NCC201161_NOT Supporting Documents_20200324

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NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* Oldham
1 b. Specific Lot This field any be used to list specifc lot nunbers.
Numbers
2. County* Chatham
3. Highway or Street 3151 US HWY 15 / 501 N
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
35.7625
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.1626
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
Estirrated Construction Project Start late
10. Date to End *
06/30/2020
Estirrated Construction Project End late
11. SIC (Primary) *
Other (0000)
Standard Industrial C]assification for Development
12. Acres to be
1.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.32
(acres)*
14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *

Project Tracking ID NCC-CHATH-2020-Oldham
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 Brooks Creek
Waterbody* %r e of waterbody into which stormwater runoff will discharge
15b. Waterbody 16-36
Index No. * NCWaterbody Index NArrber
Stormwater r- No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Haw River
Receiving Waterbody narre
Waterbody
15d. Waterbody 16-(28.875)
Index No. NCWaterbody Index Number
15e. Additional Cape Fear River
Receiving Waterbody narre
Waterbody
15f. Waterbody 18-(1)
Index No. NCWaterbody Index Number
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*
Note: Stormwater discharges from construction activities associated with oil and gas exploration, production,
processing, treatment, or transmission facilities are eligible for the exemption from NPDES permit coverage except
in very limited instances. Do not proceed with this application before consulting this EPA fact sheet and verifying a
permit applies.

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 Self
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Scott
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Oldham
If Corporation, enter Registered Agent Last Wre
3b. Title * Owner
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-422-9626
Telephone No.*
6. Permittee Mailing Street Address
Address* 3151 US Hwy 15 / 501 N
Address Line 2
city State / Frovince / Region
Pittsboro NC
Fbstal / Zip Code Country
27312 US
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
3151 US Hwy 15 / 501 N
Address Line 2
City
State / Ffovince / Plegion
Pittsboro
NC
Flostal / Zip Code
Country
27312
US
8. Type of
Individual
Ownership*

C. Site Contact information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Scott
Contact - First
Name *
2. Primary Site
Oldham
Contact - Last
Name *
3. Title
Owner
4. Site Contact E-
[e-mail]
mail Address*
This person will be copied on all correspondence.
5. Site Contact
919-422-9626
Telephone No.
6.Organization
Self
Name
9. Site Contact
Street Address
Mailing Address*
3151 US HWY 15 / 501 N
Address Line 2
city
Pittsboro
Fbstal / Zip Code
27312
10. Consultant Name
(Optional)
Bryan Harris
First and Last nacre
11. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
12. Consultant
919-789-0744
Telephone No.
State / Rovince / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/11/2020
Approved *
2. E&SC Plan Project 2019-08107
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 Approved - Chatham - S&EC - Oldham NOV - 2020-
Approval letter or 287.43KB
03-11.pdf
Grading Permit* Mist beFDFfornat
Site Map (Optional) Helpful for linear project review
Harris - OldHam EC Only EC1 (1)++.pdf 342.62KB
Mast be RDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
6. NOI Certification NOI cert form stormwater - Signed.pdf 367.05KB
Form * Mast be RDFfornat
YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link) to The Stormwater Program
at the address on the form for the application to fulfill federal application requirements. The Certification Form must be
signed by the person listed in Section B (Permittee Information) or by an authorized responsible person within the same
organization. NOTE: The person who signs the paper form must be the same person to electronically certify
and sign the eNO1.
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 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
rJ 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.
* rJ 1 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.
* 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 *
�jrvt 11.417. W'
Type Name* Scott Oldham
Title * Owner
Organization* Self
Date * 03/24/2020