NCC201140_NOI Application_20200320

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/19/2020 9:13:39 AM (NCG01 NOI Submission)
Approve by Clark, Paul 3/19/2020 4:03:27 PM (Review- Construction NOI 23269)
• McCoy, Suzanne reassigned the task to Clark, Paul 3/19/2020 2:37 PM
. The task was assigned to Farkas, Jim J by round robin distribution 3/19/2020 9:14 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 23, 2020 5:00
PM 3/19/2020 9:14 AM
Submit by McCoy, Suzanne 3/20/2020 4:12:15 PM (Payment Verification for NCC201140)
* Laura Peters
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/20/2020 4:11 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 30, 2020 5:00 PM
3/19/2020 4:03 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Cedar Lane
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers CL 5
2. County* Chatham
3. Highway or Street 137 Cedar Lane
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Pittsboro
5. State * NC
6. Zip Code* 27312
7. Latitude* Enter the latitude in decimal degrees
35.7262
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-79.1798
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*
03/24/2020
Estimated Construction Project Start Rate
10. Date to End *
08/24/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
0.07
disturbed*
(including off -site borrow and waste areas)
13. Total site area 0.34
(acres)*

14. Post- 0.07
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-CHATF-1-2020-Cedar Lane
Tracking ID 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 Robeson Creek
Waterbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-38-(3)
Index No.* NCWaterbody Index Number
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 Triple A Homes
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Laura
IF Corporation, enter Plegistered Agent First Barre
3. Last Name* Peters
If Corporation, enter Faegistered Agent Last Wre
3b. Title Estimating & Permitting
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9498120991
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1117
Address Line 2
city
Holly Springs
Fostal / Zip Code
27540
Check box if the rJ Yes
street address the
same as mailing
address
State / Frovince / Region
North Carolina
Country
United States
7. Permittee Street
Street Address
Address*
PO Box 1117
Address Line 2
City
State / Ffovince / Fbgion
Holly Springs
North Carolina
Flostal / Zip Code
Country
27540
United States
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Laura
Contact - First
Name *
2. Primary Site Peters
Contact - Last
Name *
3. Title
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 9498120991
Telephone No.*
6. Organization Triple A Homes
Name
7. Site Contact Street Address
Mailing Address* PO Box 1117
Address Line 2
City
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 03/16/2020
Approved *
2. E&SC Plan Project 2020-01976
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Chatham 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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan CL 5 Soil Erosion Sedimentation Letter of Aproval
Approval letter or 287.56KB
3.16.2020.pdf
Grading Permit
Mist be RDFforrrat
Site Map (Optional) Helpful for linear project review
Mast be FDFform3t
Notes (Optional) 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 CL 5 NCG01-eNO1-Certification-Form-20190507-
Form 177.46KB
DEMLR-SW.pdf
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
��rrr�fr C�F�r'tJ
Type Name* Laura Peters
Title Estimating & Permitting
Organization Triple A Homes
Date * 03/19/2020

F. Tracking and COC Info
NOI Tracking No. 23269
NC Reference No. NCG01-2020-1140
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201140
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1140
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.)