NCC230176_Modification Review_20240711

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 7/9/2024 11:45:58 AM(ADD TO FILE Submittal)
Approve by bethany.georgoulias 7/11/2024 9:19:28 AM(Construction COC ADD TO FILE Review-NCC230176)
• The task was assigned to bethany.georgoulias.The due date is:July 12,2024 5:00 PM
7/9/2024 11:46:00 AM

Ago Permit for DEQMODIFICATION
Construction0i00
0000
Certificate of NCC230176
Coverage(COC)No.* Enter the Certificate of Coverage Number(Use capital letters)
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A May be blank if N/A May be blank if N/A
2023 Annual Fee Status 2024 Annual Fee Status
May be blank if N/A PAID
May be blank if N/A
Information associated with this permit:
Project Name South Fork Village-Phase 1
Address S. Peacehaven Road,Winston Salem, NC
County Forsyth
Latitude 36.0627
Longitude -80.3590
Permittee Listed LeoTerra Peace Haven, LLC
Legally Responsible Christopher Lyons
Individual At the time of Modification Request(not looked up again at review)
NC Reference No. NCG01-2023-0176
E&SC Plan ID EN2200073
Original NOI Tracking 123302
No.*
Date COC Issued* Effective Date at Submittal
04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.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.
Additional denuded area approved by Winston-Salem.

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.)
WS Approval Letter.pdf 451.44KB
NOI Signed 7.9.24.pdf 498.65KB
Signed FRO Form 7.9.24.pdf 918.23KB
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 143-215.613(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 NCG010000 General Permit. For more information on signatory requirements,see Part IV,Section B, Item
(6)of that permit.
Signature
('4t"WMP4''1t a�J9 WJ
Type Name* Christopher Lyons
Title* Manager
Organization* LeoTerra Peace Haven, LLC
Date* 07/09/2024
Email Address* [e-mail]
Email for confirmation
Telephone Number* 7046148359
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 07/11/2024
Rescinded Since
Submitted?
Current Effective Date Current Expiration Date Permit Version
4/1/2024 3/31/2029 2.00