NCC203076_Modification Review_20201007

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/7/2020 8:59:18 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/7/2020 9:01:37 AM (Construction COC ADD TO FILE Review- NCC203076)
• The task was assigned to Georgoulias, Bethany. The due date is: October 12, 2020 5:00 PM
10/7/2020 8:59 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of
NCC203076
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Seven Hills Subdivision
Address
4852 Seven Hills Road, Pfafftown, NC
County
Forsyth
Latitude
36.1882
Longitude
-80.4102
Permittee Listed
Gregory Garrett
Legally Responsible
Gregory Garrett
Individual
NC Reference No.
NCG01-2020-3076
E&SC Plan ID
EN2000104
Original NOI
28428
Tracking No.*
Date COC Issued*
07/20/2020
Prior Rescission
This field will populate only if CCChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
f Multiple Reasons (List)
Addional IVbre information if necessary
Explanation
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets). For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation Seven Hills COWS Erosion Revision approval
71.22KB
letter. pdf
Wst be FDFfornat
North Carolina General Statute 143-215.6113 (i) provides that:
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto exceed ten thousand
dollars ($10,000).
� I hereby request modification to coverage under the NPDES Stormwater Permit
for the subject project site. I am familiar with the information contained in this
request and to the best of my knowledge and belief such information is true,
complete and accurate.
Specify if you are:* r The Legally Responsible Individual
f Authorized Responsible Person*
*This form must be signed by a responsible corporate officer that 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
C�1"'-Z75-
Type Name* Gregory Garrett
Title * Owner
Organization* Braxton Development
Date * 10/07/2020
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 3363997197
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confin-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 10/07/2020
Rescinded Since
Submitted?

Request Date 20201007
Formatted
Review Date 20201007
Formatted