NCC193180_NOI Application_20191213

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/12/2019 11:37:21 AM (NCG01 NOI Submission)
Approve by Clark, Paul 12/12/2019 11:50:53 AM (Review- Construction NOI 19488)
• The task was assigned to Clark, Paul by round robin distribution 12/12/2019 11:37 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 16, 2019 5:00
PM 12/12/2019 11:37 AM
Submit by McCoy, Suzanne 12/13/2019 7:40:24 AM (Payment Verification for NCC193180)
* CA Lewis inc.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/13/2019 7:39 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 23, 2020 5:00 PM
12/12/2019 11:51 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Holy Infant Catholic Church
2. County* Durham
3. Highway or Street 5000 Southpark Dr Durham, NC 27713
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Durham
5. State * NC
6. Zip Code * 27713
7. Latitude * Enter the latitude in decimal degrees
35.9134
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.9444
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*
12/16/2019
Estimated Construction Project Start Date
10. Date to End*
12/18/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
9.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
14.93
(acres) *
14. Post-
3.51
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-DURHA-2019-Holy Infant Catholic Church
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. 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 Crooked Creek
Waterbody* Ibrre of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 16-41-1-16-(1)
Index No.* NCWaterbody Index Number
Stormwater V 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. ^
Fternittee Inforrration - Legally Fbsponsible Entity and Individual
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 C.A. Lewis, Inc.
Name *
2. First Name* John
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Laney
If Corporation, enter Faegistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address *
5. Permittee 1-252-757-3536
Telephone No.*
6. Permittee Mailing Street Address
Address* 2825 S Charles Blvd
Address Line 2
city
Greenville
Fbstal / Zip Code
27858-5934
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
2825 S Charles Blvd
Address Line 2
City
Greenville
Fbstal / Zip Code
27858-5934
State / F rovince / Faegion
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Jay
Contact - First
Name *
3. Primary Site
Cox
Contact - Last
Name *
4. Title
Superintendent
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
1-252-714-7033
Telephone No.*
7. Organization
C.A. Lewis, Inc.
Name
8. Site Contact
Street Address
Mailing Address*
2825 S Charles Blvd
Address Line 2
City
Greenville
Fbstal / Zip Code
27858-5934
9. Consultant Name
(Optional)
Ross Woodall
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11.Consultant
1-252-757-3536
Telephone No.
State / Rovince / Fbgion
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/16/2019
Approved *
2. E&SC Plan Project 6009-12
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Durham City/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 E&SC Plan Approval.pdf
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification Scan20191212113350.pdf
Form Mist be R7Ffon-rat
This is an Express F No
Review Project* r Yes
365.69KB
180.8KB

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse 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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ 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.
* 17 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
f Authorized Responsible Person*
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
Cc1 1/Z),s?WSJ
Type Name* John David Laney
Title President
Organization C.A. Lewis, inc.
Date * 12/12/2019

F. Tracking and COC Info
NOI Tracking No. 19488
NC Reference No. NCG01-2019-3180
Uses 'count number' variable (incremrented by SP)
Certificate of NCC193180
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 3180
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)