NCC193240_NOI Application_20191220

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/16/2019 4:41:08 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 12/17/2019 3:03:38 PM (Review- Construction NOI 19626)
• The task was assigned to Morman, Alaina by round robin distribution 12/16/2019 4:41 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 18, 2019 5:00
PM 12/16/2019 4:41 PM
Submit by Lucas, Annette 12/20/2019 4:46:23 PM (Payment Verification for NCC193240)
* Town of Clayton
• Lucas, Annette assigned the task to Lucas, Annette 12/20/2019 4:45 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 28, 2020 5:00 PM
12/17/2019 3:03 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * U-5530LA — Sam's Branch Greenway/North O'Neil Crossing
2. County* Johnston
3. Highway or Street North O'Neil Street (SR 1708)
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Town of Clayton
5. State * NC
6. Zip Code * 27520
7. Latitude * Enter the latitude in decimal degrees
35.6626
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-78.4425
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*
01/13/2020
Estimated Construction Project Start Date
10. Date to End*
09/30/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Other (0000)
Standard Industrial Classification for Ceveloprrent
12. Acres to be
0.82
disturbed*
(including off -site borrow and waste areas)
13. Total site area
0.82
(acres) *
14. Post-
0.27
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-JOHNS-2020-U-5530LA — Sam's Branch Greenway/North
Tracking ID
O'Neil Crossing
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 NEUSE RIVER
Waterbody* arm of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-(38.5)
Index No.* NCWaterbody Index Nurrber
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. ^
Flarnittee 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 Town of Clayton
Name *
2. First Name* Adam
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name * Lindsay
If Corporation, enter Faegistered Agent Last %rre
3b. Title Town Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-553-5002
Telephone No.*
6. Permittee Mailing Street Address
Address* 111 E. 2nd Street
Address Line 2
PO Box 879
City State / Frovince / Faegion
Clayton NC
Fbstal / Zip Code Country
27528 USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 111 E. 2nd Street
Address Line 2
City
State / Frovince / Fbgion
Clayton
NC
Fbstal / Zip Code
Country
27528
USA

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Government - Municipal
Ownership *
2. Primary Site
Joshua
Contact - First
Name *
3. Primary Site
Baird
Contact - Last
Name *
4. Title
Town Engineer
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919-359-9379
Telephone No.*
7. Organization
Town of Clayton
Name
8. Site Contact
Street Address
Mailing Address*
111 E. 2nd Street
Address Line 2
PO Box 879
Cty
Clayton
Fbstal / Zip Code
27528
9. Consultant Name
(Optional)
Kimley-Horn and Associates
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
919-677-2175
Telephone No.
State / Rovince / Fbgion
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/10/2019
Approved *
2. E&SC Plan Project JOHNS-2020-006
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 * 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 JOHNS-2020-006 LOA MOD 20191210 revised. pdf 68.9KB
Approval Mist be RDFfornat
letter/documentation
6. NOI Certification SKM_C65819121617390.pdf 838.62KB
Form Mist be FDFfon-rat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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
Type Name *
Adam Lindsay
Title
Town Manager
Organization
Town of Clayton
Date *
12/16/2019

F. Tracking and COC Info
NOI Tracking No. 19626
NC Reference No. NCG01-2019-3240
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193240
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3240
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.)