NCC215002_Modification Review ADD SEVERAL LOTS_20211013

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/11/2021 12:31:11 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 10/13/2021 9:07:55 AM (Construction COC ADD TO FILE Review -
NCC215002)
• The task was assigned to Georgoulias, Bethany A. The due date is: October 14, 2021 5:00 PM
10/11/2021 12:31 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC215002
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
The Walk at East Village
Address
109 Village Walk Drive, Clayton, NC
County
Johnston
Latitude
35.6422
Longitude
-78.4430
Permittee Listed
Holden Barnett Properties LLC
Legally Responsible
Thomas Holden
Individual
NC Reference No.
NCG01-2021-5002
E&SC Plan ID
16-33-C
Original NOI
63971
Tracking No.*
Date COC Issued*
09/03/2021
Prior Rescission
This field will populate only if CCChas already been rescinded.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 Nbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Add Phase 2 Lots: 172, 157, 198, 195, 49, 168
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 IRSCApproval, (lose -Out Doc, etc.)
Documentation EC Clayton Plan Approval Letter Lots (phase2 -
133.95KB
172,157,198,195,49,168).pdf
Wst be FDFformat
North Carolina General Statute 143-215.6113 (i) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 notto exceed ten thousand
dollars ($10,000).
� 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
f 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
Type Name* Thomas P Holden
Title * President
Organization* Holden Barnett Properties LLC
Date * 10/11 /2021
Email Address* [e-mail]
En -ail for confirmation
Telephone Number* 9192912445
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional errailfor confirrration
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 10/13/2021
Rescinded Since
Submitted?

Request Date 20211011
Formatted
Review Date 20211013
Formatted