20090320 Ver 2_401 Application_20110511

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Corps action ID no.
o DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps: ? Section 404 Permit ? Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ? Yes ? No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
? 401 Water Quality Certification -Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification -Express X? Riparian Buffer Authorization
1e. Is this notification solely for the record
because written approval is not required? For the record only for DWQ
401 Certification:
? Yes ? No For the record only for Corps Permit:

? Yes ? No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in-lieu fee program.
? Yes Q No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ?X No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ? No
2. Project Information
2a. Name of project: DWQ#09-0320 -`" "-°---- --__,
2b. County: Granville LIE; LP__3 L%
2c. Nearest municipality / town: Oxford
2d. Subdivision name: Oxford Township MAY O ? 20 11
2e. NCDOT only, T.I.P. or state project no:

MMOQ
3. Owner Information Wepandu 8 WATER W) 4_URIY?
3a. Name(s) on Recorded Deed: Richard J Shagott / Mary E Shagott
3b. Deed Book and Page No. Book 598, Page 744
3c. Responsible Party (for LLC if
applicable): Richard J Shagott (not sure what this is referring to though)
3d. Street address: 109 Franklin St
3e. City, state, zip: Oxford, NC, 27565-1173
3f. Telephone no.: Cell: 818-229-7271
3g. Fax no.:
3h. Email address: [e-mail]
Page 1 of 10
PCN Form - Version 1.4 January 2009
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name: Same as above
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable);
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10
B. Project Information and Prior Project History
1. Property Identification
la. Property identification no. (tax PIN or parcel ID): Record 12664 /Map # 192318302193
1b. Site coordinates (in decimal degrees): Latitude: 36.18283 Longitude: 78.34895
1c. Property size: 6.9 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project: unnamed tributary or creek
2b. Water Quality Classification of nearest receiving water unknown
2c. River basin: Tar River
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:
The property has a 300' road frontage on Franklin St. The front yard the the creek bisects is approximately 150' deep. The slope of the property is
from the house to the creek and street to the creek
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 700
3d. Explain the purpose of the proposed project:
A temporary bridge consisting of a 17-1/2 foot x 4 foot black 2-1/2 to 3 inch black cast iron or composite pipe was placed in the creek during the installa
M
3e. Describe the overall project in detail, including the type of equipment to be used:
TA Loving contractors removed old sewer line and replaced it with a 12 " line using a variety of heavy digging and grading equipment
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past? ? Yes ? No ?X Unknown

Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? ? Preliminary ? Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past. ? Yes ? No p Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes Q No
6b. If yes, explain.
Page 3 of 10
PCN Form - Version 1;4 January 2009
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
? Wetlands ? Streams - tributaries X? Buffers ? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary 2b.
Type of impact 2c.
Type of wetland 2d.
Forested 2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other) 2f.
Area of
impact
(acres)
W1 Choose one Choose one Yes/No -
W2 Choose one Choose one Yes/No
W3 Choose one Choose one Yes/No -
W4 Choose one Choose one Yes/No
W5 Choose one Choose one Yes/No
W6 Choose one Choose one Yes/No -
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary m 3b.
Type of impact 3c.
Stream name 3d.
Perennial (PER) or
intermittent (INT)? 3e.
Type of
jurisdiction 3f.
Average
stream
width
(feet) 3g.
Impact
length
(linear
feet)
S1 Choose one -
S2 Choose one
S3 Choose one _
S4 Choose one
S5 Choose one -
S6 Choose one
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form - Version 1.4 January 2009
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
I do not have the information necessary to answer this question, though the chief engineer for the City of Oxford (Larry Thomas, 919-603-1113) did
examine it and said he had no issues with it.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Both sides of the bank of the creek was fortified with heavy rock for approx 25 - 30 feet
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ? No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this
project? ? Mitigation bank
? Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:

3b. Credits Purchased (attach receipt and letter) Type: Choose one
Type: Choose one
Type: Choose one Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Makin a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form - Version 1.4 January 2009
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
? Yes [X No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? ? Yes ?X No
1b. If yes, then is a diffuse flow plan included? If no, explain why.
? Yes No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? %
2b. Does this project require a Stormwater Management Plan? ? Yes ? No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local governments jurisdiction is this project?

3b. Which of the following locally-implemented stormwater management programs
apply (check all that apply): ? Phase II
? NSW
? USMP
? Water Supply Watershed
[] Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes ? No
4. DWQ Stormwater Program Review

4a. Which of the following state-implemented stormwater management programs apply
(check all that apply): ?Coastal counties
?HQW
?ORW
?Session Law 2006-246
?Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes ? No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 8 of 10
PCN Form - Version 1.4 January 2009
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federal/state/local) funds or the El Yes ? No
use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ?Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ? Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (I 5A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes XQ No
or Riparian Buffer Rules (15A NCAC 2B.0200)?
2b. Is this an after-the-fact permit application? 59 Yes ? No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
Under ordinary circumstances, the temporary bridge and other temporary modifications to the property would, in accordance of the terms of the
contract, be removed after the project is completed. It is to my advantage to have it left in place. The contracting company is willing to do that
providing it can be legally relieved of the responsibility for having to remove it.
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in El Yes []x No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. 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.
Page 9 of 10
PCN Form - Version 1.4 January 2009
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat? ? Yes ? No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? ? Yes ? No
5c. If yes, indicate the USFWS Field Office you have contacted. -
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes ? No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
? Yes ? No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ? No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
Richard J Shagott /,J? April 28, 2011
Applicant/Agent's Printed Name Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant Is provided.) Date
Page 10 of 10
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