SW4091101_CURRENT PERMIT_20100426

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW �oqzlol
DOC TYPE
� CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
/PI
YYYYMMDD

s��
NC®E�
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
March 23, 2010
Ms. Rhonda Moffitt
Hospice of Randolph County, Inc.
PO Box 9
Asheboro, NC 27204
Resources
Subject-. Stormwater Permit No. SW4091101
Hospice of Randolph MR11710
High Density Commercial Bio-Retention Project N,C! 136Ht 9f (:Nff
Randolph County APR 2 6 2010
W;nsron-5arem
Regional Office
Dear Ms. Moffitt:
Dee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management. Permit Application for the
Hospice of Randolph County on March 18, 2010. Staff review of the plans and specifications has
determined that the project, as proposed, will comply with the Stormwater Regulations set forth in Title 15A
NCAC 2H.1000 and Session Law 2006-246. We are forwarding Permit No. SW4091101, dated March 23.
2010, for the construction, operation and maintenance of the subject project and the stormwater BMPs.
This permit shall be effective from the date of issuance until March 23, 2020, and shall be subject to the
conditions and limitations as specified therein, Please pay special attention to the Operation and
Maintenance requirements in this permit. Failure to establish an adequate system for inspection and
maintenance of the stormwater management system will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within thirty (30) days following receipt of this permit.
This request must be in the form of a written petition, conforming to Chapter 150B of the North Carolina
General Statutes, and filed with the Office of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC
27611-7447. Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Winston-Salem Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Brian Lowther at [phone]; or
[e-mail].
Sincerely,
>� �' '�_ 7�z�
for Coleen H. Sullins
cc: Winston-Salem Regional Office
Central Files
SPU Files
WeIJa rids and Stormwater Branch 011E
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 North Car of i na
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1.877-623-6748 ,/ atlmall�/
Interne[: www.ncwatefqualiry.org s� ;/
An Equal Opportunity 1 Affirmative Action Employer

A
State Stormwater Permit
Permit No. SW4091101
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Hospice of Randolph County, Inc.
Hospice of Randolph
416 Vision Drive, Asheboro & Randolph County
FOR THE
construction, operation and maintenance of one bioretention cell in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to as
the "stormwater rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved by
the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until March 23, 2020, and shall
be subject to the following specified conditions and limitations:
IM11*1[elzE-*tIFM1 11IN91-_1
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 on page 2 of this permit. The stormwater
control has been designed to handle the runoff from 62,808 square feet of
impervious area.
3. The tract will be limited to the amount of built -upon area as indicated in Section
1.7 of this permit, and per the application documents and as shown on the
approved plans. The bui't-upon area for the future development is limited to
62,808 square feet.
4. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
Page 1 of 6

State Stormwater Permit
Permit No. SW4091101
7. The following design criteria have been provided in the bioretention cell and must,
be maintained at design condition:
a. Drainage Area, Acres:
4.924
Onsite, ft :
80,586
Offsite, ft2:
0
b. Total Imperviou� Surfaces, ft2:
62,808
Onsite, ft :
62,808
Offsite, ft2:
0
G. Design Storm, inches:
1"
d. Max. Ponded Depth, feet:
9"
e. Seasonal High Water Table, fmsl:
706
f. Planting Media Depth, feet:
4'
g. Cell Dimensions, feet:
150' by 45'
h. Bottom Elevationp, fmsl:
708
i. Surface Area, ft :
6,750
j. Permitted Storage Volume, ft3:
5,100
k. Bypass 1 Storage Elevation, fmsl:
714.75
I. Predevelopment 1 year 24 hour:
0.07
M. Post development 1 year 24 hour:
0.155
n. Drawdown Time, hours:
24
o. Underdrain Diameter, inches:
6"
P. Total number of plants provided:
45
q. Receiving Stream/River Basin:
Haskett Creek 1 Cape Fear
r. Stream Index Number:
17-12
s. Classification of Water Body:
"C"
II. SCHEDULE OF COMPLIANCE
1. The stormwater management system shall.be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
'
2. During construction, erosion shall be kept to
a minimum and any eroded areas of
the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan
must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. - Sediment removal.
G. Mowing and re -vegetation of slopes and the filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
f. Debris removal and unclogging of all.drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. —`Access to the cell and outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work and
what actions were taken.
5. The permittee shall submit to the Division of Water Quality an annual summary
report of the maintenance and inspection records for each BMP. The report
shall summarize the inspection dates, results of the inspections, and the
maintenance work performed at each inspection.
Page 2 of 6

State Stormwater Permit
Permit No. SW4091101
6. The facilities shall be constructed as shown on the approved plans. This permit
shall become void unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other
supporting data.
7. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
9. Access to the stormwater facilities shall be maintained via appropriate recorded
easements at all times.
10. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership. }
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
11. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the,notice, the permittee shall submit a written time schedule to the
Director for mod;fying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, to the
Division of Water Quality, accompanied by the supporting documentation as
listed on page 2 of the form. The approval of this request will be considered on
its merits and may or may not be approved.
Page 3 of 6

State Stormwater Permit r
Permit No. SW4091101
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to.transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Water Quality, in
accordance with North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The. permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8/ Unless specified elsewhere, permanent seeding requirements for they stormwater
control must follow the guidelines established in the North Carolina Erosion and
" Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does -not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with ail required forms and
documentation at least 180 days prior to the expiration date of this permit.
/ Permit issued this the 23rd day of March 2010.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. SW4091101
Hospice of Randolph
Stormwater Permit No. SW4091101
Randolph County
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 5 of 6

State Stormwater Permit r
Permit No. SW4091101
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that the
runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
7. Trash rack is provided on the outlet/bypass structure.
8. All slopes are grassed with permanent vegetation, per the vegetation plan.
9. Vegetated .slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
.11. The permitted amounts of surface area and/or volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13.. All required design depths are provided.
14. All required parts of the system are provided, such as a vegetated shelf,
and a forebay'.
15. The required system dimensions are provided per the approved plans.
cc: NCDENR-DWQ Regional Office -
Page 6 of 6

State Stormwater Permit
Permit No. SW4091101
Hospice of Randolph
Stormwater Permit No. SW4091101
Randolph County
Designer's Certification
I, 0. fiJOLLL S ,*mt J,5r,9g-as a duly registered P--fc55,`„ e e-" in the
State of North Carol, having been authorized to observe eriodica I weekly/
full time) the construction of the project,
0:5 1 e,
(Project Name)
for 9%0"RA 4eFFr7T_(Project owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number Z& 4
Date _ 1 - if) —
SEAL_
nFE'Aal
T Yry SEAL
26447 _=
I
sw
Page 5 of 6

