NCC191870_Modification Review (LEG RESP CHANGE)_20230110

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/3/2023 1:40:03 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 1/10/2023 10:53:23 AM (Construction COC ADD TO FILE Review - NCC191870)
* Legally responsible person updated 1/10/2023. Reviewer noted approval for new lots was a few years
ago; permit contact confirmed they are catching up with adding documentation to the COC.
• The task was assigned to Georgoulias, Bethany A. The due date is: January 6, 2023 5:00 PM
1/3/2023 1:40 PM

Certificate of NCC191870
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name Collybrooke - DR Horton Lots
Address 150 Willowbrooke Way, Stokesdale, NC
County Rockingham
Latitude 36.0000
Longitude-80.0000
Permittee Listed DR Horton. Inc.
Legally Responsible Jessica Meyer
Individual
NC Reference No. NCG01-2019-1870
E&SC Plan ID ROCKI-2019-015
Original NOI Tracking 15863
No. *
Date COC Issued* 09/16/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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)
adding additional lots and change of party
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
Adding ROCKI-2021-1018 lots 21-40 and 92-102 and change of responsible party
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 SKM_C750i23010313360.pdf 120.19KB
ROCKI-2021-018_20201123 Approval_Express.pdf 8.09MB
Must be PDF format
North Carolina General Statute 143-215.613 (1) 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
9&,a2.sa
Type Name* Tracey Davis
Title* Division NPDES Administrator
Organization* D.R. Horton Inc
Date * 01 /03/2023
Email Address* [e-mail]
Email for confirmation
Telephone Number* 9194972163
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 01/10/2023
Rescinded Since
Submitted?