NCC192579_Modification Review_20200518

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/15/2020 2:50:41 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 5/18/2020 7:52:47 AM (Construction COC ADD TO FILE Review- NCC192579)
• The task was assigned to Georgoulias, Bethany. The due date is: May 20, 2020 5:00 PM
5/15/2020 2:50 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC192579
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Olde Poplar
Address
9628 Beatties Ford Rd, Huntersville, NC
County
Mecklenburg
Latitude
35.3563
Longitude
-80.8919
Permittee Listed
Olde Poplar, LLC
Legally Responsible
Jesse Goodwin
Individual
NC Reference No.
NCG01-2019-2579
E&SC Plan ID
397465
Original NOI
17876
Tracking No.*
Date COC Issued*
10/31/2019
Prior Rescission
This field will populate only if COChas already been rescinded.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 Legally Responsible Individual Has Changed
r Multiple Reasons (List)
Addional We information if necessary
Explanation Original COC was for construction of the shared driveway for the subdivision.
Modification will add the lots to the COC as well.
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). For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (%vised ERSC Approval, (lose -Out Doc, etc.)
Documentation EC Permit Only Approval Ltr #406513.pdf 153.59KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate any recording or monitoring device 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 notto e)ceed ten thousand
dollars ($10,000).
rJ I 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.
Specify if you are:* r The Legally Responsible Individual
f Authorized Responsible Person*
*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
Type Name* Jesse Goodwin
Title * Manager
Organization * Olde Poplar LLC
Date * 05/15/2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 7043638377
Contact nun ber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 05/18/2020
Request Date 20200515
Formatted

Review Date 20200518
Formatted