State Stormwater Permit
Permit No. SW4091101
t
Certification Requirements:
✓
1.
The drainage area to the system contains approximately the permitted
acreage.
f
2.
The drainage area to the system contains no more than the permitted
amount of built -upon area.
3.
All the built -upon area associated with the project is graded such that the
runoff drains to the system.
✓
4.
All roof drains are located such that the runoff is directed into the system.
f
5.
The outlet/bypass structure elevations are per the approved plan.
f
6.
The outlet structure is located per the approved plans.
7.
Trash rack is provided on the outlet/bypass structure.
J
8.
All slopes are grassed with permanent vegetation, per the vegetation plan.
V
9.
Vegetated slopes are no steeper than 3.1.
✓
10.
The inlets are located per the approved plans and do not cause short-
-ii suiting of the system.
11.
The permitted amounts of surface area and/or volume have been
provided.
f
12.
Required drawdown devices are correctly sized per the approved plans.
✓
13.
All required design depths are provided.
14.
All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
_ ✓
15.
The required system dimensions are provided per the approved plans.
cc: NCDENR-DWQ Regional Office
Page 6 of 6

;f• x�� .,� J`. .. k L;��,''�.re x 6�; ,. 5- „ ,q nS �, ,1$ ,'1.
DWQiUSE:
NI:Y,�..
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 Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
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.):
Hospice of Randolph
2. Location of Project (street address):
416 Vision Drive
City:Asheboro County:Randolph __ _ Zip:27203
3. Directions to project (from nearest major intersection):'
Take Highway 85 South take US Hwy 220 South toward Asheboro. Take Vision Drive Exit. Site 1 mile
4. Latitude:35° 44' 10" N Longitude:790 49' 05" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
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 ®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 DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, SW 4091101 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: 3.0 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:Sedimentation /Erosion Control permit was issued on 10-28-09
under the Job Name "Hospice of Randolph"
Form SWU-101 Version 07Iuly2009 Page I 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:Hospice of Randolph County, Inc.
Signing Official & Title:Rhonda Moffitt, CEO/President
b.Contact information for person listed in item I above:
Street Address: 416 Vision Drive
City: Asheboro State: NC Zip: 27203
Mailing Address (if applicable): P.O. Box 9
City: Asheboro State:NC Zip: 27204
Phone: ( 336 ) 672-9300 Fax: { 336 ) 672-0868
Email: rhonda.moffitt©hospiceofrandolph.org
Please check the appropriate box. The applicant listed above is:
N 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:Hospice of Randolph County, Inc.
Signing Official & Title:Rhonda B. Moffitt, CEO/President
b. Contact information for person listed in item 2a above:
Street Address:416 Vision Drive
City:Asheboro State:NC Zip:27203
Mailing Address (if applicable):P.O. Box 968
City:Asheboro State:NC Zip:27204
Phone: ( 336 ) 672-9300 Fax: ( 336 672-0868
Email: rhonda.moffitt©hospiceofrandolph.org
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:
Signing Official & Title:
b.Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ) Fax: ( )
Email:
4. Local jurisdiction for building permits: City of Asheboro
Point of Contact:Larry Trotter Phone #: (336 ) 626-120lx231
Form SWU-101 Version 07July2009 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly, summarize how the stormwater runoff will be treated.
Stormwater will flow overland to a series of catch basins and be collected and directed to a single outlet
discharging onto RipRap and then water is released into a Bio-retention Cell for treatment. _
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.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.
4. Total Property Area: 4.924 acres
5. Total Coastal Wetlands Area: 0 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`:4.924 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 belozo the Normal High Water (NNW) line or Mean High Water
(MHW) lure, and coastal wetlands landward from the NHW (or MHIN) lime. The resultant project area is used to
calculate overall percent built upon area (BUA). Noii-coastal zetlands landward of the NHW (or MHW) litre tit ay
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 29.28
9. I -low many drainage areas does the project have? 1 (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
Haskett Creek
Stream Class *
C
Stream Index Number *
17-12
Total Drainage Area (so
80,586
On -site Drainage Area (so
80,586
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
62,808
Impervious Area** total
77.90
Impervious** Surface Area
Drainage Area
Drainage Area _
Drainage Area
Draina e Area
On -site Buildings/Lots (so
15,780
On -site Streets (so
23,989
On -site Parking (so
5,985
On -site Sidewalks (so
3,690
Other on -site (so
0
Future(so
13,364
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
62,808
Stream Class and Index Number can be determined at; Itttp,11h2o.enr.state. nc.rrs/bitrrs/reports/reportsWB.ltttttl
!tu ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidpewalks, gravel areas, etc.
rt** Report only that amount of existing BUA that will remain after development. Do not report any cxistittg BUA that
is to be removed and which will be replaced bif new BUA.
Form SWU-101 Version 07July2009 Page 3 of 6

11. How was the off -site impervious area Iisted above determined? Provide documentation. None Listed
Site is currently 100% wooded
Projects in Union County: Contact DWQ 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 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 htto://h2o.enr.state.nc.us/su/bmn forms.htm.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://h2o.enr.state.nc.us/su/bmp forms.htm. The complete application package
should be submitted to the appropriate DWQ Office. (The appropriate office may be found by locating project
on the interactive online map athttp://h2o.enr.state.nc.us/su/msi maps.htm.)
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 http://h2o.enr.state.nc.us/su/bmp forms.htm.
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. OriginaI of the applicable Supplement Form(s) (sealed sigged 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
h"://www.envhelp.org/pates/onestopexpress.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 1h mile of the site boundary, include the 1h
mile radius on the map.
7. Sealed, signed and dated calculations.
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).
Form SWU-101 Version 07July2009 Page 4 of 6
Initials
rots
N/A
rwS

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify ! p,
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"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 DWQ to verify the SHWT prior
to submittal, [phone] )
H-
A copy of the most current property deed. Deed book: 1231 Page No: 1515
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 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.
hU:/ /www.secretary.state.nc.us/Corporations/CSearch.asl2x
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://h2o.enr.state.nc.us/su/bmp forms.htm#deed restrictions. 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 DWQ, 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:
Consulting Firm:
Mailing Address:
City: State: Zip:
Phone: { ) Fax: ( )
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) Rhonda B. Moffitt CE0/President , 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 1a) Rhonda B. Mo(dtt with (print or type name of organization Iisted in
Contact Information, item 1b) Rhonda i3. Moffitt 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 07July2009 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 DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ 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 penal 'es of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: ��.�-- _ late:
I, a Notary Public for the State of NJoo f-k C6 en I 'Aja—County of
I-eAndo(I)h do hereby certify that KkDr&& "B - McY•'K" personally appeared
before me this 11*day of hJ4UJA1JXft� 2W3 , and acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal, �Ol.Qu�t� 0"
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item 2) Rhonda B Moffitt CEO/President ,
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, SL 2006-246 (Ph. II — Post Construction) or SL 2008-211.
Date:
I, (l • LDk a Notary Public for the State of _NQr f� County of
k do hereby certify that :Rhonda- -F. _ AoY -ff _ personally appeared
before me this eday of h 606nbee �pq . and acknowledge the due execution of the application for a
stormwater plermit. Witness my hand and official seal, t j
p�'., , ++ SEAL
r�i; �, ,.,'.., ,.• j` .� �,,," , My commission expires U.A, .
A .r _,p ,....�•. ,.
Form SWU-101 Version 07July2009 Page 6 of 6

