NCC203826_NOI Application_20200902

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/1/2020 10:56:07 AM (NCG01 NOI Submission)
Approve by Clark, Paul 9/1/2020 12:15:14 PM (Review- Construction NOI 30780)
• The task was assigned to Clark, Paul by round robin distribution 9/1/2020 10:56 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 3, 2020 5:00
PM 9/1/2020 10:56 AM
Submit by Selkane, Aziza 9/2/2020 3:53:17 PM (Payment Verification for NCC203826)
* Stocks Engineering, P.A.
• Selkane, Aziza assigned the task to Selkane, Aziza 9/2/2020 3:52 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 13, 2020 5:00 PM
9/1/2020 12:15 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 * Bojangles at Spring Hope, NC
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Nash
3. Highway or Street South NC 581
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Spring Hope
5. State * NC
6. Zip Code * 27882
7. Latitude* Enter the latitude in decinal degrees
35.9342
8. Longitude* Enter the longitude in decir al degrees (MJST be negative)
-78.0991
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*
09/15/2020
Estimated Construction Project Start Date
10. Date to End *
05/03/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
14.26
disturbed*
(including off -site borrow and waste areas)
13. Total site area 74.11
(acres) *

14. Post- 4.71
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-NASH-2020-Bojangles at Spring Hope, NC
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 Hendricks Creek
Waterbody* Dame of waterbody into which storrrwater runoff will discharge
15b. Waterbody 28-55-2
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.
Rarmttee 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 PesponsibleEntity
Name * It's Farm Time, LLC
If perrrittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Brad
If Corporation, enter Faegistered Agent First Nerre
3. Last Name* Mercer
If Corporation, enter Fbgistered Agent Last I\brre
3b. Title Director of Real Estate
4. Permitee E-mail [e-mail]
Address*
5. Permittee 1-800-366-9921
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box277
Address Line 2
City
Kinston
Postal / Zip Code
28502
Check box if the r Yes
street address the
same as mailing
address
State / Province / Fbgion
NC
Country
us
7. Permittee Street
Street Address
Address*
377 North Queen Street
Address Line 2
City
State / Province / Pegion
Kinston
NC
Fbstal / Zip Code
Country
28501
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Kevin
Contact - First
Name *
2. Primary Site
Varnell
Contact - Last
Name *
3. Title
Chief Operations Officer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
252-459-8196
Telephone No.
6. Organization
Stocks Engineering
Name
7. Site Contact
Street Address
Mailing Address*
801 East Washington Street
Address Line 2
City
Nashville
Fbstal / Zip Code
27856
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
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 09/01/2020
Approved *
2. E&SC Plan Project NASF-1-2021-001
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 * Raleigh (RRO)
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 Permit NASH-2021-
Approval letter or
325.06KB
00120200901 _LOA. pdf
Grading Permit
Mist be FCFfon-rat
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 Bojangles Signed Form.pdf 824.07KB
Form
Mist 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 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
r 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 * Brad Mercer
Title Director of Real Estate
Organization Legally Plesponsible Entity
It's Farm Time, LLC
Date * 09/01 /2020

F. Tracking and COC Info
NOI Tracking No. 30780
NC Reference No.
NCG01-2020-3826
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203826
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3826
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. NCC203826-2020
Invoice Due Date 10/1/2020
Initial Fee $ 100.00
Invoice Status OPEN