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HomeMy WebLinkAboutNCC192304_NOI Application_20191014Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 10/10/2019 5:26:15 PM (NCG01 NOI Submission) Approve by Clark, Paul 10/11/2019 9:03:32 AM (Review- Construction NOI 17058) • The task was assigned to Clark, Paul by round robin distribution 10/10/2019 5:27 PM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 14, 2019 5:00 PM 10/10/2019 5:27 PM Submit by McCoy, Suzanne 10/14/2019 7:58:43 AM (Payment Verification for NCC192304) * Donald A. Moss Jr. • McCoy, Suzanne assigned the task to McCoy, Suzanne 10/14/2019 7:58 AM • The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 22, 2019 5:00 PM 10/11/2019 9:03 AM r-i) iTII1T 7i) M l'11 f_T1II i 10 141 NORTH CAROLINA Ernvlronmentol qualily A. Project Information Part A. Project Location and Waterbody Inforrration 1. Project Name * 187F Lake Rd. 2. County* Camden 3. Highway or Street 187F Lake Rd. Address * Street name only is acceptable if no address nurrtrer assigned yet 4. City or Township* South Mills 5. State * NC 6. Zip Code* 27921 7. Latitude * Enter the latitude in decirral degrees 36.4121 8. Longitude * Enter the longitude in decirral degrees (MUST be negative) -76.2720 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* 10/23/2019 Estimated Construction Project Start Date 10. Date to End* 06/24/2020 Estimated Construction Project End Date 11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521) Standard Industrial aassification for Development 12. Acres to be 2.80 disturbed* (including off -site borrow and waste areas) 13. Total site area 9.14 (acres)* 14. Post- 0.30 construction (Estimated) impervious area (acres) * NCC Project NCC-CAMDE-2019-187F Lake Rd. Tracking ID Assigned autor atically 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 Pasquotank River Waterbody* Nsrre of w'aterbody into which stornwater runoff will discharge 15b. Waterbody 30-3-(1) Index No. * NCWaterbody Index Nunber 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 Donald A. & B. Marie Moss Name * 2. First Name* Donald ff Corporation, enter Registered Agent First l\brre 3. Last Name * Moss ff Corporation, enter Registered Agent Last Barre 3b. Title Owner 4. Permitee E-mail dmossecnc@gmail.com Address* 5. Permittee 252-340-4636 Telephone No.* 6. Permittee Mailing Street Address Address* 475 Sawmill Rd Address Line 2 City State / Province / Region Elizabeth City NC Rastal / Zip Code Country 27909 United States Check box if the r% Yes street address the same as mailing address 7. Permittee Street Street Address Address* 475 Sawmill Rd Address Line 2 City State / Province / Region Elizabeth City NC Rastal / Zip Code Country 27909 United States C. Site Contact Information Part C. Roiect Site Contact hforrration 1. Type of Individual Ownership* 2. Primary Site Donald Contact - First Name * 3. Primary Site Moss Contact - Last Name * 4. Title 5. Site Contact E- dmossecnc@gmail.com mail Address* 6. Site Contact 252-340-4636 Telephone No.* 7. Organization Name 8. Site Contact Street Address Mailing Address* 475 Sawmill Rd Address Line 2 city Elizabeth City Fbstal / Zip Code 27909 9. Consultant Name (optional) Kimberly Hamby First and Last narre 10. Consultant E- kim.hamby@timmons.com mail This person will be copied on all correspondence. 11. Consultant 252.621.5029 Telephone No. State / Province / Pegion NC Country United States D. E&SC Plan Part D. Erosion & Sediment Control (E&SC) Ran Approval Information ............................................................................................................................................................. 1. Date E&SC Plan 10/04/2019 Approved * 2. E&SC Plan Project Camde-2020-002 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 * Washington (WaRO) 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 Camde-2020-002 Residence for Donald and Marie Approval 1.17MB Moss - 10042019.pdf letter/documentation Mist be RDF format 6. NOI Certification NOI - Moss Residence.pdf 1.09MB Form Mist be RDFforrrat This is an Express F 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 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 �iatrtr31r1 CA Type Name * Donald A Moss Jr Title Owner Organization Donald & B. Marie Moss Date * 10/10/2019 F. Tracking and COC Info NOI Tracking No. 17058 NC Reference No. NCG01-2019-2304 Uses 'count number variable (incremrented by SP) Certificate of NCC192304 Coverage (COC) Uses 'count nunber variable (increrrentedbySP) No. * Count Number 2304 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.)