NCC190127_NOI Application_20190429

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/29/2019 5:13:25 PM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 4/30/2019 8:05:18 AM (Review- Construction NOI 10491)
• The task was assigned to Georgoulias, Bethany by round robin distribution 4/29/2019 5:13 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 1, 2019 5:00 PM
4/29/2019 5:13 PM
Submit by Georgoulias, Bethany 4/30/2019 8:05:38 AM (Payment Verification - NCG01-2019-0127)
• The task was assigned to Georgoulias, Bethany. The due date is: May 1, 2019 5:00 PM
4/30/2019 8:05 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Wilson Chick-Fil-A
2. County* Wilson
3. Highway or Street 5100 Raleigh Rd Pkwy and 5601 Lamm Rd.
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Wilson
5. State * NC
1 r-i) iTiT 7i) M 1i1 f_TiI a 10141
6. Zip Code* 27896
7. Latitude * Enter the latitude in decirral degrees
35.7643
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-78.0096
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 * 06/01 /2019
Estimated Construction Project Start Date
10. Date to End* 12/01 /2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 5.00
disturbed* (including off -site borrow and waste areas)
13. Total site area
4.04
(acres)*
14. Post-
1.89
construction
impervious area
(acres) *
NCC Project
NCC-WILSO-2019-Wilson Chick-Fil-A
Tracking ID
Assigned autorratically

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. You may
enter up to 3 waterbodies.
15a. Receiving Bloomery Swamp
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 27-86-6-3
Index No. * NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should 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 NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Lisciotti Development
Name *
2. First Name*
John
ff Corporation, enter Registered Agent First l\brre
3. Last Name *
Scribner
ff Corporation, enter Registered Agent Last Barre
4. Permitee E-mail
[e-mail]
Address*
5. Permittee 978-466-9080
Telephone No.*
6. Permittee Mailing Street Address
Address* 83 Orchard Hill Park Dr.
Address Line 2
City
Leominster
Fbstal / Zip Code
01453
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
83 Orchard Hill Park Dr.
Address Line 2
City
Leominster
Postal / Zip Code
01453
State / Province / Region
MA
Country
Worcester County
State / Province / Region
MA
Country
Worcester County

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Daniel
Contact - First
Name *
3. Primary Site Donatelli
Contact - Last
Name *
4. Title
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
404-452-7078
Telephone No.*
7. Organization
W.H. Bass Inc
Name
8. Site Contact
Street Address
Mailing Address*
11300 Johns Creek Pkwy
Address Line 2
Suite 100
city
Johns Creek
Rbstal / Zip Code
30097
State / Rovince / Plegion
GA
Country
Fulton County

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 03/29/2019
Approved *
2. E&SC Plan Project 18-22
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* City of Wilson
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan Approval letter 3-28-19.pdf 332.91KB
Approval Mist be RCFformat
letter/documentation
6. NOI Certification 2019-04-29 Wilson NC - Signed NOI Certification
Form 236.69KB
Form.pdf
Mist be RCF format
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes any false 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 under this Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice 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 not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V 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.
* I7 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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* John Scribner
Date * 04/29/2019

F. Tracking and COC Info
NOI Tracking No. 10491
NC Reference No. NCG01-2019-0127
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190127
Coverage (COC) Uses'count_nunber'variable (increrrented by SF)
No. *
Count Number 127
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed, used to assign YY digits after "NOC' in OOC no.)