NCC204801_NOI Application_20201026

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/22/2020 12:33:53 PM (NCG01 NOI Submission)
Approve by Clark, Paul 10/23/2020 2:58:51 PM (Review- Construction NOI 33827)
• The task was assigned to Clark, Paul by round robin distribution 10/22/2020 12:34 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 26, 2020 5:00
PM 10/22/2020 12:34 PM
Submit by Selkane, Aziza 10/26/2020 8:38:39 AM (Payment Verification for NCC204801)
* Dan Porter
• Selkane, Aziza assigned the task to Selkane, Aziza 10/26/2020 8:37 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 4, 2020 5:00
PM 10/23/2020 2:59 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 * Camden Commerce Park
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Camden
3. Highway or Street US Hwy 17
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* South Mills
5. State * NC
6. Zip Code * 27976
7. Latitude* Enter the latitude in decinal degrees
36.5205
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-76.3614
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*
11/02/2020
Estinated Construction Project Start Date
10. Date to End*
11/20/2020
Estirrated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial Classification for Developrrent
12. Acres to be
21.26
disturbed*
(including off -site borrow and waste areas)
13. Total site area 98.49
(acres) *

14. Post- 1.83
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-CAMDE-2020-Camden Commerce Park
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 Dismal Swamp Canal
Waterbody* Ibrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 30-3-2
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. ^
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 * Camden County
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 * Ken
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Bowman
It Corporation, enter Pbegistered Agent Last %rre
3b. Title County Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 252-338-6363
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 190
Address Line 2
City
Camden
Fbstal / Zip Code
27921
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Fbgion
North Carolina
Country
United States
7. Permittee Street
Street Address
Address*
117 NC Hwy 343 North
Address Line 2
city
State / Frovince / Region
Camden
North Carolina
Fbstal / Zip Code
Country
27921
Untied States
8. Type of
Government - County
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Dan
Contact - First
Name *
2. Primary Site
Porter
Contact - Last
Name *
3. Title
Camden County Planning Director
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
252-338-1919 Ext. 263
Telephone No.
6. Organization
Camden County
Name
7. Site Contact
Street Address
Mailing Address*
PO Box74
Address Line 2
city
Camden
Fbstal / Zip Code
27921
8. Consultant Name
(Optional)
Bill Roark
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-378-9111
Telephone No.
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/19/2020
Approved *
2. E&SC Plan Project Camde-2011-001
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 * Washington (WaRO)
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 Camde-201 1 -001 Camden Commerce Park -
Approval letter or 716.92KB
10192020 (REV).pdf
Grading Permit
Mast be RDFfon-rat
6. Site Location Map Helpful for linear project review
(Optional) F-1 USGS Quad Map.pdf 199.23KB
Mast be RDFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Provide 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 Form signed.pdf 180.21KB
Form Mast be RDFfornat
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 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 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 * Kenneth L. Bowman
Title County Manager
Organization Legally Plesponsible Entity
Camden County, NC 27921
Date * 10/22/2020

F. Tracking and COC Info
NOI Tracking No. 33827
NC Reference No. NCG01-2020-4801
Uses 'count_nunber' variable (increrrented by SP)
Certificate of NCC204801
Coverage (COC) Uses 'count nurrber' variable (increrrented by SP)
No.*
Count Number 4801
Sequential nunber for subnittal 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. NCC204801-2020
Invoice Due Date 11/22/2020
Initial Fee $ 100.00
Invoice Status OPEN