NCC200674_NOI Application_20200220

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/19/2020 12:34:43 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 2/19/2020 1:41:59 PM (Review- Construction NOI 22136)
• The task was assigned to Garcia, Lauren V by round robin distribution 2/19/2020 12:34 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 21, 2020 5:00
PM 2/19/2020 12:34 PM
Submit by McCoy, Suzanne 2/20/2020 6:52:13 AM (Payment Verification for NCC200674)
* Michelle Jackson
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/20/2020 6:51 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 1, 2020 5:00 PM
2/19/2020 1:42 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Longleaf Club Cottages Phase 2
2. County* Moore
3. Highway or Street 32 North Knoll Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Southern Pines
5. State * NC
6. Zip Code * 28387
7. Latitude * Enter the latitude in decirral degrees
35.2065
8. Longitude* Enter the longitude in decinal degrees (M. ST be negative)
-79.4183
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*
02/24/2020
Estinated Construction Project Start Date
10. Date to End*
12/24/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
0.96
disturbed*
(including off -site borrow and waste areas)
13. Total site area
2.00
(acres) *
14. Post-
0.74
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-MOORE-2020-Longleaf Club Cottages Phase 2
Tracking ID
Assignedautorratically

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 Mill Creek
Wate rbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-23-11-(1)
Index No.* NCWaterbody Index Ninber
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. ^
F2rnittee 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 R&M Commercial Real Estate, LLC
Name *
2. First Name* Ron
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Jackson
If Corporation, enter Faegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 910-944-7453
Telephone No.*
6. Permittee Mailing Street Address
Address* 335 Fields Drive
Address Line 2
city
State / Frovince / Faegion
Aberdeen
NC
Fbstal / Zip Code
Country
28315-8611
us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
335 Fields Drive
Address Line 2
ory
State / Frovince / Fbgion
Aberdeen
NC
Fbstal / Zip Code
Country
28315-8611
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Ron
Contact - First
Name *
2. Primary Site
Jackson
Contact - Last
Name *
3. Title
Manager
4. Site Contact E-
qualitybuilt1 @hotmail.com
mail Address*
5. Site Contact
910-944-7453
Telephone No.*
6. Organization
R&M Commercial Real Estate, LLC
Name
7. Site Contact
Street Address
Mailing Address*
335 Fields Drive
Address Line 2
City
State / Rovince / Region
Aberdeen
NC
Fbstal / Zip Code
Country
28315-8611
us
8. Consultant Name
(Optional)
Crawford Design Company - Kevin Lindsay
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
910-725-1107
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/31/2019
Approved *
2. E&SC Plan Project ZP-09-18
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Tovvn of Southern Pines
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project.
5. E&SC Plan Letter of Approval.pdf
Approval Wst be FDFfornat
letter/documentation
553.08KB
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NOI Signed 02.19.2020.pdf 83.1KB
Form Mast be FDFfon-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* Ron Jackson
Title Manager
Organization R&M Commercial Real Estate, LLC
Date * 02/19/2020

F. Tracking and COC Info
NOI Tracking No. 22136
NC Reference No. NCG01-2020-0674
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200674
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 674
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.)