NCC203940_NOI Application_20200909

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/4/2020 4:57:47 PM (NCG01 NOI Submission)
Approve by Clark, Paul 9/8/2020 12:06:28 PM (Review- Construction NOI 31031)
• Gwinn, Matt reassigned the task to Clark, Paul 9/8/2020 8:07 AM
. The task was assigned to Gwinn, Matt by round robin distribution 9/4/2020 4:58 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 8, 2020 5:00
PM 9/4/2020 4:58 PM
Submit by McCoy, Suzanne 9/9/2020 1:40:24 PM (Payment Verification for NCC203940)
* Homestead Vetemary
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/9/2020 1:39 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 20, 2020 5:00 PM
9/8/2020 12:06 PM

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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 30906
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Homestead Veterinary Clinic
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* Wake
3. Highway or Street 1710 & 1750 Old Reedy Creek Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Cary
5. State * NC
6. Zip Code * 27513
7. Latitude * Enter the latitude in decimal degrees
35.8326
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.7803
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* 09/14/2020
Estimated Construction Project Start Date
10. Date to End* 05/31/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Developrrent

12. Acres to be 1.48
disturbed* (including off -site borrow and waste areas)
13. Total site area 2.98
(acres) *
14. Post- 0.41
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-Homestead Veterinary Clinic
Tracking ID Assignedautonatically
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 tributary of Crabtree Creek
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-33-(3.5)
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional Waterbody narre
Receiving
Waterbody
15d. Waterbody NCWaterbody Index Nunber
Index No.
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nunber
Index No.
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 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 * lerne Enterprises, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre 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 * Randy
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Dunn
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-522-3896
Telephone No.*
6. Permittee Mailing Street Address
Address* 2232 Old Reedy Creek Road
Address Line 2
City
Cary
Fbstal / Zip Code
27513
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Fbgion
NC
Country
United States
7. Permittee Street
Street Address
Address*
lerne Enterprises, LLC
Address Line 2
2232 Old Reedy Creek Road
City
State / Ftovince / Faegion
Cary
NC
Fbstal / Zip Code
Country
27513
Wake
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Gabe
Contact - First
Name *
2. Primary Site
Everhart
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-727-7286
Telephone No.
6. Organization
J. D. Beam, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
1812 Tillery Place
Address Line 2
Suite 100
city
Raleigh
Fbstal / Zip Code
27604
8. Consultant Name
(Optional)
Leigh Potts
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-607-0323
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 08/28/2020
Approved *
2. E&SC Plan Project 19-DP-0175
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Cary
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
Approval Letter.pdf 55.78KB
Approval letter or
Mast beRDFformat
Grading Permit
6. Site Location Map
Helpful for linear project review
(Optional)
area map.pdf 2.9MB
Mast be RDF format. 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.
Approval Letter & Site Location Map provided in previous
submission.
8. NOI Certification
NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form
698.5KB
SW Signed.pdf
Mast be R7Ffon-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 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* Randy Dunn
Title Manager
Organization Legally Iesponsible Entity
lerne Enterprises, LLC
Date * 09/04/2020

F. Tracking and COC Info
NOI Tracking No. 31031
NC Reference No.
NCG01-2020-3940
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203940
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3940
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. NCC203940-2020
Invoice Due Date 10/8/2020
Initial Fee $ 100.00
Invoice Status OPEN