HomeMy WebLinkAboutNCC191056_NOI Application_20190724 Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 7/24/2019 10:44:41 AM(NCG01 NOI Submission)
Approve by Clark, Paul 7/24/2019 3:30:15 PM(Review-Construction NOI 13871)
• The task was assigned to Clark, Paul by round robin distribution 7/24/2019 10:44 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 26,2019 5:00 PM
7/24/2019 10:44 AM
Submit by Clark, Paul 7/24/2019 3:47:41 PM(Payment Verification-NCG01-2019-1056)
• The task was assigned to Clark, Paul.The due date is: July 25, 2019 5:00 PM 7/24/2019 3:30 PM
1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Ernvlronmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Holt Road to Davis Drive Water Line Connection Project
2. County* Wake
3. Highway or Street Linear Project, Multiple Roads
Address* Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* cary
5. State* INC
6.Zip Code* 27512
7. Latitude* Enter the latitude in decirral degrees
35.7657
8. Longitude* Enter the longitude in decirral degrees(MJSTbe negative)
-78.8498
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* 09/02/2019
Estimated Construction Project Start Date
10. Date to End* 07/01/2021
Estimated Construction Project End Date
11. SIC(Primary)* Other(0000)
Standard Industrial aassification for Developrrent
12.Acres to be 3.00
disturbed* (including off-site borrow and waste areas)
13.Total site area 3.00
(acres)*
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-WAKE-2019-Holt Road to Davis Drive Water Line Connection
Tracking ID Project
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 White Oak Creek
Waterbody* Nbrre of waterbody into which stormuater runoff will discharge
15b.Waterbody 16-41-6-(0.3)
Index No.* NC Waterbody Index Narrber
Stormwater No
discharges will flow Yes
to additional
wate rs*
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 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 Town of Cary
Name*
2. First Name* Glen
ff Corporation,enter Registered Agent First l\b e
3. Last Name* Harrell
Y Corporation,enter Registered Agent Last Barre
3b.Title Utilities Engineering Manager
4. Permitee E-mail brian.drake@townofcary.org
Address*
5. Permittee 919-462-3836
Telephone No.*
6. Permittee Mailing Street Address
Address* 316 North Academy Street
Address Line 2
City State/Province/Region
Cary NC
Postal/Zip Code Country
27513-4538 US
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* PO Box8005
Address Line 2
City State/Province/Region
Cary NC
Pastal/Zip Code Country
27512 United States
C. Site Contact Information
Part C.
Project Site Contact Information
...............................................................................................
1.Type of Government- Municipal
Ownership*
2. Primary Site Brian
Contact-First
Name*
3.Primary Site Drake
Contact-Last
Name*
4.Title
5.Site Contact E- Brian.Drake@TownofCary.org
mail Address*
6.Site Contact 919-462-3836
Telephone No.*
7.Organization Town of Cary
Name
8.Site Contact Street Address
Mailing Address* 316 North Academy Street
Address Line 2
City State/Province/Region
Cary NC
Rbstal/Zip Code Country
27513-4538 us
D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 07/11/2019
Approved*
2. E&SC Plan Project WAKE-2019-094
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* Raleigh (RRO)
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 WAKE-2019-094 LOA 20190711 revised.pdf 58.49KB
Approval Certificate of Approval.pdf 118.92KB
letter/documentation
Mist be RJF forrrat
6. NOI Certification NCG01-eNOI-Certification-Form-20190507-DEMLR-
Form 79.82KB
TOC.pdf
MAst be RDFforrrat
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
Type Name* Glen Harrell
Title Utilities Engineering Manager
Organization Town of Cary
Date* 07/24/2019
F. Tracking and COC Info
NOI Tracking No. 13871
NC Reference No. NCG01-2019-1056
Uses'count number variable(incremented by SP)
Certificate of NCC191056
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 1056
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.)