SW8040805_HISTORICAL FILE_20040825

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW�D��Si���
DOC TYPE
❑CURRENT PERMIT
❑ APPROVED PLANS
iISTORICAL FILE
C
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
�DXd�S
YYWMMDD

-STORMWATERANVISION
PERMIT NO. .
CODING-SHEET� ..-
RESCISSIONS
DOC TYPE - ❑ COMPLETE'
DATE OF ❑
RESCISSION YYYYMMDD
FILE = HISTORICAL

State Stormwater Management Systems
Permit No. SW8 040805
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
Karen Moriarty, Carillon Assisted Living, LLC &
Carillon Assisted Living of Southport, LLC
Carillon Assisted Living -Southport
Brunswick County
FOR THE
construction, operation and maintenance of a wet detention pond in compliance with
the provisions of 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 August 26, 2014, and sha
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 1.6 on page 3 of this permit. The stormwater
control has been designed to handle the runoff from 71,070 square feet of
impervious area.
3. The tract,,will be limited to the amount of built -upon area indicated on page 3 of
this permit, and per 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
approvedplans.
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.
Page 2 of 7

State Stormwater Management Systems
Permit No. SW8 040805
6. The following design criteria have been approved for the permitted wet detention
pond and they must be provided in the system at all times:
a.
Drainage Area, Acres:
4.48
Onsite, ft :
195,148
Offsite, ft2:
0
b.
Total Impervious Surfaces, ft2:
71,070
C.
'Design Storm, inches:
1"
d.
Pond Depth, feet:
4.0
e.
TSS removal efficiency:
90%
f.
Permanent Pool Elevation, FMSL:
9.0
g.
Permanent Pool Surface Area, ft2:
6,300
h.
Permitted Storage Volume, ft3:
9,000
i.
Temporary Storage Elevation, FMSL:
10.31
j.
Controlling Orifice:
1.5" O pipe
k.
Permitted Forebay Volume, ft3:
2,329
I.
Receiving Stream/River Basin:
Prices Creek 1 Cape Fear
M.
Stream Index Number:
CPF17 18-88-3
n.
Classification of Water Body:
"SC Sw"
II. SCHEDULE OF COMPLIANCE
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
3.. The perrAttee 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:
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 outlet structure, orifice device, flow
spreader, catch basins and piping.
g. Access to the outlet structure must be available at all times.
Page 3of7

State Stormwater Management Systems
Permit No. SW8 040805
4. Records of maintenance activities must be kept and made available upon
request to authorized personnel of DWQ. The records will indicate the date,
activity, name of person performing the work and what actions were taken.
5. Decorative spray fountains will be allowed in the stormwater treatment system,
subject to the following criteria:
a. The fountain must draw its water from less than 2' below the permanent
pool surface.
b. Separated units, where the nozzle, pump and intake are connected by
tubing, may be used only if they draw water from the surface in the
deepest part of the pond.
c. The falling water from the fountain must be centered in the pond, away
from the shoreline.
d. The maximum horsepower for a fountain in this pond is 116 horsepower.
6. The facilities shall be constructed as shown on the approved plans. This permit
shall become voidable unless the facilities are constructed in accordance with
the conditions of this permit, the approved plans and specifications, and other
supporting data.
7. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
9. Access to the stormwater facilities shall be maintained via appropriate
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.
Page 4of7
r

State Stormwater Management Systems
Permit No. SW8 040805
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
1. 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' -formal permit transfer request to the Division of Water Quality,
accompanied by a completed name/ownership change form, documentation
from the parties involved, and other supporting materials as may be appropriate.
The approval of this request will be considered on its merits and may or may not
be approved. The permittee is responsible for compliance with all permit
conditions until such time as the Division approves the transfer request.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
9. The permittee shall notify the Division any name, ownership or mailing address
changes,within 30 days.
Permit issued this the 26th day of August, 2004.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
l
Alan-W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 5 of 7

TRANSMITTAL LETTER
TO:
FROM:
Linda Lewis
David E. Criser, PE
COMPANY:
DATE:
RECEIVED
NCDENR
08/25/2004
ADDRESS:
CRISER & TROUTMAN'S PROJECT 1�UMBEAU
G 2 5 2004
�+
Cardinal Drive
5357
Wih i g on
BY:
PHONE NUMBER:
CLIENT'S REFERENCE NUMBER:
RE:
CariIlon Assisted Living, LLC
Southport, NC
WETRANSMIT: ❑ f1Tr,%cjfm ❑ UNDERSEPARATECOVI?R AHAND CARRIED B1'_ ❑ UPS/FEDF'.X -- -_- -
THE FOLLOWII G: ❑ TRACINGS ❑ PRINTS ❑ NSPECFIONREPORT ❑SHOPDRANVINGS ❑ SP-CIPiCATIONS 0 OTHER
COPIES
DATE
SHEET
NO.
DESCRIPTION
REMARKS
2
REVISED POND SIZING
CALCULATIONS
SEALED AS
REQUESTED
2
SWU-102
WET DETENTION BASIN SUPPLEMENT
PAGE TWO REVISED
Linda,
Thanks for you help.
cc: Karen Moriarty
Chris Duncan
��0000pp CRISER & 'TROUTMAN by:
:44 CONSULTING ENGINEERS David E. Criser, PE
v•
PO Box 3727 • 3809 PEACHTREE AVE., SUITE 102 • WII.MINGTON, NORTH CAROLINA 28406 • [phone] • Fax [phone]
Email: dayidk-hri<ertroutnlan.cnm

