NCC205478_NOI Application_20201130

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/25/2020 9:34:26 AM (NCG01 NOI Submission)
Approve by Meloy, Michael 11/25/2020 1:38:08 PM (Review- Construction NOI 37319)
• The task was assigned to Meloy, Michael by round robin distribution 11/25/2020 9:35 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 27, 2020 5:00
PM 11/25/2020 9:35 AM
Submit by Selkane, Aziza 11/30/2020 10:47:58 AM (Payment Verification for NCC205478)
* LKC Engineering PLLC
• Selkane, Aziza assigned the task to Selkane, Aziza 11/30/2020 10:47 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 6, 2021 5:00 PM
11/25/2020 1:39 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * Sandhills Pediatrics Clinic
1 b. Specific Lot This field nay be used to list specifc lot nunbers.
Numbers
2. County* Moore
3. Highway or Street Avenue of the Carolinas
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Southern Pines
5. State * NC
6. Zip Code * 28387
7. Latitude* Enter the latitude in decimal degrees
35.1768
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-79.4196
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*
12/30/2020
Estimated Construction Project Start Date
10. Date to End *
12/30/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
2.75
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.32
(acres) *

14. Post- 1.48
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-MOORE-2020-Sandhills Pediatrics Clinic
Tracking ID Assigned autorratically
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 Unnamed Tributary
Waterbody* Kane of waterbody into which stormroater runoff will discharge
15b. Waterbody 14-2-11-2-2-(1)
Index No.* NCWaterbody Index Nunber
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. ^
Fbrnittee 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 * S&S Partners L.L.P
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Christoph
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Diasio
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-692-2444
Telephone No.*
6. Permittee Mailing Street Address
Address* 195 West Illinois Avenue
Address Line 2
City State / Frovince / Fbgion
Southern Pines NC
Fbstal / Zip Code Country
28387-5808 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
195 West Illinois Avenue
Address Line 2
City
State / Frovince / Region
Southern Pines
NC
Fbstal / Zip Code
Country
28387-5808
us
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
_.....................................................................................................................................
1. Primary Site
Christoph
Contact - First
Name *
2. Primary Site
Diasio
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-692-2444
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
195 West Illinois Avenue
Address Line 2
City
Southern Pines
Fbstal / Zip Code
28387-5808
8. Consultant Name
(Optional)
LKC Engineering
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/10/2020
Approved *
2. E&SC Plan Project ZP-10-20 - Sandhills Pediatric Clinic
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Southern Pines
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 ESC Approval (004).pdf
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
137.21 KB
Site Location.pdf 2.88MB
Rease do not upload entire set of E&SC plans.
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.
8. NOI Certification SHP NOI.pdf 2.73MB
Form Wst be RDFforrret
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 under this 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 guilty ofa Class 2 misdemeanor which may include 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 If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 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
t'-,ryes
Type Name* Christoph Diasio
Title Owner
Organization Legally Ibsponsible Entity
S&S Partners L.L.P
Date * 11 /25/2020

F. Tracking and COC Info
NOI Tracking No. 37319
NC Reference No.
NCG01-2020-5478
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205478
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5478
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. NCC205478-2020
Invoice Due Date 12/25/2020
Initial Fee $ 100.00
Invoice Status OPEN