SW6130202_Application_20130226

DIVQ USE, ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 EM It - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/OR W Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Nahtral Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION
This fonn nuty be phntocopied far use an an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with
specifications, letters, operation and maintenance agreements, etc.):
2. Location of Project (street address):
Ff7 i 12P13
ame on plans,
1213 E. Prospect Avenue
City:Raeford County:I-Ioke Zip:28376
3. Directions to project (from nearest major intersection):
Site is located at the intersection of Hwy 401 and E. Prospect Avenue in Raeford NC a proximately 1.24
miles east of the intserrhon of Hwy 401 and Hwy 211
4. Latitude:34o 58' 46" N Longitude:790 12' 08" W of the main entrance to the project.
IL PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with nwdificatiuns also requires SWU-102 - Renewal Application Form
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 cerhficatian
2. Specify the type of project (check one):
❑Low Density ®High Density []Drams to an Offaite Stormwater System ❑Other
3. If this application is being submitted as the result of a previously rehumed 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, rt/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):
❑LAMA Major
❑NPDPS Industrial Stormwater
®Sedimentation/Erosion Control:1.89 ac of Disturbed Area
❑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 permitm/a
5. Is the project located within 5 miles of a public airport?
Ifyes, see S.L. 20I2-200, Part Vl: blip&
Form SWU-101 Version06Aug2012 Page 1 of
0
FEB 1 ] 2013

,dtl>r
III. CONTACT INFORMATION
1. a. Print Applicant / Signing Offilyd as naY' me and title (specific
designated government of(cial, individual, etc. who owns
the developer, property owner, lessee,
4-
Lc-
Signing Official &
b.Contact information for person listed in item In above:
Street Address:3735 Beam Road, Suite B
City:Cluulotte State:NC Zip:28217
Mailing Address (if applicable):3735 Beam Road, Suite B
City:Charlotte State:NC Zip:28217
Phone: (704 ) 357-1220 _ Fax: (704 )_357-0019
Email:darren.tuilt®dur rouo.com
c. Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee" (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser" (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/
Signing Official &
b.Contact information for person listed in item 2a above:
Street Address: 113 5. A janno l t
Mailing Address
Phone: ( Q /0 ) W a 4 = L/ ! US
State: AAC zip: 02 ?3 7 Sp
State: Zip:
Fax: ( q10 ) 79s— bWg
3. a. (Optional) Print the name and title of another contact such as the projecf9 construction supervisor or other
person who can answer questions about the project
Other Contact Person/Organization:Darren Tuitt
Signing Official & TitleVirector of Developmental Services
b. Contact information for person listed in item 3a above:
Mailing Address:3735 Beam Road, Suite B
City:Chartotte State:NC Zip:28217
Phone: [phone] Fax: [phone]
Email:darren.tuittOdurbangroup.com
4. Local jurisdiction for building permits: g
Point of ContactTelicia Locklear Phone tl: (910 ) 875-8161
Form SWU-101 Version D6Aug2012 Page 2 of
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1V. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the storm water runoff will be treated.
Water Quality to be treated in sand filters
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ❑ Ph II - Post Construction
3. Stormwater runoff from this project drains to the
4. Total Property Area: 1.13 acres
River basin.
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
Aree:1.13 acres
Total project area shall be calculated to exclude the following the nonual ool of impounded structures, the area
between the banks of streams and rivers, the area below the Nornml 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 landzard of the NHW (or MHW) lice may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =
9. How many drainage areas does the project have?1 (For high densihit, count 1 for each proposed engineered
stormaoater BMP, For low density and other projects, use 1 for the whole properhj 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;
Ciraina a Area 1
Drainage Area 2
Drainage Area _
Drainage Area
Receiving Stream Name
Rockfish
Stream Class *
C
Stream Index Number *
18-31-(15)
Total Drainage Area (sf)
44,866
On -site Drainage Area (sf)
37,461
Off -site Drainage Area (so
7,405
Proposed Impervious Area** (so
29,075
Impervious Area** total
81.3
Impervious *1-Surface Area:..,
Drainage Area_1
Drainage Area 2
Drainage Area. .-
Drainage Area _
On -site Buildings/Lots (so
8,320
On -site Streets (so
n/a
On -site Parkin (sf)
19,609
On -site Sidewalks (so
1,146
Other on -site (so
n/a
MEE
Future (sf)
n/a
Off -site (sf)
7,405
—ExistingBUA*** (so
n/a
Total (sf):
36,480
Stream Class and Index Number can be determined at: kitty://portal.ncdenr.org/zueb/zua/ys/csu/classifications
Inn ervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form S WU-101 Version 06Aug2012 . Page 3 of 6

