NCC230076_NOI Application_20230111

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/10/2023 11:00:41 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 1/10/2023 11:32:37 AM (Review - NOI 122103 Holly Springs Road Widening,
Phase 2)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 1/10/2023 11:01 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 13, 2023 5:00
PM. The priority is: High 1/10/2023 11:01 AM
by Workflow 1/10/2023 11:32:43 AM (Workflow Start Event)
Submit by Holloman, Tevye L 1/11/2023 9:28:19 AM (Payment Verification for NCC230076)
F Deborah Abbene
• Holloman, Tevye L assigned the task to Holloman, Tevye L 1/11/2023 9:27 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 21, 2023 5:00 PM.
The priority is: High 1/10/2023 11:32 AM

a
NORTH CAROLINA,
Enri--tn! C2-1;ly
A. Project Information
Part A.
Project Location and Waterbody Information
................................................................................................................... .
Are you submitting No
an NOI that was • Yes
rejected before?
Previous Rejected 122052
NOI No.
Prior Reviewer Name Brooklyn Broussard
la. Project Name* Holly Springs Road Widening, Phase 2
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) 659640275
659645089
659548281
659976851
659976360
659437194
659640275
659640275
659640275
659975667
659963715
659640275
659640275
659640275
659640275
659640275
659640275
659547068
659436729
659434714
659435767
659640275
659640275
659640275
659640275
659337723
659752038
659740616
659640275
659640275

bbUb4U2/b
659642267
659741830
659964944
659869842
659434812
659648488
659640275
659640275
659978417
659640275
659532926
659643091
659634981
659857892
659640275
659648250
659970135
659868136
659868503
659436729
659975527
659974591
659962669
659640275
659640275
659640275
659640275
659640275
659976212
659657014
659963897
659960953
659962611
659349104
659535893
659631955
659431418
659741803
659856858
659545052
659973368
659972213
659534409
659531934
659438951
659975165
659640275
659640275
659640275
659640275
659646327
659435896
659964245
659720523
659955204
659432768
659640275
659533926
659534903
659544002
FSAMWA

659975028
659974081
659434910
659640275
659640275
659647175
2. County* Wake
3. Highway or Street Holly Springs Rd.
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Holly Springs
5. State* INC
6. Zip Code* 27540
7. Latitude* Enter the latitude in decimal degrees
35.6553
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-78.8196
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*
12/26/2022
Estimated Construction Project Start Date
10. Date to End*
04/18/2025
Estimated Construction Project End Date
11. SIC (Primary)*
Highway (1611)
Standard Industrial Classification for Development
12. Acres to be
25.57
disturbed*
(including off -site borrow and waste areas)
13. Total site area 25.57
(acres) *
14. Post -construction 7.99
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-WAKE-2022-Holly Springs Road Widening, Phase 2
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 Middle Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 27-43-15-(1)
No. * NC Waterbody Index Number

Stormwater
discharges will flow
to additional waters*
16a. Is this project
subject to the NC
Sediment Pollution
Control Act?*
No
Yes
Yes
No, not subject to NC SPCA

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
Town of Holly Springs
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* Kendra
If Corporation, enter Registered Agent First Name
3. Last Name* Parrish
If Corporation, enter Registered Agent Last Name
3b. Title Executive Director - Utilities & Infrastructure
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-557-3935
Telephone No.*
6. Permittee Mailing Street Address
Address* 128 S Main St
Address Line 2
City
State / Province / Region
Holly Springs
NC
Postal / Zip Code
Country
27540-9092
US
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
128 S Main St
Address Line 2
City
State / Province / Region
Holly Springs
NC
Postal / Zip Code
Country
27540-9092
US
8. Type of
Ownership is only individual if an individual is named in B.1. above.
Ownership*
Government - Municipal

C. Site Contact Information
Part C.
Project Site Contact Information
1. Primary Site Tim
Contact - First
Name*
2. Primary Site Athy
Contact - Last Name*
3. Title
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact
Telephone No.*
6. Organization Name
7. Site Contact
Mailing Address*
8. Consultant Name
919-577-3128
Street Address
128 South Main Street
Address Line 2
City
Holly Springs
Postal / Zip Code
27540-9092
(Optional)
First and Last name
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
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)
919-557-3935
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 12/16/2022
Approved *
2. E&SC Plan Project WAKE-2021-048
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Raleigh (RRO)
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 WAKE-2021-048_20221216_LOA_Revision-1.pdf 259.4KB
Approval letter or Must be PDF format
Grading Permit
6. Signed FRO Financial Responsibility/Ownership Form
Financial Responsibility Ownership form
Sedimentation Pollution Control —Express Permitting 1.28MB
1.13.21.pdf
Must be PDF format
7. Site Location Map Must be PDF format (limit 20 MB)
2022-012-22 Project_Map.pdf 71.57KB
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 2023-01-06 Signed_NOI.pdf 393.81KB
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.
* 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* Kendra Parrish
Title Executive Director - Utilities & Infrastructure
Organization Legally Responsible Entity
Town of Holly Springs
Date * 01 /10/2023

F. Tracking and COC Info
NOI Tracking No. 122103
NC Reference No. NCG01-2023-0076
Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed
from workflow if eNOI approved)
Certificate of NCC230076
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. NCC230076-2023
Invoice Due Date 2/9/2023
Initial Fee $ 100.00
Invoice Status OPEN