NCC210657_NOI Application_20210203

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/1/2021 4:42:13 PM (NCG01 NOI Submission)
Approve by Gamble, Aana C 2/2/2021 9:58:12 AM (Review- Construction NOI 42541)
• Garcia, Lauren V reassigned the task to Gamble, Aana C 2/2/2021 8:56 AM
• The task was assigned to Garcia, Lauren V by round robin distribution 2/1/2021 4:42 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 3, 2021 5:00
PM 2/1/2021 4:42 PM
Submit by Selkane, Aziza 2/3/2021 9:29:54 AM (Payment Verification for NCC210657)
* Christopher Roberts
• Selkane, Aziza assigned the task to Selkane, Aziza 2/3/2021 9:29 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 16, 2021 5:00 PM
2/2/2021 9:58 AM

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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 42017
NOI No.
Prior Reviewer Aana Gamble
Name
1a. Project Name * Elliott Road Extension - Phase 1
1 b. Specific Lot
This field may be used to list specifc lot nunbers.
Numbers
This is a new Town road - starts at
intersection of Fordham Blvd and ends at
Ephesus Church Street
1 c. Parcel ID
List all RW associated w ith this project.
Number(s) (PIN)
No Pins - New road Does begin at 4 Bypass
Lane with Pin: 9799-34-0248
2. County*
Orange
3. Highway or Street South Elliott Road and Fordham Blvd.
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Town of Chapel Hill
5. State * NC
6. Zip Code* 27514
7. Latitude* Enter the latitude in decimal degrees
35.9325
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-79.0237
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* 01/22/2021
Estirrated Construction Project Start Date

10. Date to End *
03/01 /2023
Estinated Construction Project End Cate
11. SIC (Primary)*
Highway (1611)
Standard Industrial aassification for Developrnent
12. Acres to be
1.18
disturbed*
(including off -site borrow and waste areas)
13. Total site area 4.00
(acres) *
14. Post- 3.90
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-ORANG-2021-Elliott Road Extension - Phase 1
Tracking ID Assignedautorraticaly
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 Booker Creek - Jordan
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-41-1-15-2-(5)
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 Responsible Entity
Name * Town of Chapel Hill
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 * Lance
If Corporation, enter Registered Agent First %rre
3. Last Name* Norris
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Public Works Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-969-5100
Telephone No.*
6. Permittee Mailing Street Address
Address* 6850 Millhouse Road
Address Line 2
Building #1
City
Chapel Hill
Fbstal / Zip Code
27516
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
6850 Millhouse Road
Address Line 2
Building #1
city
Chapel Hill
Fbstal / Zip Code
27516
State / Ffovince / Fbgion
North Carolina
Country
United States
State / Frovince / Region
North Carolina
Country
United States
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Government -Municipal

C. Site Contact Information
Part C.
^
Project Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Chris
Contact - First
Name *
2. Primary Site
Roberts
Contact - Last
Name *
3. Title
Manager of Engineering and Infrastructure
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-624-8984
Telephone No.*
6. Organization
Town of Chapel Hill
Name
7. Site Contact
Street Address
Mailing Address*
6850 Millhouse Road
Address Line 2
City
State / Province / Region
Chapel Hill
North Carolina
Postal / Zip Code
Country
27516
United States
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
919-969-5100
Default is legally responsible person telephone

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/30/2020
Approved *
2. E&SC Plan Project ORANG-2021-004
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. 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 ORANG-2021-004_20201030_LOA.pdf 267.1KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFfornat (lint 20IVB)
Town of Chapel Hill Elliott Road Extension Project
40.62KB
Vicinity Map.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.
Updated and clearer NOI attached
8. NOI Certification 2021-02-01 - Updated NOI - Elliott Road Ext Phase
Form 1.pdf 245.92KB
Mist be RDFfornat
This is an Express F 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:* IT The Legally Responsible Person named on this Notice of Intent
f 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* Lance Norris
Title Public Works Director
Organization Legally Responsible Entity
Town of Chapel Hill
Date * 02/01 /2021

F. Tracking and COC Info
NOI Tracking No. 42541
NC Reference No.
NCG01-2021-0657
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC210657
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 657
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC210657-2021
Invoice Due Date 3/4/2021
Initial Fee $ 100.00
Invoice Status OPEN