NCC190335_NOT Closeout Documents_20210331

SEDIMENTATION INSPECTION REPORT (City of Winston-Salem/Forsyth County)
Winston-Salem Traffic Field Operations Department Permit #: EN1900073
Erosion Control Division
P.O. Box 2511 Date: 12/15/2020
Winston-Salem, NC 27102
Report by: Wesley Williams
Revised 7-1-19 Phone: [phone]
Project: Location:
The Gables at Bridgton Place Ph. 2 Sect. 3 399 Inlet Place Drive
1. Pictures: ("x" One) Yes: No: X
2. Potential for NPDES Violation: ("x" One) Yes: No: X Describe:
3. Weather and soil conditions: Sun/Wet Initial inspection: ("x" One) Yes: No: X
4. Is site currently under notice of violation? ("x" One) Yes: No: X
5. Is the site in compliance with S.P.C.A. and rules? ("x" One) Yes: X No: If no, check violations below:
6. Violations: ("X" all applicable sections)
( )--- No approved plan, [UDO See. 5-7 (G) ; & G.S. 113A-57 (4) and 15A N.C.A.C4B.0107(c)]
( )--- Failure to follow approved plan, [UDO Sec.5-20.1; & G.S. 113A-61.1]
( )--- Failure to submit revised plan, [UDO Sec. 5-18.2; & G.S. 113A-54.1(b) and 15A N.C.A.C. 4B.0118(a)]
( )--- Failure to provide adequate groundcover, [UDO Sec. 5-7 (D)(1); & G.S. 113A-57(3); & 15A N.C.A.C. 413.0007(b) or 15A N.C.A.C.
4B.0124(e)]
( )--- Insufficient measures to retain sediment on site, [UDO Sec. 5-7 (D)(1); & G.S. 113A-57(3)]
( )--- Failure to take all reasonable measures, LUDO Sec. 5-5.2; & 15A N.C.A.C.4130105]
( )--- Inadequate buffer zone, [UDO Sec. 5-7 (A); & G.S. 113A-57(1)]
( )--- Graded slopes and fills too steep, [UDO Sec. 5-7 (B); & G.S. 113A-57(2) or 15A N.C.A.C. 413.0124(d)]
( )--- Unprotected exposed slopes, [ UDO Sec. 5-7 (D)(2); & G.S. 113A-57(2)]
( )--- Failure to install and maintain erosion control measures, [UDO Sec. 5-13; & 15A N.C.A.C. 4B.0113]
( )--- Failure to keep current self -inspection records, [G.S. 113A-54.1 & 15A NCAC 0413. 0131]
( )--- Other (describe):
7. Contact made with (name): Bruce Hubbard Title
8. Contact Method: phone # () email (x) fax # () letter() person ( )
9. Corrective actions needed:
No corrective actions needed at the time of inspection.
10. Comments: () No devices in place ( ) Additional devices needed ( ) Devices need maintenance (X) Devices in & functioning
( ) No seeding noted ( ) Partially seeded (X) Areas seeded ( ) Off -site sedimentation (Yes) Project in compliance
The site is in stable condition and all phases of construction are complete per the approved plan. Please submit for the
eNOT and provide documentation.

Print this form, complete, scan and upload to the electronic NOT (Rescission) form,
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: C I q a�
Name of Project:�T�� Pti3 C
d a4vv Sec
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater
Permit for the subject facility. I am familiar with the information contained in this request, and to the best
of my knowledge and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: �1��g V� iI\ ST(Vr- Cc _9
*Legally Responsible Person: _ Ali L e--��-
Title of Legally Responsible Person:
*Signature:
Print Name and
Date:
e of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.