HomeMy WebLinkAboutSW5161102_CURRENT PERMIT_20161117STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW lit) a
DOC TYPE
FO' CURRENT PERMIT
(❑
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
YYYYM M DD
Energy, Mineral
and Land Resources
ENVIRONMENTAL OUALITV
November 17, 2016
Mr. Allan J Luihn, President
Luihn Four, Inc.
2950 Gateway Centre Boulevard
Morrisville, North Carolina 27560
Subject: Stormwater Permit No. SW5161102
Taco Bell, Youngsville, NC, Franklin County
Dear Mr. Luihn:
PAT MCCRORY
Gore,..
DONALD R. VAN DER VAART
seaemrr
TRACY DAVIS
� gl
DEC - 7 7016
NC DENR Raleigh Regional office
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on November 9, 2016. Staff review of the plans
and specifications has determined that the project, as proposed, will comply with the Stormwater
Regulations set forth in Tide 15A Section NCAC 21-1.1000. We are forwarding Permit No. SW5161102,
dated March 3, 2016, for the construction, operation and maintenance of the subject project and the
stormwater system. This permit shall be effective from the date of issuance until November 8, 2024, or
until rescinded and shall be subject to the conditions and limitations as specified therein, and does not
supersede any other agency permit that may be required.
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.NCOA-H.com. Unless such demands are made
this permit shall be final and binding.
This project will be kept on file at the Raleigh Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Mike Randall at (919) 807-6374; or
mike.randall@ncdenr.gov.
Sincerely,
for Tracy E. Davis, ?PE, CPM, Director
cc: SW5161102 File, Raleigh Regional Office
cc: Michael Palmer, Luihn Floors, Inc.
Jeremy Beckett, P.E., Commercial Site Design, PLLC
Chris Clayton, Commercial Site Design, PLLC
Sonic of North Carolina I Enviromnertal Quality I Energy. Minendl and land Reso=es
1612 Mail Service Center I Raleigh, North Carolina 27699-1612
919-807-6375
State Stormwater Permit
Permit No. SW5161102
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT QUALITY
STATE STORMWATER MANAGEMENT PERMIT
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
Mr. Allan J Luihn, President
Luihn Four, Inc.
Taco Bell, Youngsville, NC, Franklin County
FOR THE
construction, operation and maintenance of a stormceptor 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 State and considered a part of this permit.
This permit shall be effective from the date of issuance until November 10, 2024, and shall
be subject to the following specified conditions and limitations:
1. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. The stormceptor is approved for the management of stormwater runoff as described
in the application documents and as shown on the approved plans.
3. 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.
4. The runoff from all built -upon area within the permitted drainage area of this project
must be directed into the stormceptor.
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 4
State Stormwater Permit'
Permit No. SW5161102
It. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
The permittee shall at all time provide the operation and maintenance necessary to
assure the stormceptor 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.
Records of maintenance activities must be kept for the stormceptor. The reports will
indicate the date, activity, name of person performing the work and what actions
were taken.
4. The permittee shall submit an annual summary report of the maintenance and
inspection records for each of the stormceptor. The report shall summarize the
inspection dates, results of the inspections, and the maintenance work performed at
each inspection.
5. The stormceptor shall be constructed in accordance with the approved plans and
specifications, the conditions of this permit, and with other supporting data.
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 stormceptor certifying that it 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.
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. 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 was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
9. A copy of the approved plans and specifications shall be maintained on file by the
Page 2 of 4
State Stormwater Permit
Permit No. SW5161102
Permittee for a minimum of eight years from the date of the completion of
construction.
10. 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 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 State,
accompanied by the supporting documentation: The -approval of,this request will be
considered on its merits and may or may not be approved.
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 State, 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 DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
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.
Approved plans and specifications for this project are incorporated by reference and
are enforceable parts of the permit.
Page 3 of 4
State Stormwater Permit'
Permit No. SW5161102
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 11 cn day of November, 2016.
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4
State Stormwater Permit
Permit No. SW5161102
Taco Bell, Youngsville, NC, Franklin 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.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
cc: NCDEQ-DEMLR Regional Office
Page 1 of 1
Permit Number:
Qo be provided b), DIVQ)
STiaz#A -m (2--
644-§Jonnflifter 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 maintenance procedures:
- The drainage area will be carefully managed to reduce the sediment load to the
S� STa2Mrac.PiD2-
- The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds
six inches.
Srd P UE?T ?
T ne to system will be inspected quarterly. 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:
Entire BMP
Trash/debris is present.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as
applicable)
pavement surface.
possible.
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too large for repair.
Storm ' artridges
Cartridges not performin <s
Replace cartridges u acturer's
\ I�
l�+
designed - see C &M
docum ctcrmine if cartridge
recomm lolls.
. mtenance is required.
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of
the sediment offsite.
The outlet device is damaged
Repair or re lace the outlet device.
Receiving water
Hrosion or other signs of damage
Contact the NC Division of Water
have occurred at the outlet.
Quality 401 Oversight Unit at 919-733-
1786.
