NCC190013_NOI Application_20190404

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/4/2019 10:09:13 PM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 4/5/2019 7:58:17 AM (Review- Construction NOI 9890)
• The task was assigned to Georgoulias, Bethany by round robin distribution 4/4/2019 10:09 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 8, 2019 5:00 PM
4/4/2019 10:09 PM
Submit by Georgoulias, Bethany 4/5/2019 7:58:42 AM (Payment Verification - NCG01-2019-0013)
The task was assigned to Georgoulias, Bethany. The due date is: April 8, 2019 5:00 PM
4/5/2019 7:58 AM

1r-i)iTiT7G)MFalif_TiIa10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * HYDE PARK BAPTIST CHURCH
2. County* Robeson
3. Highway or Street 301 ROBERTS AVE
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* LUMBERTON
5. State * NC
6. Zip Code* 28358
7. Latitude * Enter the latitude in decirral degrees
34.6161
8. Longitude * Enter the longitude in decirral degrees (MUST be negative)
-78.9824
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 * 05/01 /2019
Estimated Construction Project Start Date
10. Date to End* 05/01 /2021
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 7.00
disturbed* (including off -site borrow and waste areas)
13. Total site area
13.40
(acres)*
14. Post-
3.54
construction
impervious area
(acres) *
NCC Project
NCC-ROBES-2019-HYDE PARK BAPTIST CHURCH
Tracking ID
Assigned autorratically

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. You may
enter up to 3 waterbodies.
15a. Receiving BIG DITCH (MILL BRANCH
Waterbody * Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 14-15
Index No. * NCWaterbody Index Nunber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs *
15c. Additional LUMBER RIVER
Receiving Waterbody nacre
Waterbody
15d. Waterbody 14-(13)
Index No. NCWaterbody Index Ninber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index %n-ber
Index No.
16a. Is this project r Yes
subject to the NC f No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Perrrittee Information - Legally Fbsponsible Entity and Individual
.........................................................................................................................................................................
1. Organization HYDE PARK BAPTIST CHURCH
Name *
2. First Name*
RANDY
If Corporation, enter Fbgistered Agent First %rre
3. Last Name *
HAMMONDS
If Corporation, enter Registered Agent Last Ibrre
4. Permitee E-mail
[e-mail]
Address*
5. Permittee 910-608.1266
Telephone No.*
6. Permittee Mailing Street Address
Address* 301 ROBERTS AVE
Address Line 2
City
LUMBERTON
Postal / Zip Code
28358
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
301 ROBERTS AVE
Address Line 2
City
LUMBERTON
Postal / Zip Code
28358
State / Province / Fbgion
NC
Country
US
State / Province / Region
NC
Country
US
h

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site LARRY
Contact - First
Name *
3. Primary Site ANDERSON
Contact - Last
Name *
4. Title PE
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 910-608-2808
Telephone No.*
7. Organization
Anderson Engineering & Associates, PA
Name
8. Site Contact
Street Address
Mailing Address*
305 N. Chippewa Street
Address Line 2
PO BOX 1736
City
Lumberton
Rbstal / Zip Code
28358
State / Province / Region
North Carolina
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/01/2019
Approved *
2. E&SC Plan Project Robes-2019-019
Number/ID* Assigned by agency or local program
3. E&SC Plan f• State DEQ Office
Approved by r Local Program
4. State DEQ Office * Fayetteville (FRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan 20190404094643.pdf
Approval Mist be R7Ffornat
letter/documentation
6. NOI Certification 20190404100739.pdf
Form Mist be RDFforrrat
This is an Express f• No
Review Project* r Yes
233.08KB
2.07MB

E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* rJ 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ 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:* r The Responsible Person named on this Notice of Intent
r 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
Type Name * Randy Lynn Hammonds
Date * 04/04/2019

F. Tracking and COC Info
NOI Tracking No. 9890
NC Reference No. NCG01-2019-0013
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190013
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 13
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed, used to assign YY digits after "NOC' in OOC no.)