NCC190008_NOI Application_20190403

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/3/2019 10:13:31 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 4/3/2019 10:20:02 AM (Review- Construction NOI 9832)
• The task was assigned to McCoy, Suzanne by round robin distribution 4/3/2019 10:13 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 5, 2019 5:00 PM
4/3/2019 10:13 AM
Submit by McCoy, Suzanne 4/3/2019 10:20:50 AM (Payment Verification - NCG01-2019-0008)
• The task was assigned to McCoy, Suzanne. The due date is: April 4, 2019 5:00 PM
4/3/2019 10:20 AM

1r-i)iTII�T:2,11111711MF11f_TiIa10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Mason Park Phase 3
2. County* Johnston
3. Highway or Street Josephine Road
Address * Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Cleveland
5. State * NC
6. Zip Code* 27529
7. Latitude * Enter the latitude in decirral degrees
35.5713
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-78.5102
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. Date to End*
11. SIC (Primary)*
12. Acres to be
disturbed *
13. Total site area
(acres)*
14. Post -
construction
impervious area
(acres) *
04/15/2019
Estirrated Construction Project Start Date
06/28/2019
Estirrated Construction Project End Date
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Developrrant
11.50
(including off -site borrow and waste areas)
32.08
3.78

NCC Project NCC-JOHNS-2019-Mason Park Phase 3
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. You may
enter up to 3 waterbodies.
15a. Receiving Swift Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-43-(8)
Index No. * NCWaterbody Index Nmber
Stormwater fJ 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.
Perrrittee Information - Legally Fbsponsible Entity and Individual
.........................................................................................................................................................................
1. Organization Capital Properties of Raleigh II, LLC
Name *
2. First Name* David
ff Corporation, enter Fbgistered Agent First 1\brre
3. Last Name *
Stallings
V Corporation, enter Registered Agent Last f brre
4. Permitee E-mail
[e-mail]
Address*
5. Permittee
9842005540
Telephone No.*
6. Permittee Mailing Street Address
Address* 3724 National Drive
Address Line 2
Suite 220
City State / Province / Region
Raleigh NC
Postal / Zip Code Country
27612 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 3724 National Drive
Address Line 2
Suite 220
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27612
us
h

C. Site Contact Information
Part C.
Proiect Site Contact Inforrretion
1. Type of Individual
Ownership*
2. Primary Site Zach
Contact - First
Name *
3. Primary Site Daugherty
Contact - Last
Name *
4. Title
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact
9105488433
Telephone No.*
7. Organization
Shenandoah Homes, LLC
Name
8. Site Contact
Street Address
Mailing Address*
3724 National Drive
Address Line 2
Suite 220
City
Raleigh
Fbstal / Zip Code
27612
State / Province / Fbgion
NC
Country
United States
h

D. E&SC Plan
Part D.
Erosion & Sediment Control (MSC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 03/25/2019
Approved *
2. E&SC Plan Project JC# 18-086-P
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Johnston 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 Erosion & Sedimentation Control Plan Approval from
Approval 124.92KB
JoCo.pdf
letter/documentation
Mist be R7F forrret
6. NOI Certification Signed NOI.pdf 270.69KB
Form Mist be RDFfornet
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V 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.
* I7 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
r 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* Zachary Daugherty
Date * 04/03/2019

F. Tracking and COC Info
NOI Tracking No. 9832
NC Reference No. NCG01-2019-0008
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190008
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number
Sequential nunber for subrrittal that is increrrented by Stored Procedure
COC Year 2019
Year of date reviewed, used to assign YY digits after "NOC' in OOC no.)