NCC213565_NOI Application_20210614

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/10/2021 12:39:52 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 6/11/2021 7:16:05 AM (Review- Construction NOI 55308)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 6/10/2021 12:41 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 14, 2021 5:00 PM.
The priority is: High 6/10/2021 12:41 PM
Submit by McCoy, Suzanne 6/14/2021 8:58:32 AM (Payment Verification for NCC213565)
* The Veritas Group Inc. (paid two on one check)
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/14/2021 8:57 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 23, 2021 5:00 PM. The
priority is: High 6/11/2021 7:16 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 54935
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Lot # 559 Brookberry Farm/ 5730 Cedarmere Dr.
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
Lot # 559 Brookberry Farm
1 c. Parcel ID
List all R% associated w ith this project.
Number(s) (PIN)
5896-23-6234.00
2. County*
Forsyth
3. Highway or Street 5730 Cedarmere Dr.
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston Salem
5. State * NC
6. Zip Code* 27106
7. Latitude* Enter the latitude in decimal degrees
36.1143
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.3791
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* 06/07/2021
Estimated Construction Project Start late
10. Date to End* 10/11/2021
Estimated Construction Project End late

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial (aassification for Development
12. Acres to be 0.23
disturbed* (including off -site borrow and waste areas)
13. Total site area 0.46
(acres) *
14. Post- 0.12
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-FORSY-2021-Lot # 559 Brookberry Farm/ 5730 Cedarmere
Tracking ID Dr.
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 Tomahawk Creek
Waterbody* Plarreof waterbody into which stormwater runoff will discharge
15b. Waterbody 12-94-9-1
Index No. * NCWaterbody Index Number
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Waterbody name
Receiving
Waterbody
15d. Waterbody NCWaterbody Index Number
Index No.
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Number
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. ^
Fbrnittee 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 * The Veritas Group, Inc.
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 * Michael
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Enscore
It Corporation, enter Pbegistered Agent Last %rre
3b. Title President/ Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-404-1522
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box582
Address Line 2
City
Kernersville
Fbstal / Zip Code
27285
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
1620 Tredegar Road
Address Line 2
City
Kernersville
Fbstal / Zip Code
27284-3590
State / Frovince / Pegion
NC
Country
Forsyth
State / Ftovince / 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
Michael
Contact - First
Name *
2. Primary Site
Enscore
Contact - Last
Name *
3. Title
President / Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-404-1522
Telephone No.
6. Organization
The Veritas Group, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
PO Box582
Address Line 2
city
Kernersville
Fbstal / Zip Code
27285
8. Consultant Name
(Optional)
First and Last narre
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
336-404-1522
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
Forsyth

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/07/2021
Approved *
2. E&SC Plan Project 541397
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth 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 E&SC Plan Approval Letter for NCG01 App - Lot #
Approval letter or 97.1KB
559 Brookberry Farm _ 5730 Cedarmere Dr..pdf
Grading Permit
Mast be RDFfon-rat
6. Site Location Map Mist be FDFfornat (lint 201VB)
Lot 559 BBF 5730 Cedarmere Dr - Site Plan
386.36KB
Only.pdf
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies if necessary.
8. NOI Certification Lot # 559 BBF NCGO1 NOI Certification Form.pdf 889.44KB
Form Mast be Ft7Fformat
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 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
���rlrrz�ra S [}�fJrrtr•
Type Name* Michael Enscore
Title President/ Owner
Organization Legally Ibsponsible Entity
The Veritas Group, Inc.
Date * 06/10/2021

F. Tracking and COC Info
NOI Tracking No. 55308
NC Reference No.
NCG01-2021-3565
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC213565
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3565
Sequential nunber for subnittal 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. NCC213565-2021
Invoice Due Date 7/11/2021
Initial Fee $ 100.00
Invoice Status OPEN