NCC213352_NOI Application_20210603

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/1/2021 6:36:18 PM (NCG01 NOI Submission)
Approve by EADS\bcbroussard 6/2/2021 9:09:30 AM (Review- Construction NOI 54536)
. The task was assigned to EADS\bcbroussard by round robin distribution 6/1/2021 6:37 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 3, 2021 5:00 PM
6/1/2021 6:37 PM
Submit by Selkane, Aziza 6/3/2021 10:20:02 AM (Payment Verification for NCC213352)
* Ted Keith
• Selkane, Aziza assigned the task to Selkane, Aziza 6/3/2021 10:19 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 14, 2021 5:00 PM
6/2/2021 9:09 AM

.• SThF� ';
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 *
9201 Tenners Way
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
2
1 c. Parcel ID List all RED associated w ith this project.
Number(s) (PIN) 1803024284
2. County* Wake
3. Highway or Street 9201 Tenners Way
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Wake Forest
5. State * NC
6. Zip Code* 27587
7. Latitude* Enter the latitude in decimal degrees
36.0340
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.6610
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*
06/14/2021
Estimated Construction Project Start Rate
10. Date to End*
03/31/2022
Estinated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be
1.45
disturbed*
(including off -site borrow and waste areas)

13. Total site area 14.03
(acres) *
14. Post- 0.31
construction (Estinated)
impervious area
(acres) *
NCC Project NCC-WAKE-2021-9201 Tenners Way
Tracking ID Assignedautonatically
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 Little Beaverdam Creek
Waterbody* Narreof waterbody into which stornwater runoff will discharge
15b. Waterbody 27-12-3-(3)
Index No. * NCWaterbody Index Nunber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Beaverdam Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 27-12-(0.7)
Index No. NCWaterbody Index Nunber
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nunber
Index No.
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. ^
F2rnittee 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 * Ted Keith Construction, LLC.
It 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 * Ted
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Keith
It Corporation, enter Pbegistered Agent Last %rre
3b. Title member owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-427-5205
Telephone No.*
6. Permittee Mailing Street Address
Address* 7421 Stony Hill Road
Address Line 2
City
Wake Forest
Fbstal / Zip Code
27587-7348
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
7421 Stony Hill Road
Address Line 2
city
Wake Forest
Postal / Zip Code
27587-7348
State / Frovince / Region
NC
Country
us
State / Frovince / Faegion
NC
Country
us
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Individual

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Ted
Contact - First
Name *
2. Primary Site
Keith
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-427-5205
Telephone No.
6. Organization
Ted Keith Construction, LLC.
Name
7. Site Contact
Street Address
Mailing Address*
7421 Stony Hill Road
Address Line 2
city
Wake Forest
Fbstal / Zip Code
27587-7348
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]
Defauft is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
919-427-5205
Defauft 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 05/28/2021
Approved *
2. E&SC Plan Project 058176-2021
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Wake County
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 SEC-058176-2021_Approval-
Approval letter or 290.93KB
S&E_Sing IeLot_Pla n Review_Septic_5-28-21. pdf
Grading Permit
Mast be R7Ffon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
map05.pdf 1.51VIB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Provide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification Document _2021-06-01_183044.pdf 1.27MB
Form Mist be RDFforrret
This is an Express r 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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Amide or rules of the
Commission implementing this Atcle 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 If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 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:* r 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
rv(W4
Type Name* Ted Keith
Title member owner
Organization Legally Ibsponsible Entity
Ted Keith Construction. LLC.
Date * 06/01 /2021

F. Tracking and COC Info
NOI Tracking No. 54536
NC Reference No.
NCG01-2021-3352
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC213352
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3352
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. NCC213352-2021
Invoice Due Date 7/2/2021
Initial Fee $ 100.00
Invoice Status OPEN