NCC205423_NOI Application_20201124

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/23/2020 12:42:54 PM (NCG01 NOI Submission)
Approve by Meloy, Michael 11/23/2020 3:14:56 PM (Review- Construction NOI 36861)
• The task was assigned to Meloy, Michael by round robin distribution 11/23/2020 12:44 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 25, 2020 5:00
PM 11/23/2020 12:44 PM
Submit by Selkane, Aziza 11/24/2020 11:39:43 AM (Payment Verification for NCC205423)
* The Wooten Company
• Selkane, Aziza assigned the task to Selkane, Aziza 11/24/2020 11:39 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 4, 2021 5:00 PM
11/23/2020 3:15 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 36694
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name * FY2017 Wastewater System Improvements - Rosewood MHP
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* Robeson
3. Highway or Street Hornets Road (Rosewood MHP)
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Lumberton
5. State * NC
6. Zip Code * 28358
7. Latitude * Enter the latitude in decimal degrees
34.6373
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.9739
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* 11/23/2020
Estimated Construction Project Start Date
10. Date to End* 05/22/2021
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 24.20
disturbed* (including off -site borrow and waste areas)
13. Total site area 24.20
(acres) *
14. Post- 10.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-ROBES-2020-FY2017 Wastewater System Improvements -
Tracking ID Rosewood MHP
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 Meadow Branch (Lumber River Basin)
Wate rbody* N larre of waterbody into which stornwater runoff will discharge
15b. Waterbody 14-12-6-2
Index No.* NCWaterbody Index Nunber
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 * City of Lumberton
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 * Robert
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Armstrong
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Public Works Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-671-3851
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1388
Address Line 2
City
Lumberton
Fbstal / Zip Code
28359
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / i egion
NC
Country
us
7. Permittee Street
Street Address
Address*
500 North Cedar Street
Address Line 2
city
State / Frovince / Region
Lumberton
NC
Fbstal / Zip Code
Country
28358-5545
us
8. Type of
Government - Municipal
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jay
Contact - First
Name *
2. Primary Site
Jenkins
Contact - Last
Name *
3. Title
Site Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
252-205-4488
Telephone No.
6. Organization
Ralph Hodge Construction Company
Name
7. Site Contact
Street Address
Mailing Address*
2101-F Miller Road
Address Line 2
City
Wilson
Postal / Zip Code
27893
8. Consultant Name
(Optional)
Eric Olsen
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-828-0531
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 04/29/2020
Approved *
2. E&SC Plan Project ROBES-2020-021
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 * Fayetteville (FRO)
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 robes-2020-021.pdf 79.65KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mast be RDFfornal (lint 20 NB)
Site Location 2799-
2.91 MB
CD_Draw4ngs_LumbertonFY2017WWSyslmp_Rose...
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
8. NOI Certification 2020-11-18 NCG01 NOI Certification Form.pdf 152.26KB
Form Mast be RDFfon-rat
This is an Express F 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 * Robert Armstrong Jr.
Title Public Works Director
Organization Legally Plesponsible Entity
City of Lumberton
Date * 11/23/2020

F. Tracking and COC Info
NOI Tracking No. 36861
NC Reference No.
NCG01-2020-5423
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205423
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5423
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. NCC205423-2020
Invoice Due Date 12/23/2020
Initial Fee $ 100.00
Invoice Status OPEN