20191331 Ver 1_Riparian Buffer Authorization_20191001

Buffer Auth orization App lication Form
15A NCAC 02B .0233 (8)(b), .0243 (8)(b), .0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2) Buffer Authorization Online Form -
Update 10/23/2018
A. Owner/App licant In formation
For instructions on how to fill out this form, see the Buffer Authorization Application Help Document posted on DWR's 401 & Buffer page.
Please note: fields mark ed with a red asterisk * below are required. You will not be able to submit the form until all mandatory questions are answered.
Primary Contact Email:*
Who is submitting the application?*
1. Property Owner Information:
3. Age nt Information:
A. Owne r/Applicant Information
Ge neral Information
Deborah E. Shirley
Please list the contact person's email f or questions or payment on this project if needed.
Owner
Applicant other than Owner
Agent
Check all that apply
1a. Name on Re corde d De e d:*
1b. Re sponsible Party:
1c. M ailing Addre ss:*
1d. Te le phone :*
1e . Email Addre ss:*
PS NC II LP LTD PTNRP
Tomasz Wisniewski-Facility Manager
(f or Corporations)
City
Glendale
State / Province / Region
CA
Postal / Zip Code
91201
Country
USA
Street Address
701 Western Ave
Address Line 2
704-625-6647
[e-mail]
m
3a. Name :*
3b. Company Affiliation:*
3c. M ailing Addre ss:*
Deborah E. Shirley
Soil & Environmental Consultants, PA
City
Raleigh
State / Province / Region
NC
Postal / Zip Code
27615
Country
USA
Street Address
8412 Falls of Neuse Road, Ste. 104
Address Line 2
If the applicant is not the property owner, in addition to providing the Agent’s information, select ‘Applicant other than Owner’ above, enter the applicant’s
information, and attach an authorization granting the applicant owner approval.
3d. Te le phone :*3e . Email Addre ss:*
3f. Attach a signe d and date d copy of the age nt authorization form.*
9198465900 [e-mail]
Click the upload button or drag and drop files here to attach document
SEC Agent Authorization Form_Public Storage 5602
Capital Blvd - signed TW.pdf
198.05KB
PDF Only
B. Proj ect In formation an d Prior Proj ect History
1a. Name of Proje ct:*
If your project has a formal name please use this. If your project does not have a formal name, please identify your project by the owner name and
proposed activity (Jones Property Access Road, Smith Guest House, etc.) List in parentheses any other names that have been used to identify the
project in the past.
1b. Is this a publicly-funde d transportation proje ct?*
1d. Subdiv ision Name :
1e . Ne are st
M unicipality:
1f. Prope rty Size :
1g. County (or Countie s) whe re the proje ct is locate d:*
1h. Prope r ty ID#Date of Purchase
1i. Deed Information
Type of Book Book#Page #
De e d
M ap
1j. Attach a copy of the re corde d map that indicate s whe n the lot was last platte d.
1k. How would you like to prov ide the Latitude and Longitude information?*
Latitude *Longitude *
1l. Is the proje ct locate d in any of North Carolina’s twe nty coastal countie s?*
Coastal Management information can be found at:
B. Project Information and Prior Project History
1. Project Information
Public Storage-5602 Capital Blvd.
(Subdivision, facility, or establishment name)
Yes
No
N/A
Raleigh
2.11
acres
Wake
1726482908
Tax PIN or Parcel id
9/1/1994
13810 418
1984 1009
Click the upload button or drag and drop files here to attach document
PDFViewWake.pdf 183.66KB
PDF only
Address Lookup
Manually
36.8624 -78.5814
Yes
No
About Coastal Management
Staff Listing
Coastal County Lookup
2a. Name of the ne are st body of wate r to propose d proje ct:*
Link to Soil Surveys for North Carolina Counties. (Please see instructions in the Help Document to determine the most recent published version.)
2b. Wate r Quality Classification of ne are st re ce iv ing wate r:*
2c. List the total e stimate d line ar fe e t of all e xisting stre ams (inte rmitte nt and pe re nnial) on the prope rty:*
3a. De scribe the e xisting conditions on the site and the ge ne ral land use in the v icinity of the proje ct at the time of this
application:
3b. Attach an 8 ½ x 11 e xce rpt from the most re ce nt v e rsion of the USGS topographic map indicating the location of the site .
Link to TOPO Map lookup: https://viewer.nationalmap.gov/basic/
3c. Attach an 8 ½ x 11 e xce rpt from the most re ce nt v e rsion of the publishe d County NRCS Soil Surv e y M ap de picting the
proje ct site .
Link to Soil Surveys for North Carolina Counties. (Please see instructions in the Help Document to determine the most re ce nt publishe d version.)
Prov ide a de taile d de scription of the propose d activ ity including its purpose and include the type of e quipme nt to be use d:*
Attach a site plan as applicable to the proje ct:
** Below is a link with instructions on what you will need to show on your site plan.
http://edocs.deq.nc.gov/WaterResources/0/doc/402224/Page1.aspx
2. Surface Waters
Perry Creek
C; NSW
211
(linear feet only)
3. Project Description:
Existing Storage facility with structures and concrete slab. Offsite and onsite
stormwater causing erosion in the northwestern corner of the site and adjacent to a
stream. Erosion is beneath the concrete slab and stream bank. Erosion
compromising the structural stability of the concrete slab and buildings. General
land use consist of commercial development.
Click the upload button or drag and drop files here to attach document
USGS Map.pdf 2.86MB
PDF only
Click the upload button or drag and drop files here to attach document
Soil Survey Map.pdf 3.23MB
PDF only
4. Propose d Activ ity
Proposed activity includes back filling of an undermined concrete slab and
