NCC200193_NOI Application_20200123

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/15/2020 3:12:32 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 1/16/2020 9:31:55 AM (Review- Construction NOI 20740)
• The task was assigned to McCoy, Suzanne by round robin distribution 1/15/2020 3:13 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 17, 2020 5:00
PM 1/15/2020 3:13 PM
Submit by McCoy, Suzanne 1/23/2020 7:36:49 AM (Payment Verification for NCC200193)
* Drive-in Properties Inc.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/23/2020 7:36 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 27, 2020 5:00
PM 1/16/2020 9:32 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Drive -In Properties
2. County* Surry
3. Highway or Street Hwy 67
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Jonesville
5. State * NC
6. Zip Code * 28642
7. Latitude * Enter the latitude in decimal degrees
36.2394
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-80.8283
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*
01/16/2020
Estimated Construction Project Start Date
10. Date to End*
12/31/2022
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
14.20
disturbed*
(including off -site borrow and waste areas)
13. Total site area
25.00
(acres) *
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SURRY-2020-Drive-In Properties
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 Sandyberry Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-55
Index No.* NCWaterbody Index N nber
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. ^
Flarnittee 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 Drive -In Properties, LLC
Name *
2. First Name* James W.
If Corporation, enter Pegistered Agent First Barre
3. Last Name* Partin
If Corporation, enter Faegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-835-0100
Telephone No.*
6. Permittee Mailing Street Address
Address* 210 W. Main St.
Address Line 2
210 W. Main St.
City State / Frovince / Faegion
Elkin NC
Fbstal / Zip Code Country
28621 United States
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 210 W. Main St.
Address Line 2
210 W. Main St.
City
State / Frovince / Fbgion
Elkin
NC
Fbstal / Zip Code
Country
28621
United States

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
James W.
Contact - First
Name *
3. Primary Site
Partin
Contact - Last
Name *
4. Title
Manager/Owner
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
336-835-0100
Telephone No.*
7. Organization
Drive -In Properties, LLC
Name
8. Site Contact
Street Address
Mailing Address*
210 W. Main St.
Address Line 2
City
Elkin
Fbstal / Zip Code
28621
9. Consultant Name
(Optional)
M. Devin Staley, PE
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11.Consultant
336-838-2500
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 01/14/2020
Approved *
2. E&SC Plan Project YADKI-2020-007
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 * Winston-Salem (WSRO)
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 NCDENR Permit 2020-01-15.pdf 7.1 MB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification Notice of Intent Certification Executed.pdf 71.06KB
Form Mist be RDFfornat
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 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 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 *
Jack Partin
Title
Manager
Organization
Drive -In Properties, LLC
Date *
01 /15/2020

F. Tracking and COC Info
NOI Tracking No. 20740
NC Reference No. NCG01-2020-0193
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200193
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 193
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.)