NCC192002_NOI Application_20191001

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/20/2019 9:43:36 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 9/20/2019 3:04:53 PM (Review- Construction NOI 16119)
• The task was assigned to McCoy, Suzanne by round robin distribution 9/20/2019 9:43 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 24, 2019 5:00
PM 9/20/2019 9:43 AM
Submit by McCoy, Suzanne 10/1/2019 8:23:10 AM (Payment Verification for NCC192002)
* Donald Adams.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/1/2019 8:22 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 1, 2019 5:00
PM 9/20/2019 3:05 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Academy Pointe Phases 3 & 4
2. County* Johnston
3. Highway or Street Rosemary Street
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Clayton
5. State * NC
!17-8)aIsT7i)ilf1Iif_T1IIa10141
6. Zip Code* 27520
7. Latitude * Enter the latitude in decirral degrees
35.6577
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-78.4540
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*
09/23/2019
Estimated Construction Project Start Date
10. Date to End*
12/18/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
23.12
disturbed*
(including off -site borrow and waste areas)
13. Total site area 31.50
(acres)*
14. Post- 15.00
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-JOHNS-2019-Academy Pointe Phases 3 & 4
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 Neuse River
Waterbody* Nbrre of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-(38.5)
Index No. * NCWaterbody Index Number
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 Sam's Branch II, LLC
Name *
2. First Name* Reid
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Smith
ff Corporation, enter Registered Agent Last Barre
3b. Title Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-710-3326
Telephone No.*
6. Permittee Mailing Street Address
Address* 114 West Main Street Suite 102
Address Line 2
City State / Province / Region
Clayton NC
Postal / Zip Code Country
27520-2321 us
Check box if the r% Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 114 West Main Street Suite 102
Address Line 2
City
State / Province / Region
Clayton
NC
Rastal / Zip Code
Country
27520-2321
us

C. Site Contact Information
Part C.
Froiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Jon
Contact - First
Name *
3. Primary Site Harrell
Contact - Last
Name *
4. Title Development Manager
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 919-710-3326
Telephone No.*
7. Organization Sam's Branch II, LLC
Name
8. Site Contact Street Address
Mailing Address* 114 West Main Street Suite 102
Address Line 2
city
Clayton
R>stal / Zip Code
27520
9. Consultant Name (optional)
Adams & Hodge Engineering, PC
First and Last name
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 919-243-1332
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 09/13/2019
Approved *
2. E&SC Plan Project JC#19-062-C
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Johnston 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 19-062 Academy Pointe ESC Appr 9.13.19.pdf 505.84KB
Approval Mist be RDFforrrat
letter/documentation
6. NOI Certification SIGNED NCG01.pdf 419.8KB
Form Mist be RDF format
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (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 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* Reid Smith
Title Member
Organization Sam's Branch 11, LLC
Date * 09/20/2019

F. Tracking and COC Info
NOI Tracking No. 16119
NC Reference No. NCG01-2019-2002
Uses 'count number variable (incremrented by SP)
Certificate of NCC192002
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2002
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.)