NCC193166_NOI Application_20191216

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/11/2019 3:19:01 PM (NCG01 NOI Submission)
Approve by Clark, Paul 12/11/2019 3:25:11 PM (Review- Construction NOI 19451)
• The task was assigned to Clark, Paul by round robin distribution 12/11/2019 3:19 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 13, 2019 5:00
PM 12/11/2019 3:19 PM
Submit by McCoy, Suzanne 12/16/2019 1:37:31 PM (Payment Verification for NCC193166)
* Sorensen Contracting Corp.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/16/2019 1:37 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 22, 2020 5:00 PM
12/11/2019 3:25 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name *
Sorensen
2. County*
Wake
3. Highway or Street
7636 Ladora Drive
Address *
Street narre only is acceptable if no address number assigned yet
4. Cityor Township* Willow Spring
5. State * NC
6. Zip Code * 27592
7. Latitude * Enter the latitude in decimal degrees
35.5812
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.7029
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*
12/30/2019
Estimated Construction Project Start Date
10. Date to End*
07/31/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Developrrent
12. Acres to be
0.91
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.52
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*

NCC Project NCC-WAKE-2019-Sorensen
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 Black Creek
Waterbody* %neof waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-45-(2)
Index No. * NCWaterbody Index Nurrber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project
subject to the NC
Sediment Pollution
Control Act?*
16b. Is this project
subject to the US
Clean Water Act?
r Yes
r No, not subject to NC SPCA
r Yes
f No, not subject to US CWA
This project will be issued a Certificate of Coverage under NCG250000 rather than NCG010000. The Erosion and
Sediment Control Plan shall be reviewed and approved by the appropriate DEMLR Regional Office, and then this Notice
of Intent form shall be completed and submitted.

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 Land Owner
Name *
2. First Name* Michael
If Corporation, enter Registered Agent First f brre
3. Last Name* Sorensen
If Corporation, enter Faegistered Agent Last %rre
3b. Title Land Owner
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-795-5975
Telephone No.*
6. Permittee Mailing Street Address
Address* Fuquay-Varina
Address Line 2
PO Box 1105
City
State / Province / Faegion
Fuquay-Varina
NC
Postal / Zip Code
Country
27526
us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* Fuquay-Varina
Address Line 2
8505 Currin Drive
City
State / Frovince / Region
Fuquay-Varina
NC
Fbstal / Zip Code
Country
27526
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Individual
Ownership *
2. Primary Site
Michael
Contact - First
Name *
3. Primary Site
Sorensen
Contact - Last
Name *
4. Title
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919-795-5975
Telephone No.*
7. Organization
Name
8. Site Contact
Street Address
Mailing Address*
Fuquay-Varina
Address Line 2
PO Box 1105
Cty
Fuquay-Varina
Fbstal / Zip Code
27526
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 / Fbgion
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/05/2019
Approved *
2. E&SC Plan Project SEC-023662-2019
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Wake 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 US Army Cor SAW-2019-02202 signed NWP
Approval 1.57MB
verification. pdf
letter/documentation
Wake CO SEC-023662-2019 Approval Letter
276.92KB
Sediment and Erosion 12-5-19.pdf
Mast be RDFfon-rat
6. NOI Certification SIGNED NCG01 NOI Cert Form SIGNED.pdf 766.77KB
Form Mist be RDFfornat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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 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.
* 17 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
�frCcr�rrP�!Jli y�d�r%�rlrsv7!
Type Name* Michael Keith Sorensen
Title land owner
Organization land owner
Date * 12/11 /2019

F. Tracking and COC Info
NOI Tracking No. 19451
NC Reference No. NCG25-2019-3166
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193166
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3166
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.)