11. How was the off -site impervious area listed above detennined? Provide documentation. square foota¢e of
roadway that drains onto the site and ultimat* into the BMP's
Noiects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent storunvarer requirements as per 15A NCAC 028.0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwatcr 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://portaincdenr.org/web/wg/ws/su/bmnmanual.
VL SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http://portal.nedenr.or_g/web/wq/ws/su/statesw/forms does. The complete
application package should be submitted to the appropriate DWQ Office. (Ibe appropriate office may be
found by locating project on the interactive online map at hLto://portal.ncdenr.om/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 documeuts MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package fromhitp://portal.ncdenr.org/web/wq/ws/su/statesw/forms does.
Initials
1. Original and one copy of the Stor mwaterManagement Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants N
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
http://www.envhelp.or&[pa es oneatooexoress.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 stor awater 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'/r mile of the site boundary, include the Sh
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). UV5
S. 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 NIIW line of tidal
waters, and any coastal wetlands landward of the MIf W 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 NH W) 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.
L 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 tine 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),
NonnSWU-101 Version06Aug20t2 Page 4of6

9. Copy of any applicable soils report with the associated SHWT elevations (Please identify _
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration 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: Scli:dule a site visit for DiNQ to verify lire SHWI prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: Page No: _
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 Is, 2a, mid/or 3a per 15A NCAC 21-1.1003(c).
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.
httu://www.secretary.state.nc.us)Co orations/CSearch.aspx
VH. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, krt 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: / /poYW.ncdenr.org/web/wo/ws/su/statesw/forms does. Download time latest versions for each submittal.
In the instances where the applicant is diffe»ent 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 non 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.
VIIL 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 EngmeenCarlton T. Burton, PE
Consulting Firm: Burton Engineering Associates _
Mailing Address:5950 Fairview Road, Suits 100
City:Charlolte
Phone: (704 ) 553-g881
Emaiblukeb®burtonengineering.mnm
State:NC 7.ip:28210
Fax: (704 _ 1 553-8860
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
1, (print or type name of person listed in Contact Information, item 2a) Dayne C. Crumpler . certify that I
own the property identified fn this permit application, and thus give permission to (print or hype name of person
listed in Contact Infrmnation, item 1a) Mal M L • 4LL&/ with (print or type name oforganizahbn listed in
Contact Information, item l a)7r ti'31tnr% !Z. `1/Fy�/jinENr 411 to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWIJ-101 Version 06Aug2012 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 Storinwater 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.
Date: / — Zcf13
1, Philip Holmes a Notary Public for the State of North Carolina County of
Hoke . do hereby certify that Dayne C. Crumpler personally appeared
before me this 18 day of January J 2013 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires December 11, 2016
X. APPLICANTS CERTIFICATION
1, (print or type name of person listed in Contact Information, item la) William L. Allen
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 whit the requirements of the
applicable stormwater ules er 15A NCAC 2H .1000 mid any other applicable state stormwater requirements.
Signature: �`i _ Date:
a Notary Public for the State of _(�i r - C�� County of
do hereby certify that _w"0-.- — earn personally appeared
before me this �( ay ofA_ G 13, and acknowledge the due execution of the application for
a stormwater permit. Wi ness my he and official seal,
SP.AL
My commission
Form SW-101 Version 06Aug2012 Page 6 of 6
la!gIa-

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.
I, , a Notary Public for the State of . County of
do hereby certify that
before me this _ day of
personally appeared
and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
6=111
My commission
X. APPLICANT'S CERTIFICATION
1, (print or hjpe name of person listed in Contact Information, item la) William L. Allen
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 covenan .will be recorded, and that the proposed project complies with the requirements of the
applicable stormw r rules 41--�
der 15A NCAC 2I1.1000 and any other applicable state stormwater requirements.
Signature:Cd� Date: 13 13
Ir a Notary Public fo the State ofCounty of
do hereby certify that -VLI i ate lam( ✓� personally appeared
before me this J3 day of 41Lpk,p.-1 t I A , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires 1245
Form SWU-101 Version 06Aug2012 Page 6 of