NCC202549_NOI Application_20200618

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/17/2020 10:05:14 AM (NCG01 NOI Submission)
Approve by Morman, Alaina 6/17/2020 11:28:27 AM (Review- Construction NOI 27105)
• Morman, Alaina reassigned the task to Morman, Alaina 6/17/2020 10:24 AM
• The task was assigned to Farkas, Jim J by round robin distribution 6/17/2020 10:05 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 19, 2020 5:00 PM
6/17/2020 10:05 AM
Submit by McCoy, Suzanne 6/18/2020 8:42:44 AM (Payment Verification for NCC202549)
* Wilson D Warren
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/18/2020 8:42 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 29, 2020 5:00 PM
6/17/2020 11:28 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 26937
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name * Essex Place Apartments
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Forsyth
3. Highway or Street Kester Mill Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
6. Zip Code * 27103
7. Latitude * Enter the latitude in decimal degrees
36.0692
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.3458
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* 06/22/2020
Estimated Construction Project Start Date
10. Date to End* 06/22/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Residential, Other than SFE (1522)
Standard Industrial aassification for Developrrent

12. Acres to be 4.13
disturbed* (including off -site borrow and waste areas)
13. Total site area 5.18
(acres) *
14. Post- 1.80
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-FORSY-2020-Essex Place Apartments
Tracking ID 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 Little Creek
Wate rbody* %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 12-94-11
Index No.* NCWaterbody Index Nurrber
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. ^
F2rnittee Inforrration - Legally Fa sponsible 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 *
Past the Mall, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Linwood
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Davis
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3364090994
Telephone No.*
6. Permittee Mailing Street Address
Address* 812 Sylvan Road
Address Line 2
City
State / Rovince / Pbegion
Winston-Salem
NC
Fbstal / Zip Code
Country
27104
USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
812 Sylvan Road
Address Line 2
City
State / Frovince / Region
Winston-Salem
NC
Fbstal / Zip Code
Country
27104
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Rocky
Contact - First
Name *
2. Primary Site
Keim
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-309-1994
Telephone No.
6. Organization
Rehab Builders
Name
7. Site Contact
Street Address
Mailing Address*
401 East 4th Street
Address Line 2
city
Winston-Salem
Fbstal / Zip Code
27101
8. Consultant Name
(Optional)
Nick Buysse
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
7049026169
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 06/11/2020
Approved *
2. E&SC Plan Project EN2000027
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 Essex Place - Erosion Control Email Approval.pdf 175.36KB
Approval letter or Essex Place - Stamped Approved Sheet.pdf 921.2KB
Grading Permit
Mist be FDFforrrat
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.
8. NOI Certification NCG01 Notice of Intent Certification Form - Essex
Form 226.14KB
Place 2020-06-11.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 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
Type Name* Linwood L. Davis, Jr.
Title Manager
Organization Legally Ibsponsible Entity
Past the Mall, LLC
Date * 06/17/2020

F. Tracking and COC Info
NOI Tracking No. 27105
NC Reference No. NCG01-2020-2549
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202549
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2549
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.)