NCC193371_NOI Application_20200113

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/31/2019 11:14:59 AM (NCG01 NOI Submission)
Approve by Clark, Paul 12/31/2019 12:11:47 PM (Review- Construction NOI 20071)
• Georgoulias, Bethany reassigned the task to Clark, Paul 12/31/2019 11:47 AM
• The task was assigned to Garcia, Lauren V by round robin distribution 12/31/2019 11:15 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 2, 2020 5:00
PM 12/31/2019 11:15 AM
Submit by McCoy, Suzanne 1/13/2020 1:27:44 PM (Payment Verification for NCC193371)
* Langtree Village Apartments LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/13/2020 1:27 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 11, 2020 5:00
PM 12/31/2019 12:11 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Langtree Village Apartments
2. County* Iredell
3. Highway or Street 110 Wades Way
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Mooresville
5. State * NC
6. Zip Code * 28117
7. Latitude * Enter the latitude in decimal degrees
35.5347
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.8628
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*
12/18/2019
Estimated Construction Project Start Date
10. Date to End*
10/02/2020
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Other
than SFE (1522)
Standard Industrial Classification for Ceveloprrent
12. Acres to be
21.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
25.00
(acres) *
14. Post-
6.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-IREDE-2019-Langtree Village Apartments
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 Work Creek
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-105
Index No.* NCWaterbody Index N,irrber
Stormwater rJ No
discharges will flow r- Yes
to additional
wate rs *
16a. Is this project r 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 Langtree Village Apartments, LLC
Name *
2. First Name* David
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Jacobs
If Corporation, enter Faegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 791 Greenlawn Drive
Address Line 2
Suite 7
city
Columbia
Fbstal / Zip Code
29209-2641
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
791 Greenlawn Drive
Address Line 2
Suite 7
aty
Columbia
Fbstal / Zip Code
29209-2641
State / Ftovince / Faegion
SC
Country
USA
State / Frovince / Fbgion
SC
Country
USA

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Individual
Ownership *
2. Primary Site
Joseph
Contact - First
Name *
3. Primary Site
Blydenburgh
Contact - Last
Name *
4. Title
Site Foreman
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
[phone]
Telephone No.*
7. Organization
China Construction
Name
8. Site Contact
Street Address
Mailing Address*
110 Wades Way
Address Line 2
City
Mooresville
Fbstal / Zip Code
28117
9. Consultant Name
(Optional)
Ronald George
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
[phone]
Telephone No.
State / Rovince / Fbgion
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/07/2015
Approved *
2. E&SC Plan Project MVLLE-2016-039
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Iredell 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 LOAM Langtree Village Apartments 12-7-15.pdf 70.22KB
Approval LOAM Langtree Village Apartments 12-18-19.pdf 52.05KB
letter/documentation
Mist be R7Ffon-rat
6. NOI Certification NOI Signed Form.pdf 459.86KB
Form Mist be R7Ffon-rat
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
Type Name* David Jacobs
Title Manager
Organization Langtree Village Apartments, LLC
Date * 12/31 /2019

F. Tracking and COC Info
NOI Tracking No. 20071
NC Reference No. NCG01-2019-3371
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193371
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3371
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.)