20111029 Ver 1_Complete File_20111212

j'A A LT;-WYWA
'
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
December 12, 2011
DWQ Project # 11 -1029
Craven County
Eastern Dermatology Properties II, LLC
Attn: Cameron L. Smith
420 Spring Forest Road
Greenville, NC 27834
Subject Property: Eastern Dermatology Properties II
Neuse River Basin, Wilson Creek (NEU 10, 27- 101 -37; NSW, C, Sw)
AUTHORIZATION of Neuse River Buffer Rule (15A NCAC 02B.0233) Authorization
Certificate
Dear Mr. Smith:
You have our authorization, in accordance with 15A NCAC 02B .0233 and any conditions listed
below, to impact approximately 183 ftZ of Zone 1 and 52 ftz of Zone 2 of the protected riparian
buffer to construct a proposed stormwater outfall and 18,060 ftZ of Zone 2 ft2 of the protected
riparian buffers of temporary impacts associated with grading for the construction of a
stormwater pond and parking area at the subject property as described within your application
dated November 23, 2011. In addition, you should obtain or otherwise comply with any other
required federal, state or local permits before you go ahead with your project including (but not
limited to) Erosion and Sediment Control, Non - discharge regulations.
This authorization is for the purpose and design that you described in your application. 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 authorization letter and is
thereby responsible for complying with all conditions. This authorization requires you to follow
the conditions listed below.
The Additional Conditions of the Authorization are:
1. Impacts Approved
The following impacts are hereby approved as long as all of the other specific and general
conditions of this Certification (or Isolated Wetland Permit) are met. No other impacts are
approved including incidental impacts:
North Carolina Division of Water Quality Intemet: www.iicwaterqtiali!y.org
943 Washington Square Mall Phone: [phone] One
Washington, NC 27889 FAX [phone] NorthCarofiina
An Equal OpportunitylAffirmative Action Employer — 50% Recycled110% Post Consumer Paper Amarally

Page 2 of 2
2. No Impacts Beyond those in Application
No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas
beyond the footprint of the impacts depicted in the Pre - construction Notification. All
construction activities, including the design, installation, operation, and maintenance of
sediment and erosion control Best Management Practices, shall be performed so that no
violations of state water quality standards, statutes, or rules occur.
3. Certificate of Completion
Upon completion of all work approved within this authorization, and any subsequent
modifications, the applicant is required to return the attached certificate of completion to the
401 Oversight/Express Review Permitting Unit, North Carolina Division of Water Quality,
1650 Mail Service Center, Raleigh, NC, 27699 -1650.
Any disputes over determinations regarding this Authorization Certificate (associated with the
approved buffer impacts) shall be referred in writing to the Director for a decision. The
Director's decision is subject to review as provided in Articles 3 and 4 of G.S. 150B. This
Authorization Certificate shall expire five (5) years from the date of this letter.
This letter completes the review of the "No Practical Alternatives" determination under 15A
NCAC 2B .0233. This letter does not authorize any impacts to either Waters of the United States
or Waters of the State. Please contact the US Army Corps of Engineers (USACE) or NC
Division of Water Quality (DWQ) if any impacts are proposed to either of these waters. If you
have any questions, please telephone Amy Adams of the Washington Regional Office at 252-
948 -3917 or Amy Chapman of the 401 Oversight/Express Unit at 919 -715 -6823.
Si cerely,
_ L
Coleen H. _
Enclosures: Certificate of Completion
Buffer Rules
cc: Matthew D. Williams, Baldwin Design Consultants, PA
708 -D Cromwell Drive, Greenville, NC 27858
Corps of Engineers Washington Field Office
DWQ 401 Oversight/Express Unit
DCM, Morehead Office
DLR, WaRO
File copy
Filename: 11 -1029
Amount Approved (Units)
Plan Location or Reference
Buffers
18,295 (square ft.)
I Plan Sheet 1 of 1
2. No Impacts Beyond those in Application
No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas
beyond the footprint of the impacts depicted in the Pre - construction Notification. All
construction activities, including the design, installation, operation, and maintenance of
sediment and erosion control Best Management Practices, shall be performed so that no
violations of state water quality standards, statutes, or rules occur.
3. Certificate of Completion
Upon completion of all work approved within this authorization, and any subsequent
modifications, the applicant is required to return the attached certificate of completion to the
401 Oversight/Express Review Permitting Unit, North Carolina Division of Water Quality,
1650 Mail Service Center, Raleigh, NC, 27699 -1650.
Any disputes over determinations regarding this Authorization Certificate (associated with the
approved buffer impacts) shall be referred in writing to the Director for a decision. The
Director's decision is subject to review as provided in Articles 3 and 4 of G.S. 150B. This
Authorization Certificate shall expire five (5) years from the date of this letter.
This letter completes the review of the "No Practical Alternatives" determination under 15A
NCAC 2B .0233. This letter does not authorize any impacts to either Waters of the United States
or Waters of the State. Please contact the US Army Corps of Engineers (USACE) or NC
Division of Water Quality (DWQ) if any impacts are proposed to either of these waters. If you
have any questions, please telephone Amy Adams of the Washington Regional Office at 252-
948 -3917 or Amy Chapman of the 401 Oversight/Express Unit at 919 -715 -6823.
Si cerely,
_ L
Coleen H. _
Enclosures: Certificate of Completion
Buffer Rules
cc: Matthew D. Williams, Baldwin Design Consultants, PA
708 -D Cromwell Drive, Greenville, NC 27858
Corps of Engineers Washington Field Office
DWQ 401 Oversight/Express Unit
DCM, Morehead Office
DLR, WaRO
File copy
Filename: 11 -1029

