SW6121005_CURRENT PERMIT_20121217

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW RA &5
DOC TYPE
� CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE
A04 lA Z!7
YYYYMMDD

A�A
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Taner Esensoy
Purdue Drive Investments, LLC
304 Summertime Road
Fayetteville, NC 28303
Division of Water Quality
Charles Wakild, RE,
Director
November 14, 2012
Subject: Stormwater Permit No. SW6121005
Rainbow Pediatrics
High Density Commercial Bio-Retention Project
Hoke County
Dear Mr. Esensoy:
Dee Freeman
Secretary
DENR-FRO
DEC 17 2012
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for
Rainbow Pediatrics on October 31, 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. SW6121005, dated November 14, 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 November 14, 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 by filing a written petition with the Office of Administrative Hearings (OAH).
The written petition must conform to Chapter 150B of the North Carolina General Statutes. Per NCGS 143-
215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this permit. You should
contact the OAH with all questions regarding the filing fee (if a filing fee is required) and/or the details of the
filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via telephone at 919-431-3000, or visit
their website at www.NCOAH.com. 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,
for Charles Wakild, PE, Director
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www.ncwaterquallty.org
An Equal Opportunity 4 Affirmative Action Employer
Cc: SW6121005 File
Ec: Ned Garber - The Rubicon Group
C. Heath Wadsworth, PE - Call Sign Engineers
Mike Lawyer - Fayetteville Regional Office
Nne
orthCarolina
NatundY

State Stormwater Permit
Permit No. SW6121005
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
Purdue Drive Investments, LLC
Rainbow Pediatrics
142 Paraclete Drive, Raeford, Hoke County
FOR THE
construction, operation and maintenance of a 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 November 14, 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 1.7 of this permit. The stormwater control has been
designed to handle the runoff from 43,124 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.
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. SW6121005
7. The following design criteria have been provided in the bioretention cell and must
be maintained at design condition:
a. Drainage Area, acres:
Onsite, ft :
Offsite, ft2:
b. Total Impervioug Surfaces, ft2:
Onsite, ft
Offsite, ft2:
C. Design Storm, inches:
d. Max. Ponded Depth, feet:
e. Seasonal High Water Table, fmsl
f. Planting Media Depth, feet:
g. Cell Dimensions, feet:
h. Planting Elevation, frsl:
i. Top Surface Area, ft
j. Permitted Storage Volume, ft3:
k. Bypass / Storage Elevation, fmsl:
I. Drawdown Time, hours:
M. Underdrain Diameter, inches:
n. Total number of plants provided:
o. Receiving Stream/River Basin: '
p. Stream Index Number:
q. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
1.46
63,764
0
43,124
43,124
0
1.0
1.0
243.5
2.0
220x12
249.0
4,844
4,165
250.0
48
6.0
grass sod
UT to Stewarts Crk. / Cape Fear
18-23-33
1,C,1
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.
C. 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. SW6121005 .
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. 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 modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification,iri 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
Permit No. SW6121005
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 the 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 all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 14th day of November, 2012.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
for 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. SW6121005
Rainbow Pediatrics
Stormwater Permit No. SW6121005
Hoke 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
Permit No. SW6121005
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 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 forebays, media,
underdrains, vegetation, and outlet structure.
15. 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
Cc: Danny Paschal — Hoke County
Page 6 of 6

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
ro 3� t z
j -7S
I vaS
Applicable 1411e : ❑ Coastal SW —1995 ❑ CoastaI SW — 2008 Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
2. Location of Project (street address):
lete Drive
City:Raeford County:Hoke Zip:28376
3. Directions to project (from nearest major intersection):
Take US 401 from Fa aetteville towards Raeford. The project is at the corner of Brock Road and US 401 on the
right. _..._
4. Latitude:35° 1' 57" N Longitude:79° 6' 30" W of the main entrance to the project.
II. PERMIT INFORMATION:
1.a.Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenetoals with modifications also requires SWU-102 - Renernal Application For?n
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, n/a and the previous name of the project, if different than currently
proposed, n/a
4. a. Additional Project Requirements (check applicable blanks, information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑CAMA Major ®Sedimentation/Erosion Control: 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,
issue date and the type of each permit:Not vet acquired, in review process.
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part Vl: http://12ortal.ncdenr.orgZweb/wq/ws/su/statesw/ruies laws
p� T
DENF: •. Art -i'::,t�.Ai,7Y
Wetland &
Form SWU-101 Version 06Aug2012 Page l of 6

