Form_(Application)

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 ❑ Ph 11- Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ 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
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.):
Siler School
2. Location of Project (street address):
502 W Third St
City:Siler City County:Chatham Zip:27344
3. Directions to project (from nearest major intersection):
From 421 on Favetteville Avenue) Turn left onto E Raleivh St
Turn right onto N Evergreen Ave
The property is at the intersection of N Evergreen Ave and W 3rd St
4. Latitude:35° 43' 24.557" N
Longitude:79° 28' 14.462" W
of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with modifications also requires SWU-102 - Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number N/A , its issue date (if known) N/A , 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
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application, list the stormwater project number,
if assigned, N/A and the previous name of the project, if different than currently
proposed, N/A
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: 2.11 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: Under Review
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://portal.ncdenr.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:After School, LLC
Signing Official & Title:Richard Angino - Owner
b.Contact information for person listed in item 1a above:
Street Address:463 1/2 Carolina Circle
City:Winston Salem State:NC Zip:27104
Mailing Address (if applicablc):463 1/2 Carolina Circle
City:Winston Salem
State:NC
Phone: (336 ) 499-1963 Fax: ( )
Email:[e-mail]
Zip:27104
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:Chatham County
Signing Official & Title:Dan LaMontagne - County Manager
b.Contact information for person listed in item 2a above:
Street Address:12 East Street
City:Pittsboro State:NC Zip:27312
Mailing Address (if applicablc):PO Box 1809
City:Pittsboro
Phone: (919 ) 542-8200
Email:[e-mail]
State:NC
Zip:27312
Fax: (919 ) 542-8272
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: C 3 Design & Engineering, PLLC
Signing Official & Title:Chad Abbott, Principal Engineer
b.Contact information for person listed in item 3a above:
Mailing Address:2537 E Lyon Station Road, Suite 102
City:Creedmoor State:NC Zip:27522
Phone: (919 ) 625-7368 Fax: ( )
Email:[e-mail]
4. Local jurisdiction for building permits: Town of Siler City
Point of Contact:lack Meadows Phone #: (919 ) 742-2323
Form SWU-101 Version Oct. 31, 2013 Page 2 of 7

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The project consists of existing impervious areas and proposed impervious areas. The balance is supposed to
be treated per the NPDES Phase II rules. To satisfy those requirements we are treating_a portion of the
proposed parking area with a filterra that is greater than the balance of the impervious areas added. This is
further detailed in the stormwater report/narrative.
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 Cape Fear River basin.
Total Property Area: 2.32
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
Area+:2.32 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 (NHM line or Mean High Water
(MHM line, and coastal wetlands landward from the NHW (or MH1O line. The resultant project area is used to
calculate overall percent built upon area (B UA). 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 = 55.56
9. How many drainage areas does the project have?4 (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.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 7

Basin Information
Drainage Area 1
Drainage Area 2
Drainage Area 3
Drainage Area 4
Receiving Stream Name
Stream Class *
Stream Index Number
Total Drainage Area (so
4398
8778
21924
65917
On -site Drainage Area (so
4398
8778
20936
65917
Off -site Drainage Area (so
0
0
988
0
Proposed Impervious Area**(so
4398
8778
16242
27693
Impervious Area** total
100
100
74
41.36
Impervious— Surface Area
Drainage Area 1
Drainage Area 2
Drainage Area 3
Drainage Area 4
On -site Buildings/Lots (so
4398
8778
0
255
On -site Streets (so
0
0
0
0
On -site Parking (so
0
0
13179
12034
On -site Sidewalks (so
0
0
2075
3545
Other on -site (so
0
0
Future (so
0
0
Off -site (so
0
0
988
Existing BUA*** (so
0
0
11858
Total (so:
4398
1 8778
1 16242
1 27692
* Stream Class and Index Number can be determined at: http://portal.futlenr.org/zueb/wq&s/cstc%lassificatiotis
Imp envious 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. AutoCAD
Delineations of the proposed Drive Connection
Projects in Union County: Contact DEMLR Central (ice staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A NCAC 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 h_ftp://portal.ncdennorg/web/wq/ws/su/bmn-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/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 http://12ortal.ncdenr.org/web/wq/ws/su/`mals.)
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 htt2://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms docs.
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
hn://www.envheII2.org/12ages/onesto]2exgress.html for information on the Express program
Form SWU-101 Version Oct. 31, 2013 Page 4 of 7