NCC191007_NOI Application_20190718

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 7/18/2019 8:50:56 AM(NCG01 NOI Submission)
Approve by Morman,Alaina 7/19/2019 12:52:07 PM(Review-Construction NOI 13601)
• The task was assigned to Morman,Alaina by round robin distribution 7/18/2019 8:51 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 22,2019 5:00 PM
7/18/2019 8:51 AM
Submit by Morman,Alaina 7/19/2019 12:56:17 PM(Payment Verification-NCG01-2019-1007)
• The task was assigned to Morman,Alaina.The due date is:July 22,2019 5:00 PM
7/19/2019 12:52 PM

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A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Fayetteville Annexation Ph V Construction Project IX Area 23 Wells
Place Subd
2.County* Cumberland
3. Highway or Street Wells Place Subdivision
Address* Street narre only is acceptable if no address nun-ber assigned yet
4. City or Township* Fayetteville
5. State* NC
6.Zip Code* 28304
7. Latitude* Enter the latitude in decimal degrees
35.0322
8. Longitude* Enter the longitude in decirral degrees(MJST be negative)
-79.0104
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* 10/01/2019
Estimated Construction Project Start Date
10. Date to End* 11/01/2020
Estimated Construction Project End Date
11. SIC(Primary)* Other(0000)
Standard Industrial Classification for Developrrent
12.Acres to be 7.78
disturbed* (including off-site borrow and waste areas)
13.Total site area 138.00
(acres)*
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*

NCC Project NCC-CUMBE-2019-Fayetteville Annexation Ph V Construction
Tracking ID Project IXArea 23 Wells Place Subd
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 Little Rockfish Creek
Waterbody* Narre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 18-31-24-(3)
Index No.* NC Waterbody Index Ninber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs*
15c.Additional Beaver Creek(Beaver Creek Pond)
Receiving Waterbody narra
Waterbody
15d.Waterbody 18-31-24-5
Index No. NCWaterbody Index Narrber
15e.Additional Waterbody nacre
Receiving
Waterbody
15f.Waterbody NCWaterbody Index Ninber
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
.....................................................................................................................................................................
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 City of Fayetteville Pubic Works Commission
Name*
2. First Name* Joseph
ff Corporation,enter Registered Agent First l\brre
3. Last Name* Glass
ff Corporation,enter Registered Agent Last Barre
3b.Title Engineer Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-223-4740
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 1089
Address Line 2
City State/Province/Region
Fayetteville NC
Postal/Zip Code Country
28301 us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 955 Old Wilmington Road
Address Line 2
City State/Province/Region
Fayetteville NC
Postal/Zip Code Country
28301 US

C. Site Contact Information
Part C.
Project Site Contact Information
...............................................................................................
1.Type of Government- Municipal
Ownership*
2. Primary Site Misty
Contact-First
Name*
3.Primary Site Manning
Contact-Last
Name*
4.Title Engineer II
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 910-223-4736
Telephone No.*
7.Organization Fayetteville Public Works Commission
Name
8.Site Contact Street Address
Mailing Address* 955 Old Wilmington Road
Address Line 2
Oty State/Province/Region
Fayetteville NC
Fbstal/Zip Code Country
28301 us

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 06/27/2019
Approved*
2. E&SC Plan Project CUMBE-2019-174
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 cumbe-2019-174.pdf 81.9KB
Approval Mist be FDFforrrat
letter/documentation
6. NOI Certification NOI.pdf 357.29KB
Form Mist be RJFforrrat
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
[r 116 ( cl
Type Name* Joseph Glass
Title Engineer Manager
Organization Fayetteville Public Works Commission
Date* 07/18/2019

F. Tracking and COC Info
NOI Tracking No. 13601
NC Reference No. NCG01-2019-1007
Uses'count number variable(incremented by SP)
Certificate of NCC191007
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 1007
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.)