NCC202313_NOI Application_20200608

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/2/2020 4:16:27 PM (NCG01 NOI Submission)
Approve by Clark, Paul 6/3/2020 10:00:57 AM (Review- Construction NOI 26498)
• The task was assigned to Clark, Paul by round robin distribution 6/2/2020 4:16 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 4, 2020 5:00 PM
6/2/2020 4:16 PM
Submit by Garcia, Lauren V 6/8/2020 1:15:10 PM (Payment Verification for NCC202313)
* The LEADS Group PA
• Garcia, Lauren V assigned the task to Garcia, Lauren V 6/8/2020 1:14 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 15, 2020 5:00 PM
6/3/2020 10:01 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * Westbrook and Church Site
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers Alamance Co. Parcel ID: 107007
2. County* Alamance
3. Highway or Street 3725 S Church Street, Burlington, NC
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township * City of Burlington
5. State * NC
6. Zip Code * 27215
7. Latitude* Enter the latitude in decirral degrees
36.0810
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-79.5178
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*
06/05/2020
Estinated Construction Project Start Date
10. Date to End *
06/05/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
4.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 3.88
(acres) *

14. Post- 2.98
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-ALAMA-2020-Westbrook and Church Site
Tracking ID Assignedautorraticaly
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 Ingle Branch
Waterbody* N3rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-19-5-2
Index No.* NCWaterbody Index Nunber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
F2rnittee 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 *
Hursey BBQ Express #7, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Charles
IF Corporation, enter Faegistered Agent First Wre
3. Last Name*
Hursey
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Member Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-516-5196
Telephone No.*
6. Permittee Mailing Street Address
Address* 2435 Barber Road
Address Line 2
City State / Rovince / Pbegion
Elon NC
Fbstal / Zip Code Country
27244-9748 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2435 Barber Road
Address Line 2
City
State / Ftovince / Region
Elon
NC
Fbstal / Zip Code
Country
27244-9748
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Charles
Contact - First
Name *
2. Primary Site
Hursey
Contact - Last
Name *
3. Title
Member Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-516-5196
Telephone No.
6. Organization
Hursey BBQ Express #7, LLC
Name
7. Site Contact
Street Address
Mailing Address*
2435 Barber Road
Address Line 2
city
Elon
Fbstal / Zip Code
27244-9748
8. Consultant Name
(Optional)
Chad Huffine
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-227-8724
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 03/16/2020
Approved *
2. E&SC Plan Project 657
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Burlington
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 CCF_000782 APPROVED EROSION CONTROL 3-
Approval letter or 1.24MB
16-2020.pdf
Grading Permit
Mist be FDFfon-rat
6. Site Location Map Helpful for linear project review
(Optional) Mast be FDFfornat. 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.
City of Burlington EC Approval letter and signed NOI Certification
Form are both attached.
8. NOI Certification 2020-06-02 Hursey_NOI Certification
Form 682.52KB
Form_Signed.pdf
Mast be FDFfon-rat
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 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 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
ck"�&d !
Type Name* Charles Hursey
Title Member Manager
Organization Legally Ibsponsible Entity
Hursey BBQ Express #7, LLC
Date * 06/02/2020

F. Tracking and COC Info
NOI Tracking No. 26498
NC Reference No. NCG01-2020-2313
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202313
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2313
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.)