NCC201317_NOI Application_20200402

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/31/2020 5:01:57 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 4/1/2020 8:48:27 AM (Review- Construction NOI 23828)
. The task was assigned to McCoy, Suzanne by round robin distribution 3/31/2020 5:02 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 2, 2020 5:00 PM
3/31/2020 5:02 PM
Submit by McCoy, Suzanne 4/2/2020 8:30:02 AM (Payment Verification for NCC201317)
* Scott Petiprin
• McCoy, Suzanne assigned the task to McCoy, Suzanne 4/2/2020 8:29 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 13, 2020 5:00 PM
4/1/2020 8:48 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Asheville SurgCare
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Buncombe
3. Highway or Street 29 Nettlewood Drive
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Asheville
5. State * NC
6. Zip Code* 28801
7. Latitude* Enter the latitude in decimal degrees
35.5154
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-82.5258
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*
04/01/2020
Estirrated Construction Project Start Date
10. Date to End*
03/31/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
2.70
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.90
(acres)*
14. Post- 1.70
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-BUNCO-2020-Asheville SurgCare
Tracking ID Assignedautonatically
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 Four Mile Branch
Wate rbody* I\brre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 6-72
Index No. * NCWaterbody Index N nber
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. ^
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 Ryan Companies US, INC.
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
2. First Name* Connor
IF Corporation, enter ilegistered Agent First Barre
3. Last Name* Lewis
If Corporation, enter Faegistered Agent Last Wre
3b. Title Vice President Healthcare
4. Permitee E-mail [e-mail]
Address *
5. Permittee 630-328-1128
Telephone No.*
6. Permittee Mailing Street Address
Address* 533 South 3rd Street
Address Line 2
city
Minneapolis
Fbstal / Zip Code
55415
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
533 South 3rd Street
Address Line 2
City
Minneapolis
Flostal / Zip Code
55415
8. Type of Non -Government
Ownership*
State / Frovince / Region
MN
Country
US
State / Ffovince / Fbgion
MN
Country
US

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Scott
Contact - First
Name *
2. Primary Site
Petiprin
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
630-328-1128
Telephone No.
6. Organization
Ryan Companies
Name
7. Site Contact
Street Address
Mailing Address*
533 South 3rd Street
Address Line 2
City
Minneapolis
Fbstal / Zip Code
55415
8. Consultant Name
(Optional)
Michael Cain
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
828-252-5388
Telephone No.
State / Rovince / Region
MN
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/30/2020
Approved *
2. E&SC Plan Project 20-00088PZ
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 Asheville
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 Com Formal Grading Letter of Approval_3-30-20.pdf 199.21 KB
Approval letter or Mist beRDFforml
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be R7Fform3t
Notes (Optional) Provide 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 2020-03-31 NCG01 Notice of Intent Form.pdf 355.38KB
Form Mast be FDFfon-rat
This is an Express F 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 Amide 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 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
ejWh, iWa
Type Name* Connor Lewis
Title Vice President Healthcare
Organization Ryan Companies
Date * 03/31 /2020

F. Tracking and COC Info
NOI Tracking No. 23828
NC Reference No. NCG01-2020-1317
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201317
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1317
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.)