NCC202137_NOI Application_20200522

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/20/2020 5:15:52 PM (NCG01 NOI Submission)
Approve by Clark, Paul 5/21/2020 8:18:47 AM (Review- Construction NOI 25936)
• Farkas, Jim J reassigned the task to Clark, Paul 5/21/2020 7:47 AM
• The task was assigned to Farkas, Jim J by round robin distribution 5/20/2020 5:16 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 22, 2020 5:00 PM
5/20/2020 5:16 PM
Submit by Garcia, Lauren V 5/22/2020 1:54:32 PM (Payment Verification for NCC202137)
* Public Works 1
• Garcia, Lauren V assigned the task to Garcia, Lauren V 5/22/2020 1:50 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 2, 2020 5:00 PM
5/21/2020 8:19 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 25907
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Waxhaw Gravity Interceptor, Pump Station & Force Main
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers 0
2. County* Union
3. Highway or Street Rehobeth Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Waxhaw
5. State * NC
6. Zip Code * 28173
7. Latitude * Enter the latitude in decimal degrees
34.9144
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.7535
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* 10/05/2020
Estimated Construction Project Start Date
10. Date to End* 11/08/2021
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 11.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 11.00
(acres) *
14. Post- 0.03
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-UNION-2020-WaxhawGravity Interceptor, Pump Station &
Tracking ID Force Main
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 Rone Branch
Wate rbody* N larre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-138-4
Index No.* NCWaterbody Index Number
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. ^
Fl rnittee 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 * Union County Public Works
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * John
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Shutak
It Corporation, enter F;bgistered Agent Last %ne
3b. Title CIP Program Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704.283.3651
Telephone No.*
6. Permittee Mailing Street Address
Address* 500 N Main St., Suite 600
Address Line 2
City State / Rovince / F;bgion
Monroe NC
Fbstal / Zip Code Country
28112 USA
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
500 N Main St., Suite 600
Address Line 2
city
State / Ftovince / Region
Monroe
NC
Fbstal / Zip Code
Country
28112
USA
8. Type of
Government - County
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
John
Contact - First
Name *
2. Primary Site
Shutak
Contact - Last
Name *
3. Title
CIP Program Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704.283.3651
Telephone No.
6. Organization
Union County Public Works
Name
7. Site Contact
Street Address
Mailing Address*
500 N Main St., Suite 600
Address Line 2
city
Monroe
Fostal / Zip Code
28112
8. Consultant Name
(Optional)
Black & Veatch
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704.510.8464
Telephone No.
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/13/2020
Approved *
2. E&SC Plan Project UNION-2020-069
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 * Mooresville (MRO)
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
20200518081011251.pdf 550.15KB
Approval letter or
Mast beRDFformat
Grading Permit
6. Site Location Map
Helpful for linear project review
(Optional)
Waxhaw PS Vicinity Map.pdf 103.66KB
Mast be RDF format. 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 20200520 NCG01-
Form 723.48KB
eNO1_CertificationForm Executed_R1.pdf
Mast be R7Ffon-rat
This is an Express r 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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who 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 Artcle 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
0Zow ����
Type Name * John Shutak
Title CIP Program Manager
Organization Legally Plesponsible Entity
Union County Public Works
Date * 05/20/2020

F. Tracking and COC Info
NOI Tracking No. 25936
NC Reference No. NCG01-2020-2137
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202137
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2137
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.)