NCC200449_NOI Application_20200205

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/4/2020 3:58:54 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 2/5/2020 7:21:08 AM (Review- Construction NOI 21522)
• McCoy, Suzanne reassigned the task to McCoy, Suzanne 2/5/2020 7:04 AM
• The task was assigned to Morman, Alaina by round robin distribution 2/4/2020 3:59 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 6, 2020 5:00
PM 2/4/2020 3:59 PM
Submit by McCoy, Suzanne 2/5/2020 7:21:49 AM (Payment Verification for NCC200449)
* JGNC 11 LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/5/2020 7:21 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 18, 2020 5:00 PM
2/5/2020 7:21 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name *
Pine Forest II
2. County*
Iredell
3. Highway or Street
Amity Hill Rd.
Address *
Street narre only is acceptable if no address number assigned yet
4. City or Township* Statesville
5. State * NC
6. Zip Code * 28677
7. Latitude * Enter the latitude in decimal degrees
35.7399
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.8685
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*
02/10/2020
Estimated Construction Project Start Cate
10. Date to End*
02/10/2021
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Developrrent
12. Acres to be
23.90
disturbed*
(including off -site borrow and waste areas)
13. Total site area 29.36
(acres) *
14. Post- 7.97
construction (Estimated)
impervious area
(acres)*

NCC Project NCC-IREDE-2020-Pine Forest II
Tracking ID Assignedautonatically
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 Duck Creek
Wate rbody* %ne of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-108-20-4-3
Index No. * NCWaterbody Index Minter
Stormwater V 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. ^
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 JGNC II, LLC
Name *
2. First Name* Anita
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Johnson
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* 323 Walnut Street
Address Line 2
City State / Frovince / Region
Statesville North Carolina
Fbstal / Zip Code Country
28667 United States
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
323 Walnut Street
Address Line 2
City
State / Frovince / Fbgion
Statesville
North Carolina
F bstal / Zip Code
Country
28667
United States
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Michael
Contact - First
Name *
2. Primary Site
Johnson
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6. Organization
JGNC II LLC
Name
7. Site Contact
Street Address
Mailing Address*
323 Walnut Street
Address Line 2
city
Statesville
Fbstal / Zip Code
28677
8. Consultant Name
(Optional)
Corin Brown
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
[phone]
Telephone No.
State / Rovince / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 08/27/2019
Approved *
2. E&SC Plan Project STVLE-2020-011
Number/ID * Assigned by agency or local program
3. E&SC Plan
Approved by*
4. Local Program*
f State DEQ Office
r 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 8-27-19 Scan.pdf
Approval Wst be FDFfornat
letter/documentation
85.58KB
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification Signed NCG01.pdf 744.18KB
Form Mast be FDFforrrat
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* Anita R. Johnson
Title Member -Manager
Organization JGNC, LLC
Date * 02/04/2020

F. Tracking and COC Info
NOI Tracking No. 21522
NC Reference No. NCG01-2020-0449
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200449
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 449
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.)