stabilizing the erosion on the stream bank. Specifically the contractor will add
structural fill underneath the concrete parking lot and building slab, repair the
concrete pavement, fiber matting the slope in Zones 1 & 2 and adding a 4 ft wide
fiber matted reinforced vegetated ditch for the offsite and onsite flows. All proposed
work will be done without disturbing the stream bed.
Click the upload button or drag and drop files here to attach document
190910 - Public Storage Raleigh Environmental
Impact Maps.pdf
3.4MB
PDF only
5a. Hav e jurisdictional we tlands or stre am de te rminations by the Corps or State be e n re que ste d or obtaine d for this
prope rty/proje ct (including all prior phase s) in the past?*
6a. Hav e pe rmits or ce rtifications be e n re que ste d or obtaine d for this proje ct (including all prior phase s) in the past?*
7a. Is this proje ct a phase d proje ct?*
5. Jurisdictional De te rminations
Yes
No
6. Project History
Yes
No
7. Future Proje ct Plans
Yes
No
C. Proposed Impacts Inventory
1a. Proje ct is in which prote cte d Basin?*
You can find which river basin you live in at the link below.
http://www.eenorthcarolina.org/riverbasins-gis-map.asp
1c. Individually list all buffer impacts below. If any impacts require mitigation, then you MUST fill out Section D of this form.
Please note: if the impact you list below requires mitigation choose "allow w/ mitigation" under impact type.
Site # - Re ason Stre am Name Buffe r Impact *Impact Type *Zone 1 Zone 2
Total Zone 1 Impacts:
Total Zone 2 Impacts:
Total Buffe r Impacts:
Comme nts:
C. Propose d Impacts Inve ntory
Buffer Impacts
Neuse River Basin (15A NCAC 02B.0233)
Catawba River Basin (15A NCAC 02B.0243)
Randleman Lake Watershed (15A NCAC 02B.0250)
Tar-Pamlico River Basin (15A NCAC 02B.0259)
Jordan Lake Watershed (15A NCAC 02B.0267)
Goose Creek Watershed (15A NCAC 02B.0606 & 15A NCAC 02B.0607)
A-Repair of
existing
infrastructure
Map label (e.g. Road
Crossing 1)
UT to Perry
Creek
Permanent
(P)
Perm or Temp
Allowable 308.00
Square
Feet
0.00
Square
Feet
308.00
0.00
308.00
D. Imp act Justification and Mitigation
1a. Spe cifically de scribe me asure s take n to av oid or minimize the propose d impacts in de signing the proje ct.*
1b. Spe cifically de scribe me asure s take n to av oid or minimize the propose d impacts through constr uction te chnique s.*
D. Impact Justification and Mitigation
1. Avoidance and Minimization
S&EC conducted a site visit within the area of concern to confirm no wetlands
existing and to verify that the stream included enough stream criteria (i.e.
geomorphology, hydrology and biology) to not be contested. A site visit was
conducted with Stephanie Goss of the NCDWR on August 28, 2019 to review the
compromised concrete slab and the bank erosion. The initial repair design included
riprap bank stabilization and a paved flume. This repair design was modified per the
request of Ms. Goss and now does not include hardening of the stream bank, and
avoids all stream impacts.
Per the project engineers: All E&S measures will conform to the latest NCDEQ
Erosion and Sediment Control Planning and Design Manual and City of Raleigh
Requirements. All proposed work to be done without disturbing the existing stream
or below the ordinary high water mark.
E. Diffu se Flow Pl an
All buffer impacts & high ground impacts require diffuse flow or other form of stormwater treatment. If the project is subject to a state implemented
riparian buffer program, upload a plan that fully documents how diffuse flow will be maintained. All stormwater control measures (SCMs) must be
designed in accordance with the NC Stormwater Design Manual. Associated supplement forms and other documentation must be provided.
For a list of options to meet the diffuse flow requirements, click here.
1a. What type of SCM are you prov iding?*
1c. Diffuse Flow Docume ntation *
E. Diffuse Flow Plan
Level Spreader
Vegetated Conveyance (lower SHWT)
Wetland Swale (higher SHWT)
Proposed project will not create concentrated stormwater flow through the
buffer
Other SCM that removed minimum of 30% nitrogen
Click the upload button or drag and drop files here to attach document
190927 - EZ Form - Public Storage Capital Blvd.pdf 545.36KB
PDF only
F. Sup p l emen tary Information
Environmental Documentation
Violations
Please upload any additional information you would like the Division to consider during application review.
Additional Attachme nts:
Additional Comme nts:
F. Supplementary Information
1a. Doe s the proje ct inv olv e an e xpe nditure of public (fe de ral/state /local) funds or the use of public (fe de ral/state ) land?
Yes
No
2a. Is the site in v iolation of DWR We tland Rule s (15A NCAC 02H .0500), Isolate d We tland Rule s (15A NCAC 02H .1300), DWR
Surface Wate r or We tland Standards, or Riparian Buffe r Rule s (15A NCAC 02B .0200)?
2b. Is this an afte r-the -fact buffe r author ization application?
Yes
No
Yes
No
G. Additional Information
Click the upload button or drag and drop files here to attach document
20190828_102434.pdf 550.13KB
20190828_102438.pdf 567.55KB
PDF only
G. Sig n an d Su bmit
By digitally signing be low, I ce rtify that:
I have given true, accurate, and complete information on this form;
I agree that submission of this form is a “transaction” subject to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic
Transactions Act”)
I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic
Transactions Act”);
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
I intend to electronically sign and submit the application form.”
Print Name :*
Signature *
Submission Date :
G. Sign and Submitt
Deborah E. Shirley
(Auto populated field)

