NCC211465_Modification Review_20220418

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/13/2022 3:56:58 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 4/18/2022 12:58:28 PM (Construction COC ADD TO FILE Review - NCC211465)
• The task was assigned to Georgoulias, Bethany A. The due date is: April 18, 2022 5:00 PM
4/13/2022 3:57 PM

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Certificate of NCC211465
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name Asbury Chapel Farm Grading
Address 12255 Asbury Chapel Rd, Huntersville, NC
County Mecklenburg
Latitude 35.3942
Longitude-80.8094
Permittee Listed Jake Palillo
Legally Responsible Jake Palillo
Individual
NC Reference No. NCG01-2021-1465
E&SC Plan ID 415075
Original NOI Tracking 47441
No. *
Date COC Issued * 03/16/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Closed -Out Lots/Outparcels in E&SC Plan
Modification* Additional Lots/Outparcels Approved - E&SC Revised
Other Revision(s) to E&SC Plan
Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons (List)
Change in limits of disturbance, additional parcel grading,
impervious area was listed wrong on original permit, disturbed
area change
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
An expansion of planned grading area was needed. Erosion control plans were
produced (phase 2 plans) to work in conjunction with phase 1 plans which have the
existing COC.
An additional disturbed area of 13.81 AC which overlaps some of the previously
approved disturbed area(11.91 AC original COC), for a new total of 18.5 AC.
Impervious area was listed as 30 AC on original COC, this number should be 0 AC.

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 (Revised EBSC Approval, Close -Out Doc, etc.)
Documentation EC Permit Only Approval Ltr (#434112).pdf 154.79KB
Must be PDF format
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).
* 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:* The Legally Responsible Individual
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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Jacob Palillo
Title* owner
Organization* South Creek Construction Inc
Date * 04/13/2022
Email Address* [e-mail]
Email for confirmation
Telephone Number* 7043637902
Contact number 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 04/18/2022

Rescinded Since
Submitted?
Request Date 20220413
Formatted
Review Date 20220418
Formatted