I]
L`ttttlit::t:;rl
rr
Pam' • �� y�
'rn:r�Illa`�s::

Permit Number:
(to be provided by DWQ)
NIMA
®®
�pF W A 7F�O
O Y
=� r
NC ENR
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
401 CERTFICATION APPLICATION FORM
BIORETENTION CELL SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items
Checklist (Part 111) must be printed, tilled out and submitted along with all of the required information,
1. PROJECT INFORMATION
Project name
Hospice of Randolph
Contact name
H. Mack Summey, Jr., PE
Phone number
336-328-0902
Date
October 19. 2009
Drainage area number
1,85
II. DESIGN INFORMATION
Site Characteristics
Drainage area
80,586 ft2
Impervious area
62,808 ft2
Percent impervious
77.9% %
Design rainfall depth
1.0 inch
Peak Flow Calculations
Is preipost control of the 1-yr, 24-hr peak flow required?
Y (Y or N)
1-yr, 24-hr runoff depth
2.8 in
1-yr.24-hrIntensity
0,12 in/hr
Pre -development 1-yr, 24-hr peak flow
0.070 ft'lsec
Post -development 1-yr, 24-hr peak flow
0.155 ft'/sec
PrelPost 1-yr, 24-hr peak control
0.085 ft'/sec
Storage Volume: Nan -SA Waters
Minimum volume required
5,046.0 ft'
Volume provided
5,100.0 it,
OK
Storage Volume: SA Waters
1.5" runoff volume
ft'
Pre -development 1-yr, 24-hr runoff
ft'
Post -development 1-yr, 24-hr runoff
ft'
Minimum volume required
0 W
Volume provided
ft'
Cell Dimensions
Ponding depth of water
9 inches
OK
Ponding depth of water
0.75 ft
Surface area of the top of the bioretention cell
6,750.0 ft2
OK
Length:
150 ft
OK
Width:
45 ft
OK
-or- Radius
ft
Media and Soils Summary
Drawdown time, ponded volume
12 hr
OK
Drawdown time, to 24 inches below surface
12 hr
OK
Drawdown time, total:
24 hr
In -situ soil:
Soil permeability
0.60 inrhr
OK
Planting media soil:
Soil permeability
1.00 in/hr
OK
Soil composition
% Sand (by weight)
85%
OK
% Fines (by weight)
10%
OK
% Organic (by weight)
5%
OK
Total: 100%
Phosphorus index (P-Index) of media
29 (unitless)
OK
Form SW401-Bioretention-Rev.9
July 30, 2009
Parts i and II. Design Summary, Page 1 of 2

Permit Number;
(to be provided by DWQ)
Basin Elevations
Temporary pool elevation
Type of bioretention cell (answer'Y" to only one of the two
following questions):
Is this a grassed cell?
Is this a cell with trees/shrubs?
Planting elevation (top of the mulch or grass sod layer)
Depth of mulch
Bottom of the planting media soil
Planting media depth
Depth of washed sand below planting media soil
Are underdrains being installed?
How many clean out pipes are being installed?
What factor of safety is used for sizing the underdrains? (See
BMP Manual Section 12.3.6)
Additional distance between the bottom of the planting media and
the bottom of the cell to account for underdrains
Bottom of the cell required
SHWT elevation
Distance from bottom to SHWT
Internal Water Storage Zone (IWS}
Does the design include IWS
Elevation of the top of the upturned elbow
Separaiion of IWS and Surface
Planting Plan
Number of tree species
Number of shrub species
Number of herbaceous groundcover species
Additional Information
Does volume in excess of the design volume bypass the
bioretention cell?
Does volume in excess of the design volume flow evenly distributed
through a vegetated filter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
Is the SMP located at least 30 feet from surface waters (50 feet if
SA waters)?
Is the BMP located at least 100 feet from water supply wells?
Are the vegetated side slopes equal to or less than 3:1?
Is the BMP located in a proposed drainage easement with access
to a public Right of Way (ROW)?
Inlet velocity (from treatment system)
Is the area surrounding the cell likely to undergo development in
the future?
Are the slopes draining to the bioretention cell greater than 20%?
Is the drainage area permanently stabilized?
Pretreatment Used
(Indicate Type Used with an "X" in the shaded cell)
Gravel and grass
(81inches gravel followed by 3-5 ft of grass)
Grassed swale
Forebay
Other
714,75 fmsl
(Y or N)
Y (Y or N) OK media depth
714 fmsl
3 inches OK
710 fmsl
4ft
1 ft
Y (YorN)
14 OK
5 OK
1ft
708 fmsl
706 fmsl
2 ft OK
Y (Y or N)
709.32 fmsl
4,68 ft OK
3
3
3 OK
Y (Y or N) OK
Y (Y or N) OK
iA H
N (Y or N) Show how flow is evenly distributed.
Y (Y or N) OK
Y (Y or N) OK
Y (Y or N) OK
Y (Y or N) OK
1 ft/sec OK
N (Y or N) OK
N (Y or N) OK
Y (Y or N) OK
X OK
Form SW401-Bioretention-Rev.8
July 30, 2009
Parts I and It. Design Summary, Page 2 of 2