SW8 040805 Carillon Assisted Living
Subject: SW8 040805 Carillon Assisted Living
From: Linda Lewis <[e-mail]>
Date: Mon, 23 Aug 2004 17:17:58 -0400
To: David Criser <[e-mail]>
David:
Please initail page 2 of the supplement. You have answered "yes" or "no", when it
was supposed to be initialled. Item M, regarding the emergency drain mechanism, can
be initialled, since you are specifying temporary pumps as the mechanism to drain
the basin in an emergenc�r.
Please seal the revised pond design calculations.All those numbers are a little
confusing, but I think I can figure it out.
Linda
1 of 1 8/23/2004 5:21 PM

�0F \NATFRQ Michael F. Easley, Governor
4 G William G. Ross, Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
August 16, 2004
Ms. Karen Moriarty, President & CEO
Carillon Assisted Living, LLC
4901 Waters Edge Drive
Raleigh, NC 27606
Subject: Request for Additional Information
Stormwater Project No. SW8 040805
Carillon Assisted Living Southport
Brunswick County
Dear Ms. Moriarty:
The Wilmington Regional Office received a Stormwater Management Permit Application
for Carillon Assisted Living Southport on August 13, 2004, with a scheduled Express
Review Date of August 16, 2004. A preliminary review of that information has
determined that the application is not complete. The following information is needed to
continue the stormwater review:
1. Please either delineate all wetlands on site, disturbed or undisturbed, or note
on th'e plans that none exist.
2. Please report all built -upon areas in square feet on the application..
3. 1 am unable to determine how your consultant determined that 20% of the
permanent pool volume has been provided in the forebay. If the permanent
pool volume is 11,828 cubic feet, then the maximum forebay size is 2,366
cubic feet. You have reported a .forebay volume of 4,505 cubic feet.
4. The temporary pool elevation is 10.31 in the calculations and plans, but is
reported as 10.27 on the supplement.
5. Please specify pond side slope vegetation and the wetland species to be
planted on the 6:1 shelf.
6. Please dimension the east side of the pond. There is an arrow, but no
dimension. Please also add radii for the curved lines.
7. Please add the nearest intersection of two major roads to a legible vicinity
map to the plans. A major road is any 1, 2 or 3 digit NC, US or interstate
highway.
8. Please remove the references to Forebay #2 on Sheet C-6.
9. Please label the 6:1 vegetated shelf.
North Carolina Division of Water Quality 127 Cardinal Drive Extention Phone [phone] Customer Servicel-877-623.6748 taWitrally
Wilmington Regional Office Wilmington, NC 28405 FAX [phone] Internet: h2o.enr.statemcus Carolina
An Equal OpportunitylAffirmative Aetion Employer— 50% Recycled110% Post Consumer Paper

Ms. Moriarty ;
August 16, 2004
Stormwater_Application_No. SW8 040805
10. Is Carillon Assisted Living, LLC a member -managed LLC? The latest Annual
Report filed with the Secretary of State on April 14, 2004, was signed by Kenneth
Kirkman as the Manager/Member. Does this LLC have both a manager and a
president? Please -provide documentation of your current title and standing in
Carillon Assisted Living, LLC. I also noticed that Carillon Assisted Living
Southport, LLC has been formed. Will this corporation be the permittee?
Please note that this request for additional information is in response to a preliminary
review. The requested information should be received by this Office prior to August 23,
2004, or the application will be returned as incomplete. The return of a project will
necessitate resubmittal of all required items, including the application fee.
If you need additional time to submit the information, please mail or fax your request for
a time extension to the Division at the address and fax number at the bottom of this
letter. The request must indicate the date by which you expect to submit the required
information. The Division is allowed 90 days from the receipt of a completed
application to issue the permit.
The construction of any impervious surfaces, other than a construction entrance under
an approved Sedimentation Erosion Control Plan, is a violation of NCGS 143-215.1 and
is subject to enforcement action pursuant to NCGS 143-215.6A.
Please reference the State assigned project number on all correspondence. Any
original documents that need to be revised have been sent to the engineer or agent. All
original documents must be returned or new originals must be provided. Copies are not
acceptable. If you have any questions concerning this matter please feel free to call me
at [phone].
Sincerely,
Linda Lewis
Environmental Engineer
RSS/arl: S:\WQSISTORMWATIADDINFO120041040805.aug04
cc: David Criser, P.E., Criser and Troutman
Linda Lewis
Page 2 of 2