PROPERTY OWNER CERTIFICATION / AGENT AUTHORIZATION

Project Name/Description: Public Storage-5602 Capital Blvd. S&EC Project #13928

Date:

The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
69 Darlington Avenue
Wilmington, NC 28403

Attn: Field Office:

I, the undersigned, a duly authorized owner of record of the property/properties identified herein, do
authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps) and Soil &
Environmental Consultants, PA (S&EC) staff (as my agent) to enter upon the property herein described
for the purpose of conducting on-site investigations and issuing a determination associated with Waters
of the U.S. subject to Federal jurisdiction under Section 404 of the Clean Water Act and/or Section 10 of
the Rivers and Harbors Act of 1899. This document also authorizes S&EC (as my agent) to act on my
behalf and take all actions necessary for the processing, issuance and acceptance of a permit or
certification and any and all associated standard and special conditions. This notification supersedes any
previous correspondence concerning the agent for this project.

NOTICE: This authorization, for liability and professional courtesy reasons, is valid only for government
officials to enter the property when accompanied by S&EC staff. You should call S&EC to arrange a site
meeting prior to visiting the site.

PARCEL INFORMATION:
Parcel Index Number(s) (PIN): 1726482908
Site Address: 5602 Capital Blvd., Raleigh NC
Watershed: Neuse River-Perry Creek

PROPERTY OWNER INFORMATION:
Name: PS NC II LP LTD PTNRP
Address: 701 Western Ave, Glendale CA
Phone No.: Mobile No.:
Email:

________________________
Property Owner (please print) Date

Property Owner Signature

We hereby certify the above information submitted in this application is true and accurate to
the best of our knowledge.
10/01/2019
Tomasz Wisniewski (Facilities Manager)10/01/2019