A' f Permit No,
f� (fa be assigned 4y D WQ)
III �' REQUIRED: REMS`CHECKLIST "r.4u'�v��..r u .;='1>"rp.:T'� F;??.rti�'4�`s:`
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An incomplete submittal package will
result in a request for additional information. This will delay final review and approval of the project. initial in the space provided to
indicate the following design requirements have been met, if the applicant has designated an agent, the agent may initial below. If a
requirement has not been met, attach justification.
Pagel Plan
Initials
Sh�ee� Noy
1Ma t
EM
w�5 nc.��
*4
r
^V
�N
w4IT
At
M5
i "A
Awl
Rr%
� A
Plans (1' - 50' or larger) of the entire site showing:
Design at ultimate build -out,
Off -site drainage (if applicable),
Delineated drainage basins (include Rational C coefficient per basin),
Cell dimensions,
Pretreatment system,
High flow bypass system,
Maintenance access,
Recorded drainage easement and public right of way (ROM,
Clean out pipe locations,
Overflow device, and
Boundaries of drainage easement.
2. Plan details (1" = 30' or larger) for the bioretention cell showing:
Cell dimensions
Pretreatment system,
High flow bypass system,
Maintenance access,
Recorded drainage easement and public right of way (ROW),
Design at ultimate build -out,
Off -site drainage (if applicable),
Clean out pipe locations,
Overflow device, and
Boundaries of drainage easement.
Indicate the P-Index between 10 and 30
3. Section view of the bioretention cell (V = 20' or larger) showing:
Side slopes, 3:1 or lower
Underdrain system (if applicable), and
Bioretention cell layers [ground level and slope, pre-treatment, ponding depth, mulch depth, fill media
depth, washed sand, filter fabric (or choking stone if applicable), #57 stone, underdrains (if applicable),
SHWT fevel(s), and overflow structure]
4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWQ, by completing 8 submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information. All
elevations shall be in feet mean sea level (imsi). Results of soils tests of both the planting soil and the in
situ soil must include:
Soil permeability,
Soil composition (% sand, % fines, % organic), and
P-index.
5. A detailed planting plan (V = 20' or larger) prepared by a qualified individual showing:
A variety of suitable species,
Sizes, spacing and locations of plantings,
Total quantity of each type of plant specified,
A planting detail,
The source nursery for the plants, and
Fertilizer and watering requirements to establish vegetation.
6. An assurance that the installed system will meet design specifications upon initial operation once the r (�
project is complete and the entire drainage area is stabilized. 1441L' E Filiott-r w i I pirfj,or� f: na
1. A construction sequence that shows how the bioretention cell will be protected from sediment until the
entire drainage area is stabilized. S.Cc, StiWe"C A
8. The supporting calculations (including underdrain calculations, if applicable).
9. A copy of the signed and notarized inspection and maintenance (ISM) agreement.
10. A copy of the deed restriction.
Form SW401-13ioretention-Rev.7 Part lll, Page t of 1

Compliance inspection Report
Permit: SW4091101 Effective: 03/23/10 Expiration: 03/23/20 Owner: Hospice of Randolph
Project: Hospice of Randolph
County: Randolph 416 Vision Dr
Region: Winston-Salem
Contact Person: Rhonda Moffitt Title:
Directions to Project:
Type of Project: State Stormwater - HD - Bioretention
Drain Areas: 001 - (Haskett Creek) (03-06-09) ( C)
On -Site Representative(s):
Related Permits:
Inspection Date: 0710612011 Entry Time: 01:00 PM
Primary Inspector: Sue L Homewood
Secondary Inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: State Stormwater
Facility Status: ❑ Compliant IN Not Compliant
Question Areas:
0 State Stormwater
(See attachment summary)
Asheboro NC 27203
Phone: [phone]
Exit Time: 01:15 PM
Phone: [phone]
Inspection Type: Compliance Evaluation
Page: 1

Permit: SW4091101 Owner - Project: Hospice of Randolph
Inspection Date: 07/06/2011 Inspection Type: Compliance Evaluation Reason for visit: Routine
Inspection Summary:
r:I. n­:-...
Is the permit active?
Signed copy of the Engineer's certification is in the file?
Signed copy of the Operation & Maintenance Agreement is in the file?
Copy of the recorded deed restrictions is in the file?
Comment: per Engineer, site is occupied, lack of certification was oversite, will send
asap.
Built Upon Area
Is the site BUA constructed as per the permit and approval plans?
Is the drainage area as per the permit and approved plans?
Is the BUA (as permitted) graded such that the runoff drains to the system?
Comment:
SW Measures
Are the SW measures constructed as per the approved plans?
Are the inlets located per the approved plans?
Are the outlet structures located per the approved plans?
Comment:
Operation and Maintenance Yes No NA NE
Are the SW measures being maintained and operated as per the permit requirements? n ■ n n
Are the SW BMP inspection and maintenance records complete and available for review or provided to DWQ n ❑ n ■
upon request?
Comment: Some erosion in the inlet swales and sedimentation in portions of cell.
Other Permit Conditions Yes No NA NE
Is the site compliant with other conditions of the permit? ■ n n n
Comment:
Other WQ Issues Yes No NA NE
Is the site compliant with other water quality issues as noted during the inspection? ® n ❑ ❑
Comment:
Page: 2