IIL 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: Purdue Drive Investments, LLC
Signing Official & Title:Taner Esensoy, Member/Manager
b.Contact information for person listed in item 1a above:
Street Address:304 Summertime Road
City:Fayetteville State:NC Zip:28303
Mailing Address (if applicable):Same as above.
City: —
Phone: (
State:
Fax:
Ole
Email:
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:
Signing Official & Title:
b.Contact information for person listed in item 2a above:
Street Add
City:
Mailing Address (if applicable):
City:
Phone: { )
Email:
State: Zip:
State: Zip:
Fax: ( )
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:The Rubicon Group
Signing Official & Title:Ned Garber, President
b.Contact information for person listed in item 3a above:
Mailing Address:565 Gillespie Street
City:Fayetteville State:NC Zip:28301
Phone: 91{ 0 ) 323-1101
Email:[e-mail]
Fax: (91_0 ) 323-9228
4. Local jurisdiction for building permits: Hoke County
Point of Contact:Danny Paschal Phone #: (910 ) 875-9407
Form SWU-101 Version 06Aug2012 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The pro op sed parking lot and building will be designed so that runoff discharges into and is treated by a .
bio-retention 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:
ElValid 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: 1.53 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':
1.53 acres
Total project area shall be calculated to exclude the followin : the normal pool of imppounded structures, the area
mm between the banks of streams and rivers, the area below the Normal High Water (N IN) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NNW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BLIA). Non -coastal wetlands landward of the NNW (or MHW) line may be
included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 64.7 %
9. How many drainage areas does the project have?1 (For high density, count I for each proposed engineered
stormwater BMP. For low density and other projects, rise I 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
Stewarts Creek
-VD
Stream Class *
C
Stream Index Number *
18-23-33
Total Drainage Area (sf)
63,764
On -site Drainage Area (s)
63,764
Off -site Drainage Area (s)
0
Proposed Impervious Area (sf)
43,124
% Impervious Area** (total)
67.6
Impervious** Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings Lots (s)
6,561
On -site Streets (so
0
On -site Parking (sf)
36,563
On -site Sidewalks (s)
0
Other on -site (s)
0
Future (sf)
0
Off -site (sf)
0
Existing BUA*** (sf)
0
Total (s ):
43,124
Stream Class and Index Number can be determined at: http 11portal.ncdenr.org tveb/wq/ps/csu/classi cations
�* tnr ervious area is defined as the built upon area including, but not Iimited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
*** Report only that amount of existing BUA that will remain after development. Do not report any existing BLIA 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
Form SWU-101 Version 06Aug2012 Page 3 of 6

Protects in Union County: Contact DYVQ 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 1 SA 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:ZZportal.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 httpj/portal.ncdenr.ore/web/wq[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 http:L/portal.ncdenr.org/web/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 portal.ncdenr.org/web/­wq/­ws/su/statesw/forms, docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. Lf►�G!
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants Gifh�
Form. (if regatired as per Part Vtl 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 tof iJ
http://www.envhelp.org/pages/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 �t}i✓
receiving stream drains to class SA waters within 1h mile of the site boundary, include the t/i
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: f�f�
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.
L 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).
Foml SWU-101 Version 06Aug2012 Page 4 of 6

