NCC203231_Modification Review LOT 354_20210521

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/19/2021 4:44:35 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 5/21/2021 7:48:38 AM (Construction COC ADD TO FILE Review -
NCC203231)
• The task was assigned to Georgoulias, Bethany A. The due date is: May 24, 2021 5:00 PM
5/19/2021 4:44 PM

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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This field will populate only if CCChas already been rescinded.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 Lot 354 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 Documentation (%vised ESCApproval, (lose -Out Doc, etc.)
Documentation 48-0354 Letter of Approval.PDF 101.8KB
Mast be FDFfon-rat
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 Artide; 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).
17 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�~�t
Type Name* Jonathan M Showalter
Title * COO / VP
Organization* Homes by Dickerson INC
Date * 05/19/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9198474447
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional errail for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 05/21/2021
Rescinded Since
Submitted?

Request Date 20210519
Formatted
Review Date 20210521
Formatted