NCC191685_NOI Application_20190904

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/31/2019 2:08:21 PM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 9/3/2019 7:57:02 AM (Review- Construction NOI 15494)
• The task was assigned to Georgoulias, Bethany by round robin distribution 8/31/2019 2:08 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 4, 2019 5:00
PM. The priority is: High 8/31/2019 2:08 PM
Submit by McCoy, Suzanne 9/4/2019 2:12:34 PM (Payment Verification for NCC191685)
* Jamie Yoxtheimer
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/4/2019 2:12 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 15, 2019 5:00 PM.
The priority is: High 9/3/2019 7:57 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Harrisburg Park - Phase 1
2. County* Cabarrus
3. Highway or Street 191 Sims Parkway
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Harrisburg
5. State * NC
117-8) TiT 7i) ii f 1Ii f_TiI a 10141
6. Zip Code* 28075
7. Latitude * Enter the latitude in decirral degrees
35.3163
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.6598
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* 09/16/2019
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 30.90
disturbed* (including off -site borrow and waste areas)
13. Total site area
63.20
(acres)*
14. Post-
9.69
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-CABAR-2019-Harrisburg Park - Phase 1
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 Back Creek of Rocky River
Wate rbody* Nacre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 13-17-7
Index No. * NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r 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 Town of Harrisburg
Name *
2. First Name* Daniel
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Stines
ff Corporation, enter Registered Agent Last Barre
3b. Title Parks & Recreation Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-455-7275
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 100
Address Line 2
City
Harrisburg
Postal / Zip Code
28075
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r Yes
Street Address
4100 Main Street, Suite 101
Address Line 2
City
Harrisburg
Rastal / Zip Code
28075
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 Government - Municipal
Ownership*
2. Primary Site Jamie
Contact - First
Name *
3. Primary Site Yoxtheimer
Contact - Last
Name *
4. Title Project Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 704-895-8842
Telephone No.*
7. Organization
J.D. Goodrum Company
Name
8. Site Contact
Street Address
Mailing Address*
18339 Old Statesville Road
Address Line 2
Suite F
city
Cornelius
Fbstal/ Zip Code
28031
9. Consultant Name (optional)
First and Last narre
10. Consultant E- This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Province / Pegion
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
........................................................................................................................................................
1. Date E&SC Plan 08/16/2019
Approved *
2. E&SC Plan Project CABAR-2020-010
Number/ID * Assigned by agency or local program
3. E&SC Plan r 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 Harrisburg Park Phase 1 Approval with Modification
Approval 1.54MB
and Performance Rese.... pdf
letter/documentation
Mist be RDF format
6. NOI Certification NCG01-eNO1-Certification-Form-20190801-DEMLR-
Form 353.49KB
SW-SIGNED.pdf
Mist be RDF format
This is an Express r No
Review Project* r Yes
h

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
lt�l��u�17i4'c�c1
Type Name * Daniel Stines
Title Parks & Recreation Director
Organization Town of Harrisburg
Date * 08/31 /2019

F. Tracking and COC Info
NOI Tracking No. 15494
NC Reference No. NCG01-2019-1685
Uses 'count number variable (incremrented by SP)
Certificate of NCC191685
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1685
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.)