RANDOLPH COUNTY REGISTER OF DEEDS - UNOFFICIAL RECORD
Ir
;rATC OF Real U-1
N — i�AROLINa�.�41�xci,cT>
utrna 2 � o 0
pew Ts.
Pape 1 of 2
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Tax Lot No-', -...., _.,...._............... . _.,..,.., .... .._....,.,_..,.... Parcel ldankle•r No, .._...,.,,... .. .......,...., _,. ..,.,..... .......
Yeriaed b7 ....... County on the
by....... .... .... _, __ .., .__, . ., ..., _... ..-.._ ........._..
b[eO after r.mardln[ to ....,....,. _ ""'' ..._.......... PJ _$�, K,....y.
379.So.ch Cox Street.,...._..... ................................ ................. .......
Aehebara, North Car Lines l7203 .�
This la.lrvme.t Was prepared by .. HQSSA OCEURN REAPNfJI SCHHI➢LY h NELLR
Bold descripllas for the Index
NORTH CAROLINA GENERAL WARRANTY DEED
TNiS Dtt6D mad. kbl. , ,19th,. day of . .._�eeteber „ , fa. BB. by ead between
GRANTOR I GNAYTre
J, ➢. RD58, SR.
(111douer)
TIIORTON R. CLEER HQIORIAL
HOSPICE OF RANDOLPH COUNTY, INC.
f 4m 1..ear•erla4 eN.k I., ..ea eertn .. , •a&, -..a. n a+n•.,l.b, rk—ur .4 matnr. N nr.rtarin a a•nerM4P
The des4anatlon Granter and Grantee as used herein shall leelude amid parties, thole heir., suee•uery and "119-. and
shall Inetude slndular, plural, masculine, faminimr or neuter se rmtulr.d by tonlext.
WITNFS9BTFL that 1h. Grantor, for a ralaable eomldtrallon paid by the Grantee, the rseelpi of.whlrh is her.by
_
arbmwled[rd, he. and by these present. does cant, barealu, mall and eehr.y unto the Chesil, In foe slmpl., nil that
c.rtaln lot et- pared of lead dlu.L.d in the City of __.Aahebore ,,, ,,, „ ,- Aehebara T.wn.hiP.
Randolph Cmm ty, North Carolina and more portieulurly d•serihud is folloue;
Dr.ino a)1 rf Lnt P. 14.974 arrcFl of the Ras. Nubc+iviv tan as shout-,
by rint recorded in Plot Hook 9F, Pnrc 67, Ilnnrlr 1ph County
Recintry, together With s non-exclustvr rnsenerr from said 4.924
ncrrn to Lho. City of Ashrborn rv.wvr Prsrmont and drscrlhrf at-
folln++e:
HfCIIRlIN6 nt on ry lstins Iron rirr in thr West. lint- of Lot 7 of
•r',>.'.- �";.
Iloss Rul+dlvisSnn as sl,e tm by Plat rrcu rdrd It- Plot. final; 2C, Vann
;-.''•�'�",-.`�+;;
27, Ravool Ph County Ht•nlst rya Which srict Iron pipe if locotrn
•�t ck;�'; 'x
!'autL r tlrnrorr 7 n'I nntrn ]h srconLs last)5C, 73 fort from
ez l[Lfnu Irnn h41`r na,Vl nn t.ht I+nrl hsersl, corner of sriG lot;
th,nrr from an lrl rc9l nni no I`nint Fautl` a denre— 7 wi nurrs 1G
;,'.'; :.'aa_:.•.,
srcords F.'st 2N.Ol Tent to n rnlot to said line; thOn" South no
i++l
doors rti IS rl nut rs 3R r,rconds Neat. ]GP.SP fret to n mint-. In thr
1'a Rt r rn right-nt-Way line nL t1r City nr A,hrhor,, Rr.Wrr V. aerent
neat n mnnhgl r; thence with tiro F'.estern liar r.f said City
Pasv, nt Oar lh 24 dnnrors 7ft nI ,tea d5 sc conds East 72.27 feet
to n rotor in on Io right of Way line; thence Norris On cleq errs 15
nlr+tee 3a nt-rnnds t:nnt A59,1G fort to the Heninni no and
r.c.m x°ntf:i n�. fj.,tfj.1kj a:f.i�e,n rorr, or loan. It is urdrrsteind and ngrerd

RANODI-PH COUNTY REGISTER OF DEEDS - UNOFFICAAL RECORD
Page 2 Of 2
1:hnt rhr t'rb nl rr m.y upn raid rnrement nnll for Irrlal l>'t loft l"'
r,nlntrnuncr rf sm", IIn" calrnrllrn 1rnr1 tho nl•rvr c+n nrr lynx LrI
11 r. 2 tr thr lti ty !'rVrt t:n rr•rlrnt, tonrrher with ouch ti mpr• are
CC rate+rr l,vullrmrnt ail Iny tc• ncrrFanTy ip np"Tntr rnie linrr,
lr The morch line of the aerer ......nt d.seribad obove is the North lifts of Lot 3 of
T` tha Rosa Property as shown by Plot rocordod in Plot book 26, fOR. 67.
C
r C
The prowtlp Ilminebeva dncrllNd wan aeaulnd by Grsster by Inelrumant naorded la ...._....._..._........_., .. _,._ .._ ....,....
a4.ek...last..?sAp,.7l.pna,_u.........................
A mep ehowlnp the above dnedbed property h rnurdld In Plat D¢ok .....,..26.,-„-.. pef......_ fj1_'
TO HAVE AND TO HOLD the afertuid lot or pared of lead and tit privilern end \ypurteaanea thlrele Wlonflell to
ith. CranGe la fn Ample.
And tke Granter Covenant. with the Groatte, that Creator 1..alud of the pnmlm to f.. Impl., hat th. HFht to eo "
i th. I.in In dmpler that tale le ms,ketabl. and free end char of all aneumbraseea, and that Grantor w111 warrant and
I defend Its l!!le aanlset the
Iawlul el\Vm. ¢i
ate panm oel whoen.vtr except for tba neaplle¢. h.rllnafl4r atel4d.
Tlllt to the property h.nl.W,. deaeribad L. .uhlecl to the fallawln➢ e.e.ptla.e:
Nllaal; w11.aaV. . a,. a r 4er,�N r 1 \e ,ue V. VYrr .l. • r ry
1 a�MY..rule, u 1w rr • ai au, .r ur • N.rl . u1 trn Ilrll
............................................................... ............_..........-... ...........111wt1
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NORTH UR01JNA - R.rdNph O.wty
The h ms lq nnlfk.*., of �•r...t.ti �' \1.
I'falary Abele of _
k (u.l /eet{(ysaa to b. mr�. TN. I prfterod forr.Eb&.Lkn esd Icm,d.d �f�l. aNW.atp"la 1 7
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NORTH CAROLINA
RANOOLPH COUNTY
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NOTES
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FINAL MAP
ROSS R&DIVISION
PROPFRTY OF
J. D. ROSS , JR.
ASHEDORO TOWNSHIP - R4NDOLPH COUNTY
ASHE90RO , NORTH CAROL INA
SCALE r / /OOr APRIL , /9W
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TGTAL AREA = z4. 648 ACRES
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HENLEY SURVEYING 8 MAPPIN6 CO.
45MIFOOR0, NC ?770i . �
PH. : Y19. 62Y-4226 V-
u0e AJ-3 Itf
0

Summey Engineering Associates, PLLC
Engineering - Land Planning - Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] - Fax: [phone]
March 15, 2010
Re: Hospice of Randolph
Response Letter to Email
Stormwater Project No. SW409POIi'-,,.'*.; ,
Randolph County, NC f fl:N
SEA Job No. E-1524
Mr. Brian Lowther
North Carolina Division of Water Quality
Wetlands & Stormwater Branch
1617 Mail Service Center
Raleigh, North Carolina 27604
Dear Brian:
Enclosed are two (2) sets of revised plans you requested per your email dated March 4,
2010,
Item 1 — The rip rap level spreader has been deleted. Outlet pad is still shown to control
erosion at the outlet and slope transition.
Thank you again for your help and should you have any questions or concerns or
require any additional information, please do not hesitate to contact me directly at
336-328-0902.
Very Truly Yours,
Summey Engineering Associates, PLLC
// .
f
IYA
H. Mack Summey, Jr., PE
HMSJ/hmsj
Cc: Mrs. Rhonda Burch, Hospice
File

