NCC200064_NOI Application_20200107

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/6/2020 4:26:59 PM (NCG01 NOI Submission)
Approve by Clark, Paul 1/7/2020 8:29:24 AM (Review- Construction NOI 20266)
• The task was assigned to Clark, Paul by round robin distribution 1/6/2020 4:27 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 8, 2020 5:00
PM 1/6/2020 4:27 PM
Submit by McCoy, Suzanne 1/7/2020 11:29:26 AM (Payment Verification for NCC200064)
* Jack Sipe Const.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/7/2020 11:28 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 18, 2020 5:00
PM 1/7/2020 8:29 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Greater Shekinah Glory Church
2. County* Catawba
3. Highway or Street 3741 Section House Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Hickory
5. State * NC
6. Zip Code * 28601
7. Latitude * Enter the latitude in decirral degrees
35.7360
8. Longitude* Enter the longitude in decir al degrees (M. ST be negative)
-81.2480
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*
11/11/2019
Estinated Construction Project Start Date
10. Date to End*
06/30/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Other
than SFE (1522)
Standard Industrial aassification for Ceveloprrent
12. Acres to be
3.21
disturbed*
(including off -site borrow and waste areas)
13. Total site area
25.48
(acres) *
14. Post-
1.77
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-CATAW-2019-Greater Shekinah Glory Church
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 Herman Branch
Wate rbody* Narre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 11-76-1
Index No.* NCWaterbody Index Nirrber
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 Greater Shekinah Glory Ministries
Name *
2. First Name* Kathy
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Johnson
If Corporation, enter Faegistered Agent Last %rre
3b. Title Pastor
4. Permitee E-mail [e-mail]
Address *
5. Permittee 828-381-7130
Telephone No.*
6. Permittee Mailing Street Address
Address* 3066 South Highway 127
Address Line 2
city
Hickory
Fbstal / Zip Code
28602-5404
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
3066 South Highway 127
Address Line 2
Cty
Hickory
F bstal / Zip Code
28602-5404
State / Frovince / Faegion
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Gary
Contact - First
Name *
3. Primary Site
Pierce
Contact - Last
Name *
4. Title
General Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
828-244-1558
Telephone No.*
7. Organization
Jack Sipe Construction Company
Name
8. Site Contact
Street Address
Mailing Address*
P.O. Box2576
Address Line 2
City
Hickory
Fbstal / Zip Code
28603
9. Consultant Name
(Optional)
First and Last narre
10. Consultant E-
This person will be copied on all correspondence.
mail
11. Consultant
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 06/06/2019
Approved *
2. E&SC Plan Project CBPR-05-2019-31929
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Catawba 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 Greater Shekinah Glory Church approve with
Approval 68.42KB
modifications June 6 2019 with acres (002).pdf
letter/documentation
Mist be R7Fforrrat
6. NOI Certification NOI Certification Form GSG.pdf 743.16KB
Form Mist be R7Ffornat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle 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 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.
* 17 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
[�it��rf ,� �?IclrfrJcir
Type Name* Kathy B. Johnson
Title Pastor
Organization Greater Shekinah Glory Ministries
Date * 01 /06/2020

F. Tracking and COC Info
NOI Tracking No. 20266
NC Reference No. NCG01-2020-0064
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200064
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 64
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)