SW3180102 - Food Mart

r
DEMLRUSE ONLY
Date Received Fee Paid
Permit Number
a-- 8
s
Applicable Rules: £ Coastal SW —1995 £ Coastal SW — 2008
(select all that apply) £ Non -Coastal SW HQW /ORW Waters
£ Other WQ Mgmt Plan:
£ Ph II - Post Construction
£ Universal Stormwater Management Plan
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
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.):
Food Mart l / /
2. Location of Project (street address): oe (� Sl X81 ! (O / �f
6/F
1
1912 Bethany Church Road
City:Newton County:Catawba
Zip:28658
3. Directions to project (from nearest major intersection):
347 linear feet north from the intersection of Bethany Church Road (SR 1804) and Hi- wav 16.
4. Latitude:350 38' 19.86" N Longitude:810 10' 3.09" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): New Modification Renewal w/
Modification
tRenewals with modifications also requires SWU--102 —Renewal 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{,
Low Density High Density Drains to an Offsite Stormwater System Other Dc'
P ,,�^�Q./T'I N'D
3. If this application is being submitted as the result of a previously returned application or a letp�RM��rY
DEMLR requesting a state stormwater management permit application, list the stormwater project number, rlNa
if assigned, and the previous name of the project, if different than currently proposed,
2. Specify the type of project (check one):

U
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: 2.10 ac of Disturbed Area
NPDES Industrial Stormwater 404/401 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 VT httn://nortal.ncdenr.ora web/lr/rules-and-regulations
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:Thom Nguyen
Signing Official & Title:Thom Neuven-Owner
b. Contact information for person listed in item la above:
Street Address:419 31d Avenue Court NE
City:Hickory State:NC Zip:28601
Mailing Address (if applicable):See Above
City: State: Zip:
Phone: (828 ) 381-0783 Fax: f L
Email:
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 1p�roperty that the project is located on):
Property Owner/ Organization: Crh
I "J0111
Signing Official & Title: 0WvV-(' _ Thaw, kb-4�r-n
b. Contact information for person listed in item 2a above:
Street Address: q I a 3 {S't *ve- ..C -1 -
City: n ► &DIrState: � C- Zip: 21,
Mailing Address (if applicable): y 1Cl 3 isfi fk4� ° C+ E
City: "i tKDrl State: AC- Zip: Z$ CO v
Phone: ( %Q4 L_S3()-d3 Fax: ( )
Email:t Kim6efI n�u

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/Organizationjim Leonard with I.R. Leonard Construction Company
Signing Official & Title jim Leonard-Presiden /Owner
b. Contact information for person listed in item 3a above:
Mailing Address:130 Houston Road
City.Hickorv- State:NC Zip:28166
Phone: 704 ) 528-7650 Fax: (7 04 ) 622-0697
Email:[e-mail]
4. Local jurisdiction for building permits: Catawba County
Point of Contact:Chris Timberlake Phone #: (828 ) 465-8382
IV. PROJECT INFORMATION
1. In the space provided below, briefl summarize how the stormwater runoff will be treated.
SW runoff will be treated via an above ground Sandfilter/ detention basin
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 Bethany Church Broad River basin.
4. Total Property Area: 2.36 acres 5. Total Coastal Wetlands Area:.Q 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 :2.36 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 = 37.2 %

9. How many drainage areas does the project have?- (For high density, count 1 for each proposed
engineered stormwater 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
Hagan Fork
Stream Class *
C
Stream Index Number
11-76-5-2-(1)
Total Drainage Area (sf)
160,300
On-site Drainage Area (sf)
102,800
Off-site Drainage Area (sf)
57,500
Proposed Impervious Area** (sf)
38,330
% Impervious Area** (total)
37.2
Impervious— Surface Area
Drainage Area 1 Drainage Area Drainage Area Drainage Area
On-site Buildings/Lots (sf)
2,904
On-site Streets (sf)
3,316
On-site Parking (sf)
29,530
On-site Sidewalks (sf)
2,137
Other on-site (sf)
0
Future (sf)
0
Off-site (sf)
9,148
Existing BUA*** (sf)
10
Total (sf):l
47,035
Stream Class and Index Number can be determined at: h_pt : Ivortal.ncdenr.org webcla i 'cation
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.
11. How was the off-site impervious area listed above determined? Provide documentation. Deliniation of
iMpervious area usingaerial erial photographs. See stormwater impact report for elination of watersheds and
impervious areas.
Projects in Union County-: Contact DEMLR Central Office staff to check J the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per I SA 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
fromhttp:/ ortal.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./ / portal.ncdenr.org j 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 h_pt L// 12ortal.ncdenr.org web ". 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 htatim portal.ncdenr.org/webw1C f ws su I statesw/forms docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
Ofriginal of the applicable Supplement Form(s) sealed, signed and dated) and O&M agreement(s)
or each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
ht�t _/ /www.enyheIR.oreLpa es/onesto exl2ress.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/ 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 lh mile of the site boundary, include the 1h 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.
m. 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).
p. Vegetated buffers (where required).
Copy of any applicable soils report with the associated SHWT elevations (Please identify
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 BMPs, 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 77 Page No: 52
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 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.
htt_ : www.secretaz state.nc.us/Corp ratins CSearch.asvx
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:Lportal.nedenr.org/Aeb/Ir/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:Bri�T. Upton. RE.
Consulting Firm: The Isaacs Group
Mailing Address:8720 Red Oak Blvd,, Ste 420
City:Charlotte State:NCC Zip: 82 217
Phone: (704 ) 227-9406 Fax: [phone]
Email:bb [e-mail]
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) , 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 Ia)
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 assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
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I,, , �G� d /�D r�v-i a Notary Public for the State of A CcQ,,6 htyaCounty of
_ hAUA,ybo._. , do hereby certify that :133 ,rvi UQ U 49¢ n personally appeared
before me this U day of J6,Y1 vn—r &4 0\013and acknowledge the due execution of the application
for a stoZnwater, permit. Wtiness my hand and official seal,
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X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item la) , 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 stormwater rules under
15A NCAC 21-1.1000 and any other applicable state stormwater requirements.
Signature: Date-
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I, a Notary Public for the State of L) Md!ja i1i.objt6ACounty of
0 aAnX w� [7o. do hereby certify that ��nn,Nt kAU!A9.—r—o personally appeared
before me this { U day of I C, v, a n ..nJ 01% and acknowledge the due execution of the application
for a stormwater permit. Witness my hand and official seal,

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Form SWU-101 Version Oct. 31, 2013 Page of 6