SWA000221_Application Form_20230907

❑ Major Modification, replacing an existing stormwater permit— provide existing permit number: SW
Status of construction? [' Not Started [' Partially Completed [' Completed
Major modifications must be submitted by the original permittee and are allowed only if the SW permit is
not expired. Minor modifications must use Standard Permitting Process. By choosing this option, you
are also requesting that DEQ rescind the previous SW Permit upon issuance of the new Fast
Track ATC Permit.
❑ Transfer of existing Fast Track ATC Permit—provide existing ATC permit number: SWA _
2. Applicable state stormwater program(s) (check all that apply):
❑ Coastal SA-HQW ® Urbanizing Areas (Phase 2)
❑ Coastal SA-ORW ❑ Non-Coastal HQW
Is any portion of the project within 575 feet
of SA-ORW waters? ❑ Yes ❑ No ❑ Non-Coastal ORW
❑ Coastal Freshwater ORW ❑ USMP
❑ Coastal—Other
3. Other Permits (as applicable; write "NA"for those permit types that are not applicable):
Project Name Permit/Appl Issue Date Other Information
No.
CAMA Major NA
Erosion& Brookside Christian Academy submitted submitted Disturbed Area 3.9
Sedimentation Control acre
NPDES Industrial NA
Stormwater
404/401 Permit Proposed Impacts
If/ac
4. Local jurisdiction for building permits: City of Dunn _
Point of Contact:Stephen Hodges Phone#: (910 ) 230-3505 _
D. CONTACT INFORMATION
1. Applicant/Financially Responsible Party(may be an Organization):Brookside Christian Academy
Signing Official Name &Title:Meredith Gordon - President/Secretary
Street Address:2004 US 301 N
City:Dunn _ State:NC Zip:28334
Mailing Address (if different):804 W. Broad St _
City:Dunn State:NC Zip:28334
Phone: (910) 292-2107 x1010 Fax: (910) 252-9150
Email: cgordon(c�brooksideca.orq
2. If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the Secretary of
State):
Name of Registered Agent:Elizabeth Dean —
Mailing Address:804 W. Broad St. _
City:Dunn State:NC Zip:28334 _
Phone: (910) 292-2107 x1001 Fax: [phone])
Email:bdean(c�brooksideca.orq
Stormwater Fast Track ATC Application Form Page 2 of 9 Feb. 10, 2018