NCC200995_NOI Application_20200313

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/12/2020 3:54:34 PM (NCG01 NOI Submission)
Approve by Clark, Paul 3/12/2020 8:08:21 PM (Review- Construction NOI 23035)
• The task was assigned to Clark, Paul by round robin distribution 3/12/2020 3:54 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 16, 2020 5:00
PM 3/12/2020 3:54 PM
Submit by McCoy, Suzanne 3/13/2020 12:56:12 PM (Payment Verification for NCC200995)
* Inner Banks Engineering
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/13/2020 12:55 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 23, 2020 5:00 PM
3/12/2020 8:08 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Taylor's Creek Water Line and Roadway Construction
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers 080738
2. County* Pitt
3. Highway or Street 1091 Taylor's Creek Drive
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Greenville
5. State * NC
6. Zip Code* 27834
7. Latitude* Enter the latitude in decimal degrees
35.5773
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-77.4472
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*
03/12/2020
Estimated Construction Project Start Date
10. Date to End *
03/12/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
1.98
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.98
(acres)*

14. Post- 1.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-PITT-2020-Taylor's Creek Water Line and Roadway
Tracking ID Construction
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 Greens Mill Run
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 28-96
Index No.* NCWaterbody Index Number
Stormwater rJ 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 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 A&M Development of Pitt County, LLC
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* George
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Martin
If Corporation, enter Registered Agent Last Wre
3b. Title Member/Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 252-531-2599
Telephone No.*
6. Permittee Mailing Street Address
Address* 4769 NC Hwy 33 East
Address Line 2
city
Greenville
F ostal / Zip Code
27858
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
4769 NC Hwy 33 East
Address Line 2
City
Greenville
Flostal / Zip Code
27858
8. Type of Non -Government
Ownership*
State / F rovince / Region
NC
Country
USA
State / Ffovince / Fbgion
NC
Country
USA

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
George
Contact - First
Name *
2. Primary Site
Martin
Contact - Last
Name *
3. Title
Member/Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
252-531-2599
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
4769 NC Hwy 33 East
Address Line 2
City
Greenville
Fbstal / Zip Code
27858
8. Consultant Name
(Optional)
Marie Peedin
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
252-945-2983
Telephone No.
State / Rovince / Region
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/20/2019
Approved *
2. E&SC Plan Project ESCP-2019-0007
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Greenville
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)
ESCP-2019-0007 - TAYLORS CREEK APPROVAL-
677.96KB
05202019142246. pdf
Mast be R7Fforrrat
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-eNO1-Certification-Form-20190919-DEMLR-
Form SW.pdf 683.74KB
Mist be FDFfornat
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
E0t� Z - /��r? fr'-i"
Type Name* George Martin
Title Member/Manager
Organization A&M Development of Pitt County, LLC
Date * 03/12/2020

F. Tracking and COC Info
NOI Tracking No. 23035
NC Reference No. NCG01-2020-0995
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200995
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 995
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.)