NCC215577_NOI Application_20211011

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/6/2021 9:47:47 AM (NCG01 NOI Submission)
Approve by EADS\bcbroussard 10/6/2021 9:54:24 AM (Review- Construction NOI 68015)
. The task was assigned to EADS\bcbroussard by round robin distribution 10/6/2021 9:49 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 8, 2021 5:00
PM 10/6/2021 9:49 AM
Submit by Selkane, Aziza 10/11/2021 3:27:42 PM (Payment Verification for NCC215577)
* B.R.S., Inc
• Selkane, Aziza assigned the task to Selkane, Aziza 10/11/2021 3:26 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 17, 2021 5:00
PM 10/6/2021 9:54 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 67778
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Derita Branch Sanitary Sewer Improvements Project Phase 1
1 b. Specific Lot This field may be used to list spedc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 08303116,08303117, 08303118, 08303119, 08303131, 08502304, 08303128,
08303141,08502303
2. County* Mecklenburg
3. Highway or Street North Tryon Street
Address* Street name only is acceptable if no address number assigned yet
4.CityorTownship* Charlotte
5. State * NC
6. Zip Code * 28206
7. Latitude* Enter the latitude in decimal degrees
35.2519
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.8096
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* 10/04/2021
Estimated Construction Project Start Date
10. Date to End* 10/04/2022
Estimated Construction Project End Cate

11. SIC (Primary)* Other (9999)
Standard Industrial (aassification for Development
12. Acres to be 1.19
disturbed* (including off -site borrow and waste areas)
13. Total site area 1.19
(acres) *
14. Post- 0.01
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-MECKL-2021-Derita Branch Sanitary Sewer Improvements
Project Phase 1
Assigned automatically (not used)
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 Little Sugar Creek
Waterbody* Plarreof waterbody into which stormwater runoff will discharge
15b. Waterbody 11-137-8
Index No. * NCWaterbody Index Nurrber
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.
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 must 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. Permittee * Legally Pesponsible Entity
Charlotte Water
IF pernittee is an individual, enter first and last narre in this field. Otherwise, enter organization/business narre.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here.
2. First Name * Joseph
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Wilson
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Charlotte Water Chief Engineer
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7043361083
Telephone No.*
6. Permittee Mailing Street Address
Address* 5100 Brookshire Boulevard
Address Line 2
City
Charlotte
Fbstal / Zip Code
28216-3371
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
5100 Brookshire Boulevard
Address Line 2
City
Charlotte
Fbstal / Zip Code
28216-3371
State / Ffovince / i egion
NC
Country
us
State / Frovince / Region
NC
Country
us
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Government- Municipal

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Will
Contact - First
Name *
2. Primary Site
Isenhour
Contact - Last
Name *
3. Title
Vice President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7043091381
Telephone No.
6. Organization
BRS, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
208 State Hwy 49
Address Line 2
city
Richfield
Fbstal / Zip Code
28137-5731
8. Consultant Name
(Optional)
STV Engineers
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
7043309555
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
CarI.Wi [e-mail]
Default is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
7043361083
Default is legally responsible person telephone
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/14/2021
Approved *
2. E&SC Plan Project MECKL-2022-005
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 * Mooresville (MRO)
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 cwilson_9-24-2021_17-39-42 (002).pdf 1.69MB
Approval letter or Mist beRDFformat
Grading Permit
6. Signed FRO Financial Pesponsibility/Ownership Form
Derita Branch Phase 1 Financial Responsibility
259.38KB
Form.pdf
Mast be FCFfon-rat
7. Site Location Map Mast be RDFforrret (lint 201VB)
2021-09-27_Phase 1 Overview no_aerial.pdf 240.18KB
Rease do not upload entire set of E&SC plans.
8. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
9. NOI Certification Derita Phase 1 Certification Form Rev.pdf 90.12KB
Form Mast 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
psepl if sa
Type Name* Joseph Wilson
Title Charlotte Water Chief Engineer
Organization Legally Responsible Entity
Charlotte Water
Date * 10/06/2021

F. Tracking and COC Info
NOI Tracking No. 68015
NC Reference No.
NCG01-2021-5577
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC215577
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5577
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. NCC215577-2021
Invoice Due Date 11/5/2021
Initial Fee $ 100.00
Invoice Status OPEN