NCC206013_NOI Application_20210127

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/30/2020 10:37:07 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 12/31/2020 4:23:37 PM (Review- Construction NOI 39941)
• Clark, Paul reassigned the task to Garcia, Lauren V 12/30/2020 1:21 PM
* thx
• The task was assigned to Clark, Paul by round robin distribution 12/30/2020 10:37 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 1, 2021 5:00
PM 12/30/2020 10:37 AM
Subnut by Selkane, Aziza 1/27/2021 9:26:23 AM (Payment Verification for NCC206013)
* Anthony Zollicoffer
• Selkane, Aziza assigned the task to Selkane, Aziza 1/27/2021 9:25 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 11, 2021 5:00
PM 12/31 /2020 4:23 PM

.• SThF� ';
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 39812
NOI No.
Prior Reviewer Lauren Garcia
Name
1a. Project Name* Jackson Run
1 b. Specific Lot
This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID
List all Rios associated w ith this project.
Number(s) (PIN)
7763277818
7763276876
7763276824
7763275872
7763275820
7763274787
7763274735
7763273792
7763273648
7763272696
7763272644
7763275428
7763274568
7763274525
7763274284
7763273169
7763273173
7763273098
7763274013
7763274928
2. County*
Randolph
3. Highway or Street Leo Lane
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Randleman

5. State * NC
6. Zip Code* 27203
7. Latitude* Enter the latitude in decimal degrees
35.7739
8. Longitude* Enter the longitude in decimal degrees (K&STbe negative)
-79.8014
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*
11/15/2020
Estimated Construction Project Start Date
10. Date to End*
03/31/2021
Estimated Construction Project End late
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Leveloprrent
12. Acres to be
2.34
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.34
(acres) *
14. Post- 0.92
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-RANDO-2020-Jackson Run
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 Haskett Creek
Waterbody* N3rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 17-12
Index No. * NCWaterbody Index Number
Stormwater V 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 * WJH LLC
IF 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 * Dave
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Hodgman
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Regional President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9193021792
Telephone No.*
6. Permittee Mailing Street Address
Address* 3091 Governors Lake Dr, Ste 200
Address Line 2
City
Norcross
Fbstal / Zip Code
30071
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
3091 Governors Lake Dr, Ste 200
Address Line 2
city
Norcross
Fbstal / Zip Code
30071
State / Frovince / Fbgion
GA
Country
United States
State / Frovince / Faegion
GA
Country
United States
8. Type of Ojvnership is only individual if an individual is naned in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................
1. Primary Site
Tyler
Contact - First
Name *
2. Primary Site
Decker
Contact - Last
Name *
3. Title
Construction Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-817-1696
Telephone No.
6. Organization
WJH LLC
Name
7. Site Contact
Street Address
Mailing Address*
1225 Eastchester Dr
Address Line 2
City State / Province / Region
Highpoint North Carolina
Postal / Zip Code Country
27265 Guilford
8. Consultant Name (Optional)
Anthony Zollicoffer
First and Last nacre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 9193021792
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NCAs rray not populate)
12. Billing (For Annual Fee correspondence)
Telephone Default is legally responsible person telephone (older NOls rray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/18/2020
Approved *
2. E&SC Plan Project RANDO-2021-010
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 * Winston-Salem (WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan
Jacksons Run Phase 3 Lot Erosionn Control
Approval letter or
4.35MB
Permit.pdf
Grading Permit
Mast be RDFforrrat
6. Site Location Map
Wst be FDFfornat (lint 20 W)
JACKSONS RUN PHASE 3 LOT EROSION
2.79MB
CONTROL PLAN.pdf
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 if necessary.
8. NOI Certification
NCG01-eNO1-Certification-Form-20201210-DEMLR-
Form
818.38KB
SW (002)- Jacksons Run.pdf
Mist be FDFfornat
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 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 Legally Responsible Person named on this Notice of Intent
r Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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* Anthony Zollicoffer
Title Permit Coordinator
Organization Legally Plesponsible Entity
WJH LLC
Date * 12/30/2020

F. Tracking and COC Info
NOI Tracking No. 39941
NC Reference No.
NCG01-2020-6013
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC206013
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 6013
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. NCC206013-2020
Invoice Due Date 1/30/2021
Initial Fee $ 100.00
Invoice Status OPEN