Summey Engineering Associates, PLLC
Engineering • Land Planning • Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] • Fax: [phone]
March 2, 2010
Re: Hospice of Randolph
Response Letter
Stormwater Project No. SW4091101
Randolph County, NC
SEA Job No. E-1524
Mr. Brian Lowther
North Carolina Division of Water Quality
Wetlands & Stormwater Branch
1617 Mail Service Center
Raleigh, North Carolina 27604
Dear Brian:
Enclosed are two (2) sets of revised plans and supporting material you requested per your
letter dated November 23, 2009. Posted below are our Responses to your letter.
Item I — The High density box has been checked on Form SWU-101 as indicated
Item 2 — The elevation of the unturned elbow has been added to the plans and appropriate
elevations shown as required.
Item 3 — Rip rap level spreader has been shown to dissipate the flows thru a grass
vegetative filter strip before flows leave property.
Item 4 -- Soil scientist report is provided with corresponding SHWT.
Item 5 -- Required Item Checklist, Part III has been corrected.
- Drainage Basin Delineation map has been provided.
- A recorded drainage easement map will be recorded on the final.plat.
- Boundaries of the drainage easement are now shown.
- Cell Dimensions are shown.
- P-Index is indicated on the plans.
- Underdrain Calculations are provided.
Item 6 — Plan sheet 11 of 14 is now provided.
Item 7 — Supplement Sheet has been corrected to show a maximum of 9" ponding depth
in order to obtain volume required.

Item 8 -- Media Soil composition is now consistent on all information provided.
Item 9 — Planting specifications have been updated to most recent BMP Guidelines.
Item 10 -- Planting diagrams have been updated to the new BMP guidelines.
Item 11 — Existing Pavement is labeled "Existing" and Proposed asphalt is labeled
"Proposed".
Should you have any questions or concerns or require any additional information,
please do not hesitate to contact me directly at 336-328-0902.
Very Truly Yours,
Summey Engineering Associates, PLLC
L-fl a -0!- -
QL
H. ack Summey, Jr., PE i
HMSJ/hmsj
Cc: Mrs. Rhonda Burch, Hospice
File

Summey Engineering Associates, PLLC
Engineering • Land Planning • Consulting
P.O. Box 968
Asheboro, NC 27204
Phone: [phone] • Fax: [phone]
November 16, 2009em
Re: Hospice of Randolph
! CD
Application Return 41228 t'.
Y :``i
Post-Construction Permit
co
Project ID: Randolph-12/1
n0::1� o
j
Randolph County, NC
SEA Job No. E-1274
Mr. Brian Lowther
North Carolina Division of Water Quality
Wetlands and Stormwater Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Mr. Lowther:
Enclosed are two (2) sets of the revised application package including the Permit
Application and the $505 fee as you requested. It also contains all the required
information included in the original submittal that was returned to our office.
Should you have any questions or comments please do not hesitate to call me at 336-328-
0902 or email me at macknasheboro.com.
Very Truly Yours,
Summey Engineering Associates, PLI,C
I -I. Mack Summey, Jr., PE
HMSJ/hmsj
c: File

NC®ENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Ms. Rhonda B. Moffitt
Hospice of Randolph County, Inc.
416 Vision Drive
Asheboro, NC 27203
Dear Ms. Moffitt:
Division of Water Quality
Coleen H. Sullins
. Director
November 23, 2009
RECEIVED
N.C. Dent. of ENR
DEC 3 0 2099
Y:instot�-Salem
Regional Office
Subject: Request for Additional Information
Stormwater Project No. SW409.1101
Hospice of Randolph
Randolph County
Dee Freeman
Secretary
The Division of Water Quality Central Office'received a Stormwater Management Permit Application for
the subject project on November 20, 2009. A preliminary review of that information has determined that
the application is not complete. The following information is needed to continue the stormwater review:
1-. On the application (Form SWU-101) under number 2, the Low Density box is checked. Based
on the proposed percent impervious the project needs a High Density permit. Please check the
high density box.
2.- On the Bioretention Cell Supplement form in the Internal Water Storage Zone (IWS), the.
elevation of the top of the unturned elbow is entered incorrectly. The separation of 1WS and
the Surface must be 1 ft to receive the additional credit. Also, and upturned elbow is not
shown on the plan sheets.
3. On the Bioretention Cell Supplement form, Yes is indicated for the access design volume (low
evenly distributed through a vegetated filter but no details are given in the follow up questions
or on the plan sheets.
4. On the Bioretention Cell Supplement form, the SH WT elevation is 700 fmsl. Please provide a
soils report or explanation for how this elevation was found.
5. Please review the Required Item Checklist, Part 11I. There are a number of required items
missing. Some of these include:
• Delinated drainage basins. Please clearly define the drainage area.
• Recorded drainage easement and public right of way (ROW)
• Boundaries of drainage easement
• Cell Dimensions
• Indicate the P-Index between 10 and 30
• The supporting calculations (including underdrain calculations)
6. On the Required Item Checklist for the construction sequence, the Pagel Plan Sheet No. listed
was 1 I/14. '1 did not find this sheet with the submittal. Please include Plan Sheet 11/14.
Wetlands and Stormwater Branch Que
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 North Carofina
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 �atu1��l1�
Phone: 91 M07-6300 L FAX: [phone] I Customer Service: 1-877-623-6748
Internet: www ricwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer

Rhonda Moffitt
SW4091101-1-lospice of Randolph ( }'
November 23, 2009
7. On plan sheet 6/14, the max ponding depth is labeled as 6" but on the Bioretention Cell
Supplement form it is 9". Please make these consistent.
8. The Media Soil on plan sheet 6/14 needs to match the soil composition that is on the
Bioretention Cell Supplement form.
9. It appears the planting plan is too dense. Please review the section 12.3.8 in the BMP Manual
for information on selecting plants. The section has been recently updated.
10. The tree planting diagrams on plan sheet 12/14 needs to be updated to match our
recommendations for planting in the BMP manual.' From 12.3.8 — "For best survival, trees
should be planted with the top of the root ball partially out of the media. They should be
planted to have from 1/3 to 1/2 of the root ball within the media. This would leave from 2/3 to
1/2 of the root ball above the media."
11.On plan sheet 1/14, please make it clear what is existing and proposed impervious area.
Please note that this request for additional information is in response to a preliminary review. The
requested information should be received by this Office prior to January 6, 2009, or the application will
be returned as incomplete. The return of a project will necessitate resubmittal of all required items,
including the application fee.
If you need additional time to submit the information, please mail or fax your request for a time extension
to the Division at the address and fax number at the bottom of this letter. The request must indicate the
date by which you expect to submit the required information. The Division is allowed 90 days from the
receipt of a completed application to issue the permit.
Please reference the State assigned project number on all correspondence. if you have any questions
concerning this matter please feel free to call meat [phone].
Sincerely,
Brian Lowther
Environmental Engineer
cc: Winston -Salern Regional Office
DWQ Central Files
Stormwater Permitting Unit Files

