NCC214535_NOI Application_20210811

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/9/2021 10:39:07 AM(NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/9/2021 11:01:54 AM(Review-Construction NOI 61669)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/9/2021 10:40 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:August 11,2021 5:00
PM.The priority is: High 8/9/2021 10:40 AM
Submit by McCoy, Suzanne 8/11/2021 12:41:25 PM(Payment Verification for NCC214535)
* WS Parks Contracting LLC
• McCoy,Suzanne assigned the task to McCoy, Suzanne 8/11/2021 12:40 PM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: September 20,2021 5:00
PM.The priority is: High 8/9/2021 11:02 AM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Eliminatio em 'D application forcoverage under NorthCarolina's
General Permit 1 1111:STORIMATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
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 61656
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name* Dogwood Family Campground
1 b.Specific Lot This field may be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID List all RNs associated w ith this project.
Number(s)(PIN) 631904623812000
631904724461000
2.County* Carteret
3. Highway or Street 815 Lake Rd.
Address* Street name only is acceptable if no address nunber assigned yet
4.City or Township* Newport
5.State* NC
6.Zip Code* 28570
7. Latitude* Enter the latitude in decinal degrees
34.8100
8. Longitude* Enter the longitude in decimal degrees(MJSTbe negative)
-76.9390
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* 08/11/2021
Estimated Construction Project Start Date
10. Date to End* 03/31/2022
Estimated Construction Project End Cate

11.SIC(Primary)* Commercial (1542)
Standard Industrial Classification for Development
12.Acres to be 10.20
disturbed* (including off-site borrow and waste areas)
13.Total site area 18.02
(acres)*
14. Post- 2.60
construction (Estimated)
impervious area
(acres)*
Project Tracking ID NCC-CARTE-2021-Dogwood Family Campground
Assigned automatically(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 Little Run
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b.Waterbody 21-2-1
Index No.* NCWaterbody Index Number
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. ^
Fl rnittee 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* LS Family Investments, 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* William
If Corporation,enter Faegistered Agent First%rre
3. Last Name* Parks
It Corporation,enter F;bgistered Agent Last%rre
3b.Title Member/Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 252-659-2032
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box699
Address Line 2
City State/Frovince/Region
Newport NC
Fbstal/Zip Code Country
28570 Carteret
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 308 Nine Foot rd.
Address Line 2
City State/Frovince/Faegion
Newport NC
Postal/Zip Code Country
28570 Carteret
8.Type of ONnership 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 Shawn
Contact-First
Name*
2. Primary Site Parks
Contact-Last
Name*
3.Title Member/Manager
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 252-659-2032
Telephone No.*
6.Organization WS Parks Contracting, LLC
Name
7.Site Contact Street Address
Mailing Address* PO Box699
Address Line 2
CRY State/Rovince/Region
Newport NC
Postal/Zip Code Country
28570 Carteret
8. Consultant Name (Optional)
Gary MacConnell
First and Last nacre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 919-467-1239
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 [phone]
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 05/06/2021
Approved*
2. E&SC Plan Project CARTE-2021-013
Number/ID* Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4.State DEQ Office* Wilmington (WiRO)
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 Erosion&Sedimentation Permit Approval 5-6-
Approval letter or 239.23KB
2021.pdf
Grading Permit
Mast be FDFforrrat
6.Site Location Map Mist be RDFfornat(linit 201VB)
E&SC-Site Location Map.pdf 1.44MB
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 E&SC-NOI Certification Form.pdf 833.13KB
Form Mist be RDFfornat
This is an Express f No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knowinglymakes any false 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 Article;or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Artcle;or who 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 Artcle shall be guiltyofa Class 2 misdemeanor which mayinclude 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 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
4 /�x C til
Type Name* W. Shawn Parks
Title Member/Manager
Organization Legally Pesponsible Entity
LS Family Investments, LLC
Date* 08/09/2021

F. Tracking and COC Info
NOI Tracking No. 61669
NC Reference No. NCG01-2021-4535
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC214535
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 4535
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. NCC214535-2021
Invoice Due Date 9/8/2021
Initial Fee $ 100.00
Invoice Status OPEN