SW6120306_CURRENT PERMIT_20120524

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

'iftAirli"in
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Pei -due
Governor
Mr. Brian Clodfelter
PAR 5 DEVELOPMENT GROUP, L.L.C.
2860-B NC 5 Highway
Aberdeen, NC 28315
Division of Water Quality
Charles 1r11akild, P.E.
Director
April 12, 2012
Subject: Stormwater Permit No. SW6120306
Dollar General Store -- Buffalo Lake Road
High Density Commercial Infiltration Basin Project
Harnett County
Deal- Mr. Clodfelter:
DE1 V R-FRO
KAv 2 4 2012
DWQ
Dee freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for Dollar
General Store - Buffalo Lake Road on March 26, 2012. 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. SW6120306, dated April 12, 2012,
for the construction, operation and maintenance of the subject project and the Stormwater BM Ps.
This permit shall be effective from the date of issuance until April 12, 2020 and shall be subject to the
conditions and limitations as specified therein, and does not supersede any other agency permit that may be,
required. Please pay special attention to the conditions listed in this permit regarding the Operation and
Maintenance of the BMP(s), recordation of deed restrictions, procedures for changes of ownership,
transferring the permit, and renewing the permit. Failure to establish an adequate system for operation and
maintenance of the stormwater management system, to record deed restrictions, to follow the procedures for
transfer of the permit, or to renew the permit, 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 ofa. 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 Fayetteville Regional Office. If you have any questions, or need additional
information concerning this matter, please contact Robert Patterson at [phone], or
[e-mail].
Sincerely,
cc: SW6120306 File"
James P. Cameron - JFDA, LLC
Wilton C. Jones
for Charles Wakild, P.E. ec: C. Heath Wadsworth, PE - Call Sign Engineers, PA
Mike Lawyer - Fayetteville Regional Office
Wetlands and Stormwaler Branch One
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 NorthCarolina
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Naturally
Internet: www ncwaterquality.org
An Equal Opportunity 1 Affirmative ActionEmployer

State Stormwater Permit
Permit No. SVV6120306
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
PAR 5 DEVELOPMENT GROUP, L.L.C.
Dollar General Store — Buffalo Lake Road
55 Buffalo Lake Rd. (SR1115), Sanford, Harnett County
FOR THE
construction, operation and maintenance of one (1) infiltration basin 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 April 12, 2020, and shall be
subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
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 1.8 of this permit. The stormwater control has been
designed to handle the runoff from 29,335 square feet of impervious area.
3. This basin is approved, and must be maintained, to provide 2.Ox the minimum
required treatment volume (based on the 1.0" design storm) in order to waive the
requirement of providing the 30' vegetated filter strip.
4. The tract will be limited to the amount of built -upon area indicated in Section 1.8
of this permit, and as shown on the approved plans.
5. 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.
6. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
Page 1 of 6

Stake Stormwater Permit
Permit No. SW6120306
7. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
8. The following design criteria have been permitted for the infiltration basin,and
must be provided and maintained at design condition:
a
61
C.
d.
e.
f.
9h.
Drainage Area, acres:
Onsite, ft
Offsite, ftz:
Total Impervioul Surfaces, ftz:
Onsite, ft .
Offsite, ftz:
Design Storm, inches:
Basin Depth, feet:
Bottom Elevation, FMStz:
Bottom Surface Area, ft
Bypass Weir Elevation, FMSy
Permitted Storage Volume, ft
Type of Soil:
Expected Infiltration Rate, inlhr:
Seasonal High Water Table, FMSL:
Time to Draw Down, hours:
Receiving Stream/River Basin:
Stream Index Number:
Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
1.01
44,016
0
29,335
29,335
0
1.0
1.5
261.0
1,675
262.5
4,750
Loamy Sand
0.70
259.0
24.0
Barbeque Creek 1 Cape Fear
18-20-13
11C11
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 times 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:
4
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and revegetation of slopes and the vegetated filter.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans and
specifications.
f. Debris removal and unclogging of bypass structure, infiltration media, flow
spreader, catch basins, piping and vegetated filter.
g. A clear access path to the bypass structure must be available at all times.
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. S"'6126306
6. The stormwater treatment system shall be constructed in accordance with the
approved plans and specifications, the conditions of this permit, and with other
supporting data.
7. 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.
8. 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.
9. Access to the stormwater facilities shall be maintained via appropriate
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 modifying 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 to any person or entity 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
to the Division of Water Quality, signed by both parties, and accompanied by the
appropriate 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
Permi� No, SW6120306
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
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 Quaiity, 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, file Fermiiiee snail take irtirriediate 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 reissuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
controls 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 all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 12th day of April, 2012.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
xwv�
Tor Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4 of 6

