SWG010035_Application Form_20211122

N.C. DIVISION OF WATER QUALITY
SURFACE WATER PROTECTION SECTION
STATE STORMIWATER NOTICE OF INTENT (NOI)
FOR AGENCY USE ONLY
Date Received
Year Month Da
Certificate of Coverage
'q IWI I I I I I I
Check If I Amount
Permit Assigned to
State Stormwater Management Application Notice of Intent for coverage under the General Stormwater
Management Permit for a Single Family Residence.
For the construction, operation and maintenance of impervious areas associated with a single family
residence.
(Please print or type)
1. Mailing address of owner/developer: (The address to which all permit correspondence will be mailed.)
Owner/Developer Name Juan Carlos Morales Bautista
Street Address 5612 Cardinal Landing Drive
City Raleigh State NC ZIP Code 27603
Telephone No. [phone] Fax
2. Proposed Project Information:
Project Name Brothers Steel Erectors and Welding, LLC
Street Address
of the Project 981 Carson Gregory Rd
City Angier State NC ZIP Code 27501
County Harnett
Contact Person Juan Carlos Morales Bautista
Mailing Address 5612 Cardinal Landing Drive
City Raleigh State NC ZIP Code 27603
Telephone No. [phone] Fax
3. Physical Location Information:
Please provide the street address of the project and describe how to get to the project, using street names,
state road numbers, and the distance and direction from the nearest major intersection:
From intersection of NC Highway 27and NC Highway 55 in Coats, NC proceed north on NC 55 towards Angier for approximately 0.8 miles.
Turn riaht on Carson Greaory Rd. (SR 1547) r)ro*ect is located apr)roximately 5,100 feet on the left.
4. What is the name of the receiving stream? Black River
5. River Basin Cape Fear Receiving Stream Classification C;Sw
6. This Certificate of Coverage is being submitted as a result of:
,0 New or proposed project El Modification to an existing project
• • • Permit Number:
Date project is scheduled to begin construction 09-15-2021
7. What is the total project area above mean high water?
547,375
8. What is the total amount of built -upon area proposed at this site? 86,582.5
It 2
ft 2
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9. Has the built -upon area been minimized to the extent practicable?
■ •
10. Is the runoff from the built -upon area outside the vegetative buffer directed away from surface waters, to the
extent practicable?
r ■ �
11. Is the project within 575' of the Mean High Water line of class ORW waters?
[:]YES (Please show the 575' AEC line on plans) EZ NO
(If yes, total built -upon area must be less than or equal to 25% of the total project area within the AEC above mean high water.)
12. Are there any wetlands on the site? R YES (please delineate on the plans) EZ NO
Name and affiliation of person making this determination:
13. Please list all Best Management Practices employed at this site:
grass trapezoidal swale from road ditch to existing low area of site
grass roadside ditches draining asphalt roadway
14. Certification:
North Carolina General Statute 143-215.6B (i) provides that:
Any person who knowingly makes any false 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 Article; 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 Article shall be guilty of a Class 2 misdemeanor
which may include a fine not to exceed $10,000. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both, for a similar offense.)
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit will
constitute the permit requirement for the project and is enforceable in the same manner as an individual permit.
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed name of person signing
Title: Owner /
Juan Carlos Morales Bautista
it- (-0 -
(Date signed)
A check or money order must accompany this Notice of Intent for $505.00, made payable to: NCDENR.
Your application will be returned unprocessed unless all of the following items are submitted:
EZ This completed form
Two sets of site and grading plans
A check for $505.00 (previously submitted)
A USGS map with the project clearly located on it.
Mail the entire package to: NCDENR Division of Water Quality
Surface Water Protection Section — Stormwater
at the Appropriate Contact Address (see the following page)
Note:
The submission of this document does not guarantee the issuance of a Certificate of Coverage under the General
Permit.
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