NCC191117_NOI Application_20190729

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/29/2019 2:32:17 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 7/29/2019 3:46:52 PM (Review- Construction NOI 14113)
• The task was assigned to McCoy, Suzanne by round robin distribution 7/29/2019 2:32 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 31, 2019 5:00 PM
7/29/2019 2:32 PM
Submit by McCoy, Suzanne 7/29/2019 3:47:37 PM (Payment Verification - NCG01-2019-1117)
• The task was assigned to McCoy, Suzanne. The due date is: July 30, 2019 5:00 PM
7/29/2019 3:46 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Bittle Creek
2. County* Johnston
3. Highway or Street Buffalo Rd (SR1003)
Address * Street name only is acceptable if no address numtrer assigned yet
4. City or Township* Wilders
5. State * NC
1r-G)a�T7i)ilfaIif_T1IIa10141
6. Zip Code* 27527
7. Latitude * Enter the latitude in decimal degrees
35.6780
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.3606
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*
08/05/2019
Estimated Construction Project Start Date
10. Date to End*
10/31 /2019
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
8.90
disturbed*
(including off -site borrow and waste areas)
13. Total site area 17.98
(acres)*
14. Post- 2.21
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-JOHNS-2019-Bittle Creek
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 Mill Creek
Wate rbody* I\brre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-39
Index No. * NCWaterbody Index Ninber
Stormwater fJ No
discharges will flow r Yes
to additional
wate rs *
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 Saint John's Wood, LLC
Name *
2. First Name* James
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Lipscomb
ff Corporation, enter Registered Agent Last Barre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-422-4704
Telephone No.*
6. Permittee Mailing Street Address
Address* 3407 Barber Mill Rd
Address Line 2
City
Clayton
Postal / Zip Code
27520
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
3407 Barber Mill Rd
Address Line 2
City
Clayton
Rastal / Zip Code
27520
State / Province / Region
nc
Country
usa
State / Province / Region
nc
Country
usa

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site James
Contact - First
Name *
3. Primary Site Lipscomb
Contact - Last
Name *
4. Title Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 919-422-4704
Telephone No.*
7. Organization
Saint John's Wood, LLC
Name
8. Site Contact
Street Address
Mailing Address*
3407 Barber Mill Rd
Address Line 2
City
Clayton
Fbstal / Zip Code
27520
State / Province / Region
nc
Country
usa

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 07/26/2019
Approved *
2. E&SC Plan Project 19-073-P
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Johnston 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 19-073 Bittle Creek ESC Appr 7.26.19.pdf 505.93KB
Approval Mist be RCFformat
letter/documentation
6. NOI Certification BITTLE CREEK- OWNERS SIGNED NCG01
Form 446.49KB
FORM.pdf
Mist be RCF format
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
017aw a, ,adrd�lf
Type Name* James Lipscomb
Title Manager
Organization Saint John's Wood, LLC
Date * 07/29/2019

F. Tracking and COC Info
NOI Tracking No. 14113
NC Reference No. NCG01-2019-1117
Uses 'count number variable (incremrented by SP)
Certificate of NCC191117
Coverage (COC) Uses'count_nunber'variable (incremented by SF)
No. *
Count Number 1117
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in OOCno.)