SW3190504_Application_20190520

DEMLR USE ONLY
Date Received
Fee Paid Permit Number
o- Zo -LCt
K, Torn 1 si 5 tG1 0 5 o tf
Applicable Rules: ❑ CoastaI SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters D Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources r�'`
STORMWATER MANAGEMENT PERMIT APPLICA1WNrftJM\
This for►n pray be photocopied for use as an original MAY 2 Q 2019
I. GENERAL INFORMATION
DENR-LAND QUALITY
1. Project Name (subdivision, facility, or establishment name -should be consiggQR4C'MWATfffqftRQ*f
plans, specifications, letters, operation and maintenance agreements, etc.):
Line 118 Retrofit
2. Location of Project (street address):
799 Waxhaw -Indian Trails Rd.
City: Waxhaw County:Union Zip:28173
3. Directions to project (from nearest major intersection):
200' north of intersection Waxhaz-Indian Trail Rd mid Will PlYler Rd
4. Latitude:34* 59' 15" N Longitude:80° 4T 16" W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
Mcnezoals with modifications also requires SWU-102 - Rerternal Application Fonzr
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 ❑1-Iigh Density El 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 Ftormwater management permit application, list the stormwnter 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: 2.94 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:NCDEO Sediment/Erosion Control Union-2019-070
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part Vl: htt11://portal;ncdenr_org/vveb lrtiles and-r ulahoFs
Form SWU-101 Version Oct. 31, 2013 Page] of6

1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc, who owns the projec!):
Applicant/Organization:Piedmont Natural Gas Corrmanv
Signing Official & Title:Oluwasanu Odugbesan
b. Contact information for person listed in item la above:
Street Address:4720 Piedmont Row Dr
City:Charlotte State:NC Zip:28213
Mailing Address (if applicable):
City: State: Zip:
Phone: [phone] Fax: L
[e-mail]
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 Lite project is located on):
Property Owner/Organization:lgrry GillDavisand Shirley lean H. Davis
Signing Official & Title.
b. Contact information for person listed in item 2a above:
Street Address-5823 Will Plvler Rd.
City,Waxhaw State:NC Zip:28173
Mailing Address (if applicable):
City:_
Phone:
Email:
State• Zip:
Fax:
3. a. (Optional) Print the name and title of another contact such as the projeces construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:1) n ..Jqster,$ti mPlAmfjatesP.A.
Signing Official & Tide:
b.Contact information for person listed in item 3a above:
Mailing Address:601 N. Trade St. Suite 200
City:Winston-Salem — State:NC Zip:27101
Phone: [phone]
Email:[e-mail]
4. Local jurisdiction for building permits:
Point of Contact: Phone
Form SWU- 10 1 Version Oct. 31, 2013 Page 2 of 6
Fax:

1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
no bmp using #57 washed stone with geotextile fabric
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
R Approval of a Site Specific Development Plan or PUD Approval Date:
R Valid Building Permit Issued Date:
rl Other: Date:
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
n Coastal SW - 1995 0 Ph 11 - Post Construction
3, Stormwater runoff from this project drains to the Catawba River basin.
4. Total Property Area: 2,701 -acres 5. Total Coastal Wetlands Area: acres
6. Total Surface Water Area: acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Aree: 2.701 Acres
+ Total project area shall be calcztlfltcd to exclude the following: the nonsial pool of impotinded strictures, the area
between the banks of streams and rivers, the area Moto the Normal High Water (NHW) line or Mean High Water
WHIN) line, and Coastal Wetlands landward front the NHW (or MHVV) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal wetlands landward of the NHW (or MHM line may
be included in the total project area,
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 1.89 %
9. How many drainage areas does the project have?l (For high densihj, count 1 for each proposed engineered
stoninvater BMP. For I= densihl and other projects, use 1 for the whole properhj 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
Drainajze Area
Drainap-,e Area
Drainaee A - rea
Receiving Stream Name
Twelvemile
creek
Stream Class
C
Stream Index Number
11-138-2
Total Drainage Area (so
102,466
On -site Drainage Area (so
101,016
Off -site Drainage Area (so
1,450
Proposed Impervious Area**
1,904
'Y. Impervious Area" (total)- ­
Impervious" Surface Area
Drainage Area.
Drainage Area
Drainage Area
Drains Area —
On -site Buildings/Lots (so
.
On -site Streets (so
1,789
On -site Parking (so
On -site Sidewalks (so
Other on -site (so
31.5
Future (so
83.5
Off -site (sf)
Existing BUA*** (so
Total (so:
1,904
Stream {.lass and index Number can be determined at: littv:llvartal.tzcdetir.orglztjeLhi��.5 csit c assi cations
Ll 6
Iniperviotis area is defined as the built tipon area including, bitt not limited to, buildings, roads, parking areas,
sidezoalks, gravel areas, etc,
Form SVY'U- 10 1 Version Oct. 31, 2013 Page 3 of 6

