SW4190301_Application_20190307

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
o3-0.7-20t 01
Sc>V=' Cie-_ owbz * I
%tAJ 4 Iq 0.3c7 l
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
Wsr2z)
State of North Carolina N C Department of
Environmental Quality
Department of Environment and Natural Resources Received
Division of Energy, Mineral and Land Resources K R 0 4 2019
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
inston-Salem
This form may be photocopied for use as an original
Regional Office
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establislunent name - should be consistent with pr
specifications, letters, operation and maintenance agreements, etc.): t s . ; 't J
Mountain Park Elementary School ®MAR 07 2013
2. Location of Project (street address): 0ENR I AN[) C, LIAI ITY
305 Mountain Park Road SI ORMWAfER PEktd l 1 ING
City: State Road County: Surry Zip: 28676
3. Directions to project (from nearest major intersection):
From the intersection of Highway 21 and Mountain Park Road travel Northeast on Mountain Park Road
approximately 2.8 miles. Take a slight left to stay on Moutain Park Road. Travel another 0.9 miles.
Site entrance is located on the right.
4. Latitude:36° 22' 19" N Longitude:80° 51' 12" 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):
MLow Density nHi,gh Density nDrains 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, 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
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 2.29 ac of Disturbed Area
0404/401 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 permit:
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: http://portal.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 naive and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization:_ Surry County Schools
Signing Official & Title: Dr. Travis Reeves, Superintendent
b. Contact information for person listed in item 1a above:
Street Address: 209 North Crutchfield St.
City: Dobson State: NC Zip: 27017
Mailing Address (if applicable): P.O. Box 364
City: Dobson State: NC Zip: 27017
Phone: ( ._336 ) 386-8211 Fax: L336 386-4279_
Email: [e-mail]
Please check the appropriate box. The applicant listed above is:
0 The piopeily owitei (Skip to Coidacl hifoi naLloit, llein 3a)
❑ Lessee* (AlLach a copy of the lease agieeinenl acid cuinplete Coidacl lidoinution, Mein 2a Laid 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:
Mailing Address (if applicable):
Cily:
Phone: ( 1
Email:
State: Zip:
State: Zip:
Fax: ( 1
3. a. (Optional) Print the name and title of another contact such as the projects construction supervisor or other
person who can answer questions about the project:
Other Contact Person/
Signing Official & Title
b. Contact intormation for person listed in item 3a above:
Mailing Address: P® 5OX ?(04
City: - Ob5 CY) State: 1"� 0 Zip:
Phone: (3% ) 2>9f10- Fax: l 3NO ) �JRO ` f'i���
Email: ClotauOlmr Y L,. us
J
4. Local jurisdiction for building permits: Town of Do]
Point of Contact: Deanna Henderson Phone #: 336 ) 401-8350
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Due to the Low Density nature of this site, no stormwater BMP's are existing or proposed.
The stormwater will be treated by natural infiltration in the wooded area down -grade of the
developed area of the site. _
2. a. If clahning vested tights, 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 Yadkin Pee -Dee River basin.
4. Total Property Area: 18.288 acres 5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Tutul riupeity Area (4) -'Total Coastal Wetlands Aiea (5)-'I'utal Suilace Water Area (6) - lotal Project
Area': 18.288 acres
+ Total project area shall be calculated to exclude the following: the normal pool of impounded structures, the area
between the banks of streams and rivers, the area below the Normal High Water (NHW) line or Mean High Water
(MHM line, and coastal wetlands landward from the NHW (or MHW line. The resultant pproject area is used to
calculate overall percent built upon area (B UA). Non -coastal wetlands landward of the NHW (or MHM line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 21.5 %
9. How many drainage areas does the project have? 1 (For high density, count 1 for each proposed engineered
stormwater BMP For lozo densihj and other projects, use 1 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
Drainage Area 1
Drainage Area _
Drainage Area
Drainage Area _
Receiving Stream Name
Mitchell River
Stream Class
C; ORW
Stream Index Number *
12-62-(12)
Total Drainage Area (so
394634
On -site Drainage Area (sf)
394634
Off -site Drainage Area (sf)
0
Piv osed Impervious Area** sf
2.76'/6
% Impervious Area" (total
21.5 %
Impervious" Surface Area
Drainage Area 1
Drainage Area
Drainage Area
Drainage Area
On -site Buildings/Lots (sf)
52112
On -site Streets (sf)
0
On -site Parking (sf)
75064
On -site Sidewalks (so
18630
Other on -site (sf)
0
Future (sf)
25676
Off -site (sf)
0
Existing BUA*** (sf)
145806
Total (sf):
171482
* Stream Class and Index Number can be determined at: http. portal.ncdenr.org/web/wg/ps/csu/classifications
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
***Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation. N/A
Proiects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that maybe subject to more stringent stormwater requirements as per I5A 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 ht!p://portal.ncden-r.org/web/wq/­­ws/su/bmp-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
http://portal.ncdenr.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.ncdenr.org/web/wq/ws/su/maps:)
Please indicate that the following raquired information havo boon provided by initialini: in the space provided
for each item. All original documents MUS'i be signed and initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/­­wq/ws/su/­statesw/forms does.
Is
1. Original and one copy of the Stormwater 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 Form(s) (sealed, signed and dated) and O&M N/A
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
httl2://www.envhelp.org/pages/onestopexpress.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 stormwater treatment/managementfor NIA
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
Z?m
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). NIA
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
n Development/Project nA ne.
b. Engineer and firm.
c. Location map with named street-, 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 NHW line of tidal
waters, and any coastal wetlands landward of the MHW 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 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.
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).
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

