NCC203113_NOI Application_20200804

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/21/2020 11:05:48 AM (NCG01 NOI Submission)
Approve by Clark, Paul 7/21/2020 1:30:40 PM (Review- Construction NOI 28570)
• The task was assigned to Clark, Paul by round robin distribution 7/21/2020 11:06 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 23, 2020 5:00 PM
7/21/2020 11:06 AM
Submit by Selkane, Aziza 8/4/2020 9:26:12 AM (Payment Verification for NCC203113)
* Yadkin Valley Sewer Authority
• Selkane, Aziza assigned the task to Selkane, Aziza 8/4/2020 9:24 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 1, 2020 5:00
PM 7/21/2020 1:30 PM

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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 * 2018 Pump Stations Rehabilitation
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Surry
3. Highway or Street Shore St.
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Elkin
5. State * NC
6. Zip Code * 28621
7. Latitude* Enter the latitude in decimal degrees
36.2740
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-80.8580
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*
07/27/2020
Estimated Construction Project Start Date
10. Date to End *
04/16/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Developrrent
12. Acres to be
1.25
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.25
(acres) *

14. Post- 0.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-SURRY-2020-2018 Pump Stations Rehabilitation
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 Elkin Creek
Waterbody* Ibrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-54-(3.5)
Index No.* NCWaterbody Index Number
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. ^
Fbrnittee 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 *
YADKIN VALLEY SEWER AUTHORITY
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Nicole
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Johnston
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Executive Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3368359819
Telephone No.*
6. Permittee Mailing Street Address
Address* 500 NC Hwy 268 W
Address Line 2
City State / Rovince / F;bgion
ELKIN NC
Fbstal / Zip Code Country
286212812 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
500 NC Hwy 268 W
Address Line 2
City
State / Ftovince / Region
ELKIN
NC
Fbstal / Zip Code
Country
286212812
us
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Nicole
Contact - First
Name *
2. Primary Site
Johnston
Contact - Last
Name *
3. Title
Executive Director
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
3368359819
Telephone No.
6. Organization
YADKIN VALLEY SEWER AUTHORITY
Name
7. Site Contact
Street Address
Mailing Address*
500 NC HIGHWAY 268 W
Address Line 2
city
ELKIN
Fbstal / Zip Code
286212812
8. Consultant Name
(Optional)
West Consultants, PLLC
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
8285224728
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 07/08/2019
Approved *
2. E&SC Plan Project SURRY-2019-030
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 * Winston-Salem (WSRO)
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 SURRY-2019-030--EC approval.pdf 315.34KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Shore St PS Abandonment Location Map.pdf 1.36MB
Mast be RFformat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
Impervious area = 0 as all work is within non -paved easements and
no asphalt or other is on shown on the plans
8. NOI Certification 2018 PS Rehab NOI Certification Form.pdf 49.79KB
Form Wst be RDFformat
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
Type Name * Nicole Johnston
Title Executive Director
Organization Legally Responsible Entity
Yadkin Valley Sewer Authority
Date * 07/21 /2020

F. Tracking and COC Info
NOI Tracking No. 28570
NC Reference No.
NCG01-2020-3113
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203113
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 3113
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. NCC203113-2020
Invoice Due Date 8/20/2020
Initial Fee $ 100.00
Invoice Status OPEN