NCC191295_NOI Application_20190812

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/7/2019 9:14:18 AM (NCG01 NOI Submission)
Approve by Lucas, Annette 8/8/2019 5:20:53 PM (Review- Construction NOI 14555)
• The task was assigned to Lucas, Annette by round robin distribution 8/7/2019 9:14 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 9, 2019 5:00
PM 8/7/2019 9:14 AM
Submit by McCoy, Suzanne 8/12/2019 3:02:04 PM (Payment Verification for NCC191295)
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/12/2019 3:01 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 22, 2019 5:00 PM
8/8/2019 5:20 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Advent Health Care Office
2. County* Polk
3. Highway or Street HWY 108
Address * Street name only is acceptable if no address nurrber assigned yet
4. City or Township* Columbus
5. State * NC
1r-i)iTII1T7i)MfiIif_TiIa10141
6. Zip Code* 28722
7. Latitude * Enter the latitude in decirral degrees
35.2388
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-82.2225
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 * 08/31 /2019
Estimated Construction Project Start Date
10. Date to End* 09/30/2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.10
disturbed* (including off -site borrow and waste areas)
13. Total site area
3.12
(acres)*
14. Post-
0.43
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-POLK-2019-Advent Health Care Office
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 UT to Skyuka Creek
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 9-55-1-11-(2)
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 GEORGE G & TONYA S KIM
Name *
2. First Name* GEORGE G & TONYA S
ff Corporation, enter Registered Agent First Narre
3. Last Name * KIM
ff Corporation, enter Registered Agent Last Narre
3b. Title OWNER
4. Permitee E-mail [e-mail]
Address*
5. Permittee 828-817-2177
Telephone No.*
6. Permittee Mailing Street Address
Address * 188 SHADY OAK DR
Address Line 2
City
MILL SPRING
Postal / Zip Code
28756
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
188 SHADY OAK DR
Address Line 2
City
MILL SPRING
Fbstal / Zip Code
28756
State / Province / Region
NC
Country
UNITED STATES
State / Province / Region
NC
Country
UNITED STATES

C. Site Contact Information
Part C.
Proiect Site Contact Information
1. Type of Individual
Ownership*
2. Primary Site SCOTT
Contact - First
Name *
3. Primary Site ROACH
Contact - Last
Name *
4. Title EIT
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
828-247-4495
Telephone No.*
7. Organization
Odom Engineering, PLLC
Name
8. Site Contact
Street Address
Mailing Address*
Odom Engineering PLLC
Address Line 2
169 Oak St.
city
Forest City
Fbstal / Zip Code
28043
State / Province / Fbgion
NC
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 07/29/2019
Approved *
2. E&SC Plan Project POLK 2019-006
Number/ID* Assigned by agency or local program
3. E&SC Plan f• State DEQ Office
Approved by r Local Program
4. State DEQ Office * Asheville (ARO)
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 LOAwM COPA 7-29-2019.docx.pdf 116.64KB
Approval Mast be FDF format
letter/documentation
6. NOI Certification doc08560920190806144153.pdf 481.38KB
Form Mist be RDF format
This is an Express f• No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (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.
* rJ 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.
* rJ 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 t1
Type Name * Tonya Kim
Title Owner
Organization Advent Internal Medicine
Date * 08/07/2019

F. Tracking and COC Info
NOI Tracking No. 14555
NC Reference No. NCG01-2019-1295
Uses 'count number variable (incremrented by SP)
Certificate of NCC191295
Coverage (COC) Uses 'count nunber variable (increrrentedbySP)
No. *
Count Number 1295
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.)