RECEi1
JE4R
�.. NOV 0 6 2009
NC®EN nscon-Salem
fieglonal Office
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
November 2, 2009
Mr. Mack Summey
Summey Engineering Associates, PLLC
PO Box 968
Asheboro, NC 27204
Subject: Phase II Post -Construction Stormwater Permit Application Return
Hospice of Randolph.
Application Return #1228
Randolph County
Dear Mr. Summey:
The Division of Water Quality received your Stormwater Management Permit Application for the
subject project on October 27, 2009. The application is being returned because the application
lacked the necessary basic elements to accept it for review. The plans and any other
documentation that were submitted have been discarded or recycled, as appropriate. Please
address the following noted deficiencies and provide the requested information:
❑ Two sets of plans.
® A completed and signed. permit application with an original signature.
❑ The appropriate supplement form required for all projects.
❑ Sealed design calculations..
❑ A signed Operation and Maintenance Plan.
-® The required permit fee of $505.00.
❑ The results of a soils investigation, reporting the Seasonal High Water Table elevation for all
projects, and in addition for infiltration projects, reporting the soil type, and expected
infiltration rate.
The application form SWU-101 can be found at http://h2o.enr.state.nc.us/su/bmp forms.htm
Please resubmit the permit application package. Note that the 90-day statutory permit review time
begins upon receipt of a complete application. If you have any questions concerning this matter,
please contact me at [phone] or [e-mail].
Sincerely,
C�
Brian Lowther
DWQ Stormwater Permitting Unit
cc: Winston Salem Regional Office
SPU files
Wetlands and Stormwater Branch One 1617 Maio Service Center, Raleigh, North Carolina 27699-1617 NO.rt1! 1Cit1 011lIlr
Location: 512 N. Salisbury St. Raleigh. North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748 Naturally
Internet: www.ncwaterquality.org v i/
An Equal opportunity 1 Affirmative Action Employer

o�0� w A r4�Rp�
7
> r
Rhonda Burch
Hospice of Randolph
416 Vision Drive
Asheboro, NC 27203
December
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
10, 2008
Subject: Post -Construction Notification
Coleen H. Sullins, Director
Division of Water Quality
— RECEIVED
N.C. Ooot. of ENR
DEC 12'.2MO
&rjstonSalom
Regional Office
Project ID: Randolph-12110-01
Project: Hospice of Randolph
Randolph County, North Carolina
Dear Sir or Madam,
A review of the Financial Responsibility/Ownership (FRO) form required under the
Sedimentation Pollution Control Act received on December 8, 2008 has determined that the Hospice of
Randolph project may be subject to a State Stormwater Permit for Post -construction.
Unless excluded under the provisions of Session Law 2006-246, Section 8, you must submit
within 30 days an application for a Post -Construction Stormwater Permit to:
North Carolina Department of
Division of Water Quality
Stormwater Permitting Unit
Post -Construction Application
1617 Mail Service Center
Raleigh, NC 27699-1617
The Post -construction permit is in additil
permit received for construction activity from the
regarding MSI Post -Construction and Phase 11 Sc
vironment and Natural Resources
n to a North Carolina General Permit (NCGO 10000)
Division of Water Quality. For more information
sion Law 2006-246 please visit:
httpalh2o.enr.st,ite.iic.us/suN PDF S_Phase_11_Stormwaler_Program. htm
If you have any questions concerning this matter please feel free to call me at 919-807-6368 or e-
mail me at [e-mail].
Sincerely,
Brian Lowther
cc: CWinston-Salem-Regiofial.Office
Stormwater Permitting Unit Files
NorthCarolina
'xtatrrally
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone]
intemet: Location: 5 t2 N. Salisbury St, Raleigh, NC 27604 Fax [phone]
An Equal Opportun{ty/Affirmative Action Employer — 100% Recycled130% Post Consumer Paper
Customer Service
1-877-623-6748

North Carolina
Beverly Eaves Perdue
Governor
Ms. Rhonda B. Moffitt
Hospice of Randolph County, Inc.
416 Vision Drive
Asheboro, NC 27203
Dear Ms. Moffitt:
NCDENR
Department of Environment and Natural
Division of Water Quality
Coleen H. Sullins
. Director
November 23, 2009
Resources
Subject: Request for Additional Information
Stormwater Project No. SW4091101
Hospice of Randolph
Randolph County
Dee Freeman
Secretary
The Division of Water Quality Central Office received a Stornwater Management Permit Application for
the subject project on November 20, 2009. A preliminary review of that information has determined that
the application is not complete. The following information is needed to continue the stor nwater review:
1. On the application (Form SWU-101) under number 2, the Low Density box is checked. Based
on the proposed percent impervious the project needs a High Density permit. Please check the
high density box.
2. On the Bioretention Cell Supplement form in the Internal Water Storage Zone (IWS), the
elevation of the top of the unturned elbow is entered incorrectly. The separation of IWS and
the Surface must be 1 ft to receive the additional credit. Also, and upturned elbow is not
shown on the plan sheets.
3. On the Bioretention Cell Supplement form;" Yes is indicated for the access design volume flow
evenly distributed through a vegetated filter but no details are given in the follow up questions
or on the plan sheets.
4. On the Bioretention Cell Supplement form, the SI-I WT elevation is 700 fms1. Please provide a
soils report or explanation for how this elevation was found.
5. Please review the Required Item Checklist, Part 11I. There are a number of required items
missing. Some of these include:
o Delinated drainage basins. Please clearly define the drainage area.
• Recorded drainage easement and public right of way (ROW)
Boundaries of drainage easement
• Cell Dimensions
• Indicate the P-Index between 10 and 30
• The supporting calculations (including underdrain calculations)
6. On the Required Item Checklist for the construction sequence, the Pagel Plan Sheet No. listed
was 11/14. I did not find this sheet with the submittal. Please include Plan Sheet 11/14.
Wetlands and Stommater Branch _ Ile
1617 Mail Service Center, Ralegh, North Carolina 27699-1617 N orthCarol ina
Location: 512 N. Salisbury St. Ralogh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748 atura!!�
Internet www.ncwaterquality.org
An Equal opportunity 1 Affirmative k ion Employer

