NCC213459_Modification Review_20220811

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/3/2022 5:02:09 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 8/11/2022 12:17:07 PM (Construction COC ADD TO FILE Review - NCC213459)
• The task was assigned to Georgoulias, Bethany A. The due date is: August 8, 2022 5:00 PM
8/3/2022 5:02 PM

Certificate of NCC213459
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name David Hickman Brookberry
Address 1562 Autumn Park CIR,1568 Autumn Park CIR,1547 Autumn Park CIR,1451
Autumn Park CIR,1574 Autumn Park CIR,1445 Autumn Park CIR, Winston-Salem,
NC
County Forsyth
Latitude 36.1156
Longitude-80.3644
Permittee Listed David Hickman
Legally Responsible David Hickman
Individual
NC Reference No. NCG01-2021-3459
E&SC Plan ID 552597
Original NOI Tracking 54883
No. *
Date COC Issued * 06/14/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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)
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
Adding lot 376 Brookberry Farm 1152 Heron Ridge Road approval attached
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 Lot 376 BBF Erosion Control Approval.pdf 389.5KB
Must be PDF format
North Carolina General Statute 143-215.613 (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* David H Hickman
Title* President
Organization* Westphalia Construction Company, Inc.
Date * 08/03/2022
Email Address* [e-mail]
Email for confirmation
Telephone Number* 3363450768
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 08/11/2022
Rescinded Since
Submitted?