CA201108801679
SOSID: 0760591
Date Filed: 3/29/20118:22:00 AM
MPANY Elaine F. Marshall
...; .., �. LIMITED LIABILITY CO North Carolina Secretary of state
`dp.� ANNUAL REPORT i CA201108801679
NAME OF LIMITED LIABILITY COMPANi': Eastern Dermatology Properties II, LL
STATE OF INCORPORATION: NC
SECRETARY OF STATE L.L.C. ID NUMBER:
0760591
NATURE OF BUSINESS: Real Estate forMedical Practice
REGISTERED AGENT: Smith, Cameron L.
REGISTERED OFFICE MAILING ADDRESS: 420 Greenville, NC 2783 4
REGISTERED OFFICE STREET ADDRESS 420 Spring NC 27834 Pitt County
PRINCIPAL OFFICE TELEPHONE NUMBER: [phone]
PRINCIPAL OFFICE MAILING ADDRESS' G � Greenville, NC 27834 d
PRINCIPAL OFFICE STREET ADDRESS: G0 Spring Forest
27834 ad
Iv1ANAGERS/laWERS /ORGANIZERS:
Name: Richard JMurphy
Name: Walter R Gammon
Name:
Title: Manager
Name: Cameron L Smith
Title: Manager
Manager
Address:
Address:
420 Spring Forest Road
Address:
420 Spring Forest Road
Greenville, NC 27834
420 Spring Forest Road
Greenville, NC 27834
Greenville, NC 27834
Christopher B Mizelle and
Name: Richard S Lewis
Name:
Title: Member
]chine: Mary Helen Hutchinson
Manager
Title: Manager
Address:
Spring Forest Road
Title;
Address:
Address:
420 Spring Forest Road
420
Greenville, NC 27834
420 Spring Forest Road
Greenville, NC 27834
Greenville, NC 27834
Name: Eric Howell
Name: Mathijs Brentjens
Title: Manager
Title: Manager
Address:
Address:
420 Spring Forest Road
420 Spring Forest Road
Greenville, NC 27834
Gree"" I NC 27834
BY ALL LIIvII TED LIABILITY COMPANIES
CERTIFICATION OF ANNUAL REPORT MUST BE COMPLETED
03/16/2011
Camaron L Smith
DATE
FORM MUST BE SIGNED BY A MANAGER/MEMBER
Manager
Cameron L Smith
TYPE OR PRINT TITLE
TYPE OR PRINT NAME of State • Corporations Division •
Secretary
Post Office Boy: 29525 • Raleigh, NC 27626 -0525
AATIUAL REPORT FEE: $200
MAIL TO:

