NCC191870_Modification Review_20200416

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/16/2020 11:09:20 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/16/2020 12:20:48 PM (Construction COC ADD TO FILE Review- NCC191870)
• The task was assigned to Georgoulias, Bethany. The due date is: April 21, 2020 5:00 PM
4/16/2020 11:09 AM

Y. ,
NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC191870
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Collybrooke - DR Horton Lots
Address
150 Willowbrooke Way, Stokesdale, NC
County
Rockingham
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
DR Horton, Inc.
Legally Responsible
Jessica Meyer
Individual
NC Reference No.
NCG01-2019-1870
E&SC Plan ID
ROCKI-2019-015
Original NOI
15863
Tracking No.*
Date COC Issued*
09/16/2019
Prior Rescission
This field will populate only ff ODChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification* F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Multiple Reasons (List)
Addional ivbre information if necessary
Explanation Adding Phase 3, Section 1. Lots 15-20, 68-74, 83-89 - 11.35 acres
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).

Supporting Upload Supporting Documentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation Collybrooke Phase 3 Section 1 Lots 15-20, 68-74,
6.91 MB
83-89.pdf
Wst be FDFformat
North Carolina General Statute 143-215.6113 (i) 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 Artide or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis 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 Artide 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).
17 I, as an authorized representative, hereby request modification to coverage
under the NPDES Stormwater Permit for the subject project site. I am familiar
with the information contained in this request and to the best of my knowledge
and belief such information is true, complete and accurate.
'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 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
dctu'¢ 13
Type Name* Jessica Meyer
Title * NPDES Technical Compliance Administrator
Organization* DR Horton, Inc.
Date * 04/16/2020
Email Address* [e-mail]
67ail for Confirmation
Telephone Number* 919-215-6561
Contact N,imber if we need to reach you
Review Date 04/16/2020
Request Date 20200416
Formatted
Review Date 20200416
Formatted