State Stormwater Permit
Permit No. SV116120306
Dollar General Store — Buffalo Lake Road
Stormwater Permit'No. SW6120306
Harnett 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)
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 `
Permit No. SW6120306
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. Ail roar drains are located such that the runoff is directed into the systern.
5. The bypass structure weir elevation is per the approved plan.
6. The bypass structure is located per the approved plans.
7. A Trash Rack is provided on the bypass structure.
8. All slopes are grassed with permanent vegetation.
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. All required design depths are provided.
13. All required parts of the system are provided.
14. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Fayetteville Regional Office
Surface Water Protection
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
Page 6 of 6

State Stormwater Permit
• Permit No. SW6120306
Dollar General Store - Buffalo Lake Road U���—��®
Stormwater Permit No. SW6120306
Harnett County OCT 17 2012
Designer's Certification DWO
I, c. +J ,Wll-bswoi� , as a duly registered FJa ss o nr in the
State of North Carolina, having been authorized to observe (periodically/ weekly/ full
time) the construction of the project,
(Project)
for i MZ S 'D>-�'vgoPlnrpwT 4-q� P (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:
-"H-C- garrQrl Of✓ -rliS lNFIL.TF -rwrJ 134115,1�4 WR$ Nor LovVf'6�
Wtr1+ iz iNc. -E5 OF 6L-"N 4PrHb pr,� THt 'I>fSKt4 .
T+ i36; ` vM OF TW5 '3ft"5,I N A-M► , Si b7C -� LofPE S N A-vfF 6 f-t-i
Gvv .,b yN 17-4 f os 1 a N GWII�0 �, M A- --rI N U.
Signature
Registration Number Z254 Z a SEAL
Date 28421
/o / a/ '+
W
Page 5 of 6

._.
I
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..
;;,
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i �
i
.� t .'1 i

i
State Stormwater Permit
Permit No. SW6120306
Certification Requirements:
✓1. The drainage area to the system contains approximately the permitted
acreage.
_k/ 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 bypass structure weir elevation is per the approved plan.
4�6. The bypass structure is located per the approved plans.
7. A Trash Rack is provided on the bypass structure.
8. All slopes are grassed with permanent vegetation.
✓ 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.
Z 12. All required design depths are provided.
* 13. All required parts of the system are provided.
�v-- 14. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Fayetteville Regional Office
Surface Water Protection
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
North D*vwrioNS
oN ffmvtov5 Pee ,rr .
Page 6 of 6

