NCC191260_NOI Application_20190814

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/7/2019 10:01:52 AM (NCG01 NOI Submission)
Approve by Clark, Paul 8/7/2019 12:17:16 PM (Review- Construction NOI 14560)
In Please see attached email that provides explanation for why the impervious coverage is greater than
the disturbed acreage.
• The task was assigned to Clark, Paul by round robin distribution 8/7/2019 10:02 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 9, 2019 5:00
PM 8/7/2019 10:02 AM
Submit by McCoy, Suzanne 8/14/2019 9:56:55 AM (Payment Verification for NCC191260)
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/14/2019 9:56 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 21, 2019 5:00 PM
8/7/2019 12:17 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Maple Street/Merritt Street Water Improvemenets
2. County* Surry
117-8) sT.:2,G) M F1Ii (-:To a 10141
3. Highway or Street Maple, Merritt, Pippen, Porter, Willow Streets, & Rawley Avenue
Address * Street narre only is acceptable if no address nurrber assigned yet
4. City or Township * City of Mount Airy
5. State * NC
6. Zip Code* 27030
7. Latitude * Enter the latitude in decirral degrees
36.5044
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.6138
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*
04/30/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
1.04
disturbed*
(including off -site borrow and waste areas)
13. Total site area
30.00
(acres)*
14. Post-
3.50
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SURRY-201 9- Maple Street/Merritt Street Water
Tracking ID
Improvemenets
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 Lovills Creek
Waterbody* Nbrre of waterbody into which stormuater runoff will discharge
15b. Waterbody 12-72-8-(3)
Index No.* NC Waterbody Index Nunter
Stormwater V No
discharges will flow r- 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
.....................................................................................................................................................................
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 City of Mount Airy
Name *
2. First Name* Mitch
ff Corporation, enter Registered Agent First f brre
3. Last Name * Williams, P.E.
ff Corporation, enter Registered Agent Last Barre
3b. Title City Engineer
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-786-3580
Telephone No.*
6. Permittee Mailing Street Address
Address* 440 East Pine Street
Address Line 2
City
Mt Airy
Postal / Zip Code
27030-3845
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
440 East Pine Street
Address Line 2
City
Mt Airy
Postal / Zip Code
27030-3845
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 Government - Municipal
Ownership*
2. Primary Site Mitch
Contact - First
Name *
3. Primary Site Williams
Contact - Last
Name *
4. Title P.E., City Engineer
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
336-786-3580
Telephone No.*
7. Organization
City of Mount Airy
Name
8. Site Contact
Street Address
Mailing Address*
440 East Pine Street
Address Line 2
city
Mount Airy
R>stal / Zip Code
27030
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 06/20/2019
Approved *
2. E&SC Plan Project SURRY-2019-028
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 * Winston-Salem (WSRO)
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 E&S Approval Ltr 6.20.19.pdf 738.77KB
Approval Mist be RCFformat
letter/documentation
6. NOI Certification Signed NCG01 Certification Form.pdf 27.44KB
Form Mist be RJFformat
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 *
Mitch Williams, P.E.,
Title
City Engineer
Organization
The City of Mount Airy
Date *
08/07/2019

F. Tracking and COC Info
NOI Tracking No. 14560
NC Reference No. NCG01-2019-1260
Uses 'count number variable (incremrented by SP)
Certificate of NCC191260
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1260
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.)