NCC215630_NOI Application_20211011

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/8/2021 8:05:40 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 10/8/2021 10:28:04 AM (Review- Construction NOI 68246)
. The task was assigned to Broussard, Brooklyn C by round robin distribution 10/8/2021 8:06 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 12, 2021 5:00
PM 10/8/2021 8:06 AM
Submit by Selkane, Aziza 10/11/2021 3:38:27 PM (Payment Verification for NCC215630)
* Ellington and Son, Inc.
• Selkane, Aziza assigned the task to Selkane, Aziza 10/11/2021 3:37 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 19, 2021 5:00
PM 10/8/2021 10:28 AM

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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 68142
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Ellington Subdivision - Camping Creek Rd.
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) 1883962747
2. County* Franklin
3. Highway or Street Camping Creek Rd.
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Harris Township
5. State * NC
6. Zip Code* 27525
7. Latitude* Enter the latitude in decimal degrees
36.0478
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.3585
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* 10/11/2021
Estimated Construction Project Start Rate
10. Date to End* 10/11/2022
Estimated Construction Project End late

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be 15.24
disturbed* (including off -site borrow and waste areas)
13. Total site area 40.72
(acres) *
14. Post- 5.10
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-FRANK-2021-Ellington Subdivision - Camping Creek Rd.
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 Camping Creek
Waterbody* %rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 28-29-5
Index No. * NCWaterbody Index Number
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.
F2rnittee 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
Mark Ellington
It 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 * Mark
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Ellington
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-693-1230
Telephone No.*
6. Permittee Mailing Street Address
Address* 1230 Roxboro Road
Address Line 2
City State / Frovince / Fbgion
Oxford NC
Fbstal / Zip Code Country
27565-6498 us
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
1230 Roxboro Road
Address Line 2
City
State / Frovince / Faegion
Oxford
NC
Fbstal / Zip Code
Country
27565-6498
us
8. Type of
Ownership is only individual if an individual is named in B.1. above.
Ownership*
Individual

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Mark
Contact - First
Name *
2. Primary Site
Ellington
Contact - Last
Name *
3. Title
Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-693-1230
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
1023 Roxboro Road
Address Line 2
city
Oxford
Fbstal / Zip Code
27565-6498
8. Consultant Name
(Optional)
Stocks Engineering
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
252-459-8196
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
919-693-1230
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/06/2021
Approved *
2. E&SC Plan Project FRANK-2022-006
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. 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 FRANK-2022-006_20211006_LOA.pdf 285.96KB
Approval letter or Mist beRDFformat
Grading Permit
6. Signed FRO Financial Pesponsibility/Ojvnership Form
FRO form SIGNED.pdf 880.48KB
Mist be RDFfornat
7. Site Location Map Mast be RDFforrrat (lirrit 20IVB)
USGS Map - Corrected.pdf 3.8MB
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 documents support
the application. Include additional w aterbodies if necessary.
9. NOI Certification NCG01-eNOI-Certification-Form - Signed.pdf 475.94KB
Form Mast be RDFfon-rat
This is an Express F 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:* 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* Mark Ellington
Title Owner
Organization Legally Responsible Entity
Mark Ellington
Date * 10/08/2021

F. Tracking and COC Info
NOI Tracking No. 68246
NC Reference No.
NCG01-2021-5630
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC215630
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5630
Sequential nunber for subnittal 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. NCC215630-2021
Invoice Due Date 11/7/2021
Initial Fee $ 100.00
Invoice Status OPEN