NCC192523_NOI Signed Certification_20191028

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 (i), 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
XX 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.
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.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan 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.
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.
Name of Project: Oyster Pond
Legally Responsible Organizational Entity: Pierce Decelopment LLC
Responsible Person: Jimmy Pierce
Title of Legally Responsible Person: Managing Member
*Signature: v_ Date: `
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee: Jimmy Pierce Managing Member
Phone Number:( 910) 389-4139
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.

10/23/2019
New Submission
NORTH CAROLINA
Environmental Quality
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCG010000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information I B. Permittee Information I C. Site Contact information I D. E&SC Plan
E. Certification
Part A.
Project Location and Waterbody Information
.................................................................................................................
1. Project Name* oyster Pond
2. County* Pender
3. Highway or Street IN New River Drive
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Topsail
5. State* INC....................m-.....------
t
6. Zip Code* 8445
7. Latitude* Enter the latitude in decimal degrees
34.4360
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
77.5329
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina (https://ncdenr.maps.arcgis.com/apps/webappviewer/index.html?
id=9fdfc3872651444c8339d718a099a1 ac). Look for the coordinates in the bottom left corner.
9. Date to Begin 111/15/2019
Estimated Construction Project Start Date
10. Date to End* 04/30/2020" ^
Estimated Construction Project End Date
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10/23/2019 New Submission
11. SIC (Primary) * Residential, Single v
Standard Industrial Classification for Development
12. Acres to be �1.90
disturbed * (including off -site borrow and taste areas)
13. Total site area k2.82
(acres) *
14. Post- F 8
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-PENDE-2019-Oyster Pond
Assigned automatically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer (https:Hncdenr.maps.arcgis.com/apps/webappviewer/index.html?
id=6e125ad7628f494694e259c80dd64265) 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 opsail Sound
Waterbody Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 118-87-10
Index No.* NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
16a. Is this project
subject to the NC
Sediment Pollution
Control Act?*
Previous
o. Yes
No, not subject to NC SPCA
Next
https://edocs.deq.nc.gov/Forms/NCG01-NOI 2/3

10/23/2019
New Submission
STATF Construction Stormwater: Notice of Intent (NOI)
n National Pollutant Discharge Elimination System NPDES application for coverage under North Carolina's
OW
i. ' �Z
General Permit NCGO10000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
NUR rH CAROLINA
f:'nvironmentol Quality
A. Project Information I i B. Permittee Information I C. Site Contact information I D. E&SC Plan
E. Certification
Part B.
Permittee Information - Legally Responsible 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 NCGO10000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization ;Pierce Development
Name*
2. First Name* 'Jimmy
If Corporation, enter Registereld Agent First Name
3. Last Name* Pierce
If Corporation, enter Registered Agent Last Name
3b. Title* Managing Member
4. Permitee E-mail ,[e-mail]
Address*
5. Permittee y(910) 389-41-39
Telephone No.
hUps://edocs.deq.nc.gov/Forms/NCG01-NOI 1/2

10/23/2019 1 New Submission
https://edocs.deq.nc.gov/Forms/NCG01-NOI 2/2

10/23/2019
New Submission
NO I'H ::A U'LINA
E'nvironmenrul Qualify
Part C.
Project Site Contact Information
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCGO100p0: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information I B. Permittee Information I C. Site Contact information I D. E&SC Plan
E. Certification
1. Type of
Individual •
Ownership*
2. Primary Site
Jimmy
Contact - First
Name*
3. Primary Site
Pierce
Contact - Last
'
Name
4. Title
'---
Managing Member
5. Site Contact E-
[e-mail]
mail Address*
This person will be copied on all correspondence.
6. Site Contact
,[phone]
Telephone No.*
I
7. Organization Pierce Development LLC
Name
https://edocs.deq.nc.gov/Forms/NCG01-NO] 1/2

10/23/2019
New Submission
8. Site Contact Street Address
Mailing Mailing Address* 152 Great Oak Drive
............
Address Line 2
city
State / Province / Region
Hampstead �..
� NC
Postal / Zip Code
Country
28443-2142
US
9. Consultant Name (Optional)
(John L. Pierce/John L. Pierce & Associates P.A.
First and Last name
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant [phone]
Telephone No.
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Save as Draft
https://edocs.deq.nc.gov/Forms/NCG01-NOI 2/2

10/23/2019
New Submission
rdUR 111 . Ji ]LINA
EnWrormcrilaf flualiry
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCG010d00: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information B. Permittee Information I C. Site Contact information D. E&SC Plan
E. 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 ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* ✓ 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.
* ✓ The information subm�itted 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.
* i I will abide by all conditions of the NCGO10000 General Permit and the
approved Erosion and Sediment Control Plan.
* I hereby request coverage under the NCGO10000 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: * e The Responsible Person named on this Notice of Intent
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 IIas the Permittee. *An authorized individual is a responsible corporate
https://edocs.deq.nc.gov/Forms/NCGO1-NOI 1/2

10/23/2019
New Submission
rioh rIa ca:�ouri��
Environmental Qctu dry
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discha Ige Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCGO10000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information B. Permittee Information C. Site Contact information D. E&SC Plan
E. Certification
North Carolina General Statute 143-215.6E (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 ten thousand dollars ($10,000)
Under penalty of law, I certify that:
* ✓. 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.
*! I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* 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: * �' The Responsible Person named on this Notice of Intent
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
https:Hedocs.deq.nc.gov/Forms/NCG01-NOI 1/2

10/23/2019
New Submission
NOR TH CARULINA
Environmental Quadiry
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCGO10000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information B. Permittee Information C. Site Contact information D. E&SC Plan
E. Certification
North Carolina General Statute 143-215.6113 (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 pe 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 ten thousand dollars ($10,000).
Under penalty of law, I certify that:
*i 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* ✓ 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: * The Responsible Person named on this Notice of Intent
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
https://edocs.deq.nc.gov/Forms/NCGO1-NOI 1/2

10/23/2019
New Submission
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 NCGO10000 General Permit. For
more information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature * x
Type Name*
Title *
Organization
Date *
Previous
immy Pierce
!managing Member��
9 9
Pierce Development LLC
Date captured on form submission
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