NCC204640_NOI Application_20201015

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/13/2020 1:47:01 PM (NCG01 NOI Submission)
Approve by Clark, Paul 10/14/2020 9:06:30 AM (Review- Construction NOI 33051)
• The task was assigned to Clark, Paul by round robin distribution 10/13/2020 1:47 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 15, 2020 5:00
PM 10/13/2020 1:47 PM
Submit by Selkane, Aziza 10/15/2020 8:58:10 AM (Payment Verification for NCC204640)
* Ronald R. Lappin
• Selkane, Aziza assigned the task to Selkane, Aziza 10/15/2020 8:57 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 25, 2020 5:00
PM 10/14/2020 9:06 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 * First United Pentecostal Church of Greenville New Sanctuary
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Pitt
3. Highway or Street 2950 South Memorial Drive
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Greenville
5. State * NC
6. Zip Code * 27834
7. Latitude* Enter the latitude in decimal degrees
35.5808
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-77.3971
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*
11/30/2020
Estinated Construction Project Start Date
10. Date to End*
11/19/2021
Estirrated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Cassification for Developrrent
12. Acres to be
2.70
disturbed*
(including off -site borrow and waste areas)
13. Total site area 5.90
(acres) *

14. Post- 1.97
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-PITT-2020-First United Pentecostal Church of Greenville New
Tracking ID Sanctuary
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 Greens Mill Run
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 28-96
Index No.* NCWaterbody Index Number
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. ^
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 * First United Pentecostal Church of Greenville, N. C.
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 * Ronald
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Lappin
It Corporation, enter Pbegistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 252-757-3033
Telephone No.*
6. Permittee Mailing Street Address
Address* 2950 South Memorial Drive
Address Line 2
City State / Frovince / Fbgion
Greenville NC
Fbstal / Zip Code Country
27834-6223 US
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2950 South Memorial Drive
Address Line 2
City
State / Frovince / Region
Greenville
NC
Fbstal / Zip Code
Country
27834-6223
US
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Igor
Contact - First
Name *
2. Primary Site
Palyvoda
Contact - Last
Name *
3. Title
Vice President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
252-756-1390
Telephone No.*
6. Organization
Baldwin Design Consultants, PA
Name
7. Site Contact
Street Address
Mailing Address*
1700-D East Arlington Boulevard
Address Line 2
City
State / Rovince / Region
Greenville
NC
Fbstal / Zip Code
Country
27858
us
8. Consultant Name
(Optional)
Igor Palyvoda
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
252-756-1390
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/09/2020
Approved *
2. E&SC Plan Project ESCP-2020-0024
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Greenville
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
ESCP-2020-0024-First United Pentecostal Church
Approval letter or
225.83KB
of Greenville. Approval.pdf
Grading Permit
Mist be FDFfon-rat
6. Site Location Map
Helpful for linear project review
(Optional)
Mast be FDFfornat. 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
19-040 - First United Pentecostal Church of
Form
83.92KB
Greenville -Signed NOI Certification Form.pdf
Mast be FDFformat
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 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 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* Ronald Ray Lappin
Title President
Organization Legally Iesponsible Entity
First United Pentecostal Church of Greenville, N. C.
Date * 10/13/2020

F. Tracking and COC Info
NOI Tracking No. 33051
NC Reference No.
NCG01-2020-4640
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC204640
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 4640
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. NCC204640-2020
Invoice Due Date 11/13/2020
Initial Fee $ 100.00
Invoice Status OPEN