NCC192563_NOI Application_20191030

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/24/2019 3:37:04 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 10/29/2019 11:32:31 AM (Review- Construction NOI 17694)
• The task was assigned to Farkas, Jim J by round robin distribution 10/24/2019 3:37 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 28, 2019 5:00
PM 10/24/2019 3:37 PM
Submit by McCoy, Suzanne 10/30/2019 12:21:50 PM (Payment Verification for NCC192563)
* town of rich square.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/30/2019 12:21 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 10, 2019 5:00
PM 10/29/2019 11:32 AM

STME
NORTH CAROLINA
Ernvlronmental Qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Town of Rich Square - Phase 2 Water Improvements
2. County* Northampton
3. Highway or Street 109 Main Street
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township * Rich Square
5. State * NC
1r-G)ff&T7i)M1i1f_TiIa1010
6. Zip Code* 27869
7. Latitude * Enter the latitude in decirral degrees
36.2737
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-77.2845
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 *
04/01 /2020
Estimated Construction Project Start Date
10. Date to End*
12/01 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
4.50
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.50
(acres)*
14. Post- 0.20
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-NORTH-2020-Town of Rich Square - Phase 2 Water
Tracking ID Improvements
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 Bridgers Creek
Wate rbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 23-34
Index No. * NC Waterbody Index Ninber
Stormwater PF 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.
P rrrittee Information - Legally Fbsponsible 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 Town of Rich Square
Name *
2. First Name* Reginald
ff Corporation, enter Fbgistered Agent First 1\brre
3. Last Name * White
ff Corporation, enter Registered Agent Last Barre
3b. Title Mayor Pro-Tem
4. Permitee E-mail [e-mail]
Address*
5. Permittee 252-539-2315
Telephone No.*
6. Permittee Mailing Street Address
Address* 109 Main Street
Address Line 2
City
State / Province / Region
Rich Square
NC
Postal / Zip Code
Country
27869
us
Check box if the r% Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 109 Main Street
Address Line 2
City
State / Province / Region
Rich Square
NC
Pastal / Zip Code
Country
27869
us

C. Site Contact Information
Part C.
Proiect Site Contact hforrration
1. Type of Government - Municipal
Ownership*
2. Primary Site Reginald
Contact - First
Name *
3. Primary Site White
Contact - Last
Name *
4. Title Mayor Pro-Tem
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
252-539-2315
Telephone No.*
7. Organization
Town of Rich Square
Name
8. Site Contact
Street Address
Mailing Address*
109 Main Street
Address Line 2
city
Rich Square
Rbstal / Zip Code
27869
9. Consultant Name (optional)
Todd Steele
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 9196627272
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 10/18/2019
Approved *
2. E&SC Plan Project North-2020-001
Number/ID* Assigned by agency or local program
3. E&SC Plan f• State DEQ Office
Approved by r Local Program
4. State DEQ Office * Raleigh (RRO)
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 NORTH-2020-001 LOA 20191018.pdf 58.42KB
Approval Mist be FDFforrrat
letter/documentation
6. NOI Certification 20191024154926.pdf 80.81KB
Form Mist be RDFforrrat
This is an Express f• No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (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.
* 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ 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 *
Reginald White
Title
Mayor Pro-Tem
Organization
Town of Rich Square
Date *
10/24/2019

F. Tracking and COC Info
NOI Tracking No. 17694
NC Reference No. NCG01-2019-2563
Uses 'count number variable (incremrented by SP)
Certificate of NCC192563
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2563
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.)