NCC192758_NOI Application_20191114

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/13/2019 10:36:07 AM (NCG01 NOI Submission)
Approve by Clark, Paul 11/13/2019 11:12:05 AM (Review- Construction NOI 18379)
• Georgoulias, Bethany reassigned the task to Clark, Paul 11/13/2019 10:56 AM
. The task was assigned to Garcia, Lauren V by round robin distribution 11/13/2019 10:36 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 15, 2019 5:00
PM 11/13/2019 10:36 AM
Submit by McCoy, Suzanne 11/14/2019 2:26:12 PM (Payment Verification for NCC192758)
* City of Sanford
• McCoy, Suzanne assigned the task to McCoy, Suzanne 11/14/2019 2:25 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 25, 2019 5:00
PM 11/13/2019 11:12 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Tabitha Lane
2. County* Lee
3. Highway or Street Tabitha Lane
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* West Sanford Township
5. State * NC
6. Zip Code * 27330
7. Latitude * Enter the latitude in decimal degrees
35.5420
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-79.1600
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*
11/13/2019
Estimated Construction Project Start Date
10. Date to End*
12/17/2019
Estimated Construction Project End Cute
11. SIC (Primary)*
Industrial (1541)
Standard Industrial aassification for Developrrent
12. Acres to be
17.20
disturbed*
(including off -site borrow and waste areas)
13. Total site area
77.72
(acres) *
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-LEE-2019-Tabitha Lane
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 unnamed tributary to Gum Fork
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 18-4-7-2
Index No.* NCWaterbody Index Number
Stormwater V 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. ^
Fternittee Inforrration - Legally Fbsponsible Entity and Individual
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 city of sanford
Name *
2. First Name* Hal
If Corporation, enter Pegistered Agent First Barre
3. Last Name* Hegwer
If Corporation, enter Faegistered Agent Last %rre
3b. Title City Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-777-1110
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box3729
Address Line 2
225 E. Weatherspoon
city
Sanford
Fbstal / Zip Code
27330
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
P.O. Box 3729
Address Line 2
225 E. Weatherspoon
Cty
Sanford
Fbstal / Zip Code
27330
State / Ftovince / Region
NC
Country
USA
State / Frovince / Fbgion
NC
Country
USA

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
_..................................................................................................................................................................
1. Type of
Government - County
Ownership *
2. Primary Site
John
Contact - First
Name *
3. Primary Site
Crumpton
Contact - Last
Name *
4. Title
County Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919-718-4605
Telephone No.*
7. Organization
Lee County
Name
8. Site Contact
Street Address
Mailing Address*
408 Summitt Drive
Address Line 2
City
Sanford
Flostal / Zip Code
27330-3840
9. Consultant Name
(Optional)
Jason Bertoncino
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11.Consultant
919-469-3340
Telephone No.
State / Rovince / Fbgion
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/18/2019
Approved *
2. E&SC Plan Project Lee-2020-011
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Raleigh (RRO)
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 LEE-2020-011 LOA 20191018 revised.pdf 58.03KB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification NOI certification form - executed.pdf 460.56KB
Form Mist be R7Fforrrat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
* 17 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
f 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 *
Hal Hegwer
Title
City Manager
Organization
city of sanford
Date *
11 /13/2019

F. Tracking and COC Info
NOI Tracking No. 18379
NC Reference No. NCG01-2019-2758
Uses 'count number' variable (incremrented by SP)
Certificate of NCC192758
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2758
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)