CA201108801679
MANAGERS/MEMBERS /ORGANaERS: (Continued)
Name: Mathijs Brentjens
Title: Manager
Address:
420 Spring Forest Road
Greenville, NC 27834

Certification of Completion
DWQ Project No.:
Applicant:
Project Name:
Date of Issuance of Wetland Permit:
County:
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401 Oversight/Express Permitting Unit,
North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC, 27699 -1650. This form may be
returned to DWQ by the applicant, the applicant's authorized agent, or the project engineer. It is not necessary to send
certificates from all of these.
Applicant's Certification
I,
used in the observation of the
compliance and intent of the 401
and other supporting materials.
Signature:
Agent's Certification
I,
used in the observation of the
compliance and intent of the 401
and other supporting materials.
Signature:
, hereby state that, to the best of my abilities, due care and diligence was
construction such that the construction was observed to be built within substantial
Water Quality Certification and Buffer Rules, the approved plans and specifications,
Date:
, hereby state that, to the best of my abilities, due care and diligence was
construction such that the construction was observed to be built within substantial
Water Quality Certification and Buffer Rules, the approved plans and specifications,
Date:
If this project was designed by a Certified Professional
I, , as a duly registered Professional (i.e., Engineer,
Landscape Architect, Surveyor, etc.) 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

vi A T'p
r-i
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre- Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a. 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
1d. 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
1 e. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes Q 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.
j] Yes ❑ No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
0 Yes ❑ No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes [jX No
2. Project Information
2a. Name of project:
Eastern Dermatology Properties 11, LLC
2b. County:
Craven
2c. Nearest municipality / town:
Trent Woods
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
EASTERN DERMATOLOGY PROPERTIES II, LLC
3b. Deed Book and Page No.
Deed Book 3014, Page 146
3c. Responsible Party (for LLC if
applicable):
Eastern Dermatology Properties 11, LLC
on Aftywalt 11
3d. Street address:
420 Spring Forest Road
3e. City, state, zip:
Greenville, NC 27834
3f. Telephone no.:
(252) 752 -4124 V 23 2011
3g. Fax no.:
3h. Email address:
7
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Page 1 of 10
PCN Form - Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:
❑X Agent ❑ Other, specify:
4b. Name:
Matthew D. Williams, PE
4c. Business name
(if applicable):
Baldwin Design Consultants, PA
4d. Street address:
708 -D Cromwell Drive
4e. City, state, zip:
Greenville, NC 27858
4f. Telephone no.:
(252) 756 -1390
4g. Fax no.:
(252) 321 -1412
4h. Email address:
mwilliams @baidwindesignconsultants.com
5. Agent/Consultant Information (if applicable)
5a. Name:
Matthew D. Williams, PE
5b. Business name
(if applicable):
Baldwin Design Consultants, PA
5c. Street address:
708 -D Cromwell Drive
5d. City, state, zip:
Greenville, NC 27858
5e. Telephone no.:
(252) 756 -1390
5f. Fax no.:
(252) 321 -1412
5g. Email address:
mwiiliams @baldwindesignconsultants.com
03VL903A
r, k, r�
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
Parcel #: 8- 045 -026
1 b. Site coordinates (in decimal degrees):
I Latitude: 35.09167 N Longitude: 77.09167 W
1 c. Property size:
5.806 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
Wilson Creek
2b. Water Quality Classification of nearest receiving water:
C; Sw; NSW
2c. River basin:
Neuse
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:
Site as existing is residential development, with residential brick buildings and mobile homes. Site is bounded by Trent Road to the north, developed
residential land to the east and west, and a cemetery to the south.
3b. List the total estimated acreage of all existing wetlands on the property: 0.00 acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 1,176 LF
3d. Explain the purpose of the proposed project:
The purpose of the project is to re- develop the site for commercial doctor's offices, associated parking lots and entrance drive, and associated utilities.
3e. Describe the overall project in detail, including the type of equipment to be used:
Project involves demolition of existing structures, construction of new buildings and parking lots, using standard 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?
[l Yes 0 No ❑ 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?
❑X Yes ❑ No ❑ Unknown
5b. If yes, explain in detail according to "help file" instructions.
Permit applications for Stormwater Management and Erosion Control submitted to the Washington Office of DENR on October 5th, 2011.
6. Future Project Plans
6a. Is this a phased project?
Yes ❑ No
6b. If yes, explain.
Project has 2 Phases, including current construction of a building and parking lot, and future construction of a building and parking lot.
Page 3of10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1a. 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 T
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 (T)
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