Project Number:
SB
Project Manager:
1" = 1000'Scale:
06/28/19Date:
Map Title:
Source:
Figure 3- USGS Map
Public Storage 5602 Capital Blvd
Wake County, NC
USGS Wake
County _ Quad
¯0 1,000 2,000
Feet
13928.W1
1, JOPO J. Joql.14,00 certify
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from an actual is -1 Ilys.e) (survey made under
My supervision deed de ,pllon record�a M
Book Page �.r •ate_
(other); that the error of closure as calculated by
Latitudes and departures is I / Z
that the boundarles not surveyed are shown as
broken linemptgIItm information foun in
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this map "a p r m a e w'
G.3.47-30 a n d I s h and seal
this 1944..
Signed: _ 3
seer. 71x2
NORTH CAROLINA WAKE COUNTY
JoWo J. _10OP 0
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of R.I.igh for P.blie u.. ell n"«., •e.•w.nt., .ighr. of way end
p«k..hown rh•..en for ell lawf.l wrpe.•s re .hieh M• City may
d­1::.:llew M..ow• re be ..od and upon aeewtaneo rh•rw( In
wieh oil pity "iiete., «dinmrc.. and n90, len. «
onditien. of rho City of Raleigh f« the benefit of the p.blie, .aid
d•dieerim .hall be ir.•.eeobl•; Pre.idd, ary d.dieett•n of .a•..
Tent. fee .terve 4miaego ere nen md• to the City of Raleigh bur
..My rode to the .ub.•a... I I— of arty end el)
prep.rr �Y..he— hereon for th.ir ... end b.r..fit +ubi.et to eendl.
tion. el ..b ... ti -4 (6) (.) (d) vend (f) of S.ctien I and S.crion d
el the "City St r Droinov. Policy" (R ... I.,ien 1970.742 a. he
.am• racy 6. hew Citta to tiw. ew.nd.d). _
Book No. Po q. No. Stoner.n(.).f P.q Own«(
NORTH CAROLINA - WAKE COUNTY
The for ing certific a of
Notar (y) (ies) (are) certifie to be correct. This instrument was
presented for registration and recorded in this office.
This day of I , at/_/-brcIock
Kenn C. Wilkins ister of Deeds
gy
Deputy Regist r of Deeds
F,
"I, the undersigned City Clerk and Treasurer of the City of
Raleigh, do hereby certify' t,�yp pCity of Raleig ,,apsMLL dad
b s It Code, on the_► � a�+g da of
approved this plat or map and accepted the
dedications as shown thereon but on the further condition that
the City assumes no responsibility to open or maintain the some
until in the discretion and opinion of the governing body of the
City of,.Rpleigh it is in the public Interwnto do so.
City Clerk and Treasurer" d7 a
BOOK 1984 PAGE 1009
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Project Number:
SB
Project Manager:
1" = 500'Scale:
06/28/19Date:
Map Title:
Source:
Figure 2- Soil Survey Map
Public Storage 5602 Capital Blvd
Wake County, NC
Wake County Soil
Survey Sheets 30 & 40
¯0 500 1,000
Feet
13928.W1
OLD MILBURNIE RD.OAK FOREST DRTRUST DRSUMNER BLVDM
E
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D
