NCC203087_Modification Review LOT 38_20210901

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/31/2021 10:02:55 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 9/1/2021 9:06:30 AM (Construction COC ADD TO FILE Review- NCC203087)
The task was assigned to Georgoulias, Bethany A. The due date is: September 3, 2021 5:00 PM
8/31 /2021 10:02 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC203087
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Wakefield Meadows Phase 5 Lot 46
Address
1236 Tin Barn Road, Zebulon, NC
County
Wake
Latitude
35.8573
Longitude
-78.3059
Permittee Listed
Woody Built LLC
Legally Responsible
John Woody III
Individual
NC Reference No.
NCG01-2020-3087
E&SC Plan ID
SEC-039347-2020
Original NOI
28467
Tracking No.*
Date COC Issued*
07/20/2020
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Lot 38 2641 Winter Storm
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).
For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (%vised ERSC Approval, (lose -Out Doc, etc.)
Documentation 2641 S&EC approval.pdf 758.49KB
Mast be FDFfon-rat
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 Article; 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 Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to e)ceed ten thousand
dollars ($10,000).
rJ I hereby request modification to coverage under the NPDES Stormwater Permit
for the subject project site. I am familiar with the information contained in this
request and to the best of my knowledge and belief such information is true,
complete and accurate.
Specify if you are:* r The Legally Responsible Individual
r Authorized Responsible Person*
*This form must be signed by a responsible corporate officer that 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
�a [?1F'V1f
Type Name* Trina Campbell
Title * Office Manager
Organization* Woody Built LLC
Date * 08/31 /2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9198414884
Contact nun ber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 09/01/2021
Rescinded Since
Submitted?

Request Date 20210831
Formatted
Review Date 20210901
Formatted