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then indivi ually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
01
Choose one
Choose
O2 -
Choose one
Choose
03 -
Choose one
Choose
O4 -
Choose one
Choose
4f. Total open water Impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
❑X Neuse ❑ Tar - Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number—
Permanent (P) or
Temporary T
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet )
6g.
Zone 2
impact
(square
feet
B1 P
Outlet pipe from pond
Wilson Creek
No
183
52
B2 T
Construct, of pond /parkin
Wilson Creek
No
0
18,060
B3 -
Yes /No
B4 -
Yes /No
B5 -
Yes /No
E36 -
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

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.
Outflow from pond has been piped most of the way to the stream (as opposed to via ditch).
1 b. Specifically describe measures taken to avoid or minimize the proposed Impacts through construction techniques.
As little area within the buffer will be disturbed as necessary In order to construct the pond and parking lots, and install the proposed pipe and rip rap
apron that goes through the buffer.
2. Com ensato 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 ❑X 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
❑ Permiitee 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 Making 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:
S. 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 XX 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
0 Yes ❑ No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Through conversations with Bill Moore of Washington DENR office, Bill stated that piping outflow to ditch
❑ Yes XU No
was acceptable.
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
ova
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:
Runoff from site will be collected via sheet flow, curb and gutter, and a catch basin and pipe system and discharged to a proposed constructed
wetland_ Outflow from the wetland will be discharged via pipe to the existing stream on the southern boundary of the project site.
2e. Who will be responsible for the review of the Stormwater Management Plan?
Bill Moore, DENR Washington office
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
Trent Woods
❑ Phase II
❑ NSW
3b. Which of the following locally - implemented stormwater management programs
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
❑Yes ONO
attached?
4. DWQ Stormwater Program Review
©Coastal counties
❑HQW
4a. Which of the following state - implemented Stormwater management programs apply
❑ORW
(check all that apply):
❑Session Law 2006 -246
❑Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
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)
1 a. Does the project involve an expenditure of public (federal /state /local) funds or the
0 Yes
No
use of public (federal /state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
❑Yes
❑ No
environmental document pursuant to the requirements of the National or State
(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
❑ Yes
❑ No
letter.)
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
❑Yes
QX No
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
or Riparian Buffer Rules (15A NCAC 28 .0200)?
2b. Is this an after- the -fact permit application?
❑Yes
XN No
2c. If you answered "yes' to one or both of the above questions, provide an explanation of the violation(s):
3. cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
Yes
XO 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.
Useable site area will be completely used after the development proposed by this project.
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.
Sewer from this site will be collected and treated by the City of New Bern's sewer treatment system.
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?
B. 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?
Matthew D. Williams
Applicant/Agent's Printed Name
�//44V — 4ltll l
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
11/22/2011
Date
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