NCC200719_NOI Application_20200225

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/22/2020 11:51:53 AM (NCG01 NOI Submission)
Approve by Clark, Paul 2/22/2020 2:18:27 PM (Review- Construction NOI 22293)
• The task was assigned to Clark, Paul by round robin distribution 2/22/2020 11:52 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 26, 2020 5:00
PM 2/22/2020 11:52 AM
Submit by McCoy, Suzanne 2/25/2020 10:24:41 AM (Payment Verification for NCC200719)
* Anthony Wood
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/25/2020 10:24 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 6, 2020 5:00 PM
2/22/2020 2:18 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * David Bannister Subdivision Lot 1A
1 b. Specific Lot This field may be used to list specifc lot nunbers.
Numbers
2. County* Wake
3. Highway or Street 1820 Pagan Rd
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Raleigh
5. State * NC
6. Zip Code* 27603
7. Latitude* Enter the latitude in decimal degrees
35.6200
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.6600
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*
02/27/2020
Estimated Construction Project Start Date
10. Date to End *
12/18/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
0.92
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.61
(acres)*

14. Post- 0.24
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-David Bannister Subdivision Lot 1A
Tracking ID Assignedautorraticaly
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 Little Creek, Neuse
Waterbody* %rm of waterbody into which stornwater runoff will discharge
15b. Waterbody QNSW
Index No.* NCWaterbody Index Nunber
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. ^
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 Anthony Wood
Name *
2. First Name* Anthony
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Wood
If Corporation, enter Faegistered Agent Last %rre
3b. Title Mr.
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9193384546
Telephone No.*
6. Permittee Mailing Street Address
Address* 200 Hidden Cellars Drive
Address Line 2
City State / Frovince / Faegion
Holly Springs NC
Fbstal / Zip Code Country
27540-8895 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
200 Hidden Cellars Drive
Address Line 2
City
State / Frovince / Fbgion
Holly Springs
NC
Fbstal / Zip Code
Country
27540-8895
us
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Anthony
Contact - First
Name *
2. Primary Site Wood
Contact - Last
Name *
3. Title
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 9193384546
Telephone No.*
6. Organization
Name
7. Site Contact Street Address
Mailing Address* 200 Hidden Cellars Dr
Address Line 2
UY
Holly Springs
Fbstal / Zip Code
27540
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Frovince / Fegion
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/19/2020
Approved *
2. E&SC Plan Project SEC-033152-2020
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Wake County
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 SEC-033152-2020_Lot 1A_Approval-
Approval S&EConstructionPlan ReviewChecklist-V.2 WM 2- 283.51KB
letter/documentation
19-20.pdf
Mist be RDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application.
6. NOI Certification NCG01 Signed Document.pdf 1.33MB
Form Mist be RDFfornat
This is an Express r 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* Anthony Wood
Title Mr.
Organization Owner
Date * 02/22/2020

F. Tracking and COC Info
NOI Tracking No. 22293
NC Reference No. NCG01-2020-0719
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200719
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 719
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.)