NCC216593_NOI Application_20211129

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/23/2021 11:30:46 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 11/24/2021 7:07:04 AM (Review - Construction NOI 73794)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 11/23/2021 11:31 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 25, 2021 5:00
PM 11/23/2021 11:31 AM
Submit by Evans, Shaundra M 11/29/2021 8:15:18 AM (Payment Verification for NCC216593)
F K Isenhour
• Evans, Shaundra M assigned the task to Evans, Shaundra M 11/29/2021 8:14 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 5, 2022 5:00 PM
11 /24/2021 7:07 AM

NORTH CAROLINA
RrwY mrlm&tral Qualrly
A. Project Information
Part A.
Project Location and Waterbody Information
...............................................................................................................................................................................................................................................................................................................................................................................................
Are you submitting No
an NOI that was • Yes
rejected before?
Previous Rejected 73768
NOI No.
Prior Reviewer Name Brooklyn Broussard
la. Project Name* Ivy Brook
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all PINs associated with this project.
Number(s) (PIN) 6821-02-69-8499
2. County* Davidson
3. Highway or Street 2992 Hickory Tree Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State* NC
6. Zip Code* 27127
7. Latitude* Enter the latitude in decimal degrees
35.9943
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-80.2613
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* 12/01/2021
Estimated Construction Project Start Date
10. Date to End* 12/01/2022
Estimated Construction Project End Date
11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Development

12. Acres to be 8.90
disturbed* (including off -site borrow and waste areas)
13. Total site area 19.28
(acres) *
14. Post -construction 4.60
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-DAVID-2021-Ivy Brook
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 Leak Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 12-94-13-7
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Permittee Information - Legally Responsible Entity and Individual
........................................................................................................................................................................
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form must 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
1. Permittee* Legally Responsible Entity
Isenhour Homes, LLC
If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership (FRO) Form.
2. First Name* Todd
If Corporation, enter Registered Agent First Name
3. Last Name* Isenhour
If Corporation, enter Registered Agent Last Name
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 3411 Healy Drive
Address Line 2
City
State / Province / Region
Winston-Salem
NC
Postal / Zip Code
Country
27103-1409
us
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address *
3411 Healy Drive
Address Line 2
City
State / Province / Region
Winston-Salem
NC
Postal / Zip Code
Country
27103-1409
us
8. Type of
Ownership is only individual if an individual is named in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Project Site Contact Information
.................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Todd
Contact - First
Name*
2. Primary Site Isenhour
Contact - Last Name*
3. Title Project Manager
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact [phone]
Telephone No.*
6. Organization Name Isenhour Homes, LLC
7. Site Contact Street Address
Mailing Address* 3411 Healy Drive
Address Line 2
City
Winston-Salem
Postal / Zip Code
27103-1409
8. Consultant Name (optional)
Steve Causey
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant [phone]
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone (For Annual Fee correspondence)
[phone]
Default is legally responsible person telephone
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 11/22/2021
Approved *
2. E&SC Plan Project DAVID-2022-018
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Winston-Salem (WSRO)
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 APPROVAL - Erosion Control LoA DAVID-2022-
Approval letter or 198.3KB
01 8.pdf
Grading Permit
Must be PDF format
6. Signed FRO Financial Responsibility/Ownership Form
NCDEQ EC FRO_Signed_lvyBrook.PDF 337.25KB
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
C3.1 - FINAL GRADING.pdf 402.4KB
Please do not upload entire set of E&SC plans.
8. Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded documents
support the application. Include additional waterbodies if necessary.
9. NOI Certification NCG01-eNOI-Certification-
Form 385.9KB
Form_Signed_IvyBrook. PbF
Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false 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 Article; or who knowingly makes a false statement of a material
fact in a rulemaking proceeding or contested case under this 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 guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* 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:* The Legally Responsible Person named on this Notice of Intent
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
IL'-7oDP -r-SMW ?Vd -
Type Name* K.Todd Isenhour
Title Manager
Organization Legally Responsible Entity
Isenhour Homes LLC
Date * 11 /23/2021

F. Tracking and COC Info
NOI Tracking No. 73794
NC Reference No.
NCG01-2021-6593
Uses'count_numb& variable (incremented by SP)
Certificate of
NCC216593
Coverage (COC) No.*
Uses'count_number' variable (incremented by SP)
Count Number
6593
Sequential number for submittal that is incremented by Stored Procedure
COC Year
2021
Year of date reviewed (used to assign YY digits after "NCC" in COC no.)
Initial Invoice No. NCC216593-2021
Invoice Due Date 12/24/2021
Initial Fee $ 100.00
Invoice Status OPEN