DEC - 7 70
NC DENR atatetgh Fieywnal Office
Permit Number:
(to be provided by DU'Q)
0; 5rtz iz r� fz —
All other operation and maintenance activities should be in accordance with C
Inspection and Maintenance Procedures document. Any problems that are found shall be repaired
immediately. I acknowledge and agree by my signature below that I am responsible for the
performance of the maintenance procedures listed above and have received and understand Ce�
«� [ier Inspection and Maintenance Procedures document. I agree to notify DWQ of any
5� a'" ` pro ems with the system or prior to any changes to the system or responsible party.
X
Pr(ject nanle:Taco Bell - Younl;sville, NC
BMP drainage area munifier:
Print name:Allan J. Luihn - Luihn Pour, Inc.
Address: 2950 Gateway Centre Boulevard, Morrisville, NC 27560
Note: The Ic ally responsible party should not be a homeowners association unless more than 50% of the lots
have een sold and a resident of the subdivision has been named the president.
I, a Notary Public for the State of l\JOefh Carol .�
County of S ns}v do hereby certify that -A I I o- T, L-L, h n
personally appeared before me this day of IJpJC r lae r Zo I to, and acknowledge the due
execntlon of the forgoing sand filter maintenance requirements. Witness my hand and official seal,
My
SLAL
Not"v
Jo Public
C unun c
EE
Commissloniy
Explres5 12/09/Z017
J�Ty CAR O\\0P\.
DEMLR USE ONLY
Dates Rec i ed
Fee Pai
Per it Nu ber
Applicable Rules: Ll Coastal SW -1995 In Coastal SW - 2008 ❑ Ph 11- Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwa ter Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
Q�f
STORMWATER MANAGEMENT PERMIT APPLICATION FORM w J.k l
I
This form cony be photocopied for use as an original c�;(p\�/��A�
I. GENERAL INFORMATION \\�i�
1. Project Name (subdivision, facility, or establishment name - should be consistent
specifications, letters, operation and maintenance agreements, etc.):
2. Location of
3. Directions to
(street address):
County: Franklin Zip:27596
(from nearest major intersection):
proiect site is located approximately 1,400 feet on the right. The site is the property immediately south of the
4. Latitudc:36° 02' 15" N J Longitude:-78° 29' 58" W df the main entrance to the project.
-j Le
IL PERMIT INFORRMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
t RcnCloals e1111h wodifications also requires SWU-702 - Renm,al Application Forin
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit numberN/A , 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
DEMLR 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,
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: 1.1 ac of Disturbed Area
❑NPDES Industrial Stormwater ❑404/401 Pennit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Pernij Number,
issue date and the type of each permit: TACO 13ELL RESTAURAN'r - YOUNGSVILLL, NC n
5. Is the project located within 5 miles of a public airport? ®No ❑Ye
If yes, see S.L. 2012-200, Pat VI: littp://12ortal.ncdenr.org/web/ir/rules-and-regulations
Fonn SWU-101 Version Oct. 31, 2013 Page I of
❑I. CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the proiect):
Applicant/Organization: Luihn Four Inc.
Signing Official & Title: Allan 1. Luihn - President
b.Contact information for person listed in item la above:
Street Address: 2950 Gateway Centre Boulevard
City: Morrisville State:NC Zip:27560
Mailing Address (ifapplicable): Same as street address
City: State:
Phone: ( ) Fax:
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/ Organ ization:Luihn Pour, Inc.
Signing Official & TitleAllan I Luihn, President
b.Contact information for person listed in item 2a above:
Street Address:2950 Gateway Centre Blvd.
City:Morrisville State:NC Zip:27560
Mailing Address (if applicable):
City:
Phone: (919 ) 850-0558
Email:
Fax: (919 ) 869-2661
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: Michael Palmer - Luihn Four, Inc.
Signing Official & Title: Director of Facilities
b.Contact information for person listed in item 3a above:
Mailing Address: 2950 Gateway Centre Boulevard
City: Morrisville State: NC Zip: 27560
Phone: (919 ) 850-0558
Email:mike.palmer@lu ihnfood.com
Fax: (919 ) 869-2661
4. Local jurisdiction for building permits: Town of Youngsville
Point of Contact: Don Belk Phone #: (919 ) 556-5073
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6
IV. PROJECT INFORMATION
1. In the space provided below, hriefly summarize how the stormwater runoff will he treated.
, Luihn FourProprietary water quality device (i.e. Stormceptor) will be provided on the downstream end of
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. Stonnwater runoff from this project drains to the
4. Total Property Area: 1.37 acres
River basin.
