NCC192296_NOI Application_20191011

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/10/2019 12:49:05 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 10/10/2019 3:29:01 PM (Review- Construction NOI 17006)
• The task was assigned to McCoy, Suzanne by round robin distribution 10/10/2019 12:49 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 14, 2019 5:00
PM 10/10/2019 12:49 PM
Submit by McCoy, Suzanne 10/11/2019 7:59:36 AM (Payment Verification for NCC192296)
* Mary Ann Siemienik
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/11/2019 7:59 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 21, 2019 5:00
PM 10/10/2019 3:29 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Chapel Ridge Lot 185
2. County* Chatham
3. Highway or Street 343 High Ridge Lane
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Pittsboro
5. State * NC
!17-8)aIsT7i)ilf1Iif_T1IIa10141
6. Zip Code* 27312
7. Latitude * Enter the latitude in decimal degrees
35.7880
8. Longitude * Enter the longitude in decimal degrees (MIST be negative)
-79.2149
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*
10/12/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
0.42
disturbed*
(including off -site borrow and waste areas)
13. Total site area 0.53
(acres)*
14. Post- 0.14
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-CHATH-2019-Chapel Ridge Lot 185
Tracking ID Assignedautorratically
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 DRY CREEK
Waterbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-34-(0.7)
Index No. * NC Waterbody Index Ninber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional HAW RIVER
Receiving Waterbody nacre
Waterbody
15d. Waterbody 16-(28.5)
Index No. NCWaterbody Index Pbnber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Narrber
Index No.
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.
P rrrittee 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 20/20 SITE DEVELOPMENT CO., INC.
Name *
2. First Name* THOMAS
ff Corporation, enter Registered Agent First NBrre
3. Last Name * SIEMIENIK
Y Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-338-4072
Telephone No.*
6. Permittee Mailing Street Address
Address* 1204 Village Market Place
Address Line 2
Suite #275
City
Morrisville
Postal / Zip Code
27560-7508
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
1204 Village Market Place
Address Line 2
Suite #275
City
Morrisville
Postal / Zip Code
27560-7508
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us

C. Site Contact Information
Part C.
Froiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site THOMAS
Contact - First
Name *
3. Primary Site SIEMIENIK
Contact - Last
Name *
4. Title President
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
9193384072
Telephone No.*
7. Organization
20/20 SITE DEVELOPMENT CO., INC.
Name
8. Site Contact
Street Address
Mailing Address*
1204 Village Market Place
Address Line 2
Suite 275
City
State / Province / Fbgion
Morrisville
NC
Fbstal / Zip Code
Country
27560-7508
us
9. Consultant Name (optional)
Charles Odell Eliason, PLS - 3599, Land Services
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 9192008376
Telephone No.

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 10/01/2019
Approved *
2. E&SC Plan Project 2019-08027
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Chatham 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 Project Number 2019-080271-etter of Approval.pdf 90.29KB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification NCG01 NOTICE OF INTENT NOI CERTIFICATION
Form 606.5KB
FORM.pdf
Mist be RCF 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* Thomas R. Siemienik
Title President
Organization 20/20 Site Development Co., Inc.
Date * 10/10/2019

F. Tracking and COC Info
NOI Tracking No. 17006
NC Reference No. NCG01-2019-2296
Uses 'count number variable (incremrented by SP)
Certificate of NCC192296
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2296
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.)