9. Copy of any applicable soils report with the associated SHWT elevations (Please identifyj�f�
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: Schedule a site visit for DWQ to verify the SHWT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 0972 Page No: 0308
11. For corporations and limited liability corporations (LLQ: Provide documentation from the NC
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item la, 2a, and/or 3a per 15A NCAC 2H.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
ht_pt :/Jwww.secretary.state.nc.us/Corporations/CSearch.aspxx
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. I€ 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://12ortal.ncdenr.org/web/wq/ws/su/statesw/forms does. 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.
VII1. 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 (NC 28421)
Consulting Firm: Call Sign Engineers. PA
Mailing Address:104 Gillespie Street
City:Fayetteville State:NC Zip:28301
Phone: (910 ) 486-0700 Fax: (910 } 486-8900
Email:
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been fitted out, complete this
section)
I, (print or type nal7te of persvn tisted in Contact to ormation, iteni 2a) 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, itent 1a) with (print ar type name o{orVnization listed in
Contact Information, item 1a) to develop the project as current y proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 06Au92012 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:
Da
I, a Notary Public for the State of I County of
do hereby certify that personally appeared
before me this — day of , and acknowledge the due execution of the application for a
stormwater permit. Witness my hand and official seal,
SEAL
My commission expi
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 1a) Taner Esensoy
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 15 NCA .1000 and any other applicable state stormwater requirements.
77--ire: Date:_ Q/2
I r h a Notar Public for the State of ��— County of
do hereby certify that` J 10 /1 fr` L'>Pn personally appeared
before me this 2-9 day of �� ��' � %� 1 ck owledge t e du�eXeCLI�6011 �ea plication for a
stormwater permit. Witness my hand and official seal
M r;/AQ,
p !�
NOTARY
•'F1frl���r i1 IIG0►��`````
SEAL
My commission expires V
Form SWU-101 Version 06Aug2012 Page 6 of 6

Permit Number: .5W 6 f 2 1005-
(to be provided by DIVQ)
Drainage Area Number: l
Bioretention 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 location. 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 operation and maintenance procedures:
— Im.mediately after the bioretention cell is established, the plants will be watered
twice weekly if needed until the plants become established (commonly six
weeks).
— Snow, mulch or any other material will NEVER be piled on the surface of the
bioretention cell.
— Heavy equipment will NEVER be driven over the bioretention cell.
— Special care will be taken to prevent sediment from entering the bioretention cell.
— Once a year, a soil test of the soil media will be conducted.
After the bioretention cell is established, I will inspect it once a month 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:
Potentialproblems:
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
bioretention cell
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,
The pipe is clogged (if
Unclog the pipe. Dispose of the
stone verge or swale
applicable).
sediment off -site.
The pipe is cracked or
Replace the pipe.
otherwise damaged (if
a pficable).
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.
Stone verge is clogged or
Remove sediment and clogged
covered in sediment (if
—atone and replace with clean stone.
a licable).
a i-
;';
OCT 3
we ands RTER flt,;a
Form SW401-13ioretention O&M-Rev.3 "'" Page I of 4

BMP element:
The pretreatment area
The bioretention cell:
vegetation
The bioretention cell:
soils and mulch
Potential problems:
Now is bypassing
pretreatment area and/or
gullies have formed.
Sediment has accumulated to
a depth greater than three
inches.
Erosion has occurred
Weeds are present.
Best professional practices
show that pruning is needed
to maintain optimal plant
health.
Plants are dead, diseased or
dying.
"free stakes/wires are present
six months after planting
Mulch is breaking down or
has floated away.
Soils and/or mulch are
clogged with sediment.
An annual soil test shows that
pli has dropped or heavy
metals have accumulated in
the soil media.
How I will remediate the problem:
Regrade if necessary to route all
flow to the pretreatment area.
Restabilize the area after grading.
Search for the source of the
sediment and remedy the problem if
possible. Remove the sediment and
restabilize the pretreatment area.
Provide additional erosion
protection such as reinforced turf
matting or riprap if needed to
prevent future erosion problems.
Remove the weeds, preferably by
hand.
Prune according to best professional
practices.
Determine the source of the
problem: soils, hydrology, disease,
etc. Remedy the problem and
replace plants. Provide a one-time
fertilizer application to establish the
ground cover if a soil test indicates
it is necessary..
Remove tree stake/wires (which
can kill the tree if not removed).
Spot mulch if there are only random
void areas. Replace whole mulch
layer if necessary. Remove the
remaining much and replace with
triple shredded hard wood mulch at
a maximum_ depth of three inches.
Determine the extent of the clogging
- remove and replace either just the
top layers or the entire media as
needed. Dispose of the spoil in an
appropriate off -site location. Use
triple shredded hard wood mulch at
a maximum depth of three inches.
Search for the source of the
sediment and remedy the problem if
possible.
Dolomitic lime shall be applied as
recommended per the soil test and
toxic soils shall be removed,
disposed of properly and replaced
with new planting media.
Form SW401-Bioretention O&M-Rev.3 Page 2 of 4