Lawyer, Mike
From: Gordon Rose [[e-mail]]
Sent: Friday, October 26, 2012 8:48 AM
To: Lawyer, Mike
Cc: Heath Wadsworth
Subject: Buffalo Lake Road
Attachments: Stormwater Basin.docx
Mike,
When we discussed the situation at the infiltration pond for the Dollar General on Buffalo Lake Road, you had
expressed concern about the matting that had been placed in the bottom of the pond. As we discussed, this
was not a part of the design but was an oversight on the part of the contractor. You further indicated that if the
matting had not received seeding then it could remain in place as long as the matting itself did not cause
clogging. However, if the matting had received seeding, then the matting and the seeding would need to be
removed.
1 spoke to our client about this to determine what had been done. He could not tell me definitively whether the
contractor had placed seeding in the bottom of the basin or not. Therefore, he made the decision to completely
remove the matting from the bottom of the basin. I have attached a photograph of the basin now that the
matting has been removed from the bottom.
Please let us know how to proceed from here with regards to the certification. Do we need to submit a revised
certification or will this email suffice? Thanks for your help.
Gordon A. Rose, PE, LEED AP
CALL SIGN.
ENGINEERS
104 Gillespie Street
Fayetteville, NC 28301
Office: 910.486.0700
Cell: 910.322.6567
E-mail: [e-mail]

1
pia: •a �!
10/25/201.2
Dollar General — Buffalo Lake Road
Matting has been removed from bottom of basin

1 DWQ USE ONLY
Date Received
Fee Paid
Permit Number
,5a.5 -*� 113 1
1 �_ko LD 1 a 0 3.0 (e
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 KPh It - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universa[ Stormwater Management flan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This forni may be photocopied for use as an original
1. 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.):
Dollar General Store - Buffalo Lake Road
2. Location of Project (street address):
55 Buffalo Lake Road
City:Sanford Cou nty:Harnett Zip:27332
3. Directions to project (from nearest major intersection):
The project site is located near the intersection of Buffalo Lake Road and NC H WY 27.
4. Latitude:35° 19' 57.59" N Longitude:79° 02' 43.81" W of the main entrance to the project.
H. 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
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, 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):
❑LAMA Major ®Sedimentation/Erosion Control:1.6 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
k-nip data anti flip lino of aarh normif-
hors

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: Par 5 Development Group, LLC
Signing Official & Title:Brian Clocifelter, Member Manager _
b.Contact information for person listed in item I above:
Street Address:2860-B NC 5 HiQhwa
City:Aberdeen State:NC
Zip:28315
Mailing Address (if applicable):2860-B NC 5 I-tiQhway
City:Aberdeen
State:NC Zip:28315
Phone: (910 ) 944-0881 Fax: (910 ) 944-0881
Email:brianQrhetsonconnpanies.com
c. Please check the appropriate box. The applicant listed above is:
❑ The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
® Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
® Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:JEDA, LLC
Signing Official & Titlejames P. Cameron, Member
b.Contact information for person listed in item 2a above:
Street Address:12995 Highway 27 West
City:Broadway _ State:NC Zip:27505
Mailing Address (if applicable):12995 Highway 27 West
CityTroadway
State:NC
Phone: ( 1 Fax:
Email:
Zip:27505
3. a. (Optional) Print the name and title of another contact such as the projects 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:
Phone:
I mail:
State:
Fax:
Zip:
4. Local jurisdiction for building permits: Harnett County
Point of Contact:Ken Slattum Phone #: (910 ) 893-7525
Fornn SWU-101 Version 07.lun2010 Page 2 46

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the storm water runoff will be treated.
The proposed parking lot and building will be designed so that runoff discharges into and is treated by an
infiltration basin.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear (liver basin.
4. Total Property Area: 1.37
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+:1.37 acres
+ Total project area shall be calculated to eTCIMIC tllc f0ll0wlrl the normal pool of nri rounded structures, tile area
between tire banks of streams and rivers, fire area below the Norinal High Water (NHW) line or Mean High Writer
(MHW) line, and Coastal we'tlatldS landward from the NHW (or MHW) litre. The resultant project area is Used to
calculate overall percent built upon area (BI.IA). Notl-coastal zoetlarrds landward of the NHW (or MHW) Iirle ttiay
be included in the total project area.
S. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 52
9. How many drainage areas does the project have?1. (For high density, count 1 for each proposed engineered
stornizoater 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 1.
Drainage Area
Drainage Area
Drainage Area
Receiving Stream Name
Barbeque Creek
Stream Class *
C
Stream Index Number *
18-20-13
Total Drainage Area (so
44,016
On -site Drainage Area (so
44,016
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
29,335
% Impervious Area** total
67%
Impervious— Surface Area
Drainage Area 1
Drainage Area
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
9,100
On -site Streets (so
0
On -site Parking (so
20,078
On -site Sidewalks (so
0
Other on -site (so
157
Future (so
0
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
1 29,335
* Stream Class and Index Number call be determined at: http://portal.11cdellt.arg/rueb/zorl[ps/cslr/classif cafintls
* Inr �crviolrs area is defined as the built upon area including, bat not limited to, buildings, roads, parking areas,
si�ezoalks, gravel areas, etc.
Form SWU-101 Version 07.1un2010 Page 3 ol'6

