NCC213459_Modification Review_20231220

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 12/18/2023 7:42:09 PM (ADD TO FILE Submittal)
Approve by bethany.georgoulias 12/20/2023 9:15:53 AM(Construction COC ADD TO FILE Review-NCC213459)
• The task was assigned to bethany.georgoulias.The due date is: December 21,2023 5:00 PM
12/18/2023 7:42:10 PM

Ago Permit for Construction Activities DEQMODIFICATION
0i0tl
0000
Certificate of NCC213459
Coverage(COC)No.* Enter the Certificate of Coverage Number(Use capital letters)
Information associated with this permit:
Project Name David Hickman Brookberry
Address 1562 Autumn Park CIR,1568 Autumn Park CIR,1547 Autumn Park CIR,1451
Autumn Park CIR,1574 Autumn Park CIR,1445 Autumn Park CIR,Winston-Salem,
NC
County Forsyth
Latitude 36.1156
Longitude -80.3644
Permittee Listed David Hickman
Legally Responsible David Hickman
Individual At the time of Modification Request(not looked up again at review)
NC Reference No. NCG01-2021-3459
E&SC Plan ID 552597
Original NOI Tracking 54883
No.*
Date COC Issued* 06/14/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Modification*
Closed-Out Lots/Outparcels in E&SC Plan
Additional Lots/Outparcels Approved-E&SC Revised
Other Revision(s)to E&SC Plan
Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons(List)
Addional Explanation
More information(e.g.,new Site Contact details).If lots are being added,please include specific lot numbers.
Lot 633 109 Matisse Court, Lot 634 115 Matisse Court, Lot 635 121 Matisse Court, Lot 636 Matisse Court, Lot
637 224 Bright Blossom Court, Lot 638 218 Matisse Court, Lot 639 212 Matisse Court, Lot 640 206 Bright
Blossom Court
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload
applicable sheets).

For changes to the legally responsible individual, you must upload this form.
Supporting Documentation
Upload Supporting Documentation(Revised E&SC Approval,Close-Out Doc,etc.)
Lots 633 through 640 BBF Review Completed.pdf 984.84KB
Must be PDF format
Is this project funded with ARPA(American Rescue Plan Act)grant funds?
No
Yes
This question was added to the eNOl on 2/3/2023 and will not be answered in applications submitted prior to that date.
North Carolina General Statute 143-215.613(1)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).
* I hereby request modification to coverage under the NPDES Stormwater Permit for the
subject project site. I am familiar with the information contained in this request and to
the best of my knowledge and belief such information is true,complete and accurate.
Specify if you are:* The Legally Responsible Individual
Authorized Responsible Person*
"This form must be signed by a responsible corporate officer that 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* David H Hickman
Title* President
Organization* Westphalia Construction Company, Inc.
Date* 12/18/2023
Email Address* [e-mail]
Email for confirmation
Telephone Number* 336-345-0768
Contact number if we need to reach you
Note:Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email

Review Date 12/20/2023
Rescinded Since
Submitted?