NCC200769_NOI Application_20200227

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/24/2020 1:44:34 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 2/25/2020 3:23:18 PM (Review- Construction NOI 22346)
• The task was assigned to McCoy, Suzanne by round robin distribution 2/24/2020 1:45 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 26, 2020 5:00
PM 2/24/2020 1:45 PM
Submit by McCoy, Suzanne 2/27/2020 7:00:36 AM (Payment Verification for NCC200769)
* Dona Turner
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/27/2020 7:00 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 7, 2020 5:00 PM
2/25/2020 3:23 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Riverdale Sanitary Sewer Extension & Improvements
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street Riverdale Drive
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Jamestown
5. State * NC
6. Zip Code* 27282
7. Latitude* Enter the latitude in decimal degrees
35.9445
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.9120
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*
05/01/2020
Estirrated Construction Project Start Date
10. Date to End*
05/01/2021
Estinated Construction Project End Date
11. SIC (Primary) *
Other (0000)
Standard Industrial Classification for Development
12. Acres to be
4.08
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.08
(acres)*
14. Post- 500.00
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-GUILF-2020-Riverdale Sanitary Sewer Extension &
Tracking ID Improvements
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 Richland Creek
Waterbody* Narreof waterbody into which stornwater runoff will discharge
15b. Waterbody 17-7-(4)
Index No. * NCWaterbody Index Nunber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Deep River (Randleman Lake)
Receiving Waterbody narre
Waterbody
15d. Waterbody 17-(4)
Index No. NCWaterbody Index Nunber
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nunber
Index No.
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 City of High Point
Name *
2. First Name* Terry
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Houk
If Corporation, enter F3egistered Agent Last %rre
3b. Title Public Services Director
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-883-3215
Telephone No.*
6. Permittee Mailing Street Address
Address* 211 S. Hamilton Street
Address Line 2
City State / Frovince / Region
High Point North Carolina
Fbstal / Zip Code Country
27262 USA
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
211 S. Hamilton Street
Address Line 2
City
State / Frovince / Fbgion
High Point
North Carolina
Fbstal / Zip Code
Country
27262
USA
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Allan
Contact - First
Name *
2. Primary Site
Hicks
Contact - Last
Name *
3. Title
Projects Engineer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-883-3829
Telephone No.
6. Organization
City of High Point
Name
7. Site Contact
Street Address
Mailing Address*
211 S. Hamilton Street
Address Line 2
city
High Point
Fbstal / Zip Code
27260
8. Consultant Name
(Optional)
Benjamin Palmer
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-886-4821
Telephone No.
State / Rovince / Region
North Carolina
Country
USA

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 GUILF-2020-024
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 GUILF-2020-024 Approval Letter.pdf 1.14MB
Approval 190056-Street Map.pdf 372.38KB
letter/documentation
Mist be R7Fforrrat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NCG01 NOI Cert Form.pdf 824.89KB
Form Mast be Ft7Fformat
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
�rt�l' We
Type Name * Terry Houk
Title Public Services Director
Organization City of High Point
Date * 02/24/2020

F. Tracking and COC Info
NOI Tracking No. 22346
NC Reference No. NCG01-2020-0769
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200769
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 769
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.)