HomeMy WebLinkAboutNCC192394_NOI Application_20191018Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/15/2019 1:49:35 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 10/17/2019 8:40:09 AM (Review- Construction NOI 17200)
• The task was assigned to Farkas, Jim J by round robin distribution 10/15/2019 1:49 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 17, 2019 5:00
PM 10/15/2019 1:49 PM
Submit by Lucas, Annette 10/18/2019 8:46:17 AM (Payment Verification for NCC192394)
• Lucas, Annette assigned the task to Lucas, Annette 10/18/2019 8:39 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 28, 2019 5:00
PM 10/17/2019 8:40 AM
STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Cloverdale Apartments
2. County* Forsyth
3. Highway or Street 2326 Cloverdale Ave
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
1 r-i) iTII1T 7i) M l'11 f_T1II a 10141
6. Zip Code* 27103
7. Latitude * Enter the latitude in decimal degrees
36.0890
8. Longitude * Enter the longitude in decimal degrees (MIST be negative)
-80.2777
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*
01/15/2020
Estimated Construction Project Start Date
10. Date to End*
01/18/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Other
than SFE (1522)
Standard Industrial Gassification for Development
12. Acres to be
10.83
disturbed*
(including off -site borrow and waste areas)
13. Total site area
12.27
(acres)*
14. Post-
7.15
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-FORSY-2020-Cloverdale Apartments
Tracking ID
Assigned automatically
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 Peters Creek
Waterbody* Barre of waterbody into which stormuater runoff will discharge
15b. Waterbody 12-94-12-8
Index No.* NC Waterbody Index Narrber
Stormwater F No
discharges will flow r% Yes
to additional
wate rs *
15c. Additional Little Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-94-11
Index No. NCWaterbody Index Ninber
15e. Additional Waterbody nave
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Ninter
Index No.
16a. Is this project r 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 Ardmore Cloverdale LLC
Name *
2. First Name* Craig
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Peatross
Y Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail craigpeatross@yahoo.com
Address*
5. Permittee 336-971-1156
Telephone No.*
6. Permittee Mailing Street Address
Address* 1638 Funny Cide Drive
Address Line 2
City
Waxhtaw
Postal / Zip Code
28173-7205
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
1638 Funny Cide Drive
Address Line 2
City
Waxhaw
Fbstal / Zip Code
28173-7205
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us
C. Site Contact Information
Part C.
Roiect Site Contact hfon- ation
1. Type of Individual
Ownership*
2. Primary Site John
Contact - First
Name *
3. Primary Site Lomax
Contact - Last
Name *
4. Title
5. Site Contact E-
jlomax@lomaxconstruction.com
mail Address*
6. Site Contact
336-382-6309
Telephone No.*
7. Organization
Lomax Construction
Name
8. Site Contact
Street Address
Mailing Address*
P.O. Box 35169
Address Line 2
city
Greensboro
Pbstal/ Zip Code
27425
9. Consultant Name (optional)
First and Last nane
10. Consultant E- This person will be copied on all correspondence.
mail
11. Consultant
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 10/02/2019
Approved *
2. E&SC Plan Project EN1900097
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 - Cloverdale Apartments.pdf 140.68KB
Approval Mist be RCFformat
letter/documentation
6. NOI Certification Notice of intent.pdf 68.83KB
Form Mist be R7Fformat
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
6�'W '11r- �r
Type Name* Craig W Peatross
Title President
Organization Ardmore Cloverdale LLC
Date * 10/15/2019
F. Tracking and COC Info
NOI Tracking No. 17200
NC Reference No. NCG01-2019-2394
Uses 'count number variable (incremrented by SP)
Certificate of NCC192394
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2394
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.)