NCC192014_NOI Application_20190926

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/23/2019 9:29:35 AM (NCG01 NOI Submission)
Approve by Clark, Paul 9/23/2019 1:49:43 PM (Review- Construction NOI 16163)
• The task was assigned to Clark, Paul by round robin distribution 9/23/2019 9:30 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 25, 2019 5:00
PM 9/23/2019 9:30 AM
Submit by McCoy, Suzanne 9/26/2019 1:29:53 PM (Payment Verification for NCC192014)
* Ashe county board of Education.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/26/2019 1:29 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 4, 2019 5:00
PM 9/23/2019 1:49 PM

1 r-i) iTiT 7i) M fiIi (-:To a 10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Ashe County Middle School
2. County* Ashe
3. Highway or Street AEV Lane
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Jefferson
5. State * NC
6. Zip Code* 28640
7. Latitude * Enter the latitude in decirral degrees
36.4250
8. Longitude * Enter the longitude in decirral degrees (MUST be negative)
-81.4805
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*
09/25/2019
Estimated Construction Project Start Date
10. Date to End*
05/15/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
40.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
40.00
(acres)*
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-ASHE-2019-Ashe County Middle School
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 Naked Creek
Waterbody* Nbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 10-1-32
Index No. * NCWaterbody Index Narrber
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 Ashe County Board of Education
Name *
2. First Name* Phyllis
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Yates
ff Corporation, enter Registered Agent Last Barre
3b. Title Superintendent
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-246-7175
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box604
Address Line 2
City
Jefferson
Postal / Zip Code
28640
Check box if the r Yes
street address the
same as mailing
address
State / Province / Region
NC
Country
USA
7. Permittee Street Street Address
Address* 320 South Street
Address Line 2
City
State / Province / Region
Jefferson
NC
Postal / Zip Code
Country
28640
US

C. Site Contact Information
Part C.
Proiect Site Contact hforrration
1. Type of Government - County
Ownership*
2. Primary Site Jerry
Contact - First
Name *
3. Primary Site Baker
Contact - Last
Name *
4. Title Director of Maintenance
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 336-977-0987
Telephone No.*
7. Organization Ashe County Schools
Name
8. Site Contact Street Address
Mailing Address* PO Box604
Address Line 2
city
Jefferson
Pbstal / Zip Code
28640
9. Consultant Name (optional)
Jason T. Herman, PE, PLS
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11.Consultant 336-846-3352
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 08/20/2019
Approved *
2. E&SC Plan Project ASHE-2020-001
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 ASHE-2020-001_8-20-19_Approval w Perf Res.pdf 320.06KB
Approval Mast be FDFfornat
letter/documentation
6. NOI Certification NCG01_Ashe County_middle school project.pdf 2.52MB
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 *
Phyllis Yates
Title
Superintendent
Organization
Ashe County Board of Education
Date *
09/23/2019

F. Tracking and COC Info
NOI Tracking No. 16163
NC Reference No. NCG01-2019-2014
Uses 'count number variable (incremrented by SP)
Certificate of NCC192014
Coverage (COC) Uses'countnunber'variable (incremrented by SF)
No. *
Count Number 2014
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.)