'Ad �
........._
wwww�■
■...w-
August 19, 2004
Linda Lewis
NCDENR
CRISER & TROUTMA.N CONSULTING ENGINEERS
127 Cardinal Drive Extension
Wilmington, NC 28405
Re: Stormwater Project No. SW8 040805
Carillon Assisted Living Southport
Brunswick County
Dear Ms. Lewis:
We are in receipt of your August 16, 2004 letter to Karen Moriarty and have the
following responses to your request for additional information:
The wetlands were delineated on the plans as 404 areas. We are labeling them
as "404 Wetlands Area". There is only one area on site and it is mainly just
north of the entrance drive. There is another area just south of the property
line. We are not disturbing any wetlands except the ditch area along the state
highway which is off the property. The owner has received a permit to fill the
area necessary to construct the driveway.
2. We have revised page two of "Stormwater Management Permit Application"
and used square footage numbers as requested. Enclosed are two copies of the
revised pages. Please insert them into your forms.
Both the permanent and temporary forebay volumes were included on the
application for a total of 4,505 cf. The permanent forebay volume was listed
as 264 cf. It should have been listed as 2,642 cf. This represents 22.34
percent of the total volume. The design requirements listed in paragraph 1.3.e
of the Stormwater Best Mana 7ement Practices states that "The forebay
volume should equal about 20% of the total basin volume." We thought that
22.34% would be close enough. We have revised the sizes and have made the
corrections on the plans and enclose a revised copy of page one of "Wet
Detention Basin Supplement and enclose two revised copies. Please replace
these in your documents. Also enclosed is a new "Pond Calculations" sheet
that reflects the new numbers. Please attach this to the calculations. The new
numbers indicate that the forebay volume is 19.82% of the total.
RECE
AUG 2 0 2004
M.
P.O. BOX 3727 • 3809 PEACHTREE AVENUE, SUITE 102 0 WILMINGTON, N.C. 28406 • [phone] • FAX [phone]

4. The temporary pool elevation is 10.31. We have corrected page one of "Wet
Detention Basin Supplement and enclose two revised copies. Please replace
these in your documents.
5. We are using a mixture of grass seed for the pond side slope vegetation. It
will include fescue and Bermuda grass seeds. We have revised Plan Sheet C6
to indicate this item. The 6:1 shelf will be planted with arrowhead/duck
potato or pickelweed as shown on Plan Sheet C6. Please find enclosed two
copies of revised Plan Sheet C6.
6. We have added the dimensions requested.
7. We have added a vicinity map to Plan Sheet C. Enclosed are two copies of
this sheet.
8. We have removed the references to Forebay #2.
9. We have label the 6:1 vegetated shelf of Plan Sheet C6.
10. Enclosed is a copy of an e-mail from Mr. Kenneth C. Kirkham along with the
formation documentation and the Certificate of Incumbency. If you need
additional information please advise.
We trust that you have the information you need not to complete the approval of this
project. Thanks for your assistance.
Sincerely yours,
c
David E. Criser, P.E.
DEC/ggj/5357
Cc: Karen Moriarty
Chris Duncan
CRISER & TROUTMAN

State of North Carolina
Department of Environment and Natural Resources
Wilmington Regional Office
Michael F. Easley, Governor 'William G. Ross Jr., Secretary
FAX COVER SHEET
Date: I(o-04" No. Of Pages:
To: QOVe, Cf iSof From: b/7da L&$-4:5
CO: �f r'Serarf/�2n CO:
FAX #: 3R7 - 7-9-71 FAX#: 9I0-350-2004
REIV14,RKS:
127 Cardinal Drive Extension. Wilmington, \.C.'8405-3845 Telephone [phone] Fax [phone]
An Equal OpportunitN' AfGrmath'e Action Employer