BMP element:
Potentialproblems:
How I will remediate the roblem:
The underdrain system
Clogging has occurred.
Wash out the underdrain system.
if aP2licable)
The drop inlet
Clogging has occurred.
Clean out the drop inlet. Dispose of
the sediment off -site.
The drop inlet is damaged
Repair or replace the drop inlet.
The receiving water
Erosion or other signs of
Contact the NC Division of Water
damage have occurred at the
Quality 401 Oversight Unit at 919-
outlet.
733-1786.
Form SW401-13ioretention O&M-Rev.3 Page 3 of 4

Permit Number:.5w% % Z LOoS
(to he providcd by DTVQ)
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 name:Rainbow Pediatrics
BMP drainage area niimber:#1
Print name:Taner Esensoy
Title: Mana�;er/Member - Purdue Drive Investments, LLC
Address:304 Summertime Road; Fayetteville, NC 28303
Phon,
Signa
Date:
Note: The legally responsible party should riot be a homeowners association unless more than 50% of
the lots have been sold and a resident of the subdivision has been named the president.
I, J)Q _kx I�� 1-V1. A l I iY , y 1( , a Notary Public for the State of
of�j-GL �, do hereby certify that
personally appeared before me this C��
day of ItJ(,{�0- ��, and acknowledge the due execution of the
forgoing bioretejjiffmaintenance requirements. Witness my hand and official seal,
. . _ 14 411 _
NOTARY
PUBLIC
z
F
ND CO 6
SEAL
My commission expires D2,166 Lao 1 -�,
Form SW401-Bioretention 1&M-Rev. 2 Page 4 of 4

Permit No: .5 W c j Z! o Oy
(to be assigned by DWQ)
III. REQUIRED ITEMS CHECKLIST
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.
Paget Plan
Initials Sheet No.
-a
1. Plans (1" - 50' or larger) of the entire site showing:
Design at ultimate build -out,
3+�P'
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 (ROW),
Clean out pipe locations,
Overflow device, and
Boundaries of drainage easement.
l 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
46AI b i 3 Section view of the bioretention cell (1" = 20' or larger) showing:
Side slopes, 3:1 or lower
Underdrain system (if applicable), and
Sioretention cell layers ]ground level and slope, pre-treatment, pending depth, mulch depth, fill media
depth, washed sand, filter fabric (or choking stone if applicable), #57 stone, underdrains (if applicable),
SHWT level(s), and overflow structure]
':�� 1 H 4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
0f)0j0f1( of
results of the soils report must be verified in the field by DWO, by completing & submitting the soils
FC4�5tT
investigation request form. County soil maps are not an acceptable source of soils information. All
elevations shall be in feet mean sea level (fmsl). Results of soils tests of both the planting soil and the in
situ soil must include:
Sell permeability,
Soil composition (% sand, % fines, % organic), and
/,�,�
P-index
5. A detailed planting plan (1" = 20' or larger) prepared by a qualified individual showing:
Usk D
A variety of suitable species,
50b
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.
�z
6. A construction sequence that shows how the bioretention cell will be protected from sediment until the
entire drainage area is stabilized.
7. The supporting calculations (including underdrain calculations, if applicable).
/0j�J
j4fUkkOb
8. A copy of the signed and notarized inspection and maintenance (10) agreement
I/Aky
9. A copy of the deed restriction.
Form SW401-Bioretention-Rev.7 Part III, Page 1 of 1