NCC191381_NOI Application_20190815

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/14/2019 3:19:56 PM (NCG01 NOI Submission)
Approve by Lucas, Annette 8/14/2019 4:22:09 PM (Review- Construction NOI 14863)
In Note that the NOI Certification Form was emailed, the applicant inadvertently uploaded the E&SC Plan
approval twice.
• The task was assigned to Lucas, Annette by round robin distribution 8/14/2019 3:20 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 16, 2019 5:00
PM. The priority is: High 8/14/2019 3:20 PM
Submit by McCoy, Suzanne 8/15/2019 10:36:49 AM (Payment Verification for NCC191381)
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/15/2019 10:36 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 28, 2019 5:00 PM.
The priority is: High 8/14/2019 4:22 PM

117-8) sT.:2,G) M 1-11 f_TiI a 10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Charlotte Fire Station #43
2. County* Mecklenburg
3. Highway or Street 421 Clanton Road
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Charlotte
5. State * NC
6. Zip Code* 28219
7. Latitude * Enter the latitude in decirral degrees
35.1960
8. Longitude * Enter the longitude in decirral degrees (WISTbe negative)
-80.8780
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* 08/16/2019
Estimated Construction Project Start Date
10. Date to End* 06/30/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 2.25
disturbed* (including off -site borrow and waste areas)
13. Total site area
2.25
(acres)*
14. Post-
2.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-MECKL-2019-Charlotte Fire Station #43
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 irwin creek
Waterbody * Nhrre of waterbody into which stormuater runoff will discharge
15b. Waterbody 11-137-1
Index No. * NCWaterbody Index Nanber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs *
15c. Additional Little Sugar Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody NCWaterbody Index Nanber
Index No.
15e. Additional Dairy Branch
Receiving Waterbody narre
Waterbody
15f. Waterbody NCWaterbody Index Nunter
Index No.
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 Southside Constructors, Inc.
Name *
2. First Name* Darryl
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Kellough
Y Corporation, enter Registered Agent Last Barre
3b. Title Principal
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7049136355
Telephone No.*
6. Permittee Mailing Street Address
Address* [e-mail]
Address Line 2
PO Box 09011
City State / Province / Region
Charlotte North Carolina
Pastal / Zip Code Country
28219 United States
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 11319 Granite Street - D
Address Line 2
City State / Province / Region
Charlotte NC
Pastal / Zip Code Country
28273 US

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Government - Municipal
Ownership*
2. Primary Site Matt
Contact - First
Name *
3. Primary Site Sullivan
Contact - Last
Name *
4. Title Superintendent
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 7042526922
Telephone No.*
7. Organization
Southside Constructors, Inc.
Name
8. Site Contact
Street Address
Mailing Address*
PO Box09011
Address Line 2
aty
Charlotte
Fbstal / Zip Code
28219
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 08/13/2019
Approved *
2. E&SC Plan Project MECKL-2020-017
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 * Mooresville (MRO)
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 NCErosion Control Approval ashx.pdf 2.17MB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification NCErosion Control Approval ashx.pdf 2.17MB
Form Mist be RDF format
This is an Express r 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
d,- c oo
Type Name * Darryl E. Kellough
Title Principal
Organization Southside Constructors, Inc.
Date * 08/14/2019

F. Tracking and COC Info
NOI Tracking No. 14863
NC Reference No. NCG01-2019-1381
Uses 'count number variable (incremrented by SP)
Certificate of NCC191381
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1381
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.)