NCC200346_Modification Review_20200501

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/30/2020 3:58:42 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 5/1/2020 10:59:41 AM (Construction COC ADD TO FILE Review- NCC200346)
• The task was assigned to Georgoulias, Bethany. The due date is: May 5, 2020 5:00 PM
4/30/2020 3:58 PM

Y. ,
NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC200346
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Maple Leaf Village - DR Horton Lots
Address
Harvey Teague Road, Winston-Salem, NC
County
Davidson
Latitude
36.0201
Longitude
-80.1257
Permittee Listed
DR Horton, Inc.
Legally Responsible
Jessica Meyer
Individual
NC Reference No.
NCG01-2020-0346
E&SC Plan ID
DAVID-2020-029
Original NOI
21168
Tracking No.*
Date COC Issued*
01/30/2020
Prior Rescission
This field will populate only ff OOChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification* F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Multiple Reasons (List)
Addional ivbre infornation if necessary
Explanation Adding Off -site septic area. 10.33 ac
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).

Supporting Upload Supporting Documentation (%vised ERSC Approval, (lose -Out Doc, etc.)
Documentation Maple Leaf Village Off -Site Septic Letter of
7.04MB
Approval.pdf
Mist be FDFformat
North Carolina General Statute 143-215.6113 (i) provides that:
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto exceed ten thousand
dollars ($10,000).
17 I, as an authorized representative, hereby request modification to coverage
under the NPDES Stormwater Permit for the subject project site. I am familiar
with the information contained in this request and to the best of my knowledge
and belief such information is true, complete and accurate.
'This form must be signed by a responsible corporate officer that 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
dctu'¢ 13
Type Name* Jessica Meyer
Title * NPDES Technical Compliance Administrator
Organization* DR Horton, Inc.
Date * 04/30/2020
Email Address* [e-mail]
B7ail for Confirmation
Telephone Number* 919-215-6561
Contact N,imber if we need to reach you
Review Date 05/01/2020
Request Date 20200430
Formatted
Review Date 20200501
Formatted