NCC190324_NOI Application_20190520

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/20/2019 12:18:23 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 5/20/2019 4:15:43 PM (Review - Construction NOI 11169)
• The task was assigned to Morman, Alaina by round robin distribution 5/20/2019 12:18 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 22, 2019 5:00 PM
5/20/2019 12:18 PM
Submit by Morman, Alaina 5/20/2019 4:16:34 PM (Payment Verification - NCG01-2019-0324)
• The task was assigned to Morman, Alaina. The due date is: May 21, 2019 5:00 PM 5/20/2019 4:15 PM

STME
NORTH CAROLINA
Ernvlronmental Qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Harris Square
2. County* Cabarrus
3. Highway or Street NC Hwy 49 Harrisburg Veterans Road
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Harrisburg
5. State * NC
117-8) TiT 7i) it f 1Ii f_TiI a 10141
6. Zip Code* 28075
7. Latitude * Enter the latitude in decirral degrees
35.3222
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.6485
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* 05/27/2019
Estimated Construction Project Start Date
10. Date to End* 09/30/2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.00
disturbed* (including off -site borrow and waste areas)
13. Total site area
1.20
(acres)*
14. Post-
0.32
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-CABAR-2019-Harris Square
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 Rocky River
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 13-17
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
.....................................................................................................................................................................
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 J.D. Goodrum Company Inc
Name *
2. First Name* Jamie
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Yoxtheimer
ff Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7048958842
Telephone No.*
6. Permittee Mailing Street Address
Address* 18339-F Old Statesville Road
Address Line 2
City
Cornelius
Postal / Zip Code
28031
Check box if the r% Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 18339-F Old Statesville Road
Address Line 2
City
Cornelius
Rastal / Zip Code
28031
State / Province / Region
North Carolina
Country
USA
State / Province / Region
North Carolina
Country
USA

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Government - County
Ownership*
2. Primary Site Daniel
Contact - First
Name *
3. Primary Site Stines
Contact - Last
Name *
4. Title Parks Director
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
7044550726
Telephone No.*
7. Organization
Town of Harrisburg
Name
8. Site Contact
Street Address
Mailing Address*
Post Office Box 100
Address Line 2
aty
Harrisburg
Fbstal / Zip Code
28075
State / Rovince / Region
North Carolina
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/22/2019
Approved *
2. E&SC Plan Project CABAR-2019-081
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 * Mooresville (MRO)
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 HarrisSquareNCDEQApproval.pdf 112.65KB
Approval Mist be PCFfornat
letter/documentation
6. NOI Certification NOI Certification Form -Harris Square.pdf 369.55KB
Form Mist be R7Ffornat
This is an Express f• No
Review Project* r Yes

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*
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
C-11&&411 �Itrxl-r wl-lt
Type Name * Jamie Yoxtheimer
Title President
Organization J.D. Goodrum Company Inc
Date * 05/20/2019

F. Tracking and COC Info
NOI Tracking No. 11169
NC Reference No. NCG01-2019-0324
Uses 'count number variable (incremrented by SP)
Certificate of NCC190324
Coverage (COC) Uses'countnunber'variable (incremrented by SF)
No. *
Count Number 324
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.)