NCC190532_NOI Application_20190606

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/6/2019 12:35:33 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 6/7/2019 11:52:35 AM (Review- Construction NOI 11842)
In Revievwr notes Soil Erosion and Sedimentation Control Letter of Approval is actually dated 0512112019.
• The task was assigned to Morman, Alaina by round robin distribution 6/6/2019 12:35 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 10, 2019 5:00 PM
6/6/2019 12:35 PM
Submit by Morman, Alaina 6/7/2019 11:54:04 AM (Payment Verification - NCG01-2019-0532)
• The task was assigned to Morman, Alaina. The due date is: June 10, 2019 5:00 PM
6/7/2019 11:52 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Kent Dickens South
2. County* Chatham
3. Highway or Street 2342 Cornith Road
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Moncure
5. State * NC
117-8) TiT 7i) it f 1Ii f_T1II a 10141
6. Zip Code* 27559
7. Latitude * Enter the latitude in decimal degrees
35.5883
8. Longitude * Enter the longitude in decimal degrees (MIST be negative)
-79.0300
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*
06/07/2019
Estimated Construction Project Start Date
10. Date to End*
07/31 /2019
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
10.97
disturbed*
(including off -site borrow and waste areas)
13. Total site area
25.36
(acres)*
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-CHATH-2019-Kent Dickens South
Tracking ID
Assigned automatically

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 Cape Fear
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 18-(1)
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 Self
Name *
2. First Name* Frank
If Corporation, enter Registered Agent First l\b e
3. Last Name * Dickens
If Corporation, enter Registered Agent Last Barre
3b. Title Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-708-8207
Telephone No.*
6. Permittee Mailing Street Address
Address* 2503 Cornith Road
Address Line 2
City
Moncure
Postal / Zip Code
27559
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
2503 Cornith Road
Address Line 2
City
Moncure
Rastal / Zip Code
27559
State / Province / Region
North Carolina
Country
United States
State / Province / Region
North Carolina
Country
United States

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Frank
Contact - First
Name *
3. Primary Site Dickens
Contact - Last
Name *
4. Title Owner
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919-708-8207
Telephone No.*
7.Organization
Self
Name
8. Site Contact
Street Address
Mailing Address*
2503 Cornith Road
Address Line 2
city
Moncure
Fbstal / Zip Code
27559
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 05/22/2019
Approved *
2. E&SC Plan Project 2019-03314
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Chatham 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 Letter of Approval.pdf
Approval Mast be PCFfornat
letter/documentation
6. NOI Certification NCG01-eNO1-Certification-Form-Dicken South
Form (signed).pdf
Mast be RCF format
This is an Express r No
Review Project* r Yes
89.63KB
46.27KB

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
1�264.6 A t 01r. rm4wd
Type Name* Frank Kent Dicken's
Title Owner
Organization Self
Date * 06/06/2019

F. Tracking and COC Info
NOI Tracking No. 11842
NC Reference No. NCG01-2019-0532
Uses 'count number variable (incremrented by SP)
Certificate of NCC190532
Coverage (COC) Uses 'count nunber variable (increrrentedbySP)
No. *
Count Number 532
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in OOCno.)