SW6230502_Application Form_20231004

DWQ USE ONLY
Date Received
Fee Paid
Permit Number
Applicable Rules: 0 Coastal SW - 1995 Ej Coastal SW - 2008 EJ Ph 11 - Post Construction
(select all that apply) 0 Non -Coastal SW- FIQW/ORW Waters Ll Universal Stormwater Management Plan
E-I Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
Thisforin r)iay be photocopied for rise as air origbial
1. GENERAL INFORMATION
I. Project Name (subdivision, facility, or establishment name -should be consistent with project name on plans
specifications, letters, operation and maintenance agreements, etc,):
Ducks LandinE
2. Location of Project (street address):
Darroch Road
City:Lillington County:Harnett 7ip:27546
1 Directions to project (from nearest major intersection):
The pr6ectis sfcf
located avvroximatelv 3,040 ft. from the in[orinn of nnrrnrh Rnnel ­P­­ , 4 T'I;,D ,, —4
Ic—
tow
Lane.
4, Latitude:35' 18' 59.23" N — Longitude:-78'55'9.34" W of the main entrance to the
11. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ElModification 0 Renewal w/ Modifica
tRene-ivah; tvith i,;zodifications also rcqi4ircs SKU-702 - Renewal AI)I)Iicaticui Ft
b. If this application is being submitted as the result of a modification to an existing permit, list the exist
permit number , its issue date (if known)—.—, and the status of
construction: E]Not Started ElPartially Completed* El Completed* *provide a designer's cer
1 Specify the type of project (check one):
F]Low Density (gl­figfi Density E]Drains to an Offsite Stormwater System F-10ther
3. If this application is being submitted as the result of a previously returned application or a letter from I
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, and the previous name of the project, if different than currently
proposed,
4.a. Additional Project Requirements (check applicable blank,-,; information on required state permits can be
obtained by contacting the Customer Service Center at'l-877-623-674,8):
FICAMA Major ESedimentation/Erosion Control: 24.66 ac of Disturbed Area
7NPDES Industrial Stormwater 0404/401 Permit: Proposed Impacts
b. If any of these permits have already been acquired please provide the Project Name, Project/ Permit N
issue date and the type of each pert -flit:
5. Is the project located within 5 miles of a public airport? MNo RYes
Ifyes, w S,L 2012-200, Part VkhLlp� / � Li c c J11 V��
.1 l2ortaL - LL-- ��f_ a I
1~orinSWIJ-101 Version 06Aug2012 Page I of'6

Ill. CONTACT INFORMATION
L 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: Legacy Roane Construction Inc.
Signing Official & 'fitle:Travis Greene - President
b, Contact information for person listed in item I a above:
Street Address:4200.Niagara Carthaa
City:Whispering Pines SLatc:NC Zip:28327
Mailing Address (if aj:iphcable):
City: State: Zip:
Phone: [phone] Fax:
Email: Carol i naB [e-mail]
c. Please check the appropriate box. The applicant listed above is:
E'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 belo
Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a
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 applical*):
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
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 perrnits: Harnett County Planning Services
Point of Contact:Brad Sutton Phone#: (910 893-
Forni SWU-101 Version 06Aug20 12 Page 2 of 6
W)
and

Irl lervi . olis area is defined as the built iipon area inchiding, but not limited to, buildings, roads, parking areas,
si7eivalks, gravel areas, etc.
Report only that atnowit of existing BUA that will refnain after ilevelopinent. Do not report arily existing BLIA that
is to he removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation. N/A
Projects in Union County: Conlact DWC) Centrol Office sla 'to c eck effheprqject is located ivithin a Threatened &
h
Ei7daiigered Species aiwtershed that inqy besubject to morestringent stormwater reqtdreinents asper 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 1_M <k:n! n u a 1,
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 8MP
checklists are available from v.u s � L&,j�,v/ 'arnis x's The complete
_La --A
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at litt
Please indicate that the following required information have been provided by initialingin the space provided
for each itern. All original documents MUST be signed and initialed in blue ink. Download the latest versions
for each submitted application package from I Itt J ior La k, b wc J '.s/ sg!J
Initials
1, Original and one copy of the Storinwater Management Permit Application Form,
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Forru(s) (sealed, signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDE.NR. (For an: Express review, refer to
http:/ /www.c�tivhelp.org/pages/ojiestopexprcss,htryiI for inforination 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/management for
6. A USES 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).
S. Two sets of plans folded to 8.5" x 14" (seated, 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 surfac
e. n waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NH W lilies,
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MI I W (or NFlW) of tidal waters.
i. Dimensioned property/p�roject boundary with hearings & 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 docurnentation of qualifications and identify the person who
made the determination on the plans.
ii. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
Form SWU-10,1 Version 06Aug2012 Page 4 of 6

o. Drainage areas delineated (included in the main set of Mans, not as a separate document).
p. Vegetated buffers (where required).
9. Copy of any applicable sails report with the associated. S.HWT 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"xl] " copy of the MRCS County Soils map with tine
project area clearly delineated. For projects with infiltration BMl'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 is si°le visit fear DWQ to verify the 511WT"larior
to submittal, (910) 796-7,378.)
10A copy of the most current property deed. Deed book: 4134 Page No: 0386 —
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 2H.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.
htt p:/ /www.secretaLy.state.nc.usICoi-L)orations/(Search,-,ispx
VII. 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, lot size, and the allowable built -upon area must be
provided as in attachment to the completed and notarized deed restriction form. The appropriate deed,
restrictions and protective covenants forms can be downloaded from
ka LLI-1I jrt, I a1cdell�°.��rL k a lr J w nrS�� a� t 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 holders) 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 D'WQ and that they will be recorded prior to the sale of any lent.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/ear 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:
Consulting Firm,: Box,
Mailing Address:400i
City:Raleigh
Phone: [phone]
Email:[e-mail]
Suite.
State:NC
Fax: ( )
IX. PROPERTY OWNER AUTHORIZATION (i f Contact Information, iton 2 has l em. filled out, ccrrtiplete this
section)
1, (print or type name of person listed in Contract Infomiration, item 2aa) certify that 1
own the property identified in this permit application, and thus ,give permission to (print or type naanie of persoyi
listed iri Contract Inforincation, item Ica) with (print or type nuirie of org aizizcation listed in
Contract Inforniaaticm, itent Ica) 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 SWLI-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 Ston-n-water permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Narne/Ownership Change Form within 30 days, otherwise I will be operating astormwater 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.
Signature:
Da
a Notary Public for the State of County of
do hereby certify that . . ..... personally appeared
before me this — day of ) -, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
X. APPLICANT'S CERTIFICATION
1, (ta-int or (ype name of person listed in Contact Information, item 1a) Travis Greene
certifythat the information included on this permit application form is, to the he 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 storqiwater rules Ulyder;15A NCAC 2H.1000 and any other applicable state stormwater requirements
Signature: -/A ?,tU Date:
a Notary Public for the State of
7—V County of
glOr e— do hereby certify that —vz'vi�z P, C-1 re!�am�p— personally appeared.
before me this Z(,,,, day of
—ZUZ-75 and acknowledge the, due execution of the application for
a stormwater permit. Witness my hand and official seal,
�J%t I I I I I I I J�"
V
SA C�
kk.
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0 05 01,41
SEAL
My commission expires () 5 - 01
Form SWU-101 Version 06Aug2012 Page 6 of 6