NCC205643_NOI Application_20201209

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/4/2020 9:36:20 AM (NCG01 NOI Submission)
Approve by Morman, Alaina 12/7/2020 6:06:25 PM (Review- Construction NOI 38099)
• The task was assigned to Morman, Alaina by round robin distribution 12/4/2020 9:37 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 8, 2020 5:00
PM 12/4/2020 9:37 AM
Submit by Selkane, Aziza 12/9/2020 3:47:35 PM (Payment Verification for NCC205643)
* Lee County
• Selkane, Aziza assigned the task to Selkane, Aziza 12/9/2020 3:47 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 18, 2021 5:00 PM
12/7/2020 6:06 PM

.• SThF� ';
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 * Kiwanis Children's Park
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Lee
3. Highway or Street 101 ParkAve
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Sanford
5. State * NC
6. Zip Code * 27330
7. Latitude* Enter the latitude in decinal degrees
35.4750
8. Longitude* Enter the longitude in decir al degrees (MJST be negative)
-79.1890
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*
12/10/2020
Estimated Construction Project Start Date
10. Date to End *
12/10/2021
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial Cassification for Developrrent
12. Acres to be
1.88
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.54
(acres) *

14. Post- 1.09
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-LEE-2020-Kiwanis Children's Park
Tracking ID 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 Skunk Creek
Waterbody* %rm of waterbody into which stornwater runoff will discharge
15b. Waterbody 17-40-1
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.
Rarmttee 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 PesponsibleEntity
Name * Lee County
If perrrittee is an individual (i.e., organization does not apply), enter first and last nave 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 * John
If Corporation, enter Faegistered Agent First Nerre
3. Last Name* Crumpton
If Corporation, enter Fbgistered Agent Last I\brre
3b. Title County Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-718-4605
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box 1968
Address Line 2
City
Sanford
Postal / Zip Code
27330
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
r" Yes
Street Address
408 Summitt Drive
Address Line 2
UY
Sanford
Fbstal / Zip Code
27330-3840
8. Type of Government - County
Ownership*
State / Province / Fbgion
NC
Country
USA
State / Province / Pegion
NC
Country
US

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jacob
Contact - First
Name *
2. Primary Site
Smith
Contact - Last
Name *
3. Title
Construction Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-742-9410
Telephone No.
6.Organization
WithersRavenel
Name
7. Site Contact
Street Address
Mailing Address*
115 Mackenan Drive
Address Line 2
city
Cary
Postal / Zip Code
27511-7903
8. Consultant Name
(Optional)
Amy McDonald
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-427-4322
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/01/2019
Approved *
2. E&SC Plan Project LEE-2020-012
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 * Raleigh (RRO)
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 LEE-2020-012 Kiwanis Childrens
Approval letter or 453.5KB
Park_20191101_LOA.pdf
Grading Permit
Mist be R7Ffon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Kiwanis Childrens Park —Site Location.pdf 713.41KB
Rease do not upload entire set of E&SC plans.
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 Kiwanis Childrens Park _Site Location.pdf 713.41KB
Form Kiwanis Children's Park NOI Certification Form.pdf 465.45KB
Mast be R7Ffon-rat
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
?ir�rrrrrr
Type Name * John Crumpton
Title County Manager
Organization Legally Plesponsible Entity
Lee County
Date * 12/04/2020

F. Tracking and COC Info
NOI Tracking No. 38099
NC Reference No.
NCG01-2020-5643
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205643
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5643
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. NCC205643-2020
Invoice Due Date 1/6/2021
Initial Fee $ 100.00
Invoice Status OPEN