RTMNCBELS P-11324130 PARKLAKE AVENUE, SUITE 130, RALEIGH, NC 27612PHONE: [phone] FAX: [phone]THE INFORMATION, DESIGN AND CONTENT OF THIS PLAN ARE PROPRIETARY AND SHALL NOT BECOPIED OR USED FOR ANY PURPOSE WITHOUT PRIOR WRITTEN AUTHORIZATION FROM BOHLERENGINEERING. ONLY APPROVED, SIGNED AND SEALED PLANS SHALL BE UTILIZED FORCONSTRUCTION PURPOSES. © BOHLER ENGINEERING, 2018H:\2019\NCR192013\DRAWINGS\PLAN SETS\NCR192013 - EIM----->LAYOUT: COVER SHEETENVIRONMENTAL IMPACT MAPSPUBLIC STORAGE5602 CAPITAL BOULEVARDRALEIGH, NC 276169/10/19 | PMA | NCR192013LOCATION MAPPUBLIC STORAGE5602 CAPITAL BLVDRALEIGH, NCOWNERPS NC II LP LTD PTNRP701 WESTERN AVEGLENDALE CA, 91201-2349ENVIRONMENTAL IMPACT MAPSSCALE: 1"=1000'SITE DATASITE AREA: (AC.)PIN# 1726-48-2908: ±2.11 ACZONING:IX-3-PKWATERSHED:NEUSE RIVER BASINFIRM MAP DATE:MAY 2, 2006FIRM MAP NUMBER:3720172600JFLOODPLAIN: NOT IN FLOODPLAINCOVER SHEETSHEET 1 OF 4SheetNumberSheet Title1COVER2OVERALL IMPACT MAP3IMPACT AREA A4DETAIL SHEETNOTES:THE ENVIRONMENTAL IMPACT AREA INCLUDED WITHIN THIS PLAN SET IS THEPROPOSED REPAIR OF EXISTING INFRASTRUCTURE AT THE PUBLIC STORAGE SITEAT 5602 CAPITAL BOULEVARD IN RALEIGH, NORTH CAROLINA. THERE IS A SINKHOLEFORMING AND COMPROMISING THE STRUCTURAL INTEGRITY OF THE PARKING LOT &STORAGE BUILDINGS ON THE NORTH-WESTERN CORNER OF THE SITE. THEEXISTING BUILDINGS & CONCRETE PARKING LOT WERE PERMITTED, APPROVED, &BUILT IN 1983.
US HWY 1/CAPITAL BLVDLOT 45BROUGHTON FARMSSUBDIVISIONBM 1984, PG 1009N/FMLC AUTOMOTIVE, LLC5601 CAPITAL BLVDPIN: 1726-38-4995DB 12603, PG 267692,000 SFOR2.112 ACOAK FOREST DR30' ZONE 1 BUFFER20' ZONE 2 BUFFERTMNCBELS P-11324130 PARKLAKE AVENUE, SUITE 130, RALEIGH, NC 27612PHONE: [phone] FAX: [phone]THE INFORMATION, DESIGN AND CONTENT OF THIS PLAN ARE PROPRIETARY AND SHALL NOT BECOPIED OR USED FOR ANY PURPOSE WITHOUT PRIOR WRITTEN AUTHORIZATION FROM BOHLERENGINEERING. ONLY APPROVED, SIGNED AND SEALED PLANS SHALL BE UTILIZED FORCONSTRUCTION PURPOSES. © BOHLER ENGINEERING, 20181"=60'060153060H:\2019\NCR192013\DRAWINGS\PLAN SETS\NCR192013 - EIM----->LAYOUT: OVERALL IMPACT MAPENVIRONMENTAL IMPACT MAPSPUBLIC STORAGE5602 CAPITAL BOULEVARDRALEIGH, NC 276169/10/19 | PMA | NCR192013OVERALL IMPACT MAPSHEET 2 OF 4PROPERTY LINELEGENDIMPACT AREA ATOP OF BANKSTREAM C/LSANITARY EASEMENT
30' ZONE 1 BU
F
F
E
R 1'4'FIBER MATTING REINFORCEDVEGETATED DITCH(NAG C350 OR SIMILAR)FIBER MATTING SLOPE REINFORCEMENT(NAG SC250 OR SIMILAR)PROPERTY LINEPROP. STRUCTURAL FILL UNDERNEATHCONCRETE SLAB (PER DIRECTIONFROM GEOTECHNICAL ENGINEER)TOP OF BANKLOD LOD LOD LODLODLODLODLODLODLODLODLODLODLODLODLODLODLOD LODLODLODLODLODLODLODREPAIR CONCRETEPAVEMENTSTREAM CENTERLINE286287288
2
