NCC203262_NOI Application_20200731

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/28/2020 8:25:46 AM (NCG01 NOI Submission)
Approve by Clark, Paul 7/30/2020 7:52:00 AM (Review- Construction NOI 28918)
• Farkas, Jim J reassigned the task to Clark, Paul 7/29/2020 3:15 PM
. The task was assigned to Farkas, Jim J by round robin distribution 7/28/2020 8:25 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 30, 2020 5:00 PM
7/28/2020 8:25 AM
Submit by Selkane, Aziza 7/31/2020 8:11:00 AM (Payment Verification for NCC203262)
* Town of Granite Quarry
• Selkane, Aziza assigned the task to Selkane, Aziza 7/31/2020 8:10 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 10, 2020 5:00
PM 7/30/2020 7:52 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 28834
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Town of Granite Quarry Leaf & Limb Site
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* Rowan
3. Highway or Street 1040 Mar Rock
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Granite Quarry
5. State * NC
6. Zip Code * 28072
7. Latitude * Enter the latitude in decimal degrees
35.6038
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.4428
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* 07/31/2020
Estimated Construction Project Start Date
10. Date to End* 08/03/2020
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 1.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 7.53
(acres) *
14. Post- 1.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-ROWAN-2020-Town of Granite Quarry Leaf & Limb Site
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 Church Creek
Waterbody* fume of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-115.5
Index No.* NCWaterbody Index Ninber
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. ^
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 *
Town of Granite Quarry
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Jason
IF Corporation, enter Faegistered Agent First Wre
3. Last Name*
Hord
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Maintenance Supervisor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7042795596
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box351
Address Line 2
city
State / Rovince / Pbegion
Granite Quarry
NC
Fbstal / Zip Code
Country
28072
USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
143 N. Salisbury Ave
Address Line 2
city
State / Ftovince / Region
Granite Quarry
NC
Fbstal / Zip Code
Country
28072
USA
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Jason
Contact - First
Name *
2. Primary Site Hord
Contact - Last
Name *
3. Title Maintenance Supervisor
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 7042795596
Telephone No.*
6. Organization Town of Granite Quarry
Name
7. Site Contact Street Address
Mailing Address* PO Box351
Address Line 2
city
Granite Quarry
Fbstal / Zip Code
28072
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 / Pegion
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/22/2020
Approved *
2. E&SC Plan Project ROWAN-2020-007
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 Erosion Control Approval - Leaf and Limb.pdf 214.82KB
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 NCG01- NOI.pdf 83.66KB
Form Mist be RDFfornat
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 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 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
['/rzJC¢r ���r•`t�
Type Name * Jason Hord
Title Maintenance Supervisor
Organization Legally Responsible Entity
Town of Granite Quarry
Date * 07/28/2020

F. Tracking and COC Info
NOI Tracking No. 28918
NC Reference No.
NCG01-2020-3262
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203262
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3262
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC203262-2020
Invoice Due Date 8/29/2020
Initial Fee $ 100.00
Invoice Status OPEN