20001492 Ver 1_Complete File_20001129

A
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
1 ? •
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
January 4, 2001
Stokes County
DWQ Project # 001492
APPROVAL of 401 Water Quality Certification and ADDITIONAL CONDITIONS
Ms. Diane Hampton, NCDOT
2125 Cloverdale Avenue
Winston-Salem, NC 27103
Dear Ms. Hampton:
You have our approval, in accordance with the attached conditions and those listed below, to place fill material in 117 linear feet of
streams for the purpose of replacing a bridge with culverts (Bridge 196) on SR 1404 as described in your application dated November 29, 2000.
After reviewing your application, we have decided that this fill is covered by General Water Quality Certification Number 3239. This
certification allows you to use Nationwide Permit Number 14 when the Corps of Engineers issues it. In addition, you should set any other
federal, state or local permits before you go ahead with your project including (but not limited to) Sediment and Erosion Control, Coastal
Stormwater, Non-Discharge and Water Supply Water shed regulations. This approval will expire when the accompanying 404 or CASLa
permit-expires unless otherwise specified in the General Certification.
This approval is only valid for the purpose and design that you described in your application except as modified below. If you change
your project, you must notify us and you may be required to send us a new application. If the property is sold, the new owner must be given a
copy of this Certification and approval letter and is thereby responsible for complying with all conditions. If total wetland fills for this project
(now or in the future) exceed one acre, compensatory mitigation may be required as described in 15A NCAC 2H .0506 (11) (6) and (7). For this
approval to be valid, you must follow the conditions listed in the attached certification and any additional conditions listed below.
A second pipe to carry stormflow shall be installed at an elevation sufficient not to carry baseflow
2. The low flow culvert shall be installed at least 12" below the stormbed elevation.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You must act within 60 days of
the date that you receive this letter. To ask for a hearing, send a written petition, which conforms to Chapter 1508 of the North Carolina
General Statutes to the Office of Administrative Hearings, P.O. Box 27447, Raleigh, N.C. 27611-7447. This certification and its conditions are
final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If you have any questions,
please telephone John Domey at 919-733-9646.
Si rely,
I -?
e vens
Attachment
Cc: Corps of Engineers Raleigh Field Office
Winston-Salem DWQ Regional Office
File copy
Central Files
Ron Linville, WRC
Division of Water Quality • Wetlands/401 Unit
1621 Mail Service Center • Raleigh NC 27669-1621 • Telephone [phone] • FAX # [phone]
An Equal Opportunity Affirmative Action Employer
50% recycled/10% post consumer paper
111111
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
DWQ Project No.: County: _
Aoolicant:
Project Name:
Date of Issuance of 401 Water Quality Certification:
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules.
and any subsequent modifications, the applicant is required to return this certificate to the 401/Wetlands Unit.
North Carolina Division of Water Quality, 1621 Mail Service Center, Raleigh, NC, 27699-1621.This form may be
returned to DWQ by the applicant, the applicant's authorized agent, or the project engineer.It is not necessar.
to send certificates from all of these.
Applicant's Certification
I, , hereby state that, to the best of my abilities, due care and diligence
was used in the observation of the construction such that the construction was observed to be built within
substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans
and specifications, and other supporting materials.
Signature: Date:
Agent's Certification
I, , hereby state that, to the best of my abilities, due care and diligence
was used in the observation of the construction such that the construction was observed to be built within
substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans
and specifications, and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
I, , as a duly registered Professional (i.e., Engineer,
Landscape Architect, Surveyor, ect.) in the State of North Carolina, having been authorized to observe
(periodically, weekly, full time) the construction of the project, for the Permittee hereby state that, to the best of
my abilities, due care and diligence was used in the observation of the construction such that the construction
was observed to be built within substantial compliance and intent of the 401 Water Quality Certification and
Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature Registration No.