'Report only that amount of existing BUA that toil[ remain after development. Do not report arty existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. lv A
Protects in Union County: Contact DtVQ Central Office staff to check if the project is located within a Threatened &
Endangered Species tivatershecl that may be subject to snore stringent stormtivater 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 http://portal.ncdenr.org/web/wq/ws/su/bmp-manual.
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://Vortal.ncdenr.org/web/vvq/ws/su/statcs%v/fornisdocs. 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 at http://portal,rrcdenr.org/web/vvq/ivs/su/mates.)
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 htt x ortaLncdennor web we ws/su/statesw/ forms dots.
Initials
1. Original and one copy of the Stormwater Management Permit Application Norm. 1!!!W
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part Vll below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.envhelp.org/pages/onestopcxpress.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
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'/z mile of the site boundary, include the 1/2
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.
rn. 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).
I orm SWU-101 Version 07Jun2010 Page 4 of 6
for Ae
Grk

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMI's, 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 verifij the SH1NT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 2356 Page No: 75
11. 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 21-1.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http:/ /www.secretary.state.nc.us/Corporations/CSearch.aspx
VIL 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:f /portal.ncdennorg/web/wcl/ws/su/statesw/forms_docs. 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.
Vill. 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:C, Heath Wadsworth, PE
Consulting Firm: Cali Sign Engineers, PA
Mailing Address:104 Gillespie Street
City:Fayetteville State:NC Zip:28301
Phone: (910 ) 486-0700
I,"-niail:heath,wadswortli@caIIsigneii,giiieers.com
Fax: [phone]
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, iteru 2 has been filled out, complete this
section)
1, (print or type name of person listed in Contact Information, item 2a) James P, Cameron 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 In) Brian Clod cltcr with (print or type unrnre of oYgRlnnZ!ltn011 listed in
Contact Information, item 1a) Par 5 Develo mert Group LLC 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 07Jun2010 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 penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
a Notary Public for the State of
MOD-fL, , do hereby �ireby certify thatU
1�, before me this _& day of &IV A ,rend
a stormwater permit. Witness my hand and official seal,
\``��ti4111111r11rJr,��
CA P i rr,�
Notary Public
Moore County
=My Commission Expires=
06119/2016
O
X. APPLICANT'S CERTIFICATION
SEAL
Date: . -1 q- Q C j Z
N & County of
personally appeared
du e etution of the application for
My commission expires V, -( q---)-01 Y
1, (print or type narrre of person listed Ill Cori tact Information, iterr 7a) Brian Clodfeltcr _
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 stormw r rules and 15A NCAC 21-I .1000, SL 2006-246 (Ph. II -Post Construction) or SL 2008-211.
Signature: Date: -Z f.I ZE { � 2
, a Notary Public for the State of _ KJC,- ,, County of
do hereby certify that �b7(�t,� D� .�T ✓ personally appeared
before me thisday of �-a ac ¢wledge qTc�it)eVxecution of the application for
a stormwater permit. Witness my hand and official seal,
\�t�tt�ti l u u l rrrrri�� �
GC A P1Tr4;,���i//
Notary Public
Moore County
My Commission Expires=
06/ 1912016
CItiWO A R
SEA]_
My commission expires 6 -1 Ci - ao 1 U,
Form SWU-101 Version 07Jun2010 Page 6 of 6

