20031521 Ver 1_COMPLETE FILE_20030124

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Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen 11. Sullins, Deputy Director
Division of Water Quality
Asheville Regional Office
WATER QUALITY SECTION
January 8, 2004
Mr. Albert Kosderka
North Bend Baptist Church
Horton Hill Road
Green Mountain, NC 28740
Subject: Additional Information Request
401 Water Quality Certification
Application Number: 03-1521
Status of Application: On Hold
North Bend Baptist Church
Yancey County
Dear Mr. Kosderka:

The Division of Water Quality's Asheville Regional Office performed a site visit on January 7, 2004. There
are several items, which must be addressed in your application prior to the agency being able to process the
submitted application. The following items must be addressed:
1. Application Question Number 111. 4. Directions. The submitted directions do not provide sufficient detail
to locate the site in question. It appears that there are several roads, which are connected, but are not
consistent in naming. Please provide further detail on an updated Page 6 of 12, as to allow follow up
inspectors to locate this site. All detail should include both the street name and state road number for each
intersection where that road name may change.
2. Application Question Number III. 8. River Basin. The submitted application indicates that the project is
located in the Nolichucky River Basin. The Nolichucky is not a designated River Basin within the Division
of Water Quality's basin wide mapping system. On the re-submitted page 6 of 12, please refer to the one
of the State's seventeen designated river basins (Yancey County is located in the French Broad River
Basin).
3. Application Question Number VI. 1. Description of Proposed Impacts. The submitted information appears
to be incomplete. While this agency understands that you desire to place 140 linear feet of 36" pipe as part
of this project, there is no submitted information in regards to the joint manhole, nor any downstream
streambank stabilization to address the increased velocities for the discharge of the pipe. A modified page
8 of 12 should be submitted addressing these additional impacts (not only in length of impact, but also as
a verbal discussion of how these items will be accomplished.
4. Application Question Number VI. 3. Additional impacts, as referenced as need above, shall be entered on
the re-submitted page 8 of 12.
Michael P. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
-j1A
59 Woodlin Place Asheville, North Carolina 28801 Telephone [phone] Pax [phone] Customer Service 1-877-623-6748
North Bend Baptist Church
Additional Information Request
January 8, 2004
Page 2.
5. Application Question Number XI. Stormwater. This project should be designed as to eliminate the direct
discharge of collected stormwater to surface waters of the state. As part of this application should be
modified to include the removal off all downspouts from roof gutters to remove the existing direct
discharge, and additionally, all collected stormwater from paved areas should be discharged to vegetated
areas via diffuse flow. This information should be included as part of a modified page 12 of 12.
6. Application Question Number XII. Sewage Disposal. You must provide a complete discussion of how
sewage disposal is occuring, and if this project will result in a increase in the congregation, and / or useage
of the church, the ability of the existing sewage disposal to handle the additional waste. This information
should be included as part of a modified page 12 of 12.
You must submit to requested information, no later than 10 business days following receipt of this request.
Failure to do so may result in this project being returned as incomplete.
Should you have any questions, please do not hesitate to contact me at kevin.barnettnnclnail.net or at 828-251-
6208.
Sincerely,
Ad4;?--
Kevin H. Barnett,
Environmental Chemist
cc: Mr. John Dorney, Wetlands / 401 Unit
US Army Corps of Engineers, Asheville Regulatory Office
Mrs. Wanda Frazier, Asheville Regional Office (NC-DWQ)
R-c-b u
59 Woodfin Place Asheville, North Carolina 28801 Telephone [phone] Fax [phone] Customer Service 1-877-623-6748
O?O? V 4A
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimck, P. E. Director
Division of Water Quality
Colecn H. Sullins, Deputy Director
Division of Water Quality
Asheville Regional Office
WATER QUALITY SECTION
January 8, 2004
Mr. Albert Kosderka
North Bend Baptist Church
Horton Hill Road
Green Mountain, NC 28740
Subject: Additional Information Request
401 Water Quality Certification
Application Number: 03-1521
Status of Application: On Hold
North Bend Baptist Church
Yancey County
Dear Mr. Kosderka:
The Division of Water Quality's Asheville Regional Office performed a site visit on January 7, 2004. There
are several items, which must be addressed in your application prior to the agency being able to process the
submitted application. The following items must be addressed:
1. Application Question Number III. 4. Directions. The submitted directions do not provide sufficient detail
to locate the site in question. It appears that there are several roads, which are connected, but are not
consistent in naming. Please provide further detail on an updated Page 6 of 12, as to allow follow up
inspectors to locate this site. All detail should include both the street name and state road number for each
intersection where that road name may change.
2. Application Question Number III. 8. River Basin. The submitted application indicates that the project is
located in the Nolichucky River Basin. The Nolichucky is not a designated River Basin within the Division
of Water Quality's basin wide mapping system. On the re-submitted page 6 of 12, please refer to the one
of the State's seventeen designated river basins (Yancey County is located in the French Broad River
Basin).
3. Application Question Number VI. 1. Description of Proposed Impacts. The submitted information appears
to be incomplete. While this agency understands that you desire to place 140 linear feet of 36" pipe as part
of this project, there is no submitted information in regards to the joint manhole, nor any downstream
streambank stabilization to address the increased velocities for the discharge of the pipe. A modified page
8 of 12 should be submitted addressing these additional impacts (not only in length of impact, but also as
a verbal discussion of how these items will be accomplished.
4. Application Question Number VI. 3. Additional impacts, as referenced as need above, shall be entered on
the re-submitted page 8 of 12.
s+;caEr;.?t
59 Woodfin Place Asheville, North Carolina 28801 Telephone [phone] Fax [phone] Customer Service 1-877-623-6748
North Bend Baptist Church
Additional Information Request
January 8, 2004
Page 2.
5. Application Question Number XI. Stormwater. This project should be designed as to eliminate the direc
discharge of collected stormwater to surface waters of the state. As part of this application should bi
modified to include the removal off all downspouts from roof gutters to remove the existing direc
discharge, and additionally, all collected stormwater from paved areas should be discharged to vegetate(
areas via diffuse flow. This information should be included as part of a modified page 12 of 12.
6. Application Question Number XH. Sewage Disposal. You must provide a complete discussion of hov
sewage disposal is occuring, and if this project will result in a increase in the congregation, and / or useagi
of the church, the ability of the existing sewage disposal to handle the additional waste. This informatiol
should be included as part of a modified page 12 of 12.
You must submit to requested information, no later than 10 business days following receipt of this request.
Failure to do so may result in this project being returned as incomplete.
Should you have any questions, please do not hesitate to contact me at [e-mail] or at 828-251
6208.
Sincerely,
Kevin H. Barnett,
Environmental Chemist
cc: Mr. John Dorney, Wetlands / 401 Unit
US Army Corps of Engineers, Asheville Regulatory Office
Mrs. Wanda Frazier, Asheville Regional Office (NC-DWQ)
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INMEN t
59 woodfin Place Asheville, North Carolina 28801 Telephone [phone] Fax [phone] Customer Service 1-877-623-6748

