HomeMy WebLinkAboutNCC190215_NOI Application_20190508Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/8/2019 11:50:58 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 5/8/2019 1:08:03 PM (Review- Construction NOI 10797)
• The task was assigned to McCoy, Suzanne by round robin distribution 5/8/2019 11:51 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 10, 2019 5:00 PM
5/8/2019 11:51 AM
Submit by McCoy, Suzanne 5/8/2019 1:08:31 PM (Payment Verification - NCG01-2019-0215)
• The task was assigned to McCoy, Suzanne. The due date is: May 9, 2019 5:00 PM 5/8/2019 1:08 PM
STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Wheat Berry Place
2. County* Forsyth
3. Highway or Street 534 Barnes Road
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Winston Salem
5. State * NC
1r-i)iTII�T:2,11111711MI-11f_TiIa10141
6. Zip Code* 27107
7. Latitude * Enter the latitude in decimal degrees
36.0222
8. Longitude * Enter the longitude in decimal degrees (MIST be negative)
-80.2185
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*
10. Date to End*
11. SIC (Primary)*
12. Acres to be
disturbed *
13. Total site area
(acres)*
14. Post -
construction
impervious area
(acres) *
05/15/2019
Estimated Construction Project Start Date
08/05/2019
Estimated Construction Project End Date
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
2.18
(including off -site borrow and waste areas)
2.91
0.45
NCC Project NCC-FORSY-2019-Wheat Berry Place
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 Soakas Creek
Waterbody* I\brre of waterbody into which stornvwater runoff will discharge
15b. Waterbody 12-94-13-4
Index No. * NCWaterbody Index Ninber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional South Fork Muddy Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 12-94-13
Index No. NCWaterbody Index Narrber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbodyIndex Narrber
Index No.
16a. Is this project F 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
.....................................................................................................................................................................
h
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should 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. Organization Weidl Properties LLC
Name *
2. First Name*
Robert
ff Corporation, enter Registered Agent First l\brre
3. Last Name *
Weidl
ff Corporation, enter Registered Agent Last Barre
4. Permitee E-mail
robertweidl@hotmail.com
Address*
5. Permittee 336-577-7775
Telephone No.*
6. Permittee Mailing Street Address
Address* 2806 Reynolda Road
Address Line 2
#172
City
Winston Salem
Fbstal / Zip Code
27106
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
2806 Reynolda Road
Address Line 2
#172
City
Winston Salem
Postal / Zip Code
27106
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us
C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Robert
Contact - First
Name *
3. Primary Site Weidl
Contact - Last
Name *
4. Title Member -Manger
5. Site Contact E-
robertweidl@hotmail.com
mail Address*
6. Site Contact
336-577-7775
Telephone No.*
7. Organization
Weidl Properties LLC
Name
8. Site Contact
Street Address
Mailing Address*
2806 Reynola Road
Address Line 2
#172
aty
Winston Salem
Fbstal / Zip Code
27106
State / Province / Plegion
NC
Country
us
D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 05/08/2019
Approved *
2. E&SC Plan Project A/P #: EN1900066
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Winston-Salem/Forsyth 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 Review Completed - Wheat Berry Place.pdf 122.7KB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification NCG01-eNO1-Certification-Form-20190329-DEMLR-
Form SW.pdf 760.46KB
Mist be RDFforrrat
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*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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
Type Name* Alex Carter
Date * 05/08/2019
F. Tracking and COC Info
NOI Tracking No. 10797
NC Reference No. NCG01-2019-0215
Uses 'count number variable (incremrented by SP)
Certificate of NCC190215
Coverage (COC) Uses'count_nunber'variable (incremrented by SF)
No. *
Count Number 215
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)