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HomeMy WebLinkAboutSW5190901_2 - NCDEQ SW Permit App. - Signed_9/27/2019DEMLR USE ONLY Date Received Fee Paid Permit Number 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 Mgmt 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 he 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.): Deliverance Church 2. Location of Project (street address): 18020 US Hwy 64 West City:Siler City County:Chatham Zip:27344 3. Directions to project (from nearest major intersection): From the intersection of Stockyard Road U5 Hwy 64 and Ellington Road travel ap proximatley0.2 miles east. The site will be loaated on the norther side of US Highway 64. 4. Latitude:35* 44' 3.8508" N Longitude:-79° 29' 40.7148" 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, 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: 2.0 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 permit: 5. Is the project located within 5 miles of a public airport? ❑No ®Yes If yes, see S.L. 2012-200, Part VI: ht ortal.ncdenr.or T web it rules -and -re ,Wations 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: Deliverance Church of Christ Signing Official & Title:Debbie McNeil -Smith - Church Administrator b. Contact information for person listed in item 1a above: Street Address:17935 US Hwy 64 Citysiler Cit Mailing Address (if applicable):Same.as street address. City: Phone: Email: State:NC State: Fax: Zip:27344 Zip: 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 protect is located on):, n n . y Property Owner/Organi Signing Official & Title:_ b. Contact information for person listed in item 2a above: Street Address: I I q � 5 l1 �. City: State: N, I Zip: L-1 ! ` t Mailing Address (if applicable): City: State: Lip: Phone: [ i 4 - �7l �`� i Fax: L ] Email: ! esyyl I tn a d, u 3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other person who can answer auestions about the nroiect: Other Contact Person/ Signing Official & Title b. Contact information for person listed in item 3a abov Mailing Address: `1 Co City: e-f Phone: Email: State: (Li Zip: Fax: ( l 4. Local jurisdiction for building permits: Chatham Count Point of Contact:Kaitlyn Goodwin Phone #: (919 ) 5428230 Form SWU-101 Version Oct. 31, 2013 Page 2 of 6 e IV. PROJECT INFORMATION 1. In the space provided below, briefly summarize how the stormwater runoff will be treated. Proposed place of worship. This will be a low -density stornwater project that will have no proposed BMP's. The use of grassed swales and sheet flow have been utilized in the dosigp of this project. 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 Cape Fear River basin. 4. Total Property Area: 6.61 acres 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 Area+:6.61 acres + Total project area shall be calculated to exclude the followin : the normal pool of impounded structures, the area between the banks of streams and rivers, the area below the Lrinal High Water (NHW) line or Mean High Water (MHW) line, and coastal wetlands landward from the NHW (or M14M line. The resultant project area is used to calculate overall percent built upon area (BUA). Non -coastal 2[)etlauds lanrlruard of the NNW (orM1YW) litre pray be included in the total project area. 8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 24 9. How many drainage areas does the project have?1 (For high density, count I for each proposed engineered stormwater BMP. For low density and other projects, use I for the whole properhj aren.) 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 Draina a Area 1 Drainage Area _ Drainage Area Drainage Area Receiving Stream Name Blood Run Creek Stream Class * C Stream Index Number * 17-23-1 Total Drainage Area (so 288,008 On -site Drainage Area (sf) 288,008 Off -site Drainage Area (sf) 0 Proposed Impervious Area" (s 69,121 Impervious Area** total 23.999 Impervious" Surface Area Drainage Area 1 Drainage Area Drainage Area _ Drainage Area On -site Buildings/Lots (sf) 8,400 On -site Streets (sf) 0 On -site Parkin (so 10,120 On -site Sidewalks (so 1,491 Other on -site (so Future (sf) 49,110 Off -site (sf) Existing BUA*** (so 0 Total (sf): 69,121 * Stream Class and Index Number can be determined at: J Yj),,Aortal.ncdenr,orglwebht} jps/cstr/classocatic Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas, sidewalks, gravel areas, etc. Form SW-101 Version Oct. 31, 2013 Page 3 of 6 '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. 11. How was the off -site impervious area listed above determined? Provide documentation. N/A Projects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened & Endangered Species watershed that may be subject to more stringent stormwater requirements as per 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 httR*//portal.ncdenr.org/web/wq/ws/su/ibmp-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 hU:/Iz7ortal.ncdenr.org/web/wq/ws/su/stateswZfvmis flocs. 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 h!!V.Z/portal.ncdenr.org/`web/wq/ws/su/``nigl?s.) Please indicate that the following re uired information have been provided by initialin in the space provided for each item. All original documents MUST be signed and initialed in blue ink. Download the latest versions for each submitted application package from h!W://12ortal.ncdc-iir,oyZ/web/wQ/ws/suZstateswforms dgcs. Initials 1. Original and one copy of the Stormwater Management Permit Application Form. ZG 2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants 2G 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_orglpages/G"topexRross.htmI 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/management 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 mile radius on the map. 7. Sealed, signed and dated calculations (one copy). 8. 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 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. 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 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). Z 6r z 6- for Z Z 6- Z�- Z Cr Form SWU-101 Version Oct. 31, 2013 Page 4 of 6 p. Vegetated buffers (where required). Z 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: Schedule a site visit for DEMLR to verifil the SHWC prior to submittal, (910) 796-7378.) 2 6r10. A copy of the most current property deed. Deed book: 1711 Page No: 908 11. For corporations and limited liability corporations (LLC): Provide documentation from the NC Z 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. httl2:/ /www.secretary.state.nc.us/Corl2orations/­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 sixes 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 an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and protective covenants forms can be downloaded from ht!2:[/12ortal.ncdei-Lr.org/web/Ir/st-,ite- storn-iwater-forms flocs. 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 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 tot. 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:H. Mack SummeJr. P.E. Consulting Firm: Summey En ing� eering Associates, PLLC Mailing Address:P.O. Box 968 City:Asheboro State:NC Lip.27204 Phone: 336 328-0902 Fax: (336 ) 328-0922 Email:zar_h®summe en itieerin .com IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this section) I, (print or hype name of person listed in Contact Information, item 2a) , 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) with (print or type name of organization listed in Contact Information, item 1a) 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 SWU-101 Version Oct. 31, 2013 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 DEMLR Stormwater permit reverts back to ine, 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 l 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 includi the assessment of civil penalties of $25,00Q.per day, pursuant to NCG5143-215.G, yy Signature: Date: ! I, _L�r'fC(P6A a Notary Public for the State of , County of W R do hereby certify that _` (e 5 1 `' ^ personally appeared before me thisV—�day of and acknowledge the d e execiltion of the application for a stormwater permit. Witness my hand and official seal, 'h SEAL My commission expires X. APPLICANT'S CERTIFICATION 1, (print or hjpe name of person listed in Contact Information, item Ia) , 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 21-1.1000 any other applicable state sto�rlmwater requireme{nts. Signature: �-�� J Date: b ` r I, „ �� �'�^ J { '"� a Notary Public for the State of _ . County of do hereby certify that ���h�ic� S w s f� personally appeared before me this' day of / � �4 a'��4, and acknowledge the du exec tipn of the application for a stormwater permit. Witness my hand and official seal, �a%>>IMIJ11101% N 5ada� •,,� �? My Comm. Exo. s � �. ��•��� CCUiI�`aaa♦♦ SEAL My commission expires Form SWU-101 Version Oct. 31, 2013 Page 6 of 6