Entity Names
Page 1 of 1
North Carolina
Elaine F. Marshall DEPARTMENTOFTFtE
Secretary SECRETARY OF STATE
Corporations
•Corporations Home
*Important Notice
*Corporate Forms/Fees
*Corporations FAQ
*Tobacco Manufacturers
*Verify Certification,
*Online Annual Reports
Links
*Secretary Of State Home
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•Dept. of Revenue
Legislation
01999 Senate Bills
02001 Bill Summaries
*Annual Reports 1997
*Corporations 1997
IROther Legislation
Search
*By Corporate Name
*For New Corporation
'By Registered Agent
Online Orders
*Start An Order ;;
eNew Payment Procedures
PO Box 29622 Raleigh, NC 27626-0622 [phone]
Date: 8/16/2004
Click here to:
View Document Filings I
Print a pre -populated Annual Report Form I File an Annual Report I
Corporation Names
Name Name Type
NC Carillon Assisted Legal
Living, LLC
Limited Liability Company Information
SOSID:
0399857
Status:
Current -Active
Date Formed:
6/25/1996
Citizenship:
Foreign
State of Inc.:
DE
Duration:
Perpetual
Registered Agent
Agent Name: C T Corporation System
Registered Office Address: 225 Hillsborough Street
Raleigh NC 27603
Registered Mailing 225 Hillsborough Street
Address: Raleigh NC 27603
Principal Office Address: 4901 Waters Edge Drive
Suite 200
Raleigh NC 27606
Principal Mailing Address: 4901 Waters Edge Drive
Suite 200
Raleigh NC 27606
For questions or comments about the North Carolina Secretary of State's web site, please send e-mail to Webmaster.
For questions or comments concerning the Corporations Division, please send e-mail to Corporations Administrator
Click here for help downloading forms.
http://www.secretary.state.nc.us/Corporations/soskb/Corp.asp?4625711 8/16/2004

L[MITED LIABILITY COMPANY (LLcy,
,, •'*ti .ANNUAL REPORT
NAME OF LWED LIMIL.ITY COMPANY (LLC):
STATE OF REGISTRATION
SOSID: 0399857
Date Filed: 317/2001 4:06 PM
Effective: 4/4/2001
Elaine F. Marshall
North Carolina Secretary of State
- - - v . . •
SECRETARY OF STATE RLLP ID NUMBER j FISCAL YEAR ENDING: 12 31 1998
MONTHVDAYNEAR
FEDERAL EMPLOYER ID MAWEF'� 561974=
IF THIS IS THE INITIAL ANNUAL REPORT FILING. PLEASE COMPLETE THE ENTIRE FORMA. IF YOUR
REGISTERED LIMXTW tIABI M PARTMERSHIP MIFORMAATION HAS NOT CHANGED SINCE THE ❑
pREVKM REPORT, PLEASE CHECK THE BOX AND COMPLETE LINE 7 ONLY.
1. REGISTERED AGENT & REGISTERED OFFICE MAILING ADDRESS:
22S HnsbunaVh S&ON
Ra1m¢a MCZMW
2 STREET ADDRESS AND COUNTY OF REGISTERED OFFICE:
225 unwhor"o S1
Rai ff N AMC 27m -
Cora1er MRsMar
3. IF THE REGISTERED AGENT CHANCED, SIGNATURE OF THE NEW AGENT:
srA►nM 00MMUM CONSEWTO >RE aPpOrrsaexr
,. PRINCIPAL OFFICE STREET ADDRESS:
4901 Waters Bdge Drive
Suite 200
Kaleigh. BC= 27606
S. ENTER PRINCIPAL OFFICE TELEPHONE NUMBER HERE: [phone]
PLEASE WAMDE AREA CODE
B. ENTER NAME, TITLE, AND BUSINESS ADDRESS OF MANAGER(S) HERE:
NAME- No. Karen E. lbri&rtY
TITLE- President and (ZD
NAME-
TITLE-
NAME-
TIT LE-
7. BRIEFLY DESCRIBE THE NATURE Of BUSINESS:
ADDRESS- 4901 Waters Edge Drive
CITY.- ST- NC ZIP- 276M
ADDRESS -
CITY - ST- ZIP-
ADDRESS -
CITY - ST- ZIP-
c
Own and ope=ate tcd lifacilities for the elderly.
e. C = OF 7%ving
IL15i BE COMflPLim BY ALL LIMITED LLABamy COIIAPAmxs
March 2, 2001
FOR:rme
BE D BY A GENERAE PARTNER DA
nS_ Tb t
President and CEO
TYPE OR PRIM NAME -a TYPE OR PRINT TITLE ..
ANNUAL REPORT FEE: t200.00 MAIL TO: Seuetery d State • Cwporatlam bi *Mm . Rost Ofte B- 29525 • R&Wq% NC 276M-C625

