Buffer Authorization Application Form

15A NCAC 02B .0233 (8)(b), .0243 (8)(b), .0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2) Buffer Authorization Online Form - Update 10/23/2018

For instructions on how to fill out this form, see the Buffer Authorization Application Help Document posted on DWR's 401 & Buffer page.
Please note: fields marked with a red asterisk * below are required. You will not be able to submit the form until all mandatory questions are answered.

A. Owner/Applicant Information

General Information

Primary Contact Email:*field type single line
Please list the contact person's email for questions or payment on this project if needed.
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Is this project a public transportation project?*field type radio button
Is this project a public transportation project?YesNo
Who is submitting the application?*field type checkbox
Who is submitting the application?OwnerApplicant other than OwnerAgent
Check all that apply
Is there an agent working on this application but not submitting it?*field type radio button
Is there an agent working on this application but not submitting it?YesNo
Is this application for a project associated with emergency response/repairs from Hurricane Helene impacts to your project or property?*field type radio button
Is this application for a project associated with emergency response/repairs from Hurricane Helene impacts to your project or property?YesNo
1. Property Owner Information:
×
- 1a. Name on Recorded Deed:*field type single line
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- 1b. Responsible Party:field type single line
  (for Corporations)
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- 1c. Mailing Address:*field type address
  Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
  Country
- 1d. Telephone:*field type single line
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- 1e. Email Address:*field type email
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2. Applicant's Information (if different from owner):
×
- 2a. Name:*field type single line
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- 2b. Company Affiliation:field type single line
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- 2c. Mailing Address:*field type address
  Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
  Country
- 2d. Telephone:*field type single line
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- 2e. Email Address:*field type email
- 2f. Attach a signed and dated copy of the authorization granting the applicant owner approval. An agent authorization form is acceptable.*field type file upload
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3. Agent Information:
×
- 3a. Name:*field type single line
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- 3b. Company Affiliation:*field type single line
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- 3c. Mailing Address:*field type address
  Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
  Country
- 3d. Telephone:*field type number
- 3e. Email Address:*field type email
- 3f. Attach a signed and dated copy of the agent authorization form.*field type file upload
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If the applicant is not the property owner, in addition to providing the Agent’s information, select ‘Applicant other than Owner’ above, enter the applicant’s information, and attach an authorization granting the applicant owner approval.

B. Project Information and Prior Project History

1. Project Information

1a. Name of Project:*field type single line
(Subdivision, facility, or establishment name)
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If your project has a formal name please use this. If your project does not have a formal name, please identify your project by the owner name and proposed activity (Jones Property Access Road, Smith Guest House, etc.) List in parentheses any other names that have been used to identify the project in the past.
1b. Is this a publicly-funded transportation project?*field type radio button
1b. Is this a publicly-funded transportation project?YesNo
1c. TIP#field type single line
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1d. Subdivision Name:field type single line
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1e. Nearest Municipality:field type single line
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1f. Property Size:field type number
acres

	1g. County (or Counties) where the project is located:*field type drop-down
Row 1×	1g. County (or Counties) where the project is located:*field type drop-down	×

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	1h. Property ID#field type single line	Date of Purchasefield type date
Row 1×	1h. Property ID#field type single line Tax PIN or Parcel id Input blocked. Maximum character limit of 4000 characters reached.	Date of Purchasefield type date	×

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1i. Deed Information

Type of Book	Book#field type single line	Page#field type single line
Deed	Book#field type single line Input blocked. Maximum character limit of 4000 characters reached.	Page#field type single line Input blocked. Maximum character limit of 4000 characters reached.
Map	Book#field type single line Input blocked. Maximum character limit of 4000 characters reached.	Page#field type single line Input blocked. Maximum character limit of 4000 characters reached.

1j. Attach a copy of the recorded map that indicates when the lot was last platted.field type file upload
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1k. How would you like to provide the Latitude and Longitude information?*field type radio button
1k. How would you like to provide the Latitude and Longitude information?Address LookupManually
Address Lookupfield type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Latitude*field type single line
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Longitude*field type single line
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1l. Is the project located in any of North Carolina’s twenty coastal counties?*field type radio button
1l. Is the project located in any of North Carolina’s twenty coastal counties?YesNo
1m. Is the project located within a NC Division of Coastal Management Area of Environmental Concern (AEC)?*field type radio button
1m. Is the project located within a NC Division of Coastal Management Area of Environmental Concern (AEC)?YesNo
Coastal Management information can be found at:

2. Surface Waters

2a. Name of the nearest body of water to proposed project:*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Link to NRCS Published Soil Survey/USGS Topo Mapping Tool. (Please see instructions in the Help Document to determine the most recent published version.)
2b. Water Quality Classification of nearest receiving water:*field type single line
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2c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:*field type number
(linear feet only)

3. Project Description:

3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:field type multi line
3b. Attach an 8 ½ x 11 excerpt from the most recent version of the USGS topographic map indicating the location of the site.field type file upload
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Link to TOPO Map lookup: https://experience.arcgis.com/experience/a16078049de54d42a2bc384b9ceda91f
3c. Attach an 8 ½ x 11 excerpt from the most recent version of the published County NRCS Soil Survey Map depicting the project site.field type file upload
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Link to Soil Surveys for North Carolina Counties.

4. Proposed Activity

Provide a detailed description of the proposed activity including its purpose and include the type of equipment to be used:*field type multi line
Attach a site plan as applicable to the project:field type file upload
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** Below is a link with instructions on what you will need to show on your site plan.
https://edocs.deq.nc.gov/WaterResources/DocView.aspx?dbid=0&id=2488202

5. Jurisdictional Determinations

5a. Have jurisdictional wetlands or stream determinations by the Corps or State been requested or obtained for this property/project (including all prior phases) in the past?*field type radio button
5a. Have jurisdictional wetlands or stream determinations by the Corps or State been requested or obtained for this property/project (including all prior phases) in the past?YesNo

5b. Who did the determination on the jurisdictional areas?