Date
Division of Water Quality • Wetlands/401 Unit
1621 Mail Service Center • Raleigh NC 27669-1621 • Telephone [phone] • FAX # [phone]
An Equal Opportunity Affirmative Action Employer
50% recycled/10% post consumer paper
1 k11?W,J?0
1
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
MEMORANDUM
TO: John Dorney Regional Contact: Jennifer Frye
Non-Discharge Branch WO Supervisor: I arrV Coble
Date: X2/1 ai2000
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name NCDo,r - Bridle 196 on SR 1404
Project Number 00 1492
Recvd From DOT
Received Date 11/29/00 Recvd By Region 12/7/2000
Project Type road crossing
County Stokes
County2
Region Winston-Salem
Certificates Stream
Permit Wetland Wetland Wetland Stream Class Acres Feet
Type Type Impact Score Index Prim. Supp. Basin Req. Req.
O N F- 22-9 I I'R 30,201. 100.00
14 F_ O YF
F__ O Y O N F_ F_ ??- I x- F_ F_
Mitigation Wetland
MitigationType Type Acres Feet
Is Wetland Rating Sheet Attached? 0 Y 0 N Did you request more info? 0 Y 0 N
Have Project Changes/Conditions Been Discussed With Applicant? OQ Y 0 N
Is Mitigation required? 0 Y O N Recommendation: 0 Issue 0 Issue/fond 0 Deny
Provided by Region: Latitude (ddmmss) 363005 Longitude (ddmmss) 802350
Comments:
The WSRO recommends that this WO Certification he issued with the following condition:
** Recommend that one nine be installed to capture baseflow and the other installed at a higher
elevation to capture stormflow
cc: Regional Office
Central Office Page Number 1
Facility Name NCDOT - Bridge 196 on SR 1404 County Stokes

Project Number 00 1492
I Regional Contact: Jennifer Frye
Date: 12/19/2000
Comments (continued from page 1):
cc: Regional Office Page Number 2
Central Office
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DEC 1 4 4@fV
9 North Carolina Wildlife Resources Commission,,... ,
Charles R. Fldhvood, Executive Director
MEMORANDUM
TO: Diane K. Hampton, Environmental Engineer
North Carolina Department of Transportation
FROM: Ron Linville, Regional Coordinator Original Signed
Habitat Conservation Program by J. R. Linville
DATE: November 28, 2000
SUBJECT: Review of Applications by NCDOT for Spanning Bridge No. 196 Replacement with Dual Pipe
Arches, Stevens Road (SR1404), Stokes County
The North Carolina Department of Transportation (NCDOT) is requesting a letter of concurrence from the
North Carolina Wildlife Resources Commission (NCWRC) to obtain a 404 pen-nits from the U.S. Army Corps of
Engineers for the above referenced projects. The project will replace an existing bridge with two 60' - 117" X 79"
CMP Pipe Arches. The NCWRC has reviewed information provided by the applicant, and field biologists on our
staff are familiar with habitat values of the project area. These comments are provided in accordance with
provisions of the Clean Water Act of 1977 (33 U.S.C. 466 et. seq.) and the Fish and Wildlife Coordination Act (48
Stat. 401, as amended; 16 U.S.C. 661-667d).
Based on the information provided by the applicant and our information on the range of trout in the project
area, we do not believe this project will cause significant effects to waters supporting trout. Therefore, we do not
object to the projects as proposed. We generally recommend the following for culvert installations:
Culverts larger than 36" should be placed a minimum of 12" inches below the nornial streambed. Natural
streambed materials should be able to fill this 12" and remain in the culvert during flood events without
being flushed out. If the culvert is installed properly, drop outlets will be eliminated and the culvert bottom
should not be visible but covered by natural streambed materials. These materials can be salvaged during
culvert installation and then placed back in the culvert. Culverts smaller than 36" should be installed on
grade or lower in order to accommodate aquatic migration. As two pipes or barrels are to be installed, one
pipe should be placed lower in order to receive base flow. The other barrel should be at a higher elevation
(above normal flow) or be silled on each end so that it will receive flows only during storm events. The
dimension, pattern, and profile of the stream and floodplain above and below the pipes should not be
modified permanently. Any modifications should be restored upon project completion.
2. Disturbance of the stream channel must be limited to only that which is necessary to install the culvert.
Culvert should maintain above and below stream conditions at pre-construction widths and depths for bed
load self-souring and aquatic life migration.