rA SOSID: 0399857
.� .
Date Filed: 4/2U12004 9:02 AM
' 4 LIMITED ABILITY COMPANY Elaine F. Marshall
LIABILITY
}'. North Carolina Secretary of State
ANNUAL REPORT
�w arn.d
NAIMIE OF LIMITED LIABILITY COMPANY: Carillon Assisted Living, LLC
STATE OF INCORPORATION: DE
SECRETARY OF STATE L.L.C. ID NUMBER: 0399857 FEDERAL EMPLOYER ID NUMBER: 561974370
NATURE OF BUSINESS: Own and Operate Assited Living Facilities
REGISTERED AGENT: C 7'Corporation System
REGISTERED OFFICE MAILING ADDRF,SS: 22S Hillsborough Street
Raleigh, NC 27603
REGISTERED OFFICE STREET ADDRESS: 225 Hillsborough Street
Raleigh, NC 27603 County: Wake
PRINCIPAL OFFICE TELEPHONE NUMBER: [phone]
PRINCIPAL OFFICE; MAILING ADDRESS: 4901 Waters Edge Drive
Suite 200
Raleigh, NC 27606
PRINCIPAL OFFICE STREET ADDRESS:
MANAGER S/MF_M13F,R S/ORGANIZERS:
Kenneth Kirkham
Title: Cfo
4901 Waters Edge Drive Suite 200
Raleigh, NC 27606
4901 Waters Edge Drive
Suite 200
Raleigh, NC 27606
CERTIFICATION OF ANN[ JAI, REP T BE COMPLETED BY ALL LIMITED LIABILITY COMP TES
FORM MUST BE SIGNED BY.A MANAGF,R/MEMBER DAT
&t N\; � &�� � Manager/Member
TYPE TYPE NAME TYPE OR PRINT TITLE
ANNUAL REPORT FEE: $200.00 MAIL TO: Secretary of Slwc • Corporations Division Post Office Box 29525 • Raicigh, NC 27626-0525

Entity Names
Page 1 of 1
North Carolina
Elaine F. Marshall DEPARTMENT OFTFIE
Secretary SECRETARY OF STATE
Corporation's
*Corporations Home
*Important Notice
*Corporate Forms/Fees
*Corporations FAQ
*Tobacco Manufacturers
"Verify Certification
°Online Annual Reports
Links
"Secretary Of State Home
•Business License
•Register for E-Procuremen
•Dept. of Revenue
Legislation::
01999 Senate Bills
02001 Bill Summaries
*Annual Reports 1997
•Corporations 1997
'Other Legislation
Search
*By Corporate Name
*For New Corporation
pBy Registered Agent
Online Orders
*Start An Order
*New Payment Procedures
PO Box 29622 Raleigh, NC 27626-0622 [phone]
Date: 8/25/2004
Click here to:
View Document Filings I
Print a pre -populated Annual Report Form I File an Annual Report I
Corporation Names
Name Name Type
NC Carillon Assisted Living Legal
of Southport, LLC
Limited Liability Company Information
SOSID:
0731592
Status:
Current -Active
Date Formed:
6/23/2004
Citizenship:
Foreign
State of Inc.:
DE
Duration:
Perpetual
Registered Agent
Agent Name: Moriarty, Karen E.
Registered Office Address: 4901 Waters Edge Drive, Suite 200
Raleigh NC 27606
Registered Mailing 4901 Waters Edge Drive, Suite 200
Address: Raleigh NC 27606
Principal Office Address: 4901 Waters Edge Drive, Suite 200
Raleigh NC 27606
Principal Mailing Address: 4901 Waters Edge Drive, Suite 200
Raleigh NC 27606
For questions or comments about the North Carolina Secretary of State's web site, please send e-mail to Webmaster.
For questions or comments concerning the Corporations Division, please send e-mail to Corporations Administrator
Click here for help downloading forms.
http://www.secretary.state.nc.us/Corporations/soskb/Corp.asp?6480842 8/25/2004

t
State of North Carolina
Department of the Secretary of State
SOSID: 731592
Date Filed: 6/23/2004 10:42:00 AM
Elaine F. Marshall
North Carolina Secretary of State
C200416100281
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR LIMITED LIABILITY COMPANY
Pursuant to §57C-7-04 of the: General Statutes of North Carolina, the undersigned limited liability company hereby applies for a
Certificate of Authority to transact business in the State of North Carolina, and for that purpose submits the following:
1. The name of the limited liability company is: Carillon Assisted Living of Southport. LLC.
and if the limited liability company name is unavailable for use in the State of North Carolina, the name the limited
liability company wishes to use is
2. The state or country under whose laws the limited liability company was formed is: Delaware.
3. The date of formation was May 13.2004; its period of duration is: indefinite.
4. Principal office inforrr ation: (Select either a or b.)
a. ® The limited liability company has a principal office.
The street address and county of the principal office of the limited liability company is:
Number and Street: 4901 Waters Edge Drive, Suite 200
City, State, Zip Code: Raleigh, NC 27606 County: Wake
The mailing address, if different from the street address, of the principal office of the corporation is:
b. ❑ The limited !:ability company does not have a principal office.
5. The street address and counnty of the registered office in the State of North Carolina is:
Number and Street: 490I Waters Edge Drive, Suite 200
City, State, Zip Code: Raleigh, NC 27606 County: Wake
6. The mailing address, if different from the street address, of the registered office in the State of North Carolina is:
7. The name of the registered agent in the State of North Carolina is: Karen E. Mori
CORPORATIONS DIVISION
(Revised January 2002)
P. O. BOX 29622
RALEIGH, NC 27626-0622
(Form L-09)

