NCC213175_NOI Application_20210602

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/25/2021 10:49:38 AM (NCG01 NOI Submission)
Approve by Meloy, Michael K 5/26/2021 8:05:46 AM (Review- Construction NOI 53505)
• The task was assigned to Meloy, Michael K by round robin distribution 5/25/2021 10:50 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 27, 2021 5:00 PM
5/25/2021 10:50 AM
Submit by McCoy, Suzanne 6/2/2021 2:56:12 PM (Payment Verification for NCC213175)
* CLSH Partners LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/2/2021 2:55 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 7, 2021 5:00 PM
5/26/2021 8:06 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * Stonehaven Subdivision
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID List all RED associated w ith this project.
Number(s) (PIN) 6986-28-0337
2. County* Forsyth
3. Highway or Street 0 Willow Creek Road
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Kernersville
5. State * NC
6. Zip Code* 27284
7. Latitude* Enter the latitude in decinal degrees
36.1322
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.0430
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*
06/01/2021
Estinated Construction Project Start Rate
10. Date to End*
04/01/2022
Estinated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Oassification for Development
12. Acres to be
10.30
disturbed*
(including off -site borrow and waste areas)

13. Total site area 36.86
(acres) *
14. Post- 5.40
construction (Estirrated)
impervious area
(acres)*
NCC Project NCC-FORSY-2021-Stonehaven Subdivision
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. 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 UT of Reedy Fork Creek WSIII-BW,
Waterbody* Kernersville ETJ
Narre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 16-11-(1)
Index No. * NC Waterbody Index NArrber
Stormwater W No
discharges will flow F- 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. ^
Fl rnittee 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 Legally Pesponsible Entity
Name * BSC Holdings, Inc.
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Barry
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Siegal
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3362929010
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 16168
Address Line 2
City
High Point
Fbstal / Zip Code
27261
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Fbgion
NC
Country
USA
7. Permittee Street
Street Address
Address*
4421 Piedmont Parkway
Address Line 2
City
State / Frovince / Faegion
High Point
NC
Fbstal / Zip Code
Country
27260
US
8. Type of
Ownership is only individual if an individual is naned in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Barry
Contact - First
Name *
2. Primary Site
Siegal
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
3365873633
Telephone No.
6. Organization
BSC Holdings, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
PO Box 16168
Address Line 2
city
High Point
Fbstal / Zip Code
27261
8. Consultant Name
(Optional)
First and Last nacre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
3362929010
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................................................................................................__
1. Date E&SC Plan 03/09/2021
Approved *
2. E&SC Plan Project FORSY-2021-020
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan STONEHAVEN EROSION CONTROL PERMIT-1.pdf 131.65KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Wst be RDFforrret (lint 20 NB)
1639-survey 24x36 (1) use this one.pdf 240.66KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NOI certification form.pdf 521.77KB
Form Wst be RDFforrret
This is an Express r No
Review Project* r Yes

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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle 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 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:* IT The Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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
Type Name* Barry Siegal
Title President
Organization Legally Responsible Entity
BSC Holdings, Inc.
Date * 05/25/2021

F. Tracking and COC Info
NOI Tracking No. 53505
NC Reference No.
NCG01-2021-3175
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC213175
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3175
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC213175-2021
Invoice Due Date 6/25/2021
Initial Fee $ 100.00
Invoice Status OPEN