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area:O 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 follozoia the normal pool of impounded structures, the area
behveen the banks of stremns and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal zoetlands lnndzoard of the NHW (or MHW) lice uuny
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 52
9. How many drainage areas does the project have?] (For high density, count 1 for each proposed engineered
storurtoater BMP. For loin density and other projects, use 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
Draina e Arca 1
Draina e Area
Draina e Area
Drina ge Area
Receiving Stream Name
Richland Creek
Stream Class *
C; NSW
Stream Index Number *
27-21(0.5)
Total Drainage Area (so
59,678
On -site Drainage Area (so
59,678
Off -site Drainage Area (so
0
Proposed Impervious Area**(sO
31,002
% Impervious Area** total
52
Impervious** Surface Area
Drainage Area 1
Draina e Area _
Draina e Area _
Draina ge Area _
On -site Buildings/Lots (so
2,415
On -site Streets (so
18,805
On -site Parking (so
8,355
On -site Sidewalks (so
1,427
Other on -site (so
0
Future (so
0
Off -site (sf)
0
Existing BUA*** (so
0
Total (so:
31,002
* Stream Class and Index Number can be determined at: http://nortal.ncdenr.or hog ebfrarl(lzs/csu/classiFrntions
hn{;ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
siriezoalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of
***Report only that anmunt of existing BUA that will rennin after development Do not report any existing BUA that
is to be removed and eahlchWill be replaced by netu BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
Protects in Union Countv: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that inan, be subject to inore stringent stornnvater requirenients as per 15A 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 littD://Dortal.ncdenr.ore/web/wu/ws/su/bniD-manual.
VI. 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. A detailed application
instruction sheet and BMP checklists are available from
littp://portal.ncdeiir.org/web/wq/ws/su/statesw/forms_docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at http://12ortal.iicdeiir.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://portaLncdennorg/web/wq/ws/su/statesw/forms_docs.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form. lirli
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants Q /A_
Form. (if required as per Part V11 belozu)
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
littp://www.eiivlielp.org/pages/oiiestopexpress.htnil 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/managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
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:
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 NI-IW line of tidal
waters, and any coastal wetlands landward of the MI-IW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MI-iW (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.
yl--,—
C"SL
CriC—
Cti ei
ate.
NCOOK
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6
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).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify ti
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 DEMLR to verifij the SHINT prior
to submittal, (910) 796-7378.)
10. A copy of the most current property deed. Deed book: 2040 Page No: 289
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 15A NCAC 2I-I.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.
littp: / / www.secretary.state.nc.us/ Corpora tions / CSearcli.as px
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
13UA 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://portal.ncdenr.org/web/Ir/state-stormwater-
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 DEMLR, and that they will be recorded prior to the sale of any lot.
Vlll. 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: Jeremy f. Beckett, P.E.
Consulting Firm: Commercial Site Design, PLLC
Mailing Address: 8312 Creedmoor Road
Phone: (919 ) 848-6121
L'mail: becket +csitedesign.com
State: NC Zip:27613
Fax: (919 ) 848-3741
IX. PROPERTY OWNER AUTHORIZATION (if Contact information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2m) Allan I Luihn, President , certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact information, item to) Luilm Four, Inc with (print or type name of organization listed in
Contact Information, item la) Mike Pmlemer 919-850-0558 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 stornnvater system.
Form SWU-101 Version Oct. 31, 2013 Page 5 of
As the legal property owner 1 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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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 includirAul assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
X Signa
Date: No v -7 1 Zo ( to
re Sq J E Lie r,.ae1 (-\ , a Notary Public for the State of "or't h Co.ry It,- 'County of
-J 0k,6"-n , do hereby certify that i,u l K r personally appeared
before me this 1**�`day of NOV e m {fir- I 2-L31(p— and acknowledge the
due execution of the application for
a stormwater permit. Witness my hand and official seal, Q 7G'V-40 -LbJQA UY-�
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X. APPLICANT'S CERTIFICATION
1, (print or type ❑erne of person listen in Contact information, item 1 a) Allan, I L1ilm - Ludin Four, Inc.
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be c nstructed in conformance with the approved plans, that the required deed restrictions
and protective co enal s wfft he recorded, and that the proposed project complies with the requirements of the
applicable stor;�te ndes ul)Kr 15A NCAC 21-I .1000 and any other applicable state stormwater requirements.
Date: I\,IoV 71 Z01(a
I, T-e1-e SS a Gbef L,) e..., a Notary Public for the State of N� rid Cc rail, County of
Si vim_, do hereby certify that l (c+ + Lu 1 h rt personally appeared
before me this day of o, and
^acknowledge the due execution of the application for
a stormwater permit Witness my hand and official seal,CC/ U(.L1 a -? L l t,lT2i•-T---,
SEAI: tE FgF ,,,
✓o fo, m :,
My c0jh 0/0n cob/i°
o
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Form SWU-101 Version Oct. 31, 2013 Page 6 of
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COMMERCIAL e66w12/531 CHECK DATE
SITE DESIGN MEMO: Taco.Bell—Ygnngsvilie, NC November 8, 2016
ev.
8312 Crcedmoor Road •Raleigh, NC 27613 Storinwater Application Fee
LU H-1508
-PAY AMOUNT
Five Hundred Five DollarS and*******************************************00/]00 $505.00
To NCDEQ
AUTHORIZED SIGNATURE
i1"Oi3772ii' i:053i01i2W:0.005297i94625i1'