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Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 EYPh 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 mmj be photocopied for use as an original
1. 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.):
Dollar General Store - Buffalo Lake Road
2. Location of Project (street address):
55 Buffalo Lake Road
City:Sanford County:Harnett I Zip:27332
3. Directions to project (from nearest major intersection):
The ro'ect site is located near the intersection of Buffalo Lake Road and NC HWY 27.
4. Latitude:35° 19' 57.59" N Longitude:79° 02' 43.81" W of the main entrance to the project.
H. 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, 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 NSedimentation/Erosion Control:1.6 ac of Disturbed Area
❑N-PDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit.
Form SWU-101 Version 07Iun2010 Page 1 of 6

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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: Par 5 Development Group. LLC
Signing Official & Title:Brian Clodfelter, Member Manager
b.Contact information for person listed in item, Ia above:
Street Address:2860-B NC 5 Highway _
City:Aberdeen State:NC Zip:28315
Mailing Address (if applicabie):2860-11 NC 5 Highway _ _-
City:Aberdeen State:NC Zip:28315
Phone: (910 ) 944-0881 _ Fax: (910 ) 944-0881
Email:brian®rhetsoncompanies.com
c. Please check the appropriate box. The applicant listed above is:
❑ The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
® Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
® Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. ('This is the
person who owns the property that the project is located on):
Property Owner/Organization Wilton C. Jones
Signing Official & Title ;Wilton C. Tones, Property Owner
b.Contact information for person listed in item 2a above:
Street Address:
City: ' State: Zip:
Mailing Address (if applicable):PO Box 29
City:My tle Beach P _ State:SC Zip: 24 rq'
Phone: ( 1 Fax: l 1
Email
3. a. (Optional) Print the name and title of another contact such as the projects 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: ( 1 _ Fax:
4. Local jurisdiction for building permits: Harnett County
Point of Contact:Ken Slattum Phone #: (_910 ) 893-7525
Form SWU-101 Version 07Jun2010 Page 2 of 6

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IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The proposed parking lot and building will be designed so that runoff discharges into and is treated b. an
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b. If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the Cape Fear River basin.
4. Total Property Area: 1.37 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+:1.37 acres
` Total project area shall be calculated to exclude the following the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Nonnal High Water (NHM lure or Mean High Water
(MHW) tire, and coastal wetlands landwardfrom the NHW (or MHW) lime. The resultant project area is used to
calculate overall percent built rrporr area (BL1A). Norr-coastal zuetlairrls latrduiard of the NHW (or MHW) lute rrrai?
lie included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / 'Total Project Area) X 100 = 52 %
9. I -low many drainage areas does the project have?1 (For high density, count 1 for each proposed engineered
storruwater BMP. For loin density and other projects, rise 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
Barbeqtie Creek
Stream Class
C
Stream Index Number *
18-20-13
Total Drainage Area (so
44,016
On -site Drainage Area (sf)
44,016
Off -site Drainage Area (sf)
0
Pro osed Impervious Area** (so
29,335
Impervious Area** total
67%
Impervious— Surface Area
Drainage Areal,
Draina e Area _
Draina e Area
Draina e Area
On -site Buildings/Lots (so
9,100
On -site Streets (so
0
On -site Parking (so
20,078
On -site Sidewalks (so
0
Other on -site (so
157
Future(so
0
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
29,335
* Stream Class and Index Number can be determined at: Irflp://portat.rrcrletrr.or creb/zorl[lis/csrr/classi cafioas
�* lrrr Pervious area is defined as the built rrporr area including, but Prot limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form 5WU-I )I Version 07.Iun2010 Page 3 of 6

*** Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. N A
Proiects in Union County: Contact DWQ Central Office staff to check if the project is located ivithin a "Threatened &
Endangered Species ktatershed that nray be sabject to more stringent storinwilter 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 http:(/L)ortal.ncdenr.org web/wq/ws/su/bn}p-manual.
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 htt ortal.ncclenr.or web ws ws su statesw forms does. 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 at httEL:Z/portal.ncdenr.or};/weki/wq/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portii.ncdenr.org/Fs,eb/ro(l/ws/su/statesvN,/forms_docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part Vll below}
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each 13MI1.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
Irtt www.envhel p.org /pages/onesto ex ress.htmI 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
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 1/2 mile of the site boundary, include the 1/2
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.
in. 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).
-.�
for Ae
Form S W U-101 Version 07J un2010 Page 4 o1* 6

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify _-Aiz
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x11" copy of the 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: Scherhrle a site visit for DWQ to verify the 51'IINT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 1030 Page No: 954
11. 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 21-1.1003(e). The
corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http://NN,ww.secretary,state.nc.us/Corporatiotis/CSearch.aspx
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://Uortii.ncdenr.org/web %A,q/ws/su/statesw//forms_docs. 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:C. Heath Wadsworth, PE.
Consulting Firm: Call Sign Engineers, PA _
Mailing Address:104 Gillespie Street _
City:Fayetteville ^
Phone: [phone]
lamail:heath.wadsworth©cal[signengineers.com
State:NC Zip:28301
Fax. [phone]
IX. PROPERTY OWNER AUTHORIZATION (if Cat tact lnfonnation, item 2 has been filled out, complete this
section)
I, (print or type urine of person lister! in Contact hiforrnatiou, iterrn 2a) Wilton C._Jones _, certify that I
own the property identified in this permit application, and thus give permission to (print or (ype name of person
listed in Contact Information, item 1a) Brian Clod elter with (print or type name of organization listed hi
Contact Information, item 1a) Par Deyelopmext Gronrl, LLC 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.
Fora) SWU-101 Version 07.Iun2010 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 penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature:
C
Date: 3l Z d /I Z
I, -�ILWT-?z ah5 Pla#- , a Notary Public for t e State of v � County of
�. , do hereby certify that W n personally appeared
before me t f o its . and owled e the du executi the a
Y � g pPIication for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires Z4�4 azl;�2 z
X. APPLICANT'S CERTIFICATION
I, (Print or type ijame of person listed in Contact Information, itent In) Brian Clodfelter ,
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 stormwat Jtules tender 15,X NAC 2H .1000, SL 2006-246 (Ph. II -- Post Construction) or S1., 2008-211.
Signature:
Date: zP0
1, etW a -A+ YV l A-0- , a Notary Public for the State of C , , County of
do hereby certify that &IQ.UL LI CA C.lbo—l' personally appeared
before me this day of _�QLand ackt 1 �Ige the dtr x c lion of the application For
a stormwater permit. Witness my hand and official seal, `\ `l
` Notary Public
Moose CountY `
i my Commission EXP;Tes _
0611912016
T
r1q iC A\ iLo���
SISAL
My commission expires i '1 r f�
Form SWt.1-101 Version 07.1un2010 Page 6 of 6

