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HomeMy WebLinkAbout20201183 Ver 1_Determination Request_20200910Please 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. Project Name:* Is this a transportation project?* What type of request is this?* Owner Information Name on the Recorded Deed:* Responsible Party: Telephone Number: Fey Reyes f Yes r No r Buffer r Isolated Wetland Check all that apply. Fey Reyes r IP Stream Determination fJ Stream (for LLC, Corporations, businness, agency, etc.) How would you like to received your determination?* r USPS W Email Email Address:* chris.pullinger@ncdenr.gov Is there an agent or consultant responsible for the request?* r Yes r No Project Information Has anyone form DWR done a previous site visit?* r Yes r No r Other Date of Visit: Site Information Nearest Highway/Street:* Hvy 795 Nearest Town:* Goldsboro Nearest Named Stream:* Smith Mill Run River Basin:* Neuse County:* Wayne Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo. Click the upload button or drag and drop files here to attach document Rif file type only TOPO map look up: https://viewer.nationalmap.gov/basic/ Please attach a map of the site indicating project boundaries on the NRCS Soil Survey. aick the upload button or drag and drop files here to attach document Rif file type only Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC Latitude and Longitude Please provide the Latitude and Longitude for physical location for the determination that. If you have a physical address you can look up the Latitude and Longitude by typing in an address or filling out the information manually. Choose below how you would like to provide this information. f Address Lookup f Manually Latitude: Longitude: M isc attachments: pdf or lace file types only 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'); o 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 "Determination Request' form." Signature Date Submitted: Initial Review ID#* Version* Do you want to send for review?* Select Reviewer:* Select Regional Office:* G! 15 I-Ljtif6 9/10/2020 20201183 1 r Yes r No Chris Pullinger:eads\rcpullinger Washington Regional Office - (252) 946-6481