NCC203231_Modification Review LOTS 204 344_20210415

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/14/2021 2:22:06 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/15/2021 6:30:16 AM (Construction COC ADD TO FILE Review- NCC203231)
• The task was assigned to Georgoulias, Bethany. The due date is: April 19, 2021 5:00 PM
4/14/2021 2:22 PM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC203231
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
75 Leven Links Lane
Address
75 Leven Links Ln, Pinehurst, NC
County
Moore
Latitude
35.1903
Longitude
-79.4307
Permittee Listed
Homes by Dickerson INC
Legally Responsible
Jonathan Showalter
Individual
NC Reference No.
NCG01-2020-3231
E&SC Plan ID
20-3200
Original NOI
28911
Tracking No.*
Date COC Issued*
07/29/2020
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This field will populate only if CCChas already been rescinded.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 Modifying to add lots 204 and 344 Pinehurst national
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 Docurrentation (%vised EBSC Approval, (lose -Out Doc, etc.)
Documentation 48-0204 Minor EC Approval.pdf 100.42KB
48-0344 Minor EC Approval.pdf 101.27KB
Wst be FDFforrrat
North Carolina General Statute 143-215.6113 (i) 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 exceed ten thousand
dollars ($10,000).
� 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
�i�rar�f�ar 4 Ss/'tco-r�-r�~Rt
Type Name* Jonathan M Showalter
Title * COO / VP
Organization* Homes by Dickerson INC
Date * 04/14/2021
Email Address* [e-mail]
Emil for confin-ration
Telephone Number* 9198474447
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confin-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 04/15/2021
Rescinded Since
Submitted?

Request Date 20210414
Formatted
Review Date 20210415
Formatted