NCC201430_NOI Application_20200409

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/7/2020 11:44:30 AM (NCG01 NOI Submission)
Approve by Farkas, Jim J 4/9/2020 10:59:53 AM (Review- Construction NOI 24075)
• The task was assigned to Farkas, Jim J by round robin distribution 4/7/2020 11:44 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 9, 2020 5:00 PM
4/7/2020 11:44 AM
Submit by McCoy, Suzanne 4/9/2020 12:12:42 PM (Payment Verification for NCC201430)
* Stuart Parks
• McCoy, Suzanne assigned the task to McCoy, Suzanne 4/9/2020 12:12 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 21, 2020 5:00 PM
4/9/2020 11:00 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Crow Hill Lot 39'
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Forsyth
3. Highway or Street 2780 Pfafftown Forest Drive
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Pfafftown
5. State * NC
6. Zip Code* 27040
7. Latitude* Enter the latitude in decimal degrees
36.1446
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-80.3712
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
Estimated Construction Project Start Date
10. Date to End *
12/30/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Developrrent
12. Acres to be
1.18
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.92
(acres)*
14. Post- 0.25
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-FORSY-2020-Crow Hill Lot 39'
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 Oil Mill Branch
Waterbody* I\brre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 12-94-6
Index No. * NC Waterbody Index N n ber
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. ^
Fternittee Inforrration - Legally Fa sponsible 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
Legally Pesponsible Entity
Name *
Parks Family Holdings, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Stuart
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Parks
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* Post Office Box 5323
Address Line 2
City State / Rovince / Pegion
Winston-Salem NC
Fbstal / Zip Code Country
27113 us
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
11 Brookstown Avenue
Address Line 2
City
State / Frovince / Region
Winston-Salem
NC
Fbstal / Zip Code
Country
27103
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Amanda
Contact - First
Name *
2. Primary Site
Lambert
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6. Organization
Parks Family Holdings, LLC
Name
7. Site Contact
Street Address
Mailing Address*
Post Office Box5323
Address Line 2
city
Winston-Salem
Fbstal / Zip Code
27113
8. Consultant Name
(Optional)
Steve Causey
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
[phone]
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 03/09/2020
Approved *
2. E&SC Plan Project EN2000033
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth 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 Review Completed - Lot 39 Crow Hill. pdf 165.46KB
Approval letter or Mist beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Mast be FCFfornat. Rease do not upload entire set of E&SCplans.
7. 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.
8. NOI Certification doc01555120200407114126.pdf 211.13KB
Form Mist be RDFfornat
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:
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
Type Name* Stuart parks
Title Manager
Organization Legally Iesponsible Entity
Parks Family Holdings
Date * 04/07/2020

F. Tracking and COC Info
NOI Tracking No. 24075
NC Reference No. NCG01-2020-1430
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201430
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1430
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.)