NCC212578_NOI Application_20210430

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/26/2021 9:41:44 AM (NCG01 NOI Submission)
Approve by Clark, Paul B 4/28/2021 6:27:28 PM (Review- Construction NOI 50994)
• The task was assigned to Clark, Paul B by round robin distribution 4/26/2021 9:42 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 28, 2021 5:00 PM.
The priority is: High 4/26/2021 9:42 AM
Submit by Selkane, Aziza 4/30/2021 9:42:02 AM (Payment Verification for NCC212578)
* Isaiah Koonce
• Selkane, Aziza assigned the task to Selkane, Aziza 4/30/2021 9:41 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 9, 2021 5:00 PM. The
priority is: High 4/28/2021 6:27 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * Jackson Street Water Main Replacement
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all Rios associated w ith this project.
Number(s) (PIN) Not Applicable / Military Base
2. County* Cumberland
3. Highway or Street Hamilton, Armistead, Jackson, & Ricketts
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Fort Bragg
5. State * NC
6. Zip Code* 28307
7. Latitude* Enter the latitude in decimal degrees
35.1560
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.9940
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*
05/03/2021
Estimated Construction Project Start Rate
10. Date to End *
05/03/2022
Estinated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial Oassification for Development
12. Acres to be
12.63
disturbed*
(including off -site borrow and waste areas)

13. Total site area 33.22
(acres) *
14. Post- 6.49
construction (Estirreted)
impervious area
(acres) *
NCC Project NCC-CUMBE-2021-Jackson Street Water Main Replacement
Tracking ID Assigned autorratically
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 Young Lake
Waterbody* Narreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-23-27-1
Index No. * NCWaterbody Index Nurrber
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. ^
Fternittee 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 * American States Utility Services, Inc.
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 * Timothy
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Loughman
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Utility Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-495-1311
Telephone No.*
6. Permittee Mailing Street Address
Address* 2941 Logistics Street, Bldg N-6307
Address Line 2
City
Fort Bragg
Fbstal / Zip Code
28307
Check box if the V Yes
street address the
same as mailing
address
State / Frovince / Pegion
NC
Country
us
7. Permittee Street
Street Address
Address*
2941 Logistics Street, Bldg N-6307
Address Line 2
city
State / Frovince / Faegion
Fort Bragg
NC
Postal / Zip Code
Country
28307
us
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
Jeremy
Contact - First
Name *
2. Primary Site
George
Contact - Last
Name *
3. Title
Capital Projects Supervisor
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-489-8862
Telephone No.
6. Organization
American States Utility Services, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
2941 Logistics Street, Bldg N-6307
Address Line 2
city
Fort Bragg
Fbstal / Zip Code
28307
8. Consultant Name
(Optional)
First and Last nacre
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
910-495-1311
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/22/2021
Approved *
2. E&SC Plan Project CUMBE-2021-121
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 * Fayetteville (FRO)
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 NCDEQ LETTER OF APPROVAL.pdf 803.25KB
Approval letter or Mast beRFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
Jackson Street Site Location.pdf 419.42KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NOI CERTIFICATION SIGNED.pdf 359.22KB
Form Must be RDFforrret
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
ikvcY.dSf� r�srr 11101 -
Type Name * Timothy Loughman
Title Utility Manager
Organization Legally Responsible Entity
American States Utility Services, Inc.
Date * 04/26/2021

F. Tracking and COC Info
NOI Tracking No. 50994
NC Reference No.
NCG01-2021-2578
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC212578
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 2578
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. NCC212578-2021
Invoice Due Date 5/28/2021
Initial Fee $ 100.00
Invoice Status OPEN