NCC202912_NOI Application_20200713

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/8/2020 5:01:11 PM(NCG01 NOI Submission)
Approve by Clark, Paul 7/10/2020 12:54:35 PM(Review-Construction NOI 27983)
• The task was assigned to Clark, Paul by round robin distribution 7/8/2020 5:02 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 10,2020 5:00 PM
7/8/2020 5:02 PM
Submit by Selkane,Aziza 7/13/2020 8:52:05 AM(Payment Verification for NCC202912)
* S Scott Summerlin Town of Warsaw
• Selkane,Aziza assigned the task to Selkane,Aziza 7/13/2020 8:50 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:August 21, 2020 5:00 PM
7/10/2020 12:55 PM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIMATER DISCHARGES associated with construction acti\Aties(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting f•No
an NOI that was r Yes
rejected before?
1a. Project Name* Town of Warsaw
1 b.Specific Lot -This field any be used to list specifc lot numbers.
Numbers 384 E. Best Street
2.County* Duplin
3. Highway or Street 384 E. Best Street
Address* Street nacre only is acceptable if no address number assigned yet
4.City or Townsh i p* Warsaw
5.State* NC
6.Zip Code* 28398
7. Latitude* Enter the latitude in decimal degrees
34.9929
8. Longitude* Enter the longitude in decimal degrees(M.JST be negative)
-78.0803
If you do not know the latitude and longitude coordinates for this project,you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin* 07/21/2020
Estimated Construction Project Start Date
10. Date to End* 07/20/2021
Estimated Construction Project End Date
11.SIC(Primary)* Other(9999)
Standard Industrial Cassification for Development
12.Acres to be 3.00
disturbed* (including off-site borrow and waste areas)
13.Total site area 3.00
(acres)*

14. Post- 1.00
construction (Estirrated)
impervious area
(acres)*
NCC Project NCC-DUPLI-2020-Town of Warsaw
Tracking ID Assignedautorraticaly
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies-not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Stewarts Creek
Waterbody* INbrre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 18-68-2-10
Index No.* NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs*
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fternittee Inforrration-Legally Fbsponsible Entity and Individual
Important:The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who owns or operates the construction activity, such
as a president, secretary,treasurer, or vice president, or a manager that is authorized in accordance with Part IV,
Section B, Item(6)of the NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item(6) of that permit.
1.Organization Legally Pesponsible Entity
Name* Town of Warsaw
It pernittee is an individual(i.e.,organization does not apply),enter first and last narre in this field.
2. First Name* AJ.
If Corporation,enter Faegistered Agent First%rre
3. Last Name* Connors
It Corporation,enter Registered Agent Last Iona
3b.Title Mayor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-293-7814
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box464
Address Line 2
109 E Walnut Street
City State/Frovince/Region
Warsaw NC
Fbstal/Zip Code Country
28398 United States
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 121 S. Front Street
Address Line 2
City State/Province/Region
Warsaw NC
Postal/Zip Code Country
28398 United States
8.Type of Government-Municipal
Ownership*

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Scotty
Contact-First
Name*
2. Primary Site Summerlin
Contact-Last
Name*
3.Title Town Manager
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 910-293-7814
Telephone No.*
6.Organization Town of Warsaw
Name
7.Site Contact Street Address
Mailing Address* PO Box464
Address Line 2
Oty State/Rovince/Region
Warsaw NC
Postal/Zip Code Country
28398 United States
8. Consultant Name (Optional)
Cecil Madden
First and Last nacre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 9197367360
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/15/2019
Approved*
2. E&SC Plan Project DUPLI-2020-010
Number/ID* Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4.State DEQ Office* Wilmington (WiRO)
Documentation of E&SC Plan approval and the signed Notice of Intent(NOI)Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the"Notes"box below.
5. E&SC Plan Warsaw CN42 E&SC.pdf 966.81 KB
Approval letter or Mist beRFforml
Grading Permit
6.Site Location Map Helpful for linear project review
(Optional) WarsawCN42 Location Map.pdf 441.68KB
Mast be RFfornat.Rease do not upload entire set of E&SCplans.
7. Notes(Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application.Include additional waterbodies for linear projects if necessary.
384 E. Best Street is the location of the WWTP Site.
Adjacent to Stewarts Creek.
8. NOI Certification WarsawCN42 Signature.pdf 851.35KB
Form Mast be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E(i) provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled or required to be maintained under this Article or a rule implementing this Article;or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Artcle;or who falsifies,tampers with,or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project,for
satisfying the requirements of this permit,and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is,to the best of my knowledge and belief,
true,accurate, and complete based on my inquiry of the person or persons who
manage the system,or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Specify if you are:* r The Responsible Person named on this Notice of Intent
f Authorized Responsible Person*
Important:The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee,that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
owns or operates the construction activity, such as a president, secretary,treasurer,or vice president, or a manager
that is authorized in accordance with Part IV, Section B, Item(6)of the NCG010000 General Permit. For more
information on signatory requirements,see Part IV,Section B, Item(6)of that permit.
Signature
AJ Copl4o), '
Type Name* A.J. Connors
Title Mayor
Organization Legally Pesponsible Entity
Town of Warsaw
Date* 07/08/2020

F. Tracking and COC Info
NOI Tracking No. 27983
NC Reference No. NCG01-2020-2912
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC202912
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 2912
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)
Initial Invoice No. NCC202912-2020
Invoice Due Date 8/9/2020
Initial Fee $ 100.00
Invoice Status OPEN