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287288TMNCBELS P-11324130 PARKLAKE AVENUE, SUITE 130, RALEIGH, NC 27612PHONE: [phone] FAX: [phone]THE INFORMATION, DESIGN AND CONTENT OF THIS PLAN ARE PROPRIETARY AND SHALL NOT BECOPIED OR USED FOR ANY PURPOSE WITHOUT PRIOR WRITTEN AUTHORIZATION FROM BOHLERENGINEERING. ONLY APPROVED, SIGNED AND SEALED PLANS SHALL BE UTILIZED FORCONSTRUCTION PURPOSES. © BOHLER ENGINEERING, 20181"= 5'2.5 1.25505H:\2019\NCR192013\DRAWINGS\PLAN SETS\NCR192013 - EIM----->LAYOUT: IMPACT AREA AENVIRONMENTAL IMPACT MAPSPUBLIC STORAGE5602 CAPITAL BOULEVARDRALEIGH, NC 276169/10/19 | PMA | NCR192013IMPACT AREA ASHEET 3 OF 4PROPERTY LINELEGENDNOTES:1. ALL PROPOSED WORK TO BE DONE WITHOUTDISTURBING THE EXISTING STREAM OR BELOWTHE ORDINARY HIGH WATER MARK.LocationImpact TypeBuffer Zone ImpactsZone 1Zone 2AREPAIR OF EXISTING INFRASTRUCTURE308 SF0 SFZONE 1 (30')REPAIR OF EXISTING INFRASTRUCTUREIMPACT AREASLIMITS OF DISTURBANCELODSTRUCTURAL FILL UNDERNEATHCONCRETE PARKING LOT & BUILDINGSLAB. TO BE INSTALLED PERDIRECTION FROM GEOTECHNICALENGINEERFIBER MATTING SLOPEREINFORCEMENTREPAIR CONCRETEPAVEMENT
TMNCBELS P-11324130 PARKLAKE AVENUE, SUITE 130, RALEIGH, NC 27612PHONE: [phone] FAX: [phone]THE INFORMATION, DESIGN AND CONTENT OF THIS PLAN ARE PROPRIETARY AND SHALL NOT BECOPIED OR USED FOR ANY PURPOSE WITHOUT PRIOR WRITTEN AUTHORIZATION FROM BOHLERENGINEERING. ONLY APPROVED, SIGNED AND SEALED PLANS SHALL BE UTILIZED FORCONSTRUCTION PURPOSES. © BOHLER ENGINEERING, 2018H:\2019\NCR192013\DRAWINGS\PLAN SETS\NCR192013 - EIM----->LAYOUT: DETAIL SHEETENVIRONMENTAL IMPACT MAPSPUBLIC STORAGE5602 CAPITAL BOULEVARDRALEIGH, NC 2761607/31/19 | PMA | NCR192013DETAIL SHEETSHEET 4 OF 4
SUPPLEMENT-EZ COVER PAGE
LOAD SUPPLEMENT FORMS
1 Project Name Public Storage - Capital Blvd
2 Project Area (ac)2.112
3 Coastal Wetland Area (ac)0
4 Surface Water Area (ac)0
5 Is this project High or Low Density?High
6 Does this project use an off-site SCM?No
7 Width of vegetated setbacks provided (feet)0
8 Will the vegetated setback remain vegetated?No
9 Is BUA other that as listed in .1003(4)(c-d) out of the setback?No
10 Is streambank stabilization proposed on this project?Yes
11 Infiltration System 0
12 Bioretention Cell 0
13 Wet Pond 0
14 Stormwater Wetland 0
15 Permeable Pavement 0
16 Sand Filter 0
17 Rainwater Harvesting (RWH)0
18 Green Roof 0
19 Level Spreader-Filter Strip (LS-FS)0
20 Disconnected Impervious Surface (DIS)0
21 Treatment Swale 1
22 Dry Pond 0
23 StormFilter 0
24 Silva Cell 0
25 Bayfilter 0
26 Filterra 0
LOAD SUPPLEMENT FORMS
27 Name and Title:Charlie Yowell, PE
28 Organization:Bohler Engineering
29 Street address:4130 Park Lake Ave, Suite 130
30 City, State, Zip:Raleigh, NC 27612
31 Phone number(s):919-578-9000
32 Email:[e-mail]
Certification Statement:

