NCC201410_Modification Review_20210408

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/7/2021 2:46:57 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/8/2021 8:15:05 AM (Construction COC ADD TO FILE Review- NCC201410)
• The task was assigned to Georgoulias, Bethany. The due date is: April 12, 2021 5:00 PM
4/7/2021 2:47 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC201410
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Lots @ Ingleside: D.R. Horton
Address
S. Ingleside Farm Road, Iron Station, NC
County
Lincoln
Latitude
35.4501
Longitude
-81.0391
Permittee Listed
D.R. Horton, Inc.
Legally Responsible
Bart Carroll
Individual
NC Reference No.
NCG01-2020-1410
E&SC Plan ID
20-ML-01
Original NOI
24030
Tracking No.*
Date COC Issued*
05/11/2020
Prior Rescission
This field will populate only if CCChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Permit Approval for Lots 270-283
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).
For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (%vised ERSC Approval, (lose -Out Doc, etc.)
Documentation Ingleside Farms Lots 4.7.2021.pdf 1.27MB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto e)ceed ten thousand
dollars ($10,000).
rJ I hereby request modification to coverage under the NPDES Stormwater Permit
for the subject project site. 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.
Specify if you are:* r The Legally Responsible Individual
f Authorized Responsible Person*
*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 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* Bart Carroll
Title * NPDES Manager
Organization* D.R. Horton, Inc.
Date * 04/07/2021
Email Address* [e-mail]
57ail for confirmation
Telephone Number* 704-620-7373
Contact nurrber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 04/08/2021
Rescinded Since
Submitted?

Request Date 20210407
Formatted
Review Date 20210408
Formatted