NCC200761_NOI Application_20200226

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/20/2020 8:18:33 AM (NCG01 NOI Submission)
Approve by Clark, Paul 2/25/2020 12:15:00 PM (Review- Construction NOI 22168)
• The task was assigned to Clark, Paul by round robin distribution 2/20/2020 8:18 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 24, 2020 5:00
PM 2/20/2020 8:18 AM
Submit by McCoy, Suzanne 2/26/2020 6:59:24 AM (Payment Verification for NCC200761)
* Jack Fitzgerald
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/26/2020 6:59 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 7, 2020 5:00 PM
2/25/2020 12:15 PM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * South Fork Interceptor No.3 Outfall Replacement
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Forsyth
3. Highway or Street Follansbee Rd
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
6. Zip Code* 27127
7. Latitude* Enter the latitude in decimal degrees
36.0201
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-80.2518
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*
11/04/2019
Estimated Construction Project Start Date
10. Date to End *
05/20/2021
Estimated Construction Project End Cate
11. SIC (Primary) *
Other (0000)
Standard Industrial C]assification for Developrrent
12. Acres to be
19.16
disturbed*
(including off -site borrow and waste areas)
13. Total site area 19.16
(acres)*
14. Post- 19.16
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-FORSY-2019-South Fork Interceptor No.3 Outfall
Tracking ID Replacement
Assigned automatically
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 South Fork Muddy Creek
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 12-94-13
Index No. * NCWaterbody Index Number
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 Winston Salem Forsyth County Utilities
Name *
2. First Name* Courtney
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Driver
IF Corporation, enter Faegistered Agent Last %rre
3b. Title Utilities Director
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-771-5124
Telephone No.*
6. Permittee Mailing Street Address
Address* 101 North Main Street
Address Line 2
City State / Frovince / Faegion
Winston-Salem NC
Fbstal / Zip Code Country
27101 us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
101 North Main Street
Address Line 2
City
State / Frovince / Fbgion
Winston-Salem
NC
Fbstal / Zip Code
Country
27101
us
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Jack
Contact - First
Name *
2. Primary Site Fitzgerald
Contact - Last
Name *
3. Title
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 336-486-1640
Telephone No.*
6. Organization
Name
7. Site Contact Street Address
Mailing Address* 3909 Westpoint Boulevard
Address Line 2
city
Winston-Salem
Fbstal / Zip Code
27103-6728
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 / Pegion
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/25/2019
Approved *
2. E&SC Plan Project FORSY-2019-004
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 FORSY-2019-004 - Revised.pdf 323.24KB
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 E-NOI Signed.pdf 735.37KB
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
�' i'rrt�wr�,ti�itrr•�t
Type Name * Courtney Driver
Title Utilities Director
Organization Winston Salem Forsyth County Utilities
Date * 02/20/2020

F. Tracking and COC Info
NOI Tracking No. 22168
NC Reference No. NCG01-2020-0761
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200761
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 761
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.)