NCC191613_NOI Application_20190828

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/27/2019 10:57:21 AM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 8/27/2019 11:13:36 AM (Review- Construction NOI 15330)
* Regarding Begin Date: Applicant confirmed that E&SC plan was approved after commencement of
project.
• The task was assigned to Georgoulias, Bethany by round robin distribution 8/27/2019 10:57 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 29, 2019 5:00
PM 8/27/2019 10:57 AM
Submit by McCoy, Suzanne 8/28/2019 8:03:53 AM (Payment Verification for NCC191613)
* Braswell Const.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/28/2019 8:01 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 10, 2019 5:00
PM 8/27/2019 11:13 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Camberly Phase 1 a
2. County* Wake
3. Highway or Street 2209 Pierce Creek Circle
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Wake Forest
5. State * NC
1r-i)iTII1T7G)MFalif_T1IIa10141
6. Zip Code* 27587
7. Latitude * Enter the latitude in decirral degrees
35.9889
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-78.5731
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*
04/30/2019
Estimated Construction Project Start Date
10. Date to End*
04/30/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
1.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.02
(acres)*
14. Post- 0.37
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-WAKE-2019-Camberly Phase 1a
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 Mud Branch
Wate rbody* Barre of waterbody into which stormvwater runoff will discharge
15b. Waterbody 27-17-1-(2)
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 Braswell Custom Homes Inc
Name *
2. First Name* Ronald
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Braswell
Y Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7702861013
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box40159
Address Line 2
City
Raleigh
Postal / Zip Code
27629
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
3908 Blackard Pond Road
Address Line 2
City
Raleigh
Fbstal / Zip Code
27604-9789
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 Matthew
Contact - First
Name *
3. Primary Site Kerul
Contact - Last
Name *
4. Title
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 7702861013
Telephone No.*
7. Organization
Braswell Custom Homes Inc.
Name
8. Site Contact
Street Address
Mailing Address*
P.O. Box40159
Address Line 2
city
Raleigh
Fbstal / Zip Code
27629
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 08/20/2019
Approved *
2. E&SC Plan Project SEC-022915-2019
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Wake 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 Camberly Phase 1 a ESC Approval.pdf 180.57KB
Approval Mist be PCFfornat
letter/documentation
6. NOI Certification CM Phase 1a NOI Certification Form.pdf 258.28KB
Form Mist be RDFfornat
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.
* 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
Type Name* Ronald Braswell
Title President
Organization Braswell Custom Homes Inc.
Date * 08/27/2019

F. Tracking and COC Info
NOI Tracking No. 15330
NC Reference No. NCG01-2019-1613
Uses 'count _nunber'variable (increrrented by SP)
Certificate of NCC191613
Coverage (COC) Uses'count_nunber'variable (incremented by SF)
No. *
Count Number 1613
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.)