NCC200889_NOI Application_20200305

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/4/2020 2:59:09 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 3/5/2020 9:38:06 AM (Review- Construction NOI 22775)
. The task was assigned to Garcia, Lauren V by round robin distribution 3/4/2020 2:59 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 6, 2020 5:00 PM
3/4/2020 2:59 PM
Submit by McCoy, Suzanne 3/5/2020 11:44:29 AM (Payment Verification for NCC200889)
* Joseph marin
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/5/2020 11:44 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 16, 2020 5:00 PM
3/5/2020 9:38 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Popeyes Wadesboro
1 b. Specific Lot This field any be used to list specifc lot nunbers.
Numbers
2. County* Anson
3. Highway or Street 327 E Caswell
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Wadesboro
5. State * NC
6. Zip Code* 28170
7. Latitude* Enter the latitude in decimal degrees
34.9689
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.0729
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*
03/30/2020
Estimated Construction Project Start Date
10. Date to End *
07/17/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
0.65
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.18
(acres)*
14. Post- 0.44
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-ANSON-2020-Popeyes Wadesboro
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 Brush Fork
Wate rbody* Nacre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 13-42-1-3-1
Index No. * NC Waterbody Index Minter
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. ^
Fternittee Inforrration - Legally Fa sponsible 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 Leblon Franchising Holdings LLC
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Joseph
IF Corporation, enter Plegistered Agent First Barre
3. Last Name* Marin
If Corporation, enter Faegistered Agent Last Wre
3b. Title Development Officer
4. Permitee E-mail [e-mail]
Address *
5. Permittee 786-853-9950
Telephone No.*
6. Permittee Mailing Street Address
Address* 227 W 4th St
Address Line 2
Suite 219
city
Charlotte
Fbstal / Zip Code
28202
Check box if the rJ Yes
street address the
same as mailing
address
State / Frovince / Faegion
North Carolina
Country
USA
7. Permittee Street
Street Address
Address*
227 W 4th St
Address Line 2
Suite 219
City
State / Rovince / Fbgion
Charlotte
North Carolina
Flostal / Zip Code
Country
28202
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Project Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Joseph
Contact - First
Name *
2. Primary Site
Marin
Contact - Last
Name *
3. Title
Development Officer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
786-853-9950
Telephone No.
6.Organization
Leblon
Name
7. Site Contact
Street Address
Mailing Address*
227 W 4th St
Address Line 2
Suite 219
city
Charlotte
Postal / Zip Code
28202
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Province / 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 01/14/2020
Approved *
2. E&SC Plan Project ANSON-2020-003
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 * Fayetteville (FRO)
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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan
Approval letter or
Grading Permit
Site Map (Optional)
Notes (Optional)
APPROVAL ANSON 2020 003 POPEYES
79.65KB
WADESBORO.pdf
Mast be RDFformat
Helpful for linear project review
Mast be FDFform3t
Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
6. NOI Certification NCG01 Notice of Intent (NOI) Certification Form.pdf 625.03KB
Form Mast be FDFfon-rat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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 * Joseph Marin
Title Development Officer
Organization Leblon Franchising Holdings LLC
Date * 03/04/2020

F. Tracking and COC Info
NOI Tracking No. 22775
NC Reference No. NCG01-2020-0889
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200889
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 889
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.)