SW3180905_Application Form_20210712 (2)

DEMLR USE ONLY
Date Received Fee Paid ex ress on1) Permit Number
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT PLAN REVISION APPLICATION FORM
Uds form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Stormwater Management Permit Number: SW3180905
2. Project Name: Twin Lakes Subdivision
3. Permit Holder's name (specify the name of the corporation, individual, etc.):
Twin Lakes Farm LLC
4. Print Owner/Signing Official's name and title (person legally responsible for permit):
Dennis W. Moser, MAI (President)
5. Mailing Address for person listed in item 2 above:
231 Post Office Drive Suite B8
City:Indian Trail State:NC Zip:28079
Phone: (704 ) 576-0022 Fax:
Email:[e-mail]
II. PLAN REVISION INFORMATION
1. Summarize the plan revision proposed (attach additional pages if needed):
Plans have been revised to decrease the amount of piping proposed and further meet low density criteria
through coordination with DEQ in an effort to increase BUA allocation on high value Iots
III. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. The complete
application package should be submitted to the DEMLR Office that issued the permit.
1. PIease indicate that you have provided the following required information by initialing in the space provided
next to each item.
Initials
• Original & 1 copy of the Plan Revision Application Form
• Two (2) copies of revised plans (must be revisions of original approved plan sheet(s))
If apIying for Express review (only available in 20 coastal counties):
• Application fee of $500.00 (made payable to NCDENR)
VI. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in General Information, item 3) Dennis If Moser
certify that I have author' ed these plan revisions and that the information included on this plan revision
application is, to the bAsM my knowledge, correct and complete.
Signature:
Date: 1. �'u
Plan Revision Form Rev. Oct. 31, 2013