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HomeMy WebLinkAboutNCC213975_NOI Application_20210714Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 7/6/2021 12:33:52 PM (NCG01 NOI Submission) Approve by Broussard, Brooklyn C 7/7/2021 7:21:11 AM (Review- Construction NOI 58398) • The task was assigned to Broussard, Brooklyn C by round robin distribution 7/6/2021 12:34 PM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 8, 2021 5:00 PM 7/6/2021 12:34 PM Submit by McCoy, Suzanne 7/14/2021 1:06:06 PM (Payment Verification for NCC213975) * The East Group • McCoy, Suzanne assigned the task to McCoy, Suzanne 7/14/2021 1:05 PM The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 18, 2021 5:00 PM 7/7/2021 7:21 AM .• SThF� '; 1 NORTH CAROLINA EnrlronmertW quallly A. Project Information Part A. Project Location and Waterbody Information Are you submitting r No an NOI that was r Yes rejected before? Previous Rejected 58380 NOI No. Prior Reviewer Brooklyn Broussard Name 1a. Project Name * CHC Surgical Department Renovation 1 b. Specific Lot This field may be used to list specffc lot numbers. Numbers 1 c. Parcel ID List all R% associated w ith this project. Number(s) (PIN) 637614423756000 2. County* Carteret 3. Highway or Street 3500 Arendell Street Address* Street name only is acceptable if no address nunber assigned yet 4. City or Township* Morehead City 5. State * NC 6. Zip Code* 28557 7. Latitude* Enter the latitude in decinal degrees 34.7265 8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative) -76.7555 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* 09/01/2021 Estirrated Construction Project Start Date 10. Date to End* 07/31/2023 Estinated Construction Project End Date 11. SIC (Primary)* Other (9999) Standard Industrial aassification for Development 12. Acres to be 3.41 disturbed* (including off -site borrow and waste areas) 13. Total site area 17.90 (acres) * 14. Post- 12.27 construction (Estimated) impervious area (acres) * Project Tracking ID NCC-CARTE-2021-CHC Surgical Department Renovation Assigned automatically (not used) 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 Bogue Sound Waterbody* Name of waterbody into which stormwater runoff will discharge 15b. Waterbody 20-36-(8.5) Index No. * NCWaterbody Index Nurrber Stormwater V No discharges will flow r Yes to additional wate rs * 16a. Is this project r 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 Legally Pesponsible Entity Name * Carteret County General Hospital Corporation IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field. Note: The organization name must match the business entity name registered with the NC Secretary of State. You can verify the registration here. 2. First Name * Harvey If Corporation, enter Faegistered Agent First Wre 3. Last Name* Case IF Corporation, enter F;bgistered Agent Last %rre 3b. Title Chief Executive Officer 4. Permitee E-mail hcase@carterethealth.org Address* 5. Permittee 252-499-6094 Telephone No.* 6. Permittee Mailing Street Address Address* PO Drawer 1619 Address Line 2 City Morehead City Fbstal / Zip Code 28557 Check box if the street address the same as mailing address 7. Permittee Street Address* F Yes Street Address 3500 Arendell Street Address Line 2 City Morehead City Fbstal / Zip Code 28557-2901 State / Frovince / Fbgion NC Country us State / Frovince / Faegion NC Country us 8. Type of Ownership is only individual if an individual is naned in B.1. above. Ownership* Non -Government C. Site Contact Information Part C. Project Site Contact Inforrration .................................................................................................................................................................................................... 1. Primary Site Michelle Contact - First Name * 2. Primary Site Clements Contact - Last Name * 3. Title Plant Engineer 4. Site Contact E- michelle.clements@eastgroup.com mail Address* 5. Site Contact 12523479604 Telephone No. 6. Organization The East Group Name 7. Site Contact Street Address Mailing Address* 324 Evans Street Address Line 2 324 Evans Street City Greenville Postal / Zip Code 27858 8. Consultant Name (Optional) Michelle Clements First and Last narre 9. Consultant E-mail michelle.clements@eastgroup.com This person will be copied on all correspondence. 10. Consultant 2523479604 Telephone No. 11. Billing E-mail (For Annual Fee correspondence) hcase@carterethealth.org Default is legally responsible person e-rrail 12. Billing (For Annual Fee correspondence) Telephone 252-499-6094 Default is legally responsible person telephone State / Province / Region NC Country United States D. E&SC Plan Part D. ^ Erosion & Sediment Control (E&SC) Ran Approval Information ...................................................................................................................................................................................................................................................................................................................................... 1. Date E&SC Plan 06/30/2021 Approved * 2. E&SC Plan Project CARTE-2021-028 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 * Wilmington (WiRO) Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can include the beginning point and end point coordinates in the "Notes" box below). 5. E&SC Plan CARTE-2021-028 Approval 6-30-2021.pdf 231.29KB Approval letter or Mast beRDFformat Grading Permit 6. Site Location Map Mist be RDFforrret (lint 201VB) Vicinity Map - Carteret Health Care.pdf 141.83KB Rease do not upload entire set of E&SC plans. 7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support the application. Include additional waterbodies if necessary. 8. NOI Certification eNO1 Certification Signed.pdf 77.06KB Form Wst be RDF formal This is an Express r 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 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 Legally Responsible Person named on this Notice of Intent r Authorized Responsible Person* (signing on behalf of Legally Responsible Person named in Part B) 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 1W ;f1 KfWl 0 Type Name * Dennis Mock Title Plant Engineer Organization Legally Plesponsible Entity Carteret Health Care Date * 07/06/2021 F. Tracking and COC Info NOI Tracking No. 58398 NC Reference No. NCG01-2021-3975 Uses 'count_nurber' variable (increrrented by SP) Certificate of NCC213975 Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP) No.* Count Number 3975 Sequential nurrber for subrrittal that is incremented by Stored Frocedure COC Year 2021 Year of date reviewed (used to assign YY digits after "NOC' in COCno.) Initial Invoice No. NCC213975-2021 Invoice Due Date 8/6/2021 Initial Fee $ 100.00 Invoice Status OPEN