NCC201296_NOI Application_20200401

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/30/2020 3:29:31 PM (NCG01 NOI Submission)
Approve by Clark, Paul 3/31/2020 8:30:31 AM (Review- Construction NOI 23784)
. The task was assigned to Clark, Paul by round robin distribution 3/30/2020 3:29 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 1, 2020 5:00 PM
3/30/2020 3:29 PM
Submit by McCoy, Suzanne 4/1/2020 8:29:38 AM (Payment Verification for NCC201296)
* Janine Lightner
• McCoy, Suzanne assigned the task to McCoy, Suzanne 4/1/2020 8:29 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 12, 2020 5:00 PM
3/31 /2020 8:30 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * The Gardens at Cypress Lakes Village Phase 3 - Lots 439 & 440
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers 439&440
2. County* Cumberland
3. Highway or Street Debut Ave
Address* Street name only is acceptable if no address nunber assigned yet
4. Cityor Township* Grays Creek
5. State * NC
6. Zip Code* 28348
7. Latitude* Enter the latitude in decinal degrees
34.9212
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-78.8985
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
Estirrated Construction Project Start Date
10. Date to End *
09/30/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
0.39
disturbed*
(including off -site borrow and waste areas)
13. Total site area 0.39
(acres)*

14. Post- 0.17
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-CUMBE-2020-The Gardens at Cypress Lakes Village Phase 3
Tracking ID - Lots 439 & 440
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 Grays Creek (Rainey Pond, Rainbow Pond)
Wate rbodY * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 18-35-(1)
Index No.* NCWaterbody Index Nunber
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. ^
F2rnittee 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 Caviness Land Development, Inc
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Watson
If Corporation, enter Registered Agent First f brre
3. Last Name* Caviness
If Corporation, enter Faegistered Agent Last %rre
3b. Title Owner/Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9103396330
Telephone No.*
6. Permittee Mailing Street Address
Address* 1041 B Robeson Street
Address Line 2
City State / Province / Region
Fayetteville NC
Postal / Zip Code Country
28305 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
1041 B Robeson Street
Address Line 2
City
State / Province / Region
Fayetteville
NC
Fostal / Zip Code
Country
28305
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Watson
Contact - First
Name *
2. Primary Site
Caviness
Contact - Last
Name *
3. Title
Owner/Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9102370572
Telephone No.
6. Organization
Caviness Land Development, Inc
Name
7. Site Contact
Street Address
Mailing Address*
1410 B Robeson Street
Address Line 2
city
Fayetteville
Fbstal / Zip Code
28305
8. Consultant Name
(Optional)
Larry King and Associates
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
9104834300
Telephone No.
State / Rovince / Region
NC
Country
US

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/24/2020
Approved *
2. E&SC Plan Project CUMBE-2020-137
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 3-30-2020 APPROVALCUMBE-2020-137.pdf 81.26KB
Approval letter or Mast beRDFforml
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be R7Fform3t
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 3-30-2020 NCG01-eNO1-Certification-signed.pdf 96.72KB
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 *
Watson Caviness
Title
Owner/Operator
Organization
Caviness Land Development, Inc
Date *
03/30/2020

F. Tracking and COC Info
NOI Tracking No. 23784
NC Reference No. NCG01-2020-1296
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201296
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1296
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.)