HomeMy WebLinkAboutNCC190026_NOI Application_20190409Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/9/2019 2:47:10 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 4/9/2019 3:52:41 PM (Review- Construction NOI 9988)
• The task was assigned to McCoy, Suzanne by round robin distribution 4/9/2019 2:47 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 11, 2019 5:00 PM
4/9/2019 2:47 PM
Submit by McCoy, Suzanne 4/9/2019 3:56:07 PM (Payment Verification - NCG01-2019-0026)
• The task was assigned to McCoy, Suzanne. The due date is: April 10, 2019 5:00 PM
4/9/2019 3:52 PM
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NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * GRACE COVENANT CHURCH EXPANSION
2. County* Mecklenburg
3. Highway or Street 17301 STATESVILLE ROAD
Address * Street narre only is acceptable if no address nurrber assigned yet
4. City or Township* CORNELIUS
5. State * NC
6. Zip Code* 28031
7. Latitude * Enter the latitude in decirral degrees
35.4490
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-80.8680
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*
04/12/2019
Estimated Construction Project Start Date
10. Date to End*
05/30/2019
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
1.66
disturbed*
(including off -site borrow and waste areas)
13. Total site area
1.66
(acres)*
14. Post-
1.19
construction
impervious area
(acres) *
NCC Project
NCC-MECKL-2019-GRACE COVENANT CHURCH EXPANSION
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 CALDWELL STATION CREEK
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 11-115-2-(1)
Index No. * NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*
B. Permittee Information
Part B.
Perrrittee Information - Legally Responsible Entity and Individual
.........................................................................................................................................................................
1. Organization INTERNATIONAL CHURCH OF THE FOURSQUARE GOSPEL
Name *
2. First Name*
C. Paul
ff Corporation, enter Registered Agent First Nlarre
3. Last Name *
Glenn
V Corporation, enter Registered Agent Last f brre
4. Permitee E-mail
pglenn@foursquare.org
Address*
5. Permittee 704-239-0569
Telephone No.*
6. Permittee Mailing Street Address
Address* 363 Church Street North
Address Line 2
Suite 200
City
State / Province / Region
Concord
NC
Pbstal / Zip Code
Country
28025
US
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 363 Church Street North
Address Line 2
Suite 200
City
State / Province / Region
Concord
NC
Postal / Zip Code
Country
28025
US
h
C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Michael
Contact - First
Name *
3. Primary Site Carter
Contact - Last
Name *
4. Title Director
5. Site Contact E- michael@gracecovenant.org
mail Address*
6. Site Contact
7048928005 x 220
Telephone No.*
7. Organization
Grace Covenant Church
Name
8. Site Contact
Street Address
Mailing Address*
17301 Statesville Road
Address Line 2
Mailing: P.O. Box 1198, Pineville NC 28134
City
State / Rovince / Plegion
Cornelius
NC
Rbstal / Zip Code
Country
28031-9353
us
D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/05/2019
Approved *
2. E&SC Plan Project 394811
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r 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.
5. E&SC Plan EC Doc -Approved Itr #394811.pdf 73.05KB
Approval Mast be RCFformat
letter/documentation
6. NOI Certification e-NOI.pdf 36.65KB
Form Mist be RDFformat
This is an Express r No
Review Project* r Yes
E. Certification
North Carolina General Statute 143-215.6B (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.
* V 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.
* V 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.
* I7 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* Michael Carter
Date * 04/09/2019
F. Tracking and COC Info
NOI Tracking No. 9988
NC Reference No. NCG01-2019-0026
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190026
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 26
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.)