NCC192336_NOI Application_20191015

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/14/2019 9:09:19 AM (NCG01 NOI Submission)
Approve by Clark, Paul 10/14/2019 11:11:44 AM (Review- Construction NOI 17120)
• The task was assigned to Clark, Paul by round robin distribution 10/14/2019 9:10 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 16, 2019 5:00
PM 10/14/2019 9:10 AM
Submit by McCoy, Suzanne 10/15/2019 7:48:04 AM (Payment Verification for NCC192336)
* Stuart Parks.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/15/2019 7:47 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 25, 2019 5:00
PM 10/14/2019 11:11 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Brandywine Drive
2. County* Forsyth
3. Highway or Street Brandywine Drive
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Clemmons
5. State * NC
1r-G)a�T7i)Mfi1if_T1IIa10141
6. Zip Code* 27112
7. Latitude * Enter the latitude in decirral degrees
36.0657
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.3985
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*
10/21/2019
Estimated Construction Project Start Date
10. Date to End*
04/01 /2021
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
1.85
disturbed*
(including off -site borrow and waste areas)
13. Total site area 3.16
(acres)*
14. Post- 0.40
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-FORSY-2019-Brandywine Drive
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 Blanket Creek
Waterbody* I\bne of waterbody into which stornwater runoff will discharge
15b. Waterbody 12-90-(2)
Index No. * NCWaterbody Index N.arrber
Stormwater fJ 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.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
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 PMA 1 Holdings, LLC
Name *
2. First Name* Stuart
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Parks
ff Corporation, enter Registered Agent Last Barre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* Post Office Box5323
Address Line 2
City State / Province / Region
Winston-Salem NC
Postal / Zip Code Country
27113 us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 11 Brookstown Avenue Southwest
Address Line 2
City
State / Province / Region
Winston-Salem
NC
Pastal / Zip Code
Country
27101
us

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Justin
Contact - First
Name *
3. Primary Site Mendenhall
Contact - Last
Name *
4. Title Project Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact [phone]
Telephone No.*
7. Organization
Parks Family Holdings, LLC
Name
8. Site Contact
Street Address
Mailing Address*
Post Office Box5323
Address Line 2
City
Winston-Salem
Pbstal/ Zip Code
27113
9. Consultant Name (optional)
Steve Causey
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant [phone]
Telephone No.
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 09/27/2019
Approved *
2. E&SC Plan Project EN1900128
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Winston-Salem/Forsyth County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan Review Completed - Brandywine Drive Erosion
Approval 167.27KB
Control Plan.pdf
letter/documentation
Mist be RDF format
6. NOI Certification NOI Certificate - Brandywine Westchester.pdf 808.34KB
Form Mist be RDF format
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) 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 knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article 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:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V 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.
* I7 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
r 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
Type Name* Stuart C. Parks
Title Manager
Organization PMA I Holdings, LLC
Date * 10/14/2019

F. Tracking and COC Info
NOI Tracking No. 17120
NC Reference No. NCG01-2019-2336
Uses 'count number variable (incremrented by SP)
Certificate of NCC192336
Coverage (COC) Uses 'count nunber variable (increrrentedbySP)
No. *
Count Number 2336
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)