Designer
______________________________________________
Signature of Designer
______________________________________________
Date

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
that the engineering plans, specifications, operation and maintenance agreements and other supporting information are consistent
with the information provided here.
PROJECT INFORMATION
NUMBER AND TYPE OF SCMs:
DESIGNER CERTIFICATION
COMPLIANCE WITH 02H .1003(4)
Seal
DRAINAGE AREAS
1 Is this a high density project?Yes
2 If so, number of drainage areas/SCMs 1
3
Is all/part of this project subject to previous rule
versions?No
FORMS LOADED
Entire Site 1
4 Type of SCM 1 Treatment Swale
5 Total BUA in project (sq ft)73305 sf 2614 sf
6
New BUA on subdivided lots (subject to permitting)
(sq ft)n/a n/a
7
New BUA outside of subdivided lots (subject to
permitting) (sf)n/a n/a
8 Offsite - total area (sq ft)n/a n/a
9 Offsite BUA (sq ft)n/a n/a
10 Breakdown of new BUA outside subdivided lots:n/a n/a
- Parking (sq ft)n/a n/a
- Sidewalk (sq ft)n/a n/a
- Roof (sq ft)n/a n/a
- Roadway (sq ft)n/a n/a
- Future (sq ft)n/a n/a

- Other, please specify in the comment box
below (sq ft) n/a n/a
11
New infiltrating permeable pavement on
subdivided lots (sq ft)n/a n/a
12
New infiltrating permeable pavement outside of
subdivided lots (sq ft)n/a n/a
13
Exisitng BUA that will remain (not subject to
permitting) (sq ft)73305 sf 2614 sf
14 Existing BUA that is already permitted (sq ft)73305 sf 2614 sf
15 Existing BUA that will be removed (sq ft)n/a n/a
16 Percent BUA 80%n/a
17 Design storm (inches)1 in 1 in
18 Design volume of SCM (cu ft)n/a n/a
19 Calculation method for design volume n/a n/a
20
DRAINAGE AREA INFORMATION
ADDITIONAL INFORMATION
Repairment to existing stream bank to provide additional stabilization. Current
drainage area to proposed treatment swale is ±2600 sf of existing built upon
area.
Please use this space to provide any additional information about the
drainage area(s):
,t