NCC190067_NOI Application_20190418

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/18/2019 9:58:37 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 4/18/2019 10:33:30 AM (Review- Construction NOI 10231)
• The task was assigned to McCoy, Suzanne by round robin distribution 4/18/2019 9:58 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 22, 2019 5:00 PM
4/18/2019 9:58 AM
Submit by McCoy, Suzanne 4/18/2019 10:34:02 AM (Payment Verification - NCG01-2019-0067)
• The task was assigned to McCoy, Suzanne. The due date is: April 19, 2019 5:00 PM
4/18/2019 10:33 AM

1 r-i) iTiT 7i) it fiTi (-:TiI a 10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Crossroads Mission Church
2. County* Cleveland
3. Highway or Street Dekalb Street (No number assigned yet)
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Shelby
5. State * NC
6. Zip Code* 28152
7. Latitude * Enter the latitude in decirral degrees
35.2600
8. Longitude * Enter the longitude in decirral degrees (WISTbe negative)
-81.5580
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* 04/29/2019
Estimated Construction Project Start Date
10. Date to End* 12/31 /2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 3.75
disturbed* (including off -site borrow and waste areas)
13. Total site area
5.03
(acres)*
14. Post-
1.76
construction
impervious area
(acres) *
NCC Project
NCC-CLEVE-2019-Crossroads Mission Church
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 Hickory Creek
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 9-50-30
Index No. * NCWaterbody Index Number
Stormwater V No
discharges will flow rj 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.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
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
Crossroads Rescue Mission
Name *
2. First Name*
Rocky
ff Corporation, enter Registered Agent First l\b e
3. Last Name *
Shelton
ff Corporation, enter Registered Agent Last Barre
4. Permitee E-mail
[e-mail]
Address*
5. Permittee 704-473-7121
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box2090
Address Line 2
City
State / Province / Region
Shelby
NC
Fbstal / Zip Code
Country
28151
us
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 206 Mount Sinai Church Road
Address Line 2
City
State / Province / Region
Shelby
NC
Postal / Zip Code
Country
28152-0744
us

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Rocky
Contact - First
Name *
3. Primary Site Shelton
Contact - Last
Name *
4. Title Executive Director - CRM
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 704-473-7121
Telephone No.*
7. Organization Crossroads Rescue Mission
Name
8. Site Contact Street Address
Mailing Address* 206 Mount Sinai Church Rd.
Address Line 2
city
Shelby
Rbstal / Zip Code
28152
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 04/03/2019
Approved *
2. E&SC Plan Project CLEVE-2019-007
Number/ID* Assigned by agency or local program
3. E&SC Plan f• 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.
5. E&SC Plan nc approval_04182019_093145.pdf 1.69MB
Approval Mist be RDFfornat
letter/documentation
6. NOI Certification noi_04182019_095149.pdf 568.97KB
Form Mist be RDFfornat
This is an Express f• No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (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.
* 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.
* I7 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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 * Rocky L. Shelton, Sr.
Date * 04/18/2019

F. Tracking and COC Info
NOI Tracking No. 10231
NC Reference No. NCG01-2019-0067
Uses 'count_nunber variable (increrrented by SP)
Certificate of NCC190067
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 67
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.)