19970144 Ver 1_COMPLETE FILE_19970219

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DE%1 ID: 970144 ACTION ID: A CIA Rc,??_ &W I Nationwide Permit Requested (Provide Nationwide Permit #):
JOINT FORM FOR .40191997
Nation-Aide permits that require notification to the Corps of EngineM?',sCIENCSS
Nationwide permits that require application for Section 401 certification
WILMINGTON DISTRICT ENGINEER
CORPS OF ENGINEERS
DEPARTMENT OF THE ARMY
P.O. Box 1890
Wilmington, NC 28402-1890
ATTN: CESAW-CO-E
Telephone [phone]
WATER QUALITY PLANNING
DIVISION OF ENVIRONMENTAL MANAGEMENT
NC DEPARTMENT OF ENVIRONMENT, HEALTH,
AND NATURAL RESOURCES
P.O. Boy. 29535
Raleigh, NC 27626-0535
ATTN: MR.;OHN DORNEY
Telephone [phone]
ONE (1) COPY OF THIS COMPLETED APPLICATION SHOULD BE SENT TO THE CORPS OF ENGINEERS.
SEVEN (7) COPIES SHOULD BE SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT.
PLEASE PRINT.
1. Owners Name: --- _Dm i c_- Parker
2. Owners Address: 253 95 34hh Ad
3. Owners Phone Number (Home): (114.) 239 - -3 IA4 (Work):
4. If Applicable: Agent's name or responsible corporate official, address, phone number.
5:1 Location of work (MUST ATTACH MAP). County: .U e 1S aw
Nearest Town or City: 5;0, s
Specific Location (Include road numbers, landmarks, etc.): ?R" gel) A W 59 // rye'
-5 he- Cow 0
6. Name of Closest Stream/River. ,inkhorn 1C'?sfrcc`?
7. River Basin: hieas e-
8. Is this project located in a watershed classified as Trout, SA, HQW, ORW, WS I, or WS II? YES [ ] NO [ }?
9. Have any Section 404 permits been previously requested for use on this property? YES [ ] NO 11?
If yes, explain.
10. Estimated total number of acres of waters of the U.S., including wetlands, located on project site:
11. Number of acres of waters of the U.S., including wetlands, impacted by the proposed project:
Filled: Z . 5 'Ic- Drained:

Flooded:
Excavated:
Total Impacted. L 5 ??
* 7 . ...VA.
12. Description of proposed work (Attach PLANS-8 1/2" X 11" drawings only):
13. Purpose of proposed work: cess Awi
14. State reasons why the applicant believes that this activity must be carried out in wetlands. Also, note measures
taken to minimize wetland impacts.
?? WAY IO G C S1- lei a/edd - cjd.
15. You are required to contact the U.S. Fish and Wildlife Service (USFWS) and/or National Marine Fisheries Service
(NMFS) regarding the presence or any Federally listed orproposed for listing endangered or threatened species or critical
habitat in the permit area that may be affected by the proposed project. Have you done so? . ,, YES [ ] NO [ ]
RESPONSES FROM THE USFWS AND/OR NMFS SHOULD BE FORWARDED TO CORPS.
16. You are required to contact the State Historic Preservation Officer (SHPO) regarding the presence of historic
properties in the permit area which may be affected by the proposed project? Have you done so? YES [ J NO [ ]
RESPONSE FROM THE SHPO SHOULD BE FORWARDED TO CORPS.
17. Additional information required by DEM:
A. Wetland delineation map showing all wetlands, streams, and lakes on the property.
B. If available, representative photograph of wetlands to be impacted by project.
C. If delineation was performed by a consultant, include all data sheets relevant to the placement of the
delineation line.
D. If a stormwater management plan is required for this project, attach copy.
E. What is land use of surrounding property? X&AX4, Xzk, httd
F. If applicable, what is proposed method of sewage disposal? &//l
wner's Signature Date
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