NCC213349_NOI Application_20210607

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/1/2021 1:42:45 PM (NCG01 NOI Submission)
Approve by EADS\bcbroussard 6/2/2021 8:48:25 AM (Review- Construction NOI 54502)
• The task was assigned to EADS\bcbroussard by round robin distribution 6/1/2021 1:43 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 3, 2021 5:00 PM
6/1/2021 1:43 PM
Submit by McCoy, Suzanne 6/7/2021 12:20:44 PM (Payment Verification for NCC213349)
* Maple Leaf Design & Build
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/7/2021 12:20 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 14, 2021 5:00 PM
6/2/2021 8:48 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 54309
NOI No.
Prior Reviewer Michael Meloy
Name
1a. Project Name * Emmanuel Seventh Day Adventist Church
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 10503105
2. County* Mecklenburg
3. Highway or Street McLean Rd.
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Charlotte
5. State * NC
6. Zip Code* 28213
7. Latitude* Enter the latitude in decinal degrees
35.2857
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.7175
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* 09/01/2021
Estirrated Construction Project Start Date
10. Date to End* 08/31/2022
Estinated Construction Project End Date

11. SIC (Primary)* Other (9999)
Standard Industrial aassification for Development
12. Acres to be 2.18
disturbed* (including off -site borrow and waste areas)
13. Total site area 2.18
(acres) *
14. Post- 0.71
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-MECKL-2021-Emmanuel Seventh Day Adventist Church
Tracking ID Assigned automatically
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 Reedy Creek
Waterbody* %rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 13-17-8
Index No. * NCWaterbody Index Nurrber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Delta Lake
Receiving Waterbody narre
Waterbody
15d. Waterbody 13-17-8-1
Index No. NCWaterbody Index Nunber
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nurrber
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. ^
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 * South Atlantic Conference of Seventh Day Adventist
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 * Jorge
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Quintiana
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Pastor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 678-463-4778
Telephone No.*
6. Permittee Mailing Street Address
Address* 106 Flanders Drive
Address Line 2
City
Mooresville
Fbstal / Zip Code
28117-4123
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
106 Flanders Drive
Address Line 2
city
Mooresville
Fbstal / Zip Code
28117-4123
State / Frovince / Fbgion
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* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Bernie
Contact - First
Name *
2. Primary Site
Dilgert
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
828-289-6909
Telephone No.
6. Organization
Maple Leaf Design & Build Inc
Name
7. Site Contact
Street Address
Mailing Address*
259 Beechtree Circle
Address Line 2
City
Rutherfordton
Fbstal / Zip Code
28139-6912
8. Consultant Name
(Optional)
Larissa Coles
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
828-247-4495
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
678-463-4778
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 05/19/2021
Approved *
2. E&SC Plan Project LDGPL-2021-00114
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Charlotte
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 Grading Letter of Approval - Emmanuel Seventh
Approval letter or 99.56KB
Day Adventist Church.pdf
Grading Permit
Mist be FL7Ffon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
McLean Rd Site Map.pdf 78.83KB
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 eNO1 Form - Emmanuel SDA Church.pdf 983.61 KB
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
t� rrrkrrr.� 711/1 � I
Type Name* Jorge Quintiana
Title Pastor
Organization Legally Ibsponsible Entity
South Atlantic Conference of Seventh Day Adventist
Date * 06/01 /2021

F. Tracking and COC Info
NOI Tracking No. 54502
NC Reference No.
NCG01-2021-3349
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC213349
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3349
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. NCC213349-2021
Invoice Due Date 7/2/2021
Initial Fee $ 100.00
Invoice Status OPEN