NCC203612_NOI Application_20200820

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/18/2020 1:34:39 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 8/19/2020 10:54:23 AM (Review- Construction NOI 30064)
•
• The task was assigned to Morman, Alaina by round robin distribution 8/18/2020 1:36 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 20, 2020 5:00
PM 8/18/2020 1:36 PM
Submit by McCoy, Suzanne 8/20/2020 8:32:12 AM (Payment Verification for NCC203612)
* Henry VanPala
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/20/2020 8:31 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 30, 2020 5:00
PM 8/19/2020 10:54 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 * Carthusiast
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Johnston
3. Highway or Street 10459 NC HWY 50
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township * Pleasant Grove Township
5. State * NC
6. Zip Code * 27501
7. Latitude* Enter the latitude in decimal degrees
35.5136
8. Longitude* Enter the longitude in decir al degrees (KUST be negative)
-78.5797
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*
08/24/2020
Estimated Construction Project Start Date
10. Date to End *
05/28/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
1.27
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.79
(acres) *

14. Post- 0.48
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-JOHNS-2020-Carthusiast
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
unnamed pond then camp branch tributary
Waterbody*
to black creek
%rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody
27-45-6
Index No.*
NCWaterbody Index Nunber
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 *
Henry Van Pala
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Henry
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Van Pala
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-795-1399
Telephone No.*
6. Permittee Mailing Street Address
Address* 2500 Dunhaven Drive
Address Line 2
Cty
Garner
Fbstal / Zip Code
27529-5104
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address *
V Yes
Street Address
2500 Dunhaven Drive
Address Line 2
city
Garner
Fbstal / Zip Code
27529-5104
8. Type of Individual
Ownership*
State / Rovince / Legion
NC
Country
us
State / Frovince / Region
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
John
Contact - First
Name *
2. Primary Site
O'Brien
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
843-546-2667
Telephone No.
6. Organization
Consensus Construction & Consulting
Name
7. Site Contact
Street Address
Mailing Address*
4722 A HWY 17 Bypass South
Address Line 2
city
Myrtle Beach
Fbstal / Zip Code
29588
8. Consultant Name
(Optional)
KCI Associates of North Carolina, Inc.
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-278-2554
Telephone No.
State / Rovince / Region
SC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 08/17/2020
Approved *
2. E&SC Plan Project JC# 20-047-P
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Johnston 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 20-047 Carthusiast ESC appr 8.17.2020 (002).pdf 93.72KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) C-1 COVER.pdf 811.24KB
Mast be RDFformat. 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.
8. NOI Certification eNO1 Certification Signed 2.pdf 641.58KB
Form Wst be RDF format
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
Type Name* Henry Van Pala
Title Owner
Organization Legally Ibsponsible Entity
Henry Van Pala
Date * 08/18/2020

F. Tracking and COC Info
NOI Tracking No. 30064
NC Reference No.
NCG01-2020-3612
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203612
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3612
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. NCC203612-2020
Invoice Due Date 9/18/2020
Initial Fee $ 100.00
Invoice Status OPEN