t
r
APPLICATION FOR CERTIFICATE OF AUTHORITY
Page 2
8. The names, titles, and usual business addresses of the current managers of the limited liability company are:
(use artachment if necessary)
Name Business Address
Carillon Assisted Living, LLC 4901 Waters Edge Drive, Suite 200, Raleigh, NC 27606 ^T
I
9. Attached is a certificate of existence (or document of similar import), duly authenticated by the secretary of state or other official
having custody of limited liability company records in the state or country of formation. The Certificate of Existence must be
less than six months old. A_ ehotocopy of the certification cannot he accepted.
10. if the limited liability company is required to use a fictitious name in order to transact business in this State, a copy of the
resolution of its managers adopting the fictitious name is attached.
11. This application will be effective upon filing, unless a delayed date and/or time is specified:
This the day of 12004
CARILLON ASSISTED LIVING OF SOUTHPORT, LLC
Name of Limited Liability Company
By: CARILL"ASSISTED
C, Manager
By: CA, INC., Manager
By:
KwA E. Moriarty, President
Notes:
1. Filing fee is $250. This document must be fled with the Secretary of State.
CORPORATIONS DIVISION P. O. BOX 29622
(Revised January 2002)
RALEIGH, NC 27626-0622
(Form L-09)

PAGE 1
DeCcnvare
the First State
I, HARRIET SMITH WINDSOR, SECRETARY OF STATE OF THE STATE OF
DELAWARE, DO HEREBY CERTIFY "CARILLON ASSISTED LIVING OF
SOUTHPORT, LLC° IS DULY FORMED UNDER THE LAWS OF THE STATE OF
DELAWARE AND IS IN GOOD STANDING AND HAS A LEGAL EXISTENCE SO
FAR AS THE RECORDS OF THIS OFFICE SHOW, AS OF THE FOURTEENTH DAY
OF MAY, A.D. 2004.
3803022 8300
040354540
Harriet Smith Windsor, Secretary of State
AUTHENTICATION: 3111677
DATE: 05-14-04

david
From: 'Kirkham, Ken [[e-mail]]
Sent: Tuesday, August 17, 2004 5:47 FM
To: [e-mail]; [e-mail]
Cc: Moriarty, Karen
Subject: Division of Water Quality - Item #10 Response
David,
In response to Item #10 in the Division of Water Quality letter dated August 16, 2004, the permittee will be Carillon Assisted Living
of Southport, LLC. The officers who are authorized to sign on documents for Carillon Assisted Living QbS.011, ort are:
Karen E. Moriarty, President
Kenneth C. Kirkham, Secretary
Attached is a file that includes all the supporting documentation related to the formation and Authority of Carillon Assisted Living of
Southport, LLC as detailed below:
1) North Carolina Certificate of Authority,
2) North Carolina Application for Certificate of Authority,
3) Delaware Formation Certificate,
4) Delaware Certification of Formation, and
5) Carillon Certificate of Formation.
Carillon Assisted Living of Southport, LLC is 100% owned by Carillon Assisted Living, LLC. Carillon Assisted Living, LLC is the
managing Member of Carillon Ass iste Wiv3L ing of -Southport, LI_C(—A Managing -Member is similar to the general partner in'a
partnership). Karen E. Moriarty is the President of Carillon Assisted Living, LLC and Mr. Kirkham is the CFO.
The Managing -Member of Carillon Assisted Living, LLC is Carillon Assisted Living, Inc. Karen E. Moriarty is also the President of
Carillon Assisted Living, Inc. Refer to the Certificate of Incumbency which is attached evidencing Karen E. Moriarty as President.
If you have any questions please give me a call.
Ken
«Formation Documentation. pdf>> «Certificate of Incumbency.pdf>>
08/ 19/2004

-' 08/17/04 TUE 16:11 FAX [phone]
----_�_.T—_ .�._�.—ELLIS WIsV"i'ERS
(a 002
NORTH CAROLINA
Department of The Secretary of State
CERTIFICATE OF AUTHORITY
I, ELAINE F. MARSHALL, Secretary of State of the State of North Carolina, do
hereby certify that
CARILLON ASSISTED LIVING OF SOUTHPORT, LLC
having filed on this date an application conforming to the requirements of the General Statutes
of North Carolina, a copy of which is hereto attached, is hereby granted authority to transact
business in the State of North Carolina.
Document Id: C20041610023
1
IN WITNESS WHEREOF, I have hereunto
set my hand and affixed my official seal at the
City of Raleigh, this 23rd day of June, 2004
Secretary of State
09/17/04. TUE 16:12 [TX/RX N0 74941

