SWA000022__01 Stormwater Permit Application Form - Signed_5/19/2020

DEMLR USE ONLY
Date Received Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt 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.):
Cou RTYAR A-r GmeaALO LAWe
2. Location of Project (street address):
5 Nv INLaw
City:_SZ'p L-rS _ County: U N\ON
3. Directions to project (from nearest major intersection):
Zip: 261ay
14'.F rAttz So►-VK1AeA5J. wp TV MbN (A111{ S'Ve1A1S MIL.L120. >rLAkA'&6tS 00!1
4. Latitude: 55 O DS ' U " N Longitude: 60 ° 34 ' O B " W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ❑New ®Modification ❑ Renewal w/ Modificationt
tRenezoals zoith modifications also requires SVVU-102 - Renezoal Application Form
b.If this application is being submitted as the result of a modificatio to an existing permit, Iist the existing
permit number%�&aoee-o,. , its issue date (if known) 04 bit 'tall. 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, and the previous name of tine 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: 15 ac of Disturbed Area
❑NPDES Industrial Stormwater R404/401 Permit: Proposed Impacts 9 IsTgom i &pA0iAK91'ptr+iC IMFW5
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 perm.4 o eitr s �St�Ds !tT e[h+ 4t1t -014*14-1241:1" 4LI3115
-Nwo►omo - ►&SviO %lobs
5. Is the project located within 5 miles of a public airport? ['C No UYes
If yes, see S.L. 2012-200, Part VI: LtlpWkigI,lal.nedetlr.orgf web/­ti�rtile-_,1.-t<<;y;Si]x1 }Is
Form SWU-101 Version Oct. 31, 2013 Page 1 of

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 Awns th _ re Drojec ):
Applicant/Organization: &-P(AN L►.WiMS ROAD to AL
Signing Official & Title:—Bo4 K1 &bOS E' ON (arMvn-,itEs CA"LINAS
b.Contact information for person listed in item la above:
Street Address: 1020 ONAG TWLSR DfNYE,Sum %OS
City: CM 4 LOT1'e ___-- State: OL _ _ ^ Zip: Z(A
Mailing Address (if applicable):_. a AT MovC
City:
Phone: (30 _ -8311t
Email:1�kaa � .Co�,�[I►-.[>rm.
State:_
Zi
Fax: boy ) 411- 58y B _
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 nacre 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:__
Signing Official & Title:
b.Contact information for person listed in item 2a above:
Street Address:
City:
Mailing Address (if applicable):
City:
Phone:
Email:
State:
Zip:
State: _ Zip:
Fax: L� )
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: M%VZ DA %$ Mom (ommuN IT) ES
Signing Official & Titic: RCVTb(L 6"o
b. Contact information for person listed in item 3a above:
Mailing Address:S]CCIA_ t*N%Q 1_fttaQ_ _ d�vl~ i tp5
City: G4 t4R State: MLL Zip:_ Z9L4Z
Phone: ('4oy )Sal - �l$T-f, - Fax: ( )
Email:._4�11I��til4s�CMAC+�tam..ri± alr+
4. Local jurisdiction for building permits:
Point of Contact: M Aft (A% IN Phone #:
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
.$ C Df YAttm hl01F 11.& Ug-MC T O 11(A IV (15t+R
CAUMEL['60 OY 41 WE 4- 4-A AC. OrUt4gff WALIZE 194WnO Na A We-rQoNO.
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 YAQ)AL N River basin.
4. Total Property Area: 'K6 acres
5. Total Coastal Wetlands Area: 0 ----acres
6. Total Surface Water Area:_O.S ,_,__acres
7. Total Property Area (4) -Total Coastal Wetlands Area (5) -Total Surface Water Area (6) = Total Project Area':
acres
Total pro "cl area shall be calculated to elude lhe� followh : Flat, normal pool c f inr wurrded Structures, they area
belweerr 1lre� brtnlGS of streams and rivers, the are ilcdow lire' �orrnal High Water WHIN) lure or Mean Hish Wate+
(MHW) lime, and coastal wellrrnds larrdivard ffroin the NNW (car MHW) line. The resultant project area as used to
calculate overall percent Will upon area (BZIA). Non-emstal to,dands landward of the NNW for MHW) lieu array be
included in they lolal project aren.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 3Z•g %
9. How many drainage areas does the project have? (For high density, count 1 for each proposed engineered
stormzater BMP. For lozo 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 I
Drainage Area _
Drainage Area
Drainage Area
Receiving Stream Name
(� LRE�EK�
Cft,Y-
Stream Class *
L
C
Stream Index Number *
1g
13-vt-%
Total Drainage Area (sf)
LI IOU
082,1103
1b$ U4
-site Drainage Area (sf)
Az 14 OGt
Off -site Drainage Area (sf)
0
1313
Proposed Impervious Area" (sf)
3 , }
q� ►►q
% Impervious Area** (total)
y o
SdC,
Impervious" Surface Area
Drainage Area I
Drainage Area _
Drainage Area
Drainage Area _
On -site Buildings Lots (sf)
Val 4U4
-4410-+
On -site Streets (s)
$O 545
13 -4►-4
-site Parking (sf)
5 a0l
0
On -site Sidewalks (sf)
15 3K1
a LA
Other on -site (so
y qp
p
Future (s)
,_..
Off -site (s)
_
Existing BUN*** (so
0
0
Total (sf);
3-43-3s-+
ql llq
* Stream CIass and Index Number can be determined at: htfN;ortnl.r►crleuu) ter��7t?�/���[Q '�i te?tidi�s
"* litiPrr moos area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidervalks, 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 ivill be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. MI&
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

