NCC192686_NOI Application_20191113

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/6/2019 2:16:15 PM (NCG01 NOI Submission)
Approve by Clark, Paul 11/6/2019 3:58:37 PM (Review- Construction NOI 18185)
• The task was assigned to Clark, Paul by round robin distribution 11/6/2019 2:16 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 8, 2019 5:00
PM. The priority is: High 11/6/2019 2:16 PM
Submit by McCoy, Suzanne 11/13/2019 7:41:28 AM (Payment Verification for NCC192686)
* Kendall Martin
• McCoy, Suzanne assigned the task to McCoy, Suzanne 11/13/2019 7:41 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 18, 2019 5:00
PM. The priority is: High 11/6/2019 3:58 PM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Lewngton Car Wash
2. County* Davidson
3. Highway or Street 150 Lowes Blvd
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Lewngton
5. State * NC
6. Zip Code * 27292
7. Latitude * Enter the latitude in decimal degrees
35.7921
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.2594
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*
11/01/2019
Estimated Construction Project Start Date
10. Date to End*
07/01/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
1.40
disturbed*
(including off -site borrow and waste areas)
13. Total site area
1.30
(acres) *
14. Post-
0.63
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-DAVID-2019-Lewngton Car Wash
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 UT to Abbotts Creek
Wate rbody* INbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-118.5
Index No.* NCWaterbody Index Ninber
Stormwater V 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. ^
Fternittee Inforrration - Legally Fbsponsible 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 NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Hutton Lexington NC ST, LLC
Name *
2. First Name* Karen
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Hutton
If Corporation, enter Registered Agent Last %rre
3b. Title President & CEO
4. Permitee E-mail [e-mail]
Address *
5. Permittee 423-402-1993
Telephone No.*
6. Permittee Mailing Street Address
Address* 736 Cherry Street
Address Line 2
city State / Frovince / Region
Chattanooga TN
Postal / Zip Code Country
37402-1909 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 736 Cherry Street
Address Line 2
City
State / Frovince / Fbgion
Chattanooga
TN
Fbstal / Zip Code
Country
37402-1909
US

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Jesse
Contact - First
Name *
3. Primary Site
Garcia
Contact - Last
Name *
4. Title
Project Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
423-682-6027
Telephone No.*
7. Organization
BerryHutton Construction
Name
8. Site Contact
Street Address
Mailing Address*
2525 Broad Street
Address Line 2
City
Chattanooga
Fbstal / Zip Code
37408
9. Consultant Name
(Optional)
First and Last narre
10. Consultant E-
This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Rovince / f;bgion
TN
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/16/2019
Approved *
2. E&SC Plan Project David-2019-029
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
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 NCDEQ Letter of Approval 11-6-19.pdf 3.76MB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification Lexington, NC_NOI Cert Form 11-6-19.pdf 37.14KB
Form Mist be RDFfornat
This is an Express f No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) provides that:
Any person who knowingly makes anyfalse 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 Artcle; 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 Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
* 17 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
f 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
Cd ['l. `itfi411-`4W!
Type Name * Karen J. Hutton
Title President & CEO
Organization Hutton Lexington NC ST LLC
Date * 11 /06/2019

F. Tracking and COC Info
NOI Tracking No. 18185
NC Reference No. NCG01-2019-2686
Uses 'count number' variable (incremrented by SP)
Certificate of NCC192686
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2686
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)