NCC201822_NOI Application_20200511

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/29/2020 4:58:34 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 5/4/2020 8:22:08 AM (Review- Construction NOI 24978)
• Clark, Paul reassigned the task to Farkas, Jim J 4/30/2020 12:10 PM
* for you, Jim ...
• The task was assigned to Clark, Paul by round robin distribution 4/29/2020 4:58 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 1, 2020 5:00 PM
4/29/2020 4:58 PM
Submit by Garcia, Lauren V 5/11/2020 1:06:13 PM (Payment Verification for NCC201822)
* Wakefield Central Baptist Church
• Garcia, Lauren V assigned the task to Garcia, Lauren V 5/11/2020 1:05 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 15, 2020 5:00 PM
5/4/2020 8:22 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 24658
NOI No.
Prior Reviewer Jim Farkas
Name
1a. Project Name * Wakefield Central Baptist Church Parking Lot
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* Wake
3. Highway or Street 308 Proctor Street Zebulon
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Zebulon
5. State * NC
6. Zip Code * 27597
7. Latitude * Enter the latitude in decimal degrees
35.8420
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-78.3260
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* 06/01/2020
Estimated Construction Project Start Date
10. Date to End* 08/01/2020
Estimated Construction Project End Cute
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Developrrent

12. Acres to be 1.50
disturbed* (including off -site borrow and waste areas)
13. Total site area 7.13
(acres) *
14. Post- 1.59
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-Wakefield Central Baptist Church Parking Lot
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 Beaverdam Creek
Wate rbody* %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-86-2-3
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. ^
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 Legally Pesponsible Entity
Name * Wakefield Central Baptist Church
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * Mike
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Blackmon
It Corporation, enter F;bgistered Agent Last %ne
3b. Title Construction Project Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-880-2976
Telephone No.*
6. Permittee Mailing Street Address
Address* 308 Proctor Street
Address Line 2
City State / Rovince / F;bgion
Zebulon NC
Fbstal / Zip Code Country
27597 USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
308 Proctor Street
Address Line 2
City
State / Frovince / Region
Zebulon
NC
Fbstal / Zip Code
Country
27597
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Mike
Contact - First
Name *
2. Primary Site
Blackmon
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-880-2976
Telephone No.
6.Organization
Religious
Name
7. Site Contact
Street Address
Mailing Address*
308 Proctor Street
Address Line 2
city
Zebulon
Fbstal / Zip Code
27597
8. Consultant Name
(Optional)
Trent Stewart
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-302-1870
Telephone No.
State / Rovince / Region
NC
Country
USA

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 SEC-032348-2019
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Wake 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
SEC-032348-2020 -
Approval letter or
S&EConstructionPlan ReviewChecklist-V.2 WM 3- 294.26KB
Grading Permit
30-20.pdf
Mast be RFfornat
6. Site Location Map
Helpful for linear project review
(Optional)
Wst be FDFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional)
Ffovide 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.
8. NOI Certification
Notice of Intent WCBC Parking Lot Form 2.pdf 576.67KB
Form
Mast be R7Fforrrat
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 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
����/ra frs�r�r�lrPr�s'cros'
Type Name* John Michael Blackmon
Title Construction Project Manager
Organization Legally Iesponsible Entity
Wakefield Central Baptist Church
Date * 04/29/2020

F. Tracking and COC Info
NOI Tracking No. 24978
NC Reference No. NCG01-2020-1822
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201822
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1822
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.)