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HomeMy WebLinkAboutNCC221180_NOI Application_20220328Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 3/22/2022 8:45:40 AM (NCG01 NOI Submission) Approve by Morman, Alaina 3/25/2022 2:33:29 PM (Review - NOI 84725 Millers Reserve Subdivision) • The task was assigned to Morman, Alaina by round robin distribution 3/22/2022 8:46 AM • The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 25, 2022 5:00 PM 3/22/2022 8:46 AM by Workflow 3/25/2022 2:33:38 PM (Workflow Start Event) Submit by EADS\aselkane 3/28/2022 11:46:54 AM (Payment Verification for NCC221180) * Robert Dischinger • EADS\aselkane assigned the task to EADS\aselkane 3/28/2022 11:45 AM The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 6, 2022 5:00 PM 3/25/2022 2:33 PM NORTH CAROLINA Rrf OmFkm&tral Qualrly A. Project Information Part A. Project Location and Waterbody Information Are you submitting No an NOI that was Yes rejected before? la. Project Name* Millers Reserve Subdivision 1 b. Specific Lot This field may be used to list specifc lot numbers. Numbers 65 1 c. Parcel ID List all PINs associated with this project. Number(s) (PIN) 6812-35-7963 2. County* Forsyth 3. Highway or Street 4540 Ebert 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 36.0137 8. Longitude* Enter the longitude in decimal degrees (MUST be negative) -80.3029 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* 03/21/2022 Estimated Construction Project Start Date 10. Date to End* 12/29/2022 Estimated Construction Project End Date 11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521) Standard Industrial Classification for Development 12. Acres to be 24.50 disturbed * (including off -site borrow and waste areas) 13. Total site area 51.33 (acres)* 14. Post -construction 3.75 impervious area (Estimated) (acres) * Project Tracking ID NCC-FORSY-2022-Millers Reserve Subdivision 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 South Fork Muddy Creek Waterbody * Name of waterbody into which stormwater runoff will discharge 15b. Waterbody Index 12-94-13 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 Keystone Group, Inc 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* Scott If Corporation, enter Registered Agent First Name 3. Last Name* Wallace If Corporation, enter Registered Agent Last Name 3b. Title President 4. Permitee E-mail swallace@gokeystone.com Address* 5. Permittee 336-856-0111 Telephone No.* 6. Permittee Mailing Street Address Address* 3708 Alliance Drive Address Line 2 City State / Province / Region Greensboro NC Postal / Zip Code Country 27407-2016 US Check box if the Yes street address the same as mailing address 7. Permittee Street Street Address Address * 3708 Alliance Drive Address Line 2 City State / Province / Region Greensboro NC Postal / Zip Code Country 27407-2016 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 Scott Contact - First Name* 2. Primary Site Wallace Contact - Last Name* 3. Title President 4. Site Contact E-mail swallace@gokeystone.com Address* 5. Site Contact 336-856-0111 Telephone No.* 6. Organization Name Keystone Group Inc 7. Site Contact Street Address Mailing Address* 3708 Alliance Drive Address Line 2 City Greensboro Postal / Zip Code 27407-2016 8. Consultant Name (optional) Lee Bryant First and Last name 9. Consultant E-mail lib@evans-eng.com This person will be copied on all correspondence. 10. Consultant 336-482-6543 Telephone No. 11. Billing E-mail (For Annual Fee correspondence) swallace@gokeystone.com Default is legally responsible person e-mail 12. Billing Telephone (For Annual Fee correspondence) 336-856-0111 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 03/11/2021 Approved * 2. E&SC Plan Project EN2000079 Number/ID* Assigned by agency or local program 3. E&SC Plan State DEQ Office Approved by* Local Program 4. Local Program* Winston-Salem/Forsyth 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 Approval Letter.pdf 218.34KB Approval letter or Must be PDF format Grading Permit 6. Signed FRO Financial Responsibility/Ownership Form FRO.pdf 160.85KB Must be PDF format 7. Site Location Map Must be PDF format (limit 20 MB) site location.pdf 830.17KB 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 Signed NOI.pdf 404.46KB Form 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. * 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. * 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 Type Name* Scott Wallace Title President Organization Legally Responsible Entity Keystone Group, Inc Date * 03/22/2022 F. Tracking and COC Info NOI Tracking No. 84725 NC Reference No. NCG01-2022-1180 Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed from workflow if eNOI approved) Certificate of NCC221180 Coverage (COC) No.* Uses NOI number until approved, then uses NUMBER incremented by SIP (formatted and passed from workflow if eNOI approved) Initial Invoice No. NCC221180-2022 Invoice Due Date 4/24/2022 Initial Fee $ 100.00 Invoice Status OPEN