Mailing; Address: Division of Inland Fisheries • 1721 flail Service Center • Raleigh, NC 27699-1721
Telcplionc. [phone] cxt. 281 • Fax: [phone]
SR1404 Bridge No. 196 Page2 12/11/00
3. Use of riprap to armor the inlet and outlet ends of culverts should be kept to a minimum so as not to
interfere with aquatic life passage. Natural bank sloping and native plant revegetation should be used to
stabilize disturbed banks where practical to minimize thermal impacts (stream wanning due to loss of
riparian vegetation). Plants and material may be relocated from the general vicinity instead of being
purchased from a quarry or nursery.
Thank you for the opportunity to review and continent on this project. If you have any questions regarding
these continents, please contact me at 336/769-9453.
Cc: Eric Alsmeyer, US Army Corps of Engineers
,a
• : 9 2 PAYMENT
k ,; ' RECEIVED
DWQ ID: CORPS ACTION ID:
NATIONWIDE PERI?IIT REQUESTED (PROVIDE NATIONWIDE PERMIT #)
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7)
COPIES MUST BE SENT TO THE NC DIVISION OF WATER QUALITY,
ATTN: JOHN DORNEY, 4401 REEDY CREEK ROAD, RALEIGH, NC
27607. PLEASE PRINT OR TYPE
1. OWNER'S NAME: N C ?t ?' ?, v1- TRHN S t?OR AT?oN
2. MAILING ADDRESS: Z I Z 5 G Lev t?Z Dv. ?t A'IE.
SUBDIVISION NAME
CITY: W - S STATE: lac- ZIP CODE: Z '7 IO 3
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
SR\ 4o4- `6 P,16G. t9b s-??v?NS ??. 5 i?K?S ry
3. TELEPHONE NUMBER: (HOME) (WORK)
3? '7,61- 2613
4. IF APPLICABLE: AGENTS NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONENUMBER: 1aryE ??cAn-?? ?tJ,A? DG. D
?..1 ZS LLpvLRDa,?E -eve,
wiNS ??N-S??,?r1 NC 2,'?l03
5. LOCATION OF WORK (PROVIDE A MAP, PREFEtt LY A COPY OF USGS TOPOGRAPHIC MAP
OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: - NEAREST TOWN: F Ra,?? c 5 to
S To1??.5
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ECT.)
s's??' J9 6
6. IMPACTED OR NEAREST STREAM/RIVER: RIVER BASIN: ?v??okE
u N ??t A ??\%D i R i$. Tv z I C_7 c ikg . K
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), UTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-I OR WS-II)? YES [E]NO ? IF YES, EXPLAIN: 1 iZo
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES ? NO [?]-
(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION?
8. (a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES ? NO Ia I YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND
ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES ? NO [3117 YES, DESCRIBE ANTICIPATED WORK:
9. (a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND: 0. C)3
(b) ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: rye N\;
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: O EXCAVATION:
FLOODING: O OTHER : O
DRAINAGE : _ n TOTAL ACRES TO BE IMPACTED: fvoN E
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION: >J N
LENGTH BEFORE: FT AFTER: FT
WIDTH BEFORE (bascd on normal lugli water contours): FT
AVERAGE DEPTH BEFORE: FT AFTER: FT
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: ?/
CHANNEL EXCAVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? ?jp WHAT IS THE EXPECTED POND SURFACE AREA? Q lt\
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
EQUIPMENT TO BE USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
To RGPuac? 0L-t-s?larJ ZO'- C" -r Ir\ aIZ- R 9, V, E w\?N Z'
13. PURPOSE OF PROPOSED 'gVORK S S Last L ~ N 5 rk%p °?A? o N s tp? S Laps
RE Lr>LL o L-D 6 R I D C, E w\ 1 -A ?l E- W O rJ 5N r1 r c?Tl J i? .
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS)
Q I-)?'\
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY FEDERALLY
LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL
HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED: I k I 'L lx_ JQ;:Z)
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. DATE CONTACTED \ \ ?Z???
A
17. DOES THE PROJECT INV LVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF PUBLIC
(STATE) LAND? YES Lff NO ? (IF NO, GO TO 16)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENT§ OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACT? YES ? NO E3'
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE YES ? NO ?
IF ANSWER 17b IS YES. THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38).
ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON
THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OF 1 INCH EQUALS 100 FEET
OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
(c) WHAT IS LAND USE OF SURROUNDING PROPERTY?
(Q IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
SIGNED AND DATED AGENT AUTHORIZATION LETTER. IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
1. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
PROGRAM,
OWNER'S/AGENT'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED).
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'. ` PAYMENT
RECEIVED
c?
DWQ ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #)
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7)
COPIES MUST BE SENT TO THE NC DIVISION OF WATER QUALITY,
ATTN: JOHN DORNEY, 4401 REEDY CREEK ROAD, RALEIGH, NC
27607. PLEASE PRINT OR TYPE.
%
A -%,,j,4
1. OWNER'S NAME: NC ? t ?, v ?= T ??Nrv s ?oR
2. MAILING ADDRESS: 2 1 Z 5 G L -,3v t???o.
SUBDI VISION NAME iv S i4 - s ?E r?? C
CITY: W - S STATE: JNr ZIP CODE: Z '7 t0 ?
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
S4- ?f??oU? l9b s ??v6rvs ??. s i?1c?s ??unrY
3. TELEPHONE NUMBER: (HOME) (WORK)
33 6-- '7.61- 2613
4. IF APPLICABLE: AGENTS NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER:
Z1'ZS LLOVtRDA?? AVE.
5. LOCATION OF WORK (PROVIDE A MAP, PREFt ABLY A COPY OF USGS TOPOGRAPHIC MAP
OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: - NEAREST TOWN: ZA,y c 5 to
S TvKtiS
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ECT.)
Spy \ -o4j- BcZ,? J9 6
6. IMPACTED OR NEAREST STREAM/RIVER: RIVER BASIN: jy?okE
'-A tv r? A `-?c. D -1-k I a. T? a3 l C? C ?'Z= K
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQNV), UTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-I OR WS-II)? YES LgNNO ? IF YES, EXPLAIN:
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES ? NO D-
(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION?
8. (a) HAVE ANY SECTION ?,?404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES ? NO l I YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND
ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES ? NO CIF YES, DESCRIBE ANTICIPATED WORK:
9. (a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND: 0. 03
(b) ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: N,,)Na
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: O EXCAVATION:
FLOODING: O OTHER : O
DRAINAGE : TOTAL ACRES TO BE IMPACTED: tjON E
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION: iJ p,
LENGTH BEFORE: FT AFTER: IT
WIDTH BEFORE (based on nornal high water contours): FT
AVERAGE DEPTH BEFORE: FT AFTER: FT
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: ?
CHANNEL EXCAVATION: CONSTRUCTION OF A DAMIFLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? Oh WHAT IS THE EXPECTED POND SURFACE AREA? WIN
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
EQUIPMENT TO BE USED? (ATTACH PLANS; 81/2 BY I 1 DRAWINGS ONLY)
o REPuac? oc-D 1-sue AN ZC) '- 6" %rr\acR BR?At?E
13. PURPOSE OF PROPOSED ORKS S Lof t ? ?. - c N ? o N S `p? S UZ.
RE ?-r?cL -L-,S,> 3 R t a &E w \ r`1 E W (DN 5^r-,\f-7 r_? cATI ?1 i? .
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS)
N I-P\
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY FEDERALLY
LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL
HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED: ? k I zLJQ-'Z)
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. DATE CONTACTED
17. DOES THE PROJECT INV LVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF PUBLIC
(STATE) LAND? YES LNO ? (IF NO, GO TO 16)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
NT. OF THE NORTH CAROLINA
DOCUMENT PURSUANT TO THE REQUIREMEE3"
ENVIRONMENTAL POLICY ACT? YES ? NO (b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE YES ? NO ?
IF ANSWER 17b IS YES. THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. T1IE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38).
ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON
THE MAP. MAP SCALES SHOULD BE I INCH EQUALS 50 FEET OF I INCH EQUALS 100 FEET
OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
(c) WHAT IS LAND USE OF SURROUNDING PROPERTY?
(I) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
1. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
-PROGRAM
,
OWNER'S/AGENT'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED).

6
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m).?•_?i'1.1 ?1z51 e ">3 I / .5 ?I _ PREPARED BY THE
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