NCC223763_NOI Application_20221107

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/3/2022 11:37:56 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 11/4/2022 6:13:16 AM (Review - NOI 111835 Bridge Street Basin Replacement
and Rehabilitation)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 11/3/2022 11:39 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 8, 2022 5:00
PM 11/3/2022 11:39 AM
by Workflow 11/4/2022 6:13:24 AM (Workflow Start Event)
Submit by Holloman, Tevye L 11/7/2022 8:33:40 AM (Payment Verification for NCC223763)
* Eric Brown
• Holloman, Tevye L assigned the task to Holloman, Tevye L 11/7/2022 8:33 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 16, 2022 5:00
PM 11/4/2022 6:13 AM

a
NORTH CAROLINA,
Enri--tn! C2-1;ly
A. Project Information
Part A.
Project Location and Waterbody Information
................................................................................................................... .
Are you submitting No
an NOI that was Yes
rejected before?
la. Project Name* Bridge Street Basin Replacement and Rehabilitation
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all PINS associated with this project.
Number(s) (PIN) City of Eden, Rockingham County Property Owner PINs
796908972617
796908973745
796908974798
796908975859
796908987090
796912855136
796912858196
796912859382
796912867857
796912867947
796912876187
796912876192
796912877110
796912951338
796912952388
796912952710
796912955446
796912955678
796912961221
796912975391
796916835889
796916847888
796916849713
796916923869
796916936561
796916940174
797905082086
797905084175
797905087113
797905088464
797905183376
797905184338
797905184551
797905184650

797905184669
797905184768
797905185411
797905186546
797905186645
797905192188
797906371596
797906372540
797906374862
797906375609
797906375660
797906376512
797906383063
797906477909
797906485167
797906486038
797906487350
797907579688
797907579688
797909058098
797909059190
797909150183
797909151177
797909152260
797909155093
797909155119
797909155282
797909156246
797909157005
797909158100
797909158386
797909159498
797909250109
797909251234
797910350778
797910351834
797910353584
797910353826
797910354472
797910354804
797910355800
797910356661
797910357524
797910358435
797910365356
797910366430
797910367267
797910367404
797910367477
797910367759
797910368249
797910368581
797910369595
797910369763
797910371415
797910371452
797910372308
797910372390
797910372495
797910373347
797910374130
7a7alnz7azQa

797910376125
797910376378
797910378064
797910450510
797910451328
797910455739
797910461652
797910462498
797910462625
797910462698
797910463669
797910464429
797910464658
797910464759
797910464997
797910465501
797910465586
797910465777
797910466660
797910466831
797910467619
797910467784
797910468524
797910469392
797910469414
797910476048
797910476092
797911575038
797911667290
797911667290
797911667290
797913025967
797913030998
797913031834
797913031911
797913032539
797913040029
797913040262
797913040375
797913041016
797913042370
797913042588
797913048584
797913140672
797913141667
797913142744
797913143729
797913144814
797913145809
797914341217
2. County* Rockingham
3. Highway or Street Bridge Street
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Eden
5. State* NC

6. Zip Code* 27603
7. Latitude* Enter the latitude in decimal degrees
36.4869
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-79.7599
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*
11/14/2022
Estimated Construction Project Start Date
10. Date to End*
06/03/2024
Estimated Construction Project End Date
11. SIC (Primary)*
Other (9999)
Standard Industrial Classification for Development
12. Acres to be
23.50
disturbed*
(including off -site borrow and waste areas)
13. Total site area 25.00
(acres) *
14. Post -construction 15.00
impervious area (Estimated)
(acres)*
Project Tracking ID NCC-ROCKI-2022-Bridge Street Basin Replacement and
Rehabilitation
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 Matrimony Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 22-38
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
15c. Additional Mill Branch
Receiving Waterbody Waterbody name
15d. Waterbody Index 22-39.5
No. NC Waterbody Index Number
15e. Additional Dan River
Receiving Waterbody Waterbody name
15f. Waterbody Index 22-(38.5)
No. NC Waterbody Index Number

16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Permittee Information - Legally Responsible 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
1. Permittee* Legally Responsible Entity
City of Eden
If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership (FRO) Form.
2. First Name* Jon
If Corporation, enter Registered Agent First Name
3. Last Name* Mendenhall
If Corporation, enter Registered Agent Last Name
3b. Title City Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-623-2110
Telephone No.*
6. Permittee Mailing Street Address
Address* 308 East Stadium Drive
Address Line 2
City State / Province / Region
Eden NC
Postal / Zip Code Country
27288-3523 US
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 308 East Stadium Drive
Address Line 2
City State / Province / Region
Eden NC
Postal / Zip Code Country
27288-3523 us
8. Type of Ownership is only individual if an individual is named in B.1. above.
Ownership* Government - Municipal

C. Site Contact Information
Part C.
Project Site Contact Information
.................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Eric
Contact - First
Name*
2. Primary Site Brown
Contact - Last Name*
3. Title Project Manager
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact 336-215-7491
Telephone No.*
6. Organization Name Yates Construction Company, Inc.
7. Site Contact Street Address
Mailing Address* 9220 NC-65
Address Line 2
City
Stokesdale
Postal / Zip Code
27357
8. Consultant Name (optional)
Anita Robertson
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 919-256-5612
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone (For Annual Fee correspondence)
336-623-2110
Default is legally responsible person telephone
State / Province / Region
NC
Country
US

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 10/20/2022
Approved *
2. E&SC Plan Project ROCKI-2023-003
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* 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
E&SC Plan Approval Letter.pdf 3.46MB
Approval letter or
Must be PDF format
Grading Permit
6. Signed FRO
Financial Responsibility/Ownership Form
Signed FRO Form.pdf 1.77MB
Must be PDF format
7. Site Location Map
Must be PDF format (limit 20 MB)
Site Location Map.pdf 1.37MB
Please do not upload entire set of E&SC plans.
8. Notes (Optional)
Provide any additional information that might help the reviewer better understand how uploaded documents
support the application. Include additional waterbodies if necessary.
The Bridge Street Basin Replacement and Rehabilitation Project
involves repairs to the City of Eden sanitary sewer system located
within the Lower Matrimony Creek and Dan River Outfall Areas. The
Project will repair the sewer by utilizing replacement construction,
relocation and cured in -place installation. Please note that this
Project will not increase impervious area from pre- to post -
construction conditions.
9. NOI Certification NCG01 Notive of Intent (NOI) Certification Form -.pdf 421.89KB
Form Must be PDF format
This is an Express No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false 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 Article; 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 Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* 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:* The Legally Responsible Person named on this Notice of Intent
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
�111 11 1114-1lrrf/
Type Name* Jon M. Mendenhall
Title City Manager
Organization Legally Responsible Entity
City of Eden
Date * 11 /03/2022

F. Tracking and COC Info
NOI Tracking No. 111835
NC Reference No. NCG01-2022-3763
Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed
from workflow if eNOI approved)
Certificate of NCC223763
Coverage (COC) No.* Uses NOI number until approved, then uses NUMBER incremented by SIP (formatted and passed from workflow if
eNOI approved)
Initial Invoice No. NCC223763-2022
Invoice Due Date 12/4/2022
Initial Fee $ 100.00
Invoice Status OPEN