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Date:
Triage Check Dist

Project Name: Q"M`,?w-A
DWQ#: 03-159l
County: qawt"
To: X" ARO
? FRO
? MRC
? RRO
Mike Parker ?' WaRO Tom Steffens
Ken Averitte ? WiRO Noelle Lutheran
Alan Johnson ? WSRO Daryl Lamb
Steve Mitchell
From: W C,,_ -) Telephone : (919) 03- •ISd.1
The file attached is being forwarded to your for your evaluation.
Please call if you need assistance.
Stream length impacted
? Stream determination
? Wetland determination and distance to blue-line surface waters on USFW topo maps
MinimiMtion/avoidance issues
? Buffer Rules (Meuse, Tar-Pamlico, Catawba, Randleman)
? Pond fill
? Mitigation Ratios
? Ditching
?.' Are the stream and or wetland mitigation sites available and viable?
Check drawings for accuracy
? Is the application consistent with pre-application meetings?
Cumulative impact concern
Comments:
U.S. ARMY CORPS OF ENGINEERS lJ
Wilmington District
Action ID: 200331307 County: Yancey
Incomplete Application Notification
Property WETLANDS/ 401 GROUP
Owner North Bend Baptist Church
Attn: Howard Buchanan
Address 9165 Jacks Creek Road (JEC D `j 2003 G ?(p?
Green Mountain NC 28740 _
Telephone Number 828-682-2032 TER UALI J ?
Location/DescriPtion of Proposed Activity: Proposed construction of a p g atkmlot o'imp?actJ ± '-
approximately 140 linear feet of an unnamed, tributary to Jacks Creek in t1iccNolirhucky River Basin. Site
is located on the east side of SR 1339, north of its intersection with NC H'%t)A1-91 _northeast of Burnsville,
Yancey County, North Carolina.
Type of Permit Applied For (check one): 1P () NWP (X ) GP ( )
Applicable law: Section 404 of the Clean Water Act (X); Section 10, Rivers and Harbor Act ( )
YOUR APPLICATION/PRECONSTRUCTION NOTIFICATION IS INCOMPLETE AND CANNOT
BE EVALUATED UNTIL THE FOLLOWING INFORMATION IS RECEIVED (CHECK ALL THAT
APPLY):
Your application/pre-construction notification form has not been completed and/or signed. (see
remarks)
Under the conditions of Nationwide Permit you are required to submit an aquatic resource
mitigation plan. The required plan is either insufficient or has not been included with your
notification (see remarks).
X Your application/pre-construction notification did not include information describing meusures you
have implemented to avoid and minimize losses of Waters of the United States.*' '
X Your submitted project plans or maps were insufficient, too large, or not legible (see remarks)
Your application/pre-construction notification did not include a delineation of affected special
aquatic sites, including wetlands, vegetated shallows, and riffle and pool complexes as required.
X You must submit a copy of your application to the NC Wildlife Resources Commission (WRC)
since your proposed work is in a designated trout water county (see remarks section below for the
address of your WRC representative)
Other (see remarks below)
REMARKS:_ Please submit drawings/site plan depicting the proposed work. You should also provide any
information on how the proposed impacts could be avoided/minimized. A copy of the permit application
must be forwarded to the Wildlife Resource Commission: Mountain Regional Coordinator, 20830 Great
Smoky Mtn. Expressway, Waynesville, NC 28786.
Date: 10-21-03
Corps Regulatory Official: ?. - Telephone No.: 828-271-7980x.7
J
Office Use Only: Form Version May 2002
USACE Action ID No. ,?2 /? 0 S3 /3 67 DWQ No.
(if any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
I. Processing
1. Check all of the approval(s) requested for this project:
[Z Section 404 Permit F? Riparian or Watershed Buffer Rules
F] Section 10 Permit Isolated Wetland Permit from DWQ
401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested:
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here:
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: n
II. Applicant Information
1. Owner/AppM ' t Information
Name:
Mailing Address: ?APIeto
Telephone Number: G?- r1'7?T Fax Number:
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN): / 5? 2-
4. Location
County: V4 k) /" 10 Nearest Town54110 ° lire eyi r4Olt g
Subdivision ame (includ phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