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Permit Number: 5VJG 12!73CDC
(to be proi,idcd by DWQ)
Drainage Area Number:
Infiltration Basin Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a
log in a known set Iocation. Any deficient BMP elements noted in the inspection will be
corrected, repaired or replaced immediately. These deficiencies can affect the integrity
of structures, safety of the public, and the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area will be carefully managed to reduce the sediment load to the
infiltration basin.
— Immediately after the infiltration basin is established, the vegetation will be
watered twice weekly if needed until the plants become established (commonly
six weeks).
--- No portion of the infiltration basin will be fertilized after the initial fertilization
that is required to establish the vegetation.
— The vegetation in and around the basin will be maintained at a height of
approximately six inches.
After the infiltration basin is established, it will be inspected once a quarter and within
24 hours after every storm event greater than 1.0 inches (or 1.5 inches if in a Coastal
County). Records of operation and maintenance will be kept in a known set location
and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall
be repaired immediately.
BMP element:
Potentialproblem:
How I will remediate theproblem:
The entire BMP
Trash/debris is present.
Remove the trash/debris.
The perimeter of the
Areas of bare soil and/or
Regrade the soil if necessary to
infiltration basin
erosive gullies have formed.
remove the gully, and then plant a
ground cover and water until it is
established. Provide lime and a
one-time fertilizer application.
The inlet device: pipe or
The pipe is clogged (if
Unclog the pipe. Dispose of the
Swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
applicable).
Erosion is occurring in the
Regrade the Swale if necessary to
Swale (if applicable).
smooth it over and provide erosion
control devices such as reinforced
turf matting or riprap to avoid
future problems with erosion.
Dorm SW40I-[nfiltratien Basin 08-,M-Rev.3
Page I of 3

BMP element:
The forebay
The main treatment area
The embankment
The outlet device
The receiving water
Potential problem:
Sediment has accumulated
and reduced the depth to 75%
of the original design depth.
Erosion has occurred or
riprap is displaced.
Weeds are present.
A visible layer of sediment
has accumulated.
Water is standing more than
5 days after a storm event.
Weeds and noxious plants are
growing in the maul
treatment area.
Shrubs or trees have started
to grow on the embankment.
An annual inspection by an
appropriate professional
shows that the embankment
needs repair.
Clogging has occurred
The outlet device is damages
Erosion or other signs of
damage have occurred at the
outlet.
How I will remediate the problem:
Search for the source of the
sediment and remedy the problem if
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Remove the weeds, preferably by
hand. If pesticides are used, wipe
them on the plants rather than
spraying.
Search for the source of the
sediment and remedy the problem if
possible. Remove the sediment and
dispose of it in a location where it
will not cause impacts to streams or
the BMP. Replace any media that
was removed in the process.
Revegetate disturbed areas
immediately.
Replace the top few inches of filter
media and see if this corrects the
Standing water problem. If so,
revegetate immediately. If not,
consult an appropriate professional
for a more extensive repair.
Remove the plants by hand or by
wiping them with pesticide (do not
spray).
Remove shrubs or trees
immediately.
Make all needed repairs.
Clean out the outlet device. Dispose
of the sediment off -site.
Repair or replace the outlet device.
Contact the NC Division of Water
Quality 401 Oversight Unit at 9"I9-
733-1786.
Ijorm SW401-Infiltration Basin O&M-Rev.3 Page 2 of 3

Permit Number: 5Lt/t i2o 3o-f,
(to be provided by DWQ)
I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above. I agree to notify DWQ of any
problems with the system or prior to any changes to the system or responsible party.
Project nanze:Dollar General Store - Buffalo Lake Road
BMP drainage area zzu nber: I
Print name:Brian Clodfelter
Title:Member Manager Par 5 Development Group,-LLC
Address:2860-B NC 5 HiOwav; Aberdeen, NC 28315
Date:
Note: The legally responsible party should not be a homeowners association unless more than 50% of
the lots have been sold and a resident of the suhdivision has been named the president,
I, b�Citi a Notary Public for the State of
MCI lCounty of OQI't� , do hereby certify that
OVI Gist C4 OCR Cc1-1(- ►/ personally appeared before me this 2i
Z�, and acknowledge the due execution of the day of I Gb
forgoing infiltration basin maintenance requirements. Witness my hand and official seal,
A I PI I
Notary Public
MooFe County
-:My Commission Expltes`
06119/2016zz
O
SEAL
My commission expires r 3'C) t
Form 5W401-Infiltration Basin O&M-Rev.3
Page 3 of 3