Prime-ctx_lti Union _aunty: Contact DEMLR Central Office 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 http /lporiA .tarde�tir.
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
hft-.11_(?ottl. tti 1i �sl Lwgl v �StuSt_4i1e,jw_I��m��t�s. 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 1 1vRPorial.nc e_11r qm// eE /wgLy► Jsu/iii,ips.)
Please in&a!g that a ll wing re u'r nfo n v ben rovided b n' ' fi 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 h-up :l_/ rtal.rzccienr,g eV/wcfLws/s� itatesw.L(orms dons.
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 A go,
Form. (if required as per Part V11 below)
3. Original of the applicable Supplement Form(s) (ap, d, sil n St and. �� c ]. and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
hr ; Z Z www.eny!iei a ne re .h 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'h mile of the site boundary, include the 1/z
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
S. Two sets of plans folded to 83" N 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 NEW 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).
X 04e,
�
r27
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

Copy of any applicable soils report with the associated SHWT elevations (Please identify X-940M
elevations in addition to depths) as well as a map of the boring locations with the existing No SWVff 1gea
elevations and boring logs. Include an $S"xll" 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: _(925�1 Page No: 131 %M
ll. 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.
littp:Z/www,mrgtary.state.hcl,.-usICoMQriitimZ-05occh.opx
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 �p fjport,%1. ncde_n .prll�w,V +�I,fjstate-stortt�Nratrr-
forms doss. 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:9ALP�"MAi-4
Consulting Firm:�EM NaT
Mailing Address: 301 (VIcWuwor rj W%ye , 5u rx ICA
City: State: —_tACc___ Zip: —
Phone: 8 Fax: f -404 )_ q.@-07N
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (prittt or type rreirie of laer.ts listed lit Catttart lrrt►rrrtiun, ife�itt 2n)�� certify that 1
own the pproperttyy identified in this permit application, and thus give permission o (print or type itank, of persmn
lishw in Contact ltrfonnation, itein 1a) with (yrint or type itarne o or aniralion listed its
Confact Information, itest 1a) to develop the project as current�y 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 6

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 Stormwa ter permit reverts back
tome, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and
submit a completed Name/Ownership Change Forth 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 N General Statue 143-215.1 and may result in appropriate enforcement
action including the as a ent of civ'l p nalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: _ Date:
I, e� a Notary Public for the State of 46EAAN i' ,p l; , County of
do hereby certify that r' personally appeared
before me this :71 clay of C , an acknowledge the due execution of the application for a
%stormwater permit. Witness my hand and official seal, ' c
J�rrrtll��
B
► � fy _
NOTARY
PUBLICVIA
�„
lrrrt
X. APPLICANT'S CERTIFICATION
SEAL
My commission expires. 4 - i � `�
I, {print or lype nante of Person listed in Contirct Information, item 10
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 21-1.10W and any other applicabie state stormwater requirements.
Signature:
I,
a Notary Public for the State of
Date:
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
My commission expi
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6