NCC191127_NOI Application_20190729

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/29/2019 2:45:02 PM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 7/30/2019 7:01:18 AM (Review- Construction NOI 14117)
• The task was assigned to Georgoulias, Bethany by round robin distribution 7/29/2019 2:45 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 31, 2019 5:00 PM
7/29/2019 2:45 PM
Submit by Georgoulias, Bethany 7/30/2019 7:04:33 AM (Payment Verification - NCG01-2019-1127)
• The task was assigned to Georgoulias, Bethany. The due date is: July 31, 2019 5:00 PM
7/30/2019 7:01 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Blackbridge Subdivision Phase Two Lot 14
2. County* Cumberland
3. Highway or Street 4454 Low Oak Court
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* rockfish
5. State * NC
!1i)iTII1T7i)ilFill (-_TiIa1010
6. Zip Code* 28371
7. Latitude * Enter the latitude in decirral degrees
34.9500
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-78.9824
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*
04/04/2019
Estimated Construction Project Start Date
10. Date to End*
10/04/2019
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
0.29
disturbed*
(including off -site borrow and waste areas)
13. Total site area 0.29
(acres)*
14. Post- 3,800.00
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-CUMBE-2019-Blackbridge Subdivision Phase Two Lot 14
Tracking ID Assigned automatically
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 rockfish creek
Wate rbody* Barre of waterbody into which stormwater runoff will discharge
15b. Waterbody 18-31-(18)
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 Caviness Land Development, Inc.
Name *
2. First Name* Watson
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Caviness
ff Corporation, enter Registered Agent Last Barre
3b. Title Owner/Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910.237.0572
Telephone No.*
6. Permittee Mailing Street Address
Address* 1041 Robeson Street
Address Line 2
Suite B
City
Fayetteville
Postal / Zip Code
28305
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
1041 Robeson Street
Address Line 2
Suite B
City
Fayetteville
Postal / Zip Code
28305
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 WATSON
Contact - First
Name *
3. Primary Site Caviness
Contact - Last
Name *
4. Title OWNER/MANAGER
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 910.481.0503
Telephone No.*
7. Organization Caviness Land Development, Inc.
Name
8. Site Contact Street Address
Mailing Address* 639 EXECUTIVE PLACE, SUITE 400
Address Line 2
City
FAYETTEVILLE
Rbstal / Zip Code
28305
State / Province / Region
NC
Country
US

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/04/2019
Approved *
2. E&SC Plan Project CUMBE-2019-126
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 07292019_scan_143236.pdf
Approval Mist be RCFformat
letter/documentation
6. NOI Certification 07292019_scan_144137.pdf
Form Mist be RDF format
This is an Express f• No
Review Project* r Yes
150.81 KB
107.31 KB

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 * WATSON CAVINESS
Title OWNER/MAMAGER
Organization CAVINESS LAND DEVELOPMENT INC
Date * 07/29/2019

F. Tracking and COC Info
NOI Tracking No. 14117
NC Reference No. NCG01-2019-1127
Uses 'count _nunber'variable (increrrented by SP)
Certificate of NCC191127
Coverage (COC) Uses'count_nunber'variable (incremented by SF)
No. *
Count Number 1127
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)