NCC200701_NOI Application_20200224

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/19/2020 6:40:32 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 2/20/2020 11:32:36 AM (Review- Construction NOI 22163)
• The task was assigned to Morman, Alaina by round robin distribution 2/19/2020 6:40 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 21, 2020 5:00
PM. The priority is: High 2/19/2020 6:40 PM
Submit by McCoy, Suzanne 2/24/2020 11:13:32 AM (Payment Verification for NCC200701)
* Michael Salamone
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/24/2020 11:13 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 2, 2020 5:00 PM. The
priority is: High 2/20/2020 11:32 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* A.Dillon Residence
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Davidson
3. Highway or Street 1997 Happy Hill Rd.
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Lexington Township
5. State * NC
6. Zip Code* 27295
7. Latitude* Enter the latitude in decinal degrees
35.8491
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.3043
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*
02/20/2020
Estimated Construction Project Start Date
10. Date to End *
02/20/2022
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
2.11
disturbed*
(including off -site borrow and waste areas)
13. Total site area 6.88
(acres)*

14. Post- 1.11
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-DAVID-2020-A.Dillon Residence
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 Indian Grave Creek
Waterbody* %rm of waterbody into which stornwater runoff will discharge
15b. Waterbody 12-113-2
Index No.* NCWaterbody Index Number
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 ARCADIA HOMES INC
Name *
2. First Name* Jeremy
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Schumacher
If Corporation, enter Registered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address *
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 6428 Bannington Rd, Ste A
Address Line 2
6428 Bannington Road
City State / Ftovince / Region
Charlotte North Carolina
Fbstal / Zip Code Country
28226 United States
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
6428 Bannington Rd, Ste A
Address Line 2
6428 Bannington Road
City
State / Rovince / Fbgion
Charlotte
North Carolina
Fbstal / Zip Code
Country
28226
United States
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Brian
Contact - First
Name *
2. Primary Site
Welch
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6. Organization
Arcadia Homes
Name
7. Site Contact
Street Address
Mailing Address*
6428 Bannington Road
Address Line 2
Suite A
city
Charlotte
Fbstal / Zip Code
28226
8. Consultant Name
(Optional)
Wesley Kimbrell
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
[phone]
Telephone No.
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/10/2020
Approved *
2. E&SC Plan Project DAVID-2020-030
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. For linear projects, please also upload a site map showing the overall extent of the project.
5. E&SC Plan NCDEQ Approved Permit Packet.pdf 6.96MB
Approval Wst be FDFfornat
letter/documentation
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification Dillon NOI Certification - signed.pdf 529.55KB
Form Mast be FDFformat
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 * Jeremy Schumacher
Title President
Organization ARCADIA HOMES INC
Date * 02/19/2020

F. Tracking and COC Info
NOI Tracking No. 22163
NC Reference No. NCG01-2020-0701
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200701
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 701
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.)