SW3220402_Application Form_20220627

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: ❑ Coastal SW - 1995 ❑ Coastal SW - 2008 ❑ Ph 11- Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Village at Granite Quarry - Phase 2
2. Location of Project (street address):
3040 Faith Road
City:Salis
County:Rowan
3. Directions to project (from nearest major intersection):
Zip:28146
the property is located between exits 71 and 74 off I-85 on the west side of Faith Road (NCDOT S.R. 1006)
4. Latitude:35° 36' 23.8896" N Longitude:80° 27' 53.6832" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals with modifications 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 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, SW3190805 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: 34.4 ac of Disturbed Area
®NPDES Industrial Stormwater Z404/401 Permit: Proposed Impacts 9,115sf Wetlands + 1501f Stream
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:(12ermits not acquired yet)
Is the project located within 5 miles of a public airport? [:]No ®Yes
If yes, see S.L. 2012-200, Part VI: http://12ortal.ncdenr.org/web/lr/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page 1 of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization:LGI Homes NC, LLC
Signing Official & Title Jeff Webb - VP of Land Dev
b. Contact information for person listed in item 1a above:
Street Address:3037 Sherman Drive
City:Lancaster
Mailing Address (if applicablc):Same as Above
State:SC
Zip:29720
City: State: Zip:
Phone: ( 1 Fax: ( 1
Email:[e-mail]
Please check the appropriate box. The applicant listed above is:
® The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
❑ Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization:
Signing Official & Title:
b. Contact information for person listed in item 2a above:
Street Address:
City: State: Zip:
Mailing Address (if applicable):
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
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:
Signing Official & Title:
b. Contact information for person listed in item 3a above:
Mailing Address:
City: State: Zip:
Phone: ( ) Fax: ( )
Email:
4. Local jurisdiction for building permits: Town of Granite Quarry
Point of Contact:Bill Baily Phone #: (704 ) 279-5596 ext 204
Form SWU-101 Version Oct. 31, 2013 Page 2 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 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 includinghe assessment of civil penalties of up to $25,000 per, day, pursuant to NCGS 143-215.6.
Signa
Date: J` 2-2-o22
I, s L a Notary Public for the State of 00041 1 64yo l (OA- County of
tA do hereby certify that 4T' UJI0b personally appeared
before me this day of and acknop v�l�edge the ue execution of the application for
a stormwater permit. Witness my hand and official seal,
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X. APPLICANT'S CERTIFICATION
SEAL
My commission expires
I, (print or hjpe turme of person listed in Contact Iriforwation, item 1 a) Leff Webb - VP of Acquisitions an Latid Dev. certify
that the information included on this permit application form is, to the best of my knowledge, correct and that
the project will be constructed in conformance with the approved plans, that the required deed restrictions and
protective covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2H .1000 and any other applicable state stormwater requirements.
Date: 3 - �)-
c1f X-VA a Notary Public for the State of NIA C4"I'AA- County of
L,?,t en W(- do hereby certify that JW- Vii h�0 personally appeared
before me this 7roday of 14*r"' go and acknowl�ed'g,,e the due ecution of the application for
a stormwater permit. Witness my hand and official seal, �"�
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Form 5WU-101 Version Oct. 31, 2013 Page 6 of 6