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HomeMy WebLinkAboutNCC192033_NOI Application_20191002Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 9/23/2019 9:35:21 AM (NCG01 NOI Submission) Approve by McCoy, Suzanne 9/24/2019 12:59:55 PM (Review- Construction NOI 16164) • The task was assigned to McCoy, Suzanne by round robin distribution 9/23/2019 9:35 AM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 25, 2019 5:00 PM 9/23/2019 9:35 AM Submit by McCoy, Suzanne 10/2/2019 1:22:22 PM (Payment Verification for NCC192033) * Malpass Engineering and Surveying • McCoy, Suzanne assigned the task to McCoy, Suzanne 10/2/2019 1:21 PM • The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 5, 2019 5:00 PM 9/24/2019 1:00 PM 1 r-i) iTiT 7i) it f 1Ii (-_TiI a 10141 NORTH CAROLINA Ernvlronmentol qualily A. Project Information Part A. Project Location and Waterbody Information 1. Project Name * Bridge of Life Community Church 2. County* Brunswick 3. Highway or Street Mercantile Drive NE Address * Street name only is acceptable if no address number assigned yet 4. City or Township * Northwest Township 5. State * NC 6. Zip Code* 28451 7. Latitude * Enter the latitude in decimal degrees 34.2678 8. Longitude * Enter the longitude in decimal degrees (MIST be negative) -78.0589 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* 10/14/2019 Estimated Construction Project Start Date 10. Date to End* 12/31 /2019 Estimated Construction Project End Date 11. SIC (Primary)* Commercial (1542) Standard Industrial aassification for Development 12. Acres to be 5.63 disturbed* (including off -site borrow and waste areas) 13. Total site area 5.56 (acres)* 14. Post- 0.00 construction (Estimated) impervious area (acres) * NCC Project NCC-BRUNS-2019-Bridge of Life Community Church 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. 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 Banton Branch Wate rbody* Barre of waterbody into which stormuater runoff will discharge 15b. Waterbody 18-77-1-1-2 Index No.* NC Waterbody Index Narrber Stormwater W No discharges will flow F 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 Bridge of Life Community Chiurch, Inc. Name * 2. First Name* Jerome ff Corporation, enter Registered Agent First l\b e 3. Last Name * Bullard ff Corporation, enter Registered Agent Last Barre 3b. Title Registered Agent 4. Permitee E-mail jfbull1@gmail.com Address* 5. Permittee 910-540-4902 Telephone No.* 6. Permittee Mailing Street Address Address* P.O. Box217 Address Line 2 City Delco Postal / Zip Code 28436 Check box if the r Yes street address the same as mailing address State / Province / Region NC Country us 7. Permittee Street Street Address Address* 2220 Mercantile Drive Northeast Address Line 2 City State / Province / Region Leland NC Rastal / Zip Code Country 28451-4091 us C. Site Contact Information Part C. Roiect Site Contact Information 1. Type of Non -Government Ownership* 2. Primary Site Jerome Contact - First Name * 3. Primary Site Bullard Contact - Last Name * 4. Title Registered Agent 5. Site Contact E- jfbulll@gmaii.com mail Address* 6. Site Contact 910-540-4902 Telephone No.* 7. Organization Bridge of Life Community Church, Inc. Name 8. Site Contact Street Address Mailing Address* P.O. Box217 Address Line 2 city Delco Rbstal / Zip Code 28436 9. Consultant Name (optional) Jeff Malpass First and Last narre 10. Consultant E- jeffmalpass@bizec.rr.com mail This person will be copied on all correspondence. 11.Consultant 910-392-5243 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 09/17/2019 Approved * 2. E&SC Plan Project BRUNS-2020-017 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 * Wilmington (WiRO) 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 BRUNS-2020-017 Approval 9-17-2019.pdf 280.62KB Approval Mist be R7Ffornat letter/documentation 6. NOI Certification NCG01 Notice of Intent Certification Form.pdf 391.06KB 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 f } GPM"- '�;- Type Name * Jerome F. Bullard Title Registered Agent Organization Bridge of Life Community Church, Inc. Date * 09/23/2019 F. Tracking and COC Info NOI Tracking No. 16164 NC Reference No. NCG01-2019-2033 Uses 'count number variable (incremrented by SP) Certificate of NCC192033 Coverage (COC) Uses 'count _nunber'variable (increrrented bySP) No. * Count Number 2033 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.)