'Report only that atimttirt of existing BUA that iviIl remain after development. Do not report any existing BUA that
is to be rentoved and which will be replaced I»j nett' BUA.
11. How was the off -site impervious area Iisted above determined? Provide documentation.
Prolects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened d
Endangered Species iratershed that may be subject to more stringent stormwater requirements as per 15A NCAC 02B
.0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) form;
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from hLtg./12ortal.ncdenr.org/­web/wq/wslsu/bml2-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
h 1- -ZP- tal.ncdenr.org/web/wq/ws su}-stateswfforms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by Iocating project on the
interactive online map at http:l}portal.ncdennor lweb}wglwslstt/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
lhtt ortal.ncdennorg/web/wgZws/su/stateswlforms.does.
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)
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 _
httl2://www.envhell2.org/paM/­onestopgxpress.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
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 ? mile of the site boundary, include the
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.
Form S WU-101 Version Oct. 31, 2013 Page 4 of 6

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).
9. 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 MRCS 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 verifij the SNWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 7216 Page No: 498
11. For corporations and Iimited 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 21-1.1003(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.
ht_pt :/lwww.secretary.state.nc.us/Cori2orations/­­­CSearch.asr)x
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 tuven�ints furins can be downloaded from htt : i ortal,ncdenr.or lweb9lr/stag-
stormwater-forms does. 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 bolder(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 Iot.
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:Neal Tucker
Consulting Firm: Stimmel Associates P.A.
Mailing Address:601 N. Trade St. Suite 200
City: Winston-Salem
Phone: ,(336 ) 723-1067
Email:[e-mail]
State:NC Zip:27101
Fax: f I
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 Inforivatiou, item 2a) certify that I
own the property identified in this permit application, and thus give permission to (print or hype name of person
listed in Contact Information, item 1a) with (print or hjpe name of organization listed in
Contact Information, 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

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.
Signature: Date:
a Notary Public for the State of _,w County of
do hereby certify that 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
RPrEF IN/ FT)
My commission expires DENR-LAND QUALIV
G
X APPLICANT'S CERTIFICATION
1, (print or hjpe name of person listed in Cola tact Information, item Ia) Oluwasanu Odugbesan
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 2H .1000 and any other applicable state stormwater
requirements, .000-N -_--�
Date: � �---' / a 0 1
1, `ti • `''""a"eL,"— a Notary Public for the State of�to(4lt^ County of
do hereby certify that ! a W a SGant Rts_'5ersonally appeared
before me this day of �g , and ackn dge h exec 'on of the application for
a stormwater permit. Witness my hand and official seal, ---_
Tracy R Landrum
NOTARY PUBLIC
MECKLENIBURG COUNTY, N.C.
My Commission Expires 05-07.2023
SEAL
My commission expires_yke,4 0 r -W L3
Form S WU-101 Version Oct. 31, 2013 Page 6 of 6