NCC214117_NOI Application_20210715

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/13/2021 4:44:05 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 7/14/2021 7:55:01 AM (Review- Construction NOI 58978)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 7/13/2021 4:44 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 15, 2021 5:00 PM
7/13/2021 4:44 PM
Submit by McCoy, Suzanne 7/15/2021 7:38:07 AM (Payment Verification for NCC214117)
* Kay Peninger
• McCoy, Suzanne assigned the task to McCoy, Suzanne 7/15/2021 7:37 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 25, 2021 5:00 PM
7/14/2021 7:55 AM

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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 *
Dixon Village
1 b. Specific Lot
This field any be used to list specifc lot numbers.
Numbers
Lots 1-28
1 c. Parcel ID List all RED associated w ith this project.
Number(s) (PIN) 182236
2. County* Gaston
3. Highway or Street 3100 Lee Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Belmont
5. State * NC
6. Zip Code* 28056
7. Latitude* Enter the latitude in decimal degrees
35.2840
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-81.0550
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*
07/30/2021
Estimated Construction Project Start Rate
10. Date to End*
07/31/2022
Estinated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Oassification for Development
12. Acres to be
6.48
disturbed*
(including off -site borrow and waste areas)

13. Total site area 7.58
(acres) *
14. Post- 2.43
construction ([ tirrated)
impervious area
(acres) *
Project Tracking ID NCC-GASTO-2021-Dixon Village
Assigned autorratically (not used)
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 Fites Creek
Wate rbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-121-(1)
Index No.* NCWaterbody Index Nunber
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 * Habitat for Humanity of Gaston County, 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 * Kay
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Peninger
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Executive Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7048740499
Telephone No.*
6. Permittee Mailing Street Address
Address* 1840 E. Franklin Blvd.
Address Line 2
City
Gastonia
Fbstal / Zip Code
28054
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
1840 East Franklin Boulevard
Address Line 2
city
Gastonia
Fbstal / Zip Code
28054-4751
State / Frovince / Fbgion
NC
Country
United States
State / Frovince / Faegion
NC
Country
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
Kay
Contact - First
Name *
2. Primary Site
Peninger
Contact - Last
Name *
3. Title
Executive Director
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7048740499
Telephone No.*
6. Organization
Habitat for Humanity of Gaston County, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
1840 E. Franklin Blvd.
Address Line 2
City
State / Rovince / Region
Gastonia
NC
Fbstal / Zip Code
Country
28054
United States
8. Consultant Name
(Optional)
Anthony Brent Cowan
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
7042279402
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
7048740499
Default is legally responsible person telephone

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/25/2021
Approved *
2. E&SC Plan Project 1772
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Gaston 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 EC Letter Of Approval - Dixon Village -
Approval letter or 325.1KB
Resubmittal.pdf
Grading Permit
Mist be FDFfon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Dixon Village Vicinity Map.pdf 156.26KB
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 docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification Dixon NCG01-eNO1-Cert Form_Signed.pdf 445.21KB
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
Type Name* Kay Peninger
Title Executive Director
Organization Legally Ibsponsible Entity
Habitat for Humanity of Gaston County, Inc.
Date * 07/13/2021

F. Tracking and COC Info
NOI Tracking No. 58978
NC Reference No.
NCG01-2021-4117
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC214117
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 4117
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. NCC214117-2021
Invoice Due Date 8/13/2021
Initial Fee $ 100.00
Invoice Status OPEN