NCC202138_NOI Application_20200527

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/18/2020 9:15:58 AM (NCG01 NOI Submission)
Approve by Farkas, Jim J 5/21/2020 8:27:06 AM (Review- Construction NOI 25721)
• Morman, Alaina reassigned the task to Farkas, Jim J 5/18/2020 9:23 AM
. The task was assigned to Morman, Alaina by round robin distribution 5/18/2020 9:16 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 20, 2020 5:00 PM
5/18/2020 9:16 AM
Submit by Garcia, Lauren V 5/27/2020 1:59:56 PM (Payment Verification for NCC202138)
* MJ Silmser Corporation
• Garcia, Lauren V assigned the task to Garcia, Lauren V 5/27/2020 1:57 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 2, 2020 5:00 PM
5/21/2020 8:27 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 25628
NOI No.
Prior Reviewer Jim Farkas
Name
1a. Project Name* Tuttle Road Lots
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Forsyth
3. Highway or Street 320 Tuttle Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* King
5. State * NC
6. Zip Code * 27021
7. Latitude * Enter the latitude in decimal degrees
36.2574
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-80.3193
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* 05/11/2020
Estimated Construction Project Start Date
10. Date to End* 07/06/2020
Estimated Construction Project End Cute
11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Developrrent

12. Acres to be 2.50
disturbed* (including off -site borrow and waste areas)
13. Total site area 4.80
(acres) *
14. Post- 0.50
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-FORSY-2020-Tuttle Road Lots
Tracking ID Assigned automatically
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 Muddy Creek
Wate rbody* %rre of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-94-(0.5)
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 *
MJ Silmser Corporation
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Matt
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Silmser
IF Corporation, enter F;bgistered Agent Last %ne
3b. Title
President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-362-1748
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box428
Address Line 2
City
King
Fbstal / Zip Code
27021
Check box if the F Yes
street address the
same as mailing
address
State / Rovince / F;bgion
NC
Country
Stokes
7. Permittee Street
Street Address
Address*
PO Box428
Address Line 2
city
State / Frovince / Region
King
NC
Fbstal / Zip Code
Country
27021
Stokes
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Matt
Contact - First
Name *
2. Primary Site Silmser
Contact - Last
Name *
3. Title
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 336-362-1748
Telephone No.*
6. Organization
Name
7. Site Contact Street Address
Mailing Address* PO Box428
Address Line 2
city
King
Postal / Zip Code
27021
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Frovince / ILegion
NC
Country
Stokes

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/27/2020
Approved *
2. E&SC Plan Project A/P EN2000072
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 Tuttle Road approval City of W-W.pdf 95.51 KB
Approval letter or Mast 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 NCGO1 TUTTLE ROAD LOTS.pdf 824.7KB
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
( r?.Cz"-6rC�r .t
Type Name* Matt Silmser
Title President
Organization Legally Ibsponsible Entity
MJ Silmser Corporation
Date * 05/18/2020

F. Tracking and COC Info
NOI Tracking No. 25721
NC Reference No. NCG01-2020-2138
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202138
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2138
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.)