Who did the determination?

List name if known

Date

Attach

Row 1

Who did the determination?

List name if known

(Name if known)

Date

Attach

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*** Please include the date of the determination and upload a copy of the determination.
Comments:field type multi line

6. Project History

6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*field type radio button
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?YesNo

6b. List any permits/approvals that have been requested or obtained for this project in the past.

	Application Datefield type date	Date Issuedfield type date	Permit Typefield type single line
Row 1×	Application Datefield type date	Date Issuedfield type date	Permit Typefield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add

6c. Please explain and detail according to "help file" instructions.*field type multi line

7. Future Project Plans

7a. Is this project a phased project?*field type radio button
7a. Is this project a phased project?YesNo
7b. If yes, explain*field type multi line

C. Proposed Impacts Inventory

Buffer Impacts

1a. Project is in which protected Basin?*field type radio button
1a. Project is in which protected Basin?Neuse River Basin (15A NCAC 02B.0233)Catawba River Basin (15A NCAC 02B.0243)Randleman Lake Watershed (15A NCAC 02B.0250)Tar-Pamlico River Basin (15A NCAC 02B.0259)Jordan Lake Watershed (15A NCAC 02B.0267)Goose Creek Watershed (15A NCAC 02B.0606 & 15A NCAC 02B.0607)
You can find which river basin you live in at the link below.
North Carolina Protected River Basins
1b. Goose Creek Only: Is the buffer in the 100-year floodplain?field type radio button
1b. Goose Creek Only: Is the buffer in the 100-year floodplain?YesNo
1c. Individually list all buffer impacts below. If any impacts require mitigation, then you MUST fill out Section D of this form.
Please note: if the impact you list below requires mitigation choose "allow w/ mitigation" under impact type.

Site #	Site# - Reasonfield type single line	Stream Namefield type single line	Buffer Impact*field type drop-down	Impact Type*field type drop-down	Zone 1field type number	Zone 2field type number	*field type number
B 1×	Site# - Reasonfield type single line Map label (e.g. Road Crossing 1) Input blocked. Maximum character limit of 4000 characters reached.	Stream Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Buffer Impact*field type drop-down Perm or Temp	Impact Type*field type drop-down	Zone 1field type number Square Feet	Zone 2field type number Square Feet	*field type number	×

Add another impact

Total Zone 1 Impacts:field type number
Total Zone 2 Impacts:field type number
Total Buffer Impacts:field type number
Comments:field type multi line

D. Impact Justification and Mitigation

1. Avoidance and Minimization

1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project.*field type multi line
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.*field type multi line

2. Buffer Mitigation

2a. The table below identifies the square footage of impact to each zone of the riparian buffer and the required mitigation.

Goose Creek Only

	Total Impactfield type number	Multiplierfield type number	Required Mitigationfield type number
Zone 1	Total Impactfield type number Square Feet	Multiplierfield type number	Required Mitigationfield type number Square Feet

Zone 1 - Catawba Only

	Total Impactfield type number	Multiplierfield type number	Required Mitigationfield type number
Zone 1 - Catawba Only	Total Impactfield type number Square Feet	Multiplierfield type number	Required Mitigationfield type number Square Feet

Zone 1

	Total Impactfield type number	Multiplierfield type number	Required Mitigationfield type number
Zone 1	Total Impactfield type number Square Feet	Multiplierfield type number	Required Mitigationfield type number Square Feet

Zone 2

	Total Impactfield type number	Multiplierfield type number	Required Mitigationfield type number
Zone 1	Total Impactfield type number Square Feet	Multiplierfield type number	Required Mitigationfield type number Square Feet

2b. What is the mitigation plan proposed for this project?*field type checkbox
2b. What is the mitigation plan proposed for this project?Payment to private mitigation bankPayment to Division of Mitigation (DMS)Permittee responsible mitigation
2c. Provide a description of your mitigation plan.*field type multi line
2d. Attach a detailed planting plan to include plant type, date of plantings, the date of the one-time fertilization in the protected riparian buffers, and a plan sheet showing the proposed location of the plantings.*field type file upload
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2e. Attach statement of availability from mitigation provider.*field type file upload
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2f. Attach your reservation letter from DMS.*field type file upload
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2g. Comments:field type multi line

E. Diffuse Flow Plan

All buffer impacts & high ground impacts require diffuse flow or other form of stormwater treatment. If the project is subject to a state implemented riparian buffer program, upload a plan that fully documents how diffuse flow will be maintained. All stormwater control measures (SCMs) must be designed in accordance with the NC Stormwater Design Manual. Associated supplement forms and other documentation must be provided.

For a list of options to meet the diffuse flow requirements, click Here.
1a. What type of SCM are you providing?*field type checkbox
1a. What type of SCM are you providing?Level SpreaderVegetated Conveyance (lower SHWT)Wetland Swale (higher SHWT)Proposed project will not create concentrated stormwater flow through the bufferOther SCM that removed minimum of 30% nitrogen
1b. Describe how diffuse flow will be maintained:*field type multi line
1c. Diffuse Flow Documentation*field type file upload
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G. Sign and Submitt

By digitally signing below, I certify that:
- I have given true, accurate, and complete information on this form;
- I agree that submission of this form is a “transaction” subject to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic Transactions Act”)
- I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic Transactions Act”);
- I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
- I intend to electronically sign and submit the application form.”
Print Name:*field type single line
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Signature*field type signature
Submission Date:field type single line
(Auto populated field)
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