NCC215351_Modification Review LOTS 9 11-20 25_20220104

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/21/2021 11:49:10 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 1/4/2022 8:09:51 AM (Construction COC ADD TO FILE Review - NCC215351)
* We cannot revise the current project name on a COC; our current NCG01 Modification process
cannot make updates to that information and does not result in a new COC issued.
The task was assigned to Georgoulias, Bethany A. The due date is: December 24, 2021 5:00 PM
12/21 /2021 11:49 AM

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Certificate of NCC215351
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name Petree Ridge - Lots 10 & 21-24
Address "0" Petree Road, Winston-Salem, NC
County Forsyth
Latitude 36.0000
Longitude-80.0000
Permittee Listed Isenhour Homes, LLC
Legally Responsible Todd Isenhour
Individual
NC Reference No. NCG01-2021-5351
E&SC Plan ID EN2100166
Original NOI Tracking 66551
No. *
Date COC Issued * 09/28/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Closed -Out Lots/Outparcels in E&SC Plan
Modification* Additional Lots/Outparcels Approved - E&SC Revised
Other Revision(s) to E&SC Plan
Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons (List)
Additional Lots Approved-E&SC Revised; Project Name-E&SC
Revised
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
This modification is due to the purchase of additional lots by the Permittee (Isenhour
Homes, LLC). The additional lots purchased are 9, 11-20 and 25. The total disturbed
acreage has increased to 6.21 acres. As a result of the additional lots, the Project
Name was changed to a more generic name, and does not reference specific lots as
it previously did. We are requesting that the Project Name be revised and for
additional lots to be added to this Certificate of Coverage. Attached is the revised
E&SC Approval and an approved revised site drawing that covers all lots.

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 (Revised E&SC Approval, Close -Out Doc, etc.)
Documentation Review Completed - Petree Ridge Subdivision SFD
178.38KB
Lots.pdf
APPROVED C1-Site Individual Lot EC
749.57KB
Plan Additional Lots_PetreeRidgeSFDLots.pdf
Must be PDF format
North Carolina General Statute 143-215.6B (i) provides that:
Any person who knowingly makes any false 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 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 Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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:* • The Legally Responsible Individual
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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Todd Isenhour
Title* Manager
Organization* Isenhour Homes, LLC
Date * 12/21 /2021
Email Address* [e-mail]
Email for confirmation
Telephone Number* [phone]
Contact number 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 01/04/2022
Rescinded Since
Submitted?
Request Date 20211221
Formatted
Review Date 20220104
Formatted