NCC215416_NOI Application_20210930

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/28/2021 12:47:29 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 9/29/2021 7:18:41 AM (Review- Construction NOI 66751)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 9/28/2021 12:48 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 30, 2021 5:00
PM 9/28/2021 12:48 PM
Submit by Evans, Shaundra M 9/30/2021 8:54:04 AM (Payment Verification for NCC215416)
* Jennifer Mustar
• Evans, Shaundra M assigned the task to Evans, Shaundra M 9/30/2021 8:53 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 10, 2021 5:00
PM 9/29/2021 7:18 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting
IT No
an NOI that was
r Yes
rejected before?
1a. Project Name *
Murray Basin Sanitary Sewer
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
NA
1 c. Parcel ID List all Rios associated w ith this project.
Number(s) (PIN) 373308777610, 373318314939, 37331722146, 373317200984, 373210376305,
373210371330,373210276342,373209063007,372216947724,372216942387,
372216849129,372216848111,372216943105,372216834792,372215530365,
372215623515,372219504819,372218405657,372218406303
2. County* Catawba
3. Highwayor Street Section House Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Hickory
5. State * NC
6. Zip Code* 28601
7. Latitude* Enter the latitude in decimal degrees
35.7402
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-81.2465
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* 09/27/2021
Estimated Construction Project Start Date
10. Date to End* 11/23/2022
Estimated Construction Project End Date
11. SIC (Primary) * Other (9999)
Standard Industrial C]assification for Development

12. Acres to be 17.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 17.00
(acres) *
14. Post- 0.25
construction (Estinated)
impervious area
(acres) *
Project Tracking ID NCC-CATAW-2021-Murray Basin Sanitary Sewer
Assigned autorratically (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 Herman Branch/Lyle Creek
WaterbodY * Ibrreofwaterbodyinto whichstornwaterrunoff will discharge
15b. Waterbody 11-76-1
Index No.* NCWaterbody Index Nunber
Stormwater rJ 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 must 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. Permittee * Legally Pesponsible Entity
City of Hickory
IF pernittee is an individual, enter first and last narre in this field. Otherwise, enter organization/business narre.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here.
2. First Name * Warren
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Wood
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title City Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 828-323-7400
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box398
Address Line 2
Cty
Hickory
Fbstal / Zip Code
28601
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
1141 Ninth Avenue NE
Address Line 2
city
Hickory
Fbstal / Zip Code
28601
State / Ffovince / Fbgion
North Carolina
Country
United States
State / Frovince / Region
North Carolina
Country
United States
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Government- Municipal

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Shawn
Contact - First
Name *
2. Primary Site
Pennell
Contact - Last
Name *
3. Title
Public Utilities Director
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
828-323-7427
Telephone No.
6. Organization
City of Hickory
Name
7. Site Contact
Street Address
Mailing Address*
1441 Ninth Avenue NE
Address Line 2
City
Hickory
Postal / Zip Code
28601
8. Consultant Name
(Optional)
Scott Snyder
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
864-631-0439
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
828-323-7400
Default is legally responsible person telephone
State / Province / Region
North Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/29/2020
Approved *
2. E&SC Plan Project CATAW-2021-001
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 * Mooresville (MRO)
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 NCDENR Erosion Control 2020.pdf 899.85KB
Approval letter or Mist be RF format
Grading Permit
6. Signed FRO Financial Pesponsibility/Ownership Form
Murray Basin Financial Responsibility Form
337.17KB
June202O.pdf
Mast be RDFform3t
7. Site Location Map Mast be RDFforrret (lint 201VB)
Site Location Map Murray Basin.pdf 1.58MB
Rease do not upload entire set of E&SC plans.
8. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
Project involves two small pump stations, each with a force main
and replacement of gravity sewer.
9. NOI Certification Murray Basin Signed Certification- Form. pdf 461.66KB
Form Mast be RDFformat
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 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:* IT The Legally Responsible Person named on this Notice of Intent
f 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
Type Name* Warren Wood
Title City Manager
Organization Legally Plesponsible Entity
City of Hickory
Date * 09/28/2021

F. Tracking and COC Info
NOI Tracking No. 66751
NC Reference No.
NCG01-2021-5416
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC215416
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5416
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. NCC215416-2021
Invoice Due Date 10/29/2021
Initial Fee $ 100.00
Invoice Status OPEN