae-e?1G?? a Notary Public for the State of NGrA d?ir-)Q ,County of
N3S{? do hereby certify that Gerald ? &x personally appeared before me this
day of and acknowledge the due execution of the forgoing infiltration basin maintenance
requirements. Witness my hand and official seal,
Donna R. Schoeberl
NOTARY PUBLIC
Nash County, N. C. /
SEAL My commission expires
Form SW401-Low Density-Rev.2 Page 3 of 3
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