Rlionda Moffitt
SW4091 10 1 -1-lospice of Randolph
November 23, 2009
7. On plan sheet 6/14, the max ponding depth is labeled as 6" but on the Bioretention Cell
Supplement form it is 9". Please make these consistent.
8. The Media Soil on plan sheet 6/14 needs to match the soil composition that is on the
Bioretention Cell Supplement form.
9. It appears the planting plan is too dense. Please review the section 12.3.8 in the BMP Manual
for information on selecting plants. The section has been recently updated.
10. The tree planting diagrams on plan sheet 12/14 needs to be updated to match our
recommendations for planting in the BMP manual.' From 12.3.8 — "For best survival, trees
should be planted with the top of the root ball partially out of the media. They should be
planted to have from 1/3 to 1/2 of the root ball within the media. This would leave from 2/3 to
1/2 of the root ball above the media."
11. On plan sheet 1/14, please make it clear what is existing; and proposed impervious area.
Please note that this request for additional information is in response to a preliminary review. The
requested information should be received by this Office prior to January 6, 2009, or the application will
be returned as incomplete. The return of a project will necessitate resubmittal of all required items,
including the application fee.
If you need additional time to submit the information, please mail or fax your request for a time extension
to the Division at the address and fax number at the bottom of this letter. The request must indicate the
date by which you expect to submit the required information. The Division is allowed 90 days from the
receipt of a completed application to issue the permit.
Please reference the State assigned project number on all correspondence. If you have any questions
concerning this matter please feel free to call me at [phone].
Sincerely,
Brian Lowther
Environmental Engineer
cc: 'Winston-Salem Regional Office
DWQ Central Piles
Storirnvater Permitting Unit Files

Application Completeness Review
❑ First Submittal En Re -submittal Date R
Development/Project Name: j4,crkc
Receiving stream name
ved: i o Date Reviewed: By L36
'Jj k
classification: C
For post -construction requirements, a program will be deemed compliant for the areas where it is
implementing any of the following programs: WS-I, WS-II; WS-III, WS-IV, HQW, ORW, Neuse River Basin
NSW, Tar -Pamlico River Basin NSW, and the Randleman Lake Water Supply Watershed Nutrient
Management Strategy.
High Density Projects that require a 401/404 within an NSW require 85% TSS, 30% TN and 30% TP removal.
T&E Species (Goose Creek, Waxhaw Creek or Six Mile Creek Water Sheds)
Latitude and Longitude: 35' % 1' fo" _ 79 ° ' o5- "
Project Address: 64. V ;v
Engineer name and firm: Y1,_k .
►1,
Jurisdiction s4-2,
J `" ' s��, LQ ... A��
U Low Density (no curb and gutter) ❑ Low Density with curb and gutter outlets 2' igh Density El(7ther
C-t' 401/404 impacts to surface waters, wetlands, and buffers (add language to cover letter and/or addinfo letter) At,,
cir" BUA 77, fo
a( Check for $505.00 included
Ei' Original signature (not photocopy) on application
Gr Legal signature (Corporation-VPlhigher, Partnership -General Partner/higher, LLC-member/manager, Agent).
Check spelling, capitalization, punctuation: http://www.secretary.state.nc.us/corporations/tliepage.aspx
If an agent signs the application, a signed letter of authorization from the applicant must be provided which
includes the name, title, mailing address and phone number of the person signing the letter.
U For subdivided projects, a signed and notarized deed restriction statement
Ld Sealed, signed & dated calculations
U Correct supplement and O&M provided for each BMP on site (check all that were provided & number of each)
Y Bioretention
U Dry Detention Basin
U Filter Strip
U Grass Swale
U Infiltration Basin
U Infiltration Trench
U Level Spreader
U Permeable Pavement
U Restored Riparian Buffer
❑ Rooftop Runoff Management
❑ Sand Filter
❑ Stormwater Wetland
❑ Wet Detention Basin
❑ Low Density
❑ Curb Outlet
0 Off -Site
❑ NCDOT Linear Road
+ Two sets of sealed, signed & dated layout & finish grading plans with appropriate details
Narrative Description of stormwater management provided
U Soils report provided
U Wetlands delineated or a note on the plans that none exist on site and/or adjacent property
5d Details for the roads, parking area, cul-de-sac radii, sidewalk widths, curb and gutter;
V Dimensions & slopes provided
U Drainage areas delineated ref Pervious and impervious reported for each 121"Areas of high density
V Inspection and maintenance agreements provided
U Application complete ❑ Application Incomplete Returned: (Date)
Comments
February 9, 2009 Revision

SL 2006-246 Section 9 Post Construction Requirements for Non -Coastal Counties
Low -density projects
❑ No more than two dwelling units per acre or 24% built, upon area; ,
❑ Vegetated conveyances to the maximum extent practicable;
❑ Built -upon areas at least 30 feet landward of perennial and intermittent surface waters;
❑ Deed restrictions, protective covenants, and/or other restrictive language/measures.
High density protects
❑ Control and treat runoff from the first one -inch of rain.
❑ Runoff volume drawdown time must be a minimum of 48 hours, but not more than 120 hours;
❑ Discharge the storage volume at a rate equal to or less than the predevelopment discharge rate for the
one-year, 24-hour storm. . . .. , ;
❑ Achieve 85% average annual removal of total suspended solids.
❑ For BMPs that require a separation from the seasonal high-water,table (SHWT), the separation shall include
at least 12 inches of naturally occurring soil above the SHWT:
❑ Stormwater management measures must comply with the General Engineering Design Criteria For All
Projects requirements listed in 15A NCAC 2H .1008(c);
❑ All built -upon areas are at least 30 feet landward of perennial and intermittent surface waters;
❑ Deed restrictions, protective covenants, and/or other restrictive language/measures
❑ Provide a mechanism to require long-term operation and maintenance of Best Management Practices
Goose Creek, Six Mile Creek and Waxhaw Creek Watersheds
Buffer Requirements
❑ Undisturbed riparian buffers within 200 feet of water bodies within the 100-Year Floodplain and within 100 feet
of water bodies that are not within the 100-Year Floodplain. Exceptions to the undisturbed buffer
requirements are set forth in 15A NCAC 02B .0607
Stormwater Controls as required by 15A NCAC 02B .0602
❑ Control and treat the difference between the pre -development and post -development conditions for the one-
year, 24-hour storm with structural controls.
❑ Development and redevelopment shall implement stormwater management measures that promote infiltration
of flows and ground water recharge for the purpose of maintaining stream base flow.
❑ 85% average annual removal of total suspended solids.
❑ Draw down the treatment volume no faster than 48 hours, but no slower than 120 hours, for detention ponds.
❑ Discharge the storage volume at a rate equal or less than the pre -development discharge rate for the one-
year, 24-hour storm.
❑ Meet design or stormwater management measures set forth in 15A NCAC 2H .1008.
High Density Projects that require a 401/404 within an NSW
❑ 85% TSS
ci 30% TN
❑ 30% TP
February 9, 2009 Revision