' 08/17/04 TUE 16:11 FAX [phone]
ELL1S WINTERS
[a003
State of North Carolina
Department of the Secretary of State
APPLICATIOIti FOR CERTIFICATE OF AUTH
FOR LIMITED LIABILITY COMPANY
SOSID: 731592
Date Filed: 6/23/2004 10:42:00 Alai
Elaine F. Marshall
North Carolina Secretary of State
C200416100281
Pursuant to §57C-7-04 of this General Statutes of North Carolina, the undersigned limited liability companyhereby applies for a
Certificate of Authority to minsact business in the State of North Carolina, and for that purpose submits the following:
1. The name of the limited liability company is: Carillon Assisted Living: of SotttttvortLLC.
and if the limited liability company name is unavailable for use in the State of North Carolina, the name the limited
liability company wishes to use is
2. The state or country under whose laws the limited liability company was formed is: Delawu .
3. The date of formation was May l3, 2004; its period of duration is: in e i .
4. Principal office inforrziation: (Select either a or b.)
a. ® The limited liability company has a principal office.
The street address and county of the principal office of the limited liability company is:
Number and Street: 4901 Water&Edo Drive. Suite 200
City, State, Zip Code: ItaleightN(27606 County: Walc
The mailing address, if different from the street address, of the principal office of the corporation is:
b. ❑ The limited 1_ability company dues not have a principal office.
S. The street address and county of the registered office in the State of North Carolina is:
Number and Street: 4901 Waters Edge DriYe, Suite 200
City, State, Zip Code; &Ieijzh, NC 27606 County: Wake
6. The mailing address, if different from the street address, of the registered office in the State of North Carolina is:
7. The name of the registered agent in the State of North Carolina is: Karen E. MoriattV
CORPORATIONS DIVISION P. 0. BOX 29622 RALEIGH, NC 27626-0622
(Revised January 2002) (Form L-09)
08/17/04 TUE 16:12 [TY/RY 10 74941

OS/17/04 TUE 16:11 FAX [phone] ELLIS WINTERS
Q 004
APPLICATION FOR CERTIFICATE OF AUTHORITY
Page 2
&. The names, titles, and usual business addresses of the current managers of the limited liability corngany are:
(use attachment if necessary)
rVame Bu iness Address
Carillon Assisted Living, LLC _ 4901 Waters Edge Drive, Suite 200—Raleigh 14C27606_ .
4. Attached is a certificate of existence (or document of similar import), duly authenticated by the secretary of state or other official
having custody of limited liability company records in the state or country of formation. The Certificall of Elxdistegce must be
less than six months aid. A trhotacony o[ the certiiicstloo cannot be accented,
la If the limited liability company is required to use a fictitious name in order to transact business in this State, a copy of the
resolution of its managers adopting the fictitious name is attached.
11. This application will be effective upon filing, unless a delayed date and/or time is specified:
This the _day of . 2004
CARILLON ASSISTED LIVING OF SOLURPORT, LLC
Name of Limited Liability Company
By: CARILL"ASSISTED
C, Manager
By: CAR, INC., Manager
By;
KarcK E. Moriarty, President
Notes:
1. Filing fee is $250. This document must be filed with the Secretary of State.
CORPORATIONS DIVISION P. O. SOX 29622 RALEIGH, NC 27626-0622
(Revised January 2002) (Farm L-09)
08/17/04 TUE 16:12 17X/RY NO 74941

OS/17/04 TUE 16:12 FAX [phone]
--- -- — -- ----- J..T�—•------ ELLIS WINTERS
Q o05
PAGE 1
9"f e First State
I, HARRIET SMITH WINDSOR, SECRETARY OF STATE OF THE STATE OF
DELAWARE, DO HEREBY CERTIFY "CARILLON ASSISTED LIVING OF
SOi7THPORT, LLC" IS DULY FORMED UNDER THE LAWS OF THE STATE OF
DELAWARE AND IS IN GOOD STANDING AND HAS A LEGAL EXISTENCE SO
FAR AS THE RECORDS OF THIS OFFICE SHOW, AS OF THE FOURTEENTH DAY
OF MAY, A.D. 2004.
3803022 8300
040354540
`+4/ ,�lJ1.ht..Q+� �m.�-��✓Trc..-�.o�-aril
Harrier Smith Windsor, Secretary of Sure
AUTHENTICATIONS 3111677
DATE: 05-14-04
08/17/04 TUE 16:12 (TY/RY IUD 74941

