NCC216226_Modification Review_20231201

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 11/29/2023 2:48:31 PM (ADD TO FILE Submittal)
Approve by bethany.georgoulias 12/1/2023 12:10:51 PM(Construction COC ADD TO FILE Review-NCC216226)
•Legally responsible person updated 12/1/2023.
• The task was assigned to bethany.georgoulias.The due date is: December 4,2023 5:00 PM
11/29/2023 2:48:32 PM

Ago DEQMODIFICATION
Permit for Construction Activities 0itltl
0000
Certificate of NCC216226
Coverage(COC)No.* Enter the Certificate of Coverage Number(Use capital letters)
Information associated with this permit:
Project Name John Smith Road Subdivision-Phase 1 -Single Family
Address John Smith Road, Rutherfordton, NC
County Rutherford
Latitude 35.3438
Longitude -81.9661
Permittee Listed Gateway Housing, LLC
Legally Responsible Angela Anderson
Individual At the time of Modification Request(not looked up again at review)
NC Reference No. NCG01-2021-6226
E&SC Plan ID RUTHE-2022-007
Original NOI Tracking 72573
No.*
Date COC Issued* 11/09/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Modification*
Closed-Out Lots/Outparcels in E&SC Plan
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.
The current Legally Responsible Individual no longer works for the organization.
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 Documentation
Upload Supporting Documentation(Revised E&SC Approval,Close-Out Doc,etc.)
DoNotReply_20231129_1 33748.pdf 498.98KB
Must be PDF format
Is this project funded with ARPA(American Rescue Plan Act)grant funds?
No
Yes
This question was added to the eNOl on 2/3/2023 and will not be answered in applications submitted prior to that date.
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 NCG010000 General Permit. For more information on signatory requirements,see Part IV,Section B, Item
(6)of that permit.
Signature
OA4*,W�l 1WW1.�Av.*-
Type Name* Destiny Mealhouse
Title* Operations Manager
Organization* Gateway Wellness Foundation
Date* 11/29/2023
Email Address* [e-mail]
Email for confirmation
Telephone Number* 828-559-9273
Contact number if we need to reach you
Note:Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 12/01/2023

Rescinded Since
Submitted?