20120572 Ver 1_401 Application_20120612

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20120572
Office Use Only
Corps action ID no
DWQ project no
Form Version 14 January 2009
Page 1 of 10
PCN Form — Version 1 4 January 2009
Pre - Construction Notification (PCN) Form
A
Applicant Information
...c & 9—M)
1
Processing
i "'""'■- �-+� -�
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
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 [9-Riparian Buffer Authorization
le
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification
❑ Yes @1<0
For the record only for Corps Permit
❑ Yes am
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 [3-m
1g
Is the protect located in any of NC s twenty coastal counties If yes answer 1 h
below
❑ Yes BITO-
1 h Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes 13'To_
2
Project Information
2a
Name of project
F r f C man S �%Q
?-
C ! L(!O 1 rer in
2b
County
Tn term
2c
Nearest municipality / town
Nry
Sfenvin
2d
Subdivision name
P e
2e
NCDOT only T I P or state project no N
3
Owner Information
3a
Name(s) on Recorded Deed
! Q
3b
Deed Book and Page No
I I 110P 24P
JaR.
3c
Responsible Party (for LLC if
applicable)
3d
Street address
OX 0 $
3e
City state zip
C 76 Q6
ea�ll0 t Q ON
3f
Telephone no
01 AS 1- 6SS 7
3g
Fax no
—
_ r
3h
Email address
Q
Page 1 of 10
PCN Form — Version 1 4 January 2009

4 Applicant Information (if different from owner) Some
4a Applicant is
❑ Agent ❑ Other specify
4b Name
4c Business name
(if applicable)
4d Street address
4e City state zip "
4f Telephone no
4g Fax w '
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
Protect Information and Prior Protect History
1
Property Identification
1a
Property identification no (tax PIN or parcel ID)
�7
1 b
Site coordinates (in decimal degrees) I
Latitude 3 5i to
9 5q
Longitude --7g -7&,34
1c
Property size
acres 4
2
Surface Waters
2a
Name of nearest body of water to proposed protect
an
2b
Water Quality Classification of nearest receiving water
—11E S
2c
River basin
bff use
3
Protect Description
3a Describe the existing conditions on the site and the general land use n the vicinity of the protect at the time of this
application �%r0 e �cS C aD acre horse Z,f-M FI en o-P the c0neS
are elfore� tYP 00r2S !'e main -hm ber mans n
^Du� � �a c h
t seds t e
3b
List the total estimate 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
3d Explain the purpose of the proposed protect TO e rea e slTeo m cross t n Ind) o ver-
Pa+ehmans Pro eh to allow homeowner- access aereaSe on
3e
Describe the overall project in d tad including he type of equipment to be used Ex cc yo r was use
ha s+reom Dan nd to lace nPraP in 'Du c lmods (Branch
An
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 PNo ❑ 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) 3
Agency /Consultant Company
Other
4d
If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
5
Protect History
5a
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑ Yes B o ❑ Unknown
5b
If yes explain in detail according to help file instructions
6
Future Protect Plans
6a
Is this a phased project?
❑ Yes 20ko
6b
If yes explain
x-.x,x a-the r
C lveris
s%eo m
� -Side- d"P S �a fyi Page 3 of 10
were Place of in PCN Form - Version 14 January 2009 -k
allow homeowner safe access 4o all aerea8e
T-

C Proposed Impacts Inventory
1 Impacts Summary
1a Which sections were completed below for your project (check all that apply)
❑ Wetlands reams — tributaries 2'9'uffers ❑ 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
Tem ora
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
1 Ni
®
—
ii
l J
S2
Choose one Lt
rf
UT
T
©
�a
S3
Choose one
S4
Choose one
S5
Choose one
S6
Choose one
3h Total stream and tributary impacts
31 Comments
Page 4 of 10
PCN Form — Version 14 January 2009

d q
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 indivii ually list all open water impacts below
4a
Open water
impact number
Permanent (P) or
Temporary
4b
Name of waterbody
(if applicable)
4c
Type of impact
4d
Waterbody
type
4e
Area of impact (acres)
01
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
1
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
51 Expected pond surface area (acres)
51 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
ba Protect is in which protected basin?
Er euse ❑ 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
S _
es/ o
U
B2
—
e o
epoo
B3
Yes /No
B4
Yes /No
B5
Yes /No
B6
Yes/No
6h Total Buffer Impacts
61 Comments Bon
[1
L slab) k-zaiiln is a 1 lower b e under -{o b te duses
Page 5 of 10

D Impact Justification and Mitigation
1 Avoidance and Minimization
la Specifically describe measures taken to avj°id or minimize the pr p sed im acts i de igrnng project
fro sect was campiefe0 YPt�l G�,GtIC��y. Seedea i n1,161afeIy typo
coTn� wi& n a work Work decurred dun n ct; low �'loW &UA;- i
1 b Specifically describe measures taken to avoid or minimize the proposed imp cts throug construction to hn que
RId s or hI k poin-Es wen 010-m UP Orld d6ec-(e -�o I-ee
n alny was pa fm
'00 �m -ten n '�u�C�m 'glraneh Rip � p
P tc
2 Compensatory Mitigation for Impacts to Waters of the U S or Waters of the State
2a Does the protect require Compensatory Mitigation for
impacts to Waters of the U S or Waters of the State?
❑ Yes [R <o
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 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
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
*x--x d o (.0 n ' mmed is `` r , PCN Form —Version 14 January 2009
+0 s{abi I i ze banks
rn�t
!e be laq)

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?
ves to
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 protect include or is it adjacent to protected riparian buffers identified
[es ❑ No
within one of the NC Riparian Buffer Protection Rules?
lb
If yes then is a diffuse flow Ian included? If no ex lain by
by
See aj.6ehej ma s Qnd plain
r�s ❑ No
Lo
i r avee nieers
2
Stormwater Management Plan
2a
What is the overall percent imperviousness of this protect?
2b
Does this project require a Stormwater Management Plan?
❑ Yes 2 0
2c
If this protect DOES NOT require a Stormwater Management Plan explain why
2d
If this protect 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?
❑ 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 ❑ No
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)
E] 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 14 January 2009

F Supplementary Information
1 Environmental Documentation (DWQ Requirement)
la Does the project involve an expenditure of public (federal /state /local) funds or the
El Yes
o
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
❑ Yes
❑ No
letter)
Comments
2 Violations (DWQ Requirement)
2a