NCC191904_NOI Application_20190918

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/16/2019 10:24:47 AM (NCG01 NOI Submission)
Approve by Clark, Paul 9/16/2019 10:57:06 AM (Review- Construction NOI 15931)
• The task was assigned to Clark, Paul by round robin distribution 9/16/2019 10:25 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 18, 2019 5:00
PM 9/16/2019 10:25 AM
Submit by McCoy, Suzanne 9/18/2019 8:00:33 AM (Payment Verification for NCC191904)
* Linwood Reynolds.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/18/2019 8:00 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 28, 2019 5:00 PM
9/16/2019 10:57 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Sampson County Water Main Extension
2. County* Sampson
3. Highway or Street Bullard Pit Circle
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township * Dismal Township
5. State * NC
117-8) TiT 7i) it f 1Ii f_T1II a 10141
6. Zip Code* 28318
7. Latitude * Enter the latitude in decirral degrees
35.0995
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-78.6284
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*
02/01 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
4.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
4.00
(acres)*
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SAMPS-2019-Sampson County Water Main Extension
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. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving South River
Waterbody* Nbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-68-12-(0.5)
Index No. * NCWaterbody Index Water
Stormwater rJ 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 Sampson County
Name *
2. First Name* Linwood
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Reynolds
ff Corporation, enter Registered Agent Last Barre
3b. Title Public Works Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-592-0188
Telephone No.*
6. Permittee Mailing Street Address
Address* 827 Southeast Blvd
Address Line 2
City
Clinton
Postal / Zip Code
28328-4321
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
827 Southeast Blvd
Address Line 2
City
Clinton
Fbstal / Zip Code
28328-4321
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Government - County
Ownership*
2. Primary Site Linwood
Contact - First
Name *
3. Primary Site Reynolds
Contact - Last
Name *
4. Title Public Works Director
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 910-592-0188
Telephone No.*
7. Organization
Sampson County
Name
8. Site Contact
Street Address
Mailing Address*
827 Southeast Boulevard
Address Line 2
aty
Clinton
Pbstal/ Zip Code
28328-4321
9. Consultant Name (optional)
Matthew West
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 919-424-3770
Telephone No.
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 08/22/2019
Approved *
2. E&SC Plan Project SAMPS-2019-009
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 samps2019009apMod Rev. pdf 78.03KB
Approval Mist be RDFfornat
letter/documentation
6. NOI Certification NCG)! Form.pdf 45.28KB
Form Mist be RDFfornat
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 electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *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 * LINWOOD REYNOLDS
Title PUBLIC WORKS DIRECTOR
Organization SAMPSON COUNTY PUBLIC WORKS
Date * 09/16/2019

F. Tracking and COC Info
NOI Tracking No. 15931
NC Reference No. NCG01-2019-1904
Uses 'count number variable (incremented by SP)
Certificate of NCC191904
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1904
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.)