.n nnn o l ^t,,L "P.,i/ I R C -En -4L,.,.i ICa 7 A/ , tee, 6n %i _
r'n ri h'? onto 0or+vn 14111 0. ' G UrCh i 5 %rn,lwe 'nv ri1 h f.
5. Site coordinates, if available (UTM or Lat/Long ?
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Property size (acres):,
7. Nearest body of water (stream/river/sound/ocean/lake): U ( -`b W hT?-s©n rztnl'l?
River Basin: r - 1 r-
(Note - this must be one of North Ca olina's seventeen designated in,
River Basin map is available at Imp: //h2o.enr. state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinit of the project
at the time of this application: Ck r e- e
C. f P e- K i v?na \('P-14 ?^cD a r) -lrJ /' lA r r e-A .
Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used:
r r!
IV.
11. Explain the purp
Prior
ce>rre e--f-ed
ry r'`oOm -1b rove- roaA ©ve- r.
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules. i i II i r n
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
y - 790/-) )2.
VI. Proposed Impacts to Waters of the United States/Watcrs of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 7 of 12
a written description of the proposed impacts: Lae V- 4('(I I 1 qO
' ^ I'll ,. ,n 4- /,l nr- le. t ? A -T?1 _ .,-, _ _,
2. Individually list wetland impacts below:
Wetland Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

-Wl 11111J„L4 )VjJ&Uaic,y iu,u ,ueuuiy temporary impacts. impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://wNvw.fema.,Qov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property: Y p n Q_
Total area of wetland impact proposed: -0-
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)
I
Age ?-
O
OT P%Ilb
tln
eel
:2
erennlad
G ? r?e ek

*
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.uses.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mapguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: ?7? )!7e>°
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
(acres)
Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,

bay, ocean, etc.)

List cacn impact separately and identity temporary impacts. impacts include, but are not limited to: lilt, excavation, dredging,
flooding, drainage, bulkheads, etc.
VII.
5. Pond Creation / C A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): EJ uplands ? stream F1 wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts. .

VIII.
run :;L4t 91 t?r" eng5 Lql '- sdl?i )aa
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
littp:Hii2o.enr.state.nc.us/ncwetiands/strmgide html.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wrp/index htm. If use of
the NCWRP is proposed, please check the appropriate box on page three and provide the
following information:
Amount of stream mitigation requested (linear feet):
?-n
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX.
X.
Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes ? No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental, Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] review current thresholds for environmental documentation.
Yes ? No V
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No E]
Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 213 .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirem nts), or other (please identify_ )?
Yes ? No If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
Lone f extends out 3U feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
XI.
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the propert .
Pr Q?? e 1A 4- ?Al, '19 12--)
vn J m tea '. h
,22......r?<, n<, l - yy 11 0 b e nave of kt)?-h a ye e'ce?-?`Ve
XII. ? ?i f ff? f
'be Di t,os.,1(required by DV? Q)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (required by DWQ)
Is this site in violation of DW Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes R No
Is this an after-the-fact permit a ication?
Yes F? No
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
.,Z Y_
ApplicantTAgent's Si?nature ! to it d own e r Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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Page 12 of 12 `Tr LA Ste e 'D cc~ e_
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