NCC231597_NOI Application_20230526

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 5/23/2023 4:31:07 PM (NCG01 NOI Submission)
Approve by Brooklyn.Broussard 5/24/2023 6:55:47 AM (Review-NOI 142304 Sedona Farms, Lot 3)
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: May 26,2023 5:00 PM
5/23/2023 4:31:16 PM
• The task was assigned to Brooklyn.Broussard by round robin distribution 5/23/2023 4:31:16 PM
Submit by Tev.Holloman 5/26/2023 12:17:54 PM (Payment Verification for NCC231597)
•Kurian and Joyce Koshy
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:July 5,2023 5:00 PM
5/24/2023 6:56:04 AM
• Tev.Holloman assigned the task to Tev.Holloman 5/26/2023 12:16:23 PM

applicationConstruction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System(NPDES)
General Permit 1 OOOO:STORMWATER DISCHARGES associated with construction activities
NORTH CAROUNA
Environmental Quality
A. Project Information
Part A.
Project Location and Waterbody Information
...................................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting an NOI that was rejected before?
No
Yes
Previous Rejected NOI No.
142024
Prior Reviewer Name
Brooklyn Broussard
1a. Project Name*
Sedona Farms, Lot 3
1b.Specific Lot Numbers
This field may be used to list specifc lot numbers.
Lot 3
1c.Parcel ID Number(s)(PIN)
List all PINS associated with this project.
00721111
2.County*
Mecklenburg
3.Highway or Street Address*
15037 June Washam Rd.
Street name only is acceptable if no address number assigned yet
4.City or Township*
Davidson
5.State* NC
6.Zip Code* 28036
7. Latitude* Enter the latitude in decimal degrees
35.4611
8. Longitude* Enter the longitude in decimal degrees(MUST be negative)
-80.7914
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* 05/26/2023
Estimated Construction Project Start Date
10. Date to End* 05/24/2024
Estimated Construction Project End Date
11.SIC(Primary)*
Residential,Single Family Houses(SFE)(1521)
Standard Industrial Classification for Development
12.Acres to be 2.95
disturbed* (including off-site borrow and waste areas)
13.Total site area 10.25
(acres)*
14. Post-construction 0.57
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-MECKL-2023-Sedona Farms, Lot 3
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 Waterbody*
West Branch Rocky River
Name of waterbody into which stormwater runoff will discharge
15b.Waterbody Index No.*
13-17-3
NC Waterbody Index Number
Stormwater discharges will flow to additional waters*
No
Yes
16a.Is this project subject to the NC Sediment Pollution Control Act?*
Yes
No, not subject to NC SPCA
17. Is this project funded with ARPA(American Rescue Plan Act)grant funds?
No
Yes
This question was added to the eNOI on 1/26/2023 and will not be answered in applications submitted prior to that date.

B. Permittee Information
Part B.
Permittee Information-Legally Responsible 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 Responsible Entity
Kurian Koshy
If permittee is an individual,enter first and last name in this field.Otherwise,enter organization/business name.
Note: If the permittee is a business,the business must be registered with the INC Secretary of State.You can verify the
registration here. Permittee must be the same entity that is responsible for the land-disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership(FRO)Form.
2. First Name* Kurian
If Corporation,enter Registered Agent First Name
3. Last Name* Koshy
If Corporation,enter Registered Agent Last Name
3b.Title Owner
4. Permitee E-mail Address*
[e-mail]
5. Permittee Telephone No.*
9786604343
6. Permittee Mailing Address*
Street Address
P.O. Box 2424
Address Line 2
City State/Province/Region
Cornelius INC
Postal/Zip Code Country
28031-8810 us
Check box if the street address the same as mailing address
Yes
7. Permittee Street Address*
Street Address
18915 Serenity Point Lane
Address Line 2
City State/Province/Region
Cornelius NC
Postal/Zip Code Country
28031-8810 us

B.Type of Ownership*
Ownership is only individual if an individual is named in B.1.above.
Non-Government

C. Site Contact Information
Part C.
Project Site Contact Information
................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Contact-First Name*
Kurian
2. Primary Site Contact-Last Name*
Koshy
3.Title
Owner
4.Site Contact E-mail Address*
[e-mail]
5.Site Contact Telephone No.*
9786604343
6.Organization Name
7.Site Contact Mailing Address*
Street Address
P.O. Box 2424
Address Line 2
City State/Province/Region
Cornelius NC
Postal/Zip Code Country
28031 USA
8.Consultant Name
(Optional)
First and Last name
9.Consultant E-mail
This person will be copied on all correspondence.
10.Consultant Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone
(For Annual Fee correspondence)
9786604343
Default is legally responsible person telephone

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Plan Approval Information
......................................................................................................................................................................
1. Date E&SC Plan 05/17/2023
Approved*
2. E&SC Plan Project 436691
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. Local Program* Mecklenburg County
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 EC Doc-Approved Itr#436691.pdf 163.54KB
Approval letter or Must be PDF format
Grading Permit
6.Signed FRO Financial Responsibility/Ownership Form
Financial Responsibility Form(signed).pdf 286.66KB
Must be PDF format
7.Site Location Map Must be PDF format(limit 20 MB)
[3]CO3 SITE PLAN.pdf 1.64MB
Please do not upload entire set of E&SC plans.
B. Notes(Optional) Provide any additional information that might help the reviewer better understand how uploaded documents
support the application.Include additional waterbodies if necessary.
9. NOI Certification 2023-05-22 12-02.pdf 569.75KB
Form Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
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).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* If the Erosion and Sediment Control Plan approved by the delegated program is not
compliant with Part II(Stormwater Pollution Prevention Plan)of the NCG010000
General Permit, I will nonetheless ensure that all conditions of Part II of the permit are
met on the project at all times.
* 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:* The Legally Responsible Person named on this Notice of Intent
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
/Z3.,x
Type Name* Kurian Koshy
Title Owner
Organization Legally Responsible Entity
Kurian Koshy
Date* 05/23/2023

F. Tracking and COC Info
NOI Tracking No. 142304
NC Reference No. NCG01-2023-1597
Indicates NCG01 or NCG25.Uses NOI number until approved,then uses NUMBER incremented by SP(passed
from workflow if eNOI approved)
Certificate of NCC231597
Coverage(COC)No.* Uses NOI number until approved,then uses NUMBER incremented by SP(formatted and passed from workflow if
eNOI approved)
Initial Invoice No. NCC231597-2023
Invoice Due Date 6/23/2023
Initial Fee $ 100.00
Invoice Status OPEN