08/17/04 TUE 16:12 FAX [phone] ELLIS WINTERS
006
D&"are PAGE 1
The First state
I, HARRIET SMITH WINDSOR, SECRETARY OF STATE OF THE STATE OF
DELAWARE, DO HEREBY CERTIFY THE ATTACHED IS A TRUE AND CORRECT
COPY OF THE CERTIFICATE OF FORMATION OF "CARILLON ASSISTED
LIVING OF SOUTHPORT, LLC", FILED IN THIS OFFICE ON THE
THIRTEENT4 DAY OF MAY, A.D. 2004, AT 5:30 O'CLOCK P.M.
3803022 8100
Harriet Smith Windsor, Secretary of State
AUTHENTICATION: 3111655
040354509 DATE: 05-14-04
68/17/04 TUE 16:12 [TX/RC NO 74941

-. 08/17/04 TUE 16:12 FAX [phone]
ELLIS WItiTERS
[it 007
State of rkleware
Secretary of State
!Division cf Cozporations
D&11vered 05:39 PM 0511312004
F=D 05:30 .PM 0511312004
SRV 040353178 - 3803022 FILE
CERTIFICATE OF FORMATION
OF
CARMLON ,A SSISTED LWVMG OF S OZT HPORT, LLC
1. The name of the limited liability company is Carillon Assisted Living of
Southport, LLC.
2. The address of its registered affice in the scats of Delaware is First Statc
Corporate Services, Inc., 32 Laockerman Square, Suits l U9, in the city of Dover.
The n.arne of its registered agent at such address is First State Corporate Services,
Irlc.
3. This Certiflcato shall be effective on filing.
IN WTMSS WHEREOF, the undersigned has executed this Certificttte of
ForEnation of CarMan Assisted Liviug of Soutbpott. LLC this 1311- day of May,
2004_
By: CARILLON ASSISTED LIVING, LLC,
its sole member
By: CARILLON ASSISTEM VINe, INC_,
its sole Zcrnber
Ely;
Karen orlarty, Presidcat
08/17/04 TUE 16:12 [TX/RX NO 74941

CERTIFICATE OF INCUMBENVY
1. Karen E. Moriarty. the President of Carillon Assisted Living, Inc., a Delaware corporation (the
"C'c�tl�c�ratit�sl"'?. the manager of Carillon Assisted Livinc-. LLC. a Delaware limited liability company (the
--Company"). hereby certify that each of the following persons is. and has been at all times since .lanuary
1. 1997, a duly elected officer Cif the Corporation, holding the offices of the Corporation set forth opposite
his or her name. and that the signature of such person set forth next to his or her name bolo\,,' is a genuine
sicnat.rre.
IN "I III e
Karen E. Nloriart�
Mack D. Prideen.
136erly A. Gelvir
Office
President
Secretarr",
Assistant Secretary
IN 11'iTN SS WHEREOF. 1 have hereunto set my hand this "IfF 1997.
By:
Karen Moriarty
President
1. NIack D. Pridgen. 111. Secretary oftlie Corporation do hereby certify that Karen. E. Moriarty is, and has
been at all times since January 1. 1997. the duly elected President of the Corporation. and that the
signature set forth immediately above is her genuine signature.
IN 11'1T`ES$ 11 HEREOF. i have hereunto set my hand thisaay of Februarv, 1997.
By:
�Vo,k-Prrd n. 11
etary

TRANSMITTAL LETTER
TO:
FROM:
Linda Lewis
David E. Criser, PE
COMPANY:
DATE:
NCDENR
08/13/2004
ADDRESS:
CRISER & TROUTMAN'S PROJECT NUMBER:
Cardinal Drive
5357
Wilmington
PHONE NUMBER:
CLIENT'S REFERENCE NUMBER:
RE:
Carillon Assisted Living, LLC
Southport, NC
WE TI?7 \NS\IIT: ❑ ATI'ACFTD ❑ LINDERSEPARATI CONTER FIANI) CARRIED BY ❑ UPS/FEDI,x
THE FOLI.OWLNG: ❑ "TRACINGS ❑ PRI; FTS ❑ RNSPECTION REPORT ❑ SHOP DPA%VlNGS ❑ SPECIRCATI Ns ❑ O'I HER
COPIES
DATE
SHI?ET
NO.
DESCRIPTION`T
RE\TARKS.
2
SWU-101
STOR\IWATER 2\1ANAGEMENT PERMIT
APPLICATION
ORIGIN_1L & COPY
2
SWU-102
'VET DETENTT(7� R.1CT\T CTTT1TIT � ri-- --- �L & COPY
PER\11
DETA1 ! '
SETS C C6,C7, C8 & C9)
s1 Ts c On
1
2
2
2
cc:
Karen Morarty
Chris Duncan (Chris, please share with
'did �
000®eoev-
eoeoeo
oeee,
01 So rr (avn 4
CRISER & TROUTMAN
CONSULTING ENGINEERS
ay:
David . Criser, H
PO Box 3727 • 3809 PEACH-1REE :1vr., SUITE 102 • WIL.MINGTON, NORTI I CAROLINA 28406 + [phone] • hax [phone]
Email: da-,•id((-I).crisertroutnian.co rn