p. Vegetated buffers (where required).
9. Copy of any applicable soils report with the associated SHWT elevations (Please identify (-J 14
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"x11" 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: Schedule a site visit for DEMLR to verify the SHVVT prior
to submittal, [phone].)�
10. A copy of the most current property deed. Deed book: 00131 Page No: 0200
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC fWA
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 2II.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.
ht!p://www.secretaiy.state.nc.us/Corporations/­­CSearch.aspx
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 si8nificantly or the proposed
11UA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attaclunenl lu the completed ailed notarized deed tesliicaion fonn. The appio hate deed testilclioris acid
protective covenants forms can be downloaded from http://12ortal.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 signatures) 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.
VIII. 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: Eddie MacEldowney
Consulting Firm: Davis Martin Powell Engineers and Surveyors
Mailing Address: 6415 Old Plank Rd.
City: High Point -
Phone: ( 336 ) 819-5275
Einail: emac®dtrip-itic.com
State: NC Zip: z/265
Fax: ( 536 886-4458
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 2a) / ✓'4ViS v' �S 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 1a)�A '.; with (print or type name of organization listed in
Contact Information, item 1a) S� to develop the project as currently proposed. A copy of
the lease agreement or pending property s les contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
MAR 0 7 2013
Form SWU-101 Version Oct. 31, 2013 Page 5 of 6 DENR-LAND QUALITY
STORMWMER NEKMI I i ING

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 including the assessment of of up to $25,000 pei dry, puisu mL to NCGS 143-215.6.
Signature: = _\ / Date:- 2 J 2
I, a Notary Public for the State of 1� brTh CWT 0(1l, County of
Sllt�Y�l -do hereby certify that Trow IS Rcryes personally appeared
before me this (Adayof EC10YU0Yj M11 and acknowledge the due execution of the application for
a stonnwatei permit. Witness my hand and official seal,
Notary Public
Surry County
North Carolina
�
Commission Exoires
SEAL
My commission expires Onn rYlb-c-r 6, aGa
X. APPLICANT'S CERTIFICATION
I, (print or type name of person listed in Contact Information, item 1a) so rnE' QS above
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.
Signature:
a Notary Public for the State of
do hereby certify that
before me this _ day of
Date:
County of
personally appeared
and acknowledge the due execution of the application for
a stormwater permit. Witness my bland and official seal,
SEAL
My commission expires
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6