NCC190431_NOI Application_20190530

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/30/2019 12:06:03 PM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 6/3/2019 12:15:05 PM (Review- Construction NOI 11543)
* Mecklenburg County contact (Gigi Mullis) confirmed approval was for 45.72 acres to be disturbed for
this project via e-mail on 613. The revised letter will be added to the permit record.
• Georgoulias, Bethany reassigned the task to Georgoulias, Bethany 5/30/2019 8:05 PM
• The task was assigned to Morman, Alaina by round robin distribution 5/30/2019 12:06 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 3, 2019 5:00 PM
5/30/2019 12:06 PM
Submit by Georgoulias, Bethany 6/3/2019 12:19:33 PM (Payment Verification - NCG01-2019-0431)
• The task was assigned to Georgoulias, Bethany. The due date is: June 4, 2019 5:00 PM
6/3/2019 12:15 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Walden Single Family Phase 5 & 7
2. County* Mecklenburg
3. Highway or Street 13755 Huntersville-Concord Rd
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Huntersville
5. State * NC
!17-8)aIsT2,G)M111if_T1IIa10141
6. Zip Code* 28078
7. Latitude * Enter the latitude in decirral degrees
35.4195
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.8121
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*
06/03/2019
Estimated Construction Project Start Date
10. Date to End*
06/01 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
45.72
disturbed*
(including off -site borrow and waste areas)
13. Total site area 60.61
(acres)*
14. Post- 9.70
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-MECKL-2019-Walden Single Family Phase 5 & 7
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 North Prong Clarke Creek
Wate rbody* l\bre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 13-17-4-1
Index No. * NCWaterbody Index Ninber
Stormwater fJ No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F 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 TF Walden LP
Name *
2. First Name* John
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Brian
ff Corporation, enter Registered Agent Last Barre
3b. Title VP Land Development
4. Permitee E-mail [e-mail]
Address*
5. Permittee 941-388-0707
Telephone No.*
6. Permittee Mailing Street Address
Address* 6310 Capital Drive
Address Line 2
Suite 130
City
Lakewood Ranch
Postal / Zip Code
34202
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
6310 Capital Drive
Address Line 2
Suite 130
City
Lakewood Ranch
Postal / Zip Code
34202
State / Province / Region
Florida
Country
us
State / Province / Region
Florida
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site John
Contact - First
Name *
3. Primary Site Brian
Contact - Last
Name *
4. Title
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 941-388-0707
Telephone No.*
7. Organization
Name
8. Site Contact Street Address
Mailing Address* 6310 Capital Drive
Address Line 2
Suite 130
aty
Lakewood Ranch
Fbstal / Zip Code
34202
State / Rovince / Region
Florida
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 05/23/2019
Approved *
2. E&SC Plan Project 389229
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Mecklenburg County
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 PCO5 approval doc #389229.pdf 69.7KB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification NOI Certification Form.pdf 425.02KB
Form Mist be F13Ffornat
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
[f/Oi��r! _�1C�lltr
Type Name* John Brian
Title VP Land Development
Organization TF Walden LP
Date * 05/30/2019

F. Tracking and COC Info
NOI Tracking No. 11543
NC Reference No. NCG01-2019-0431
Uses 'count number variable (incremrented by SP)
Certificate of NCC190431
Coverage (COC) Uses'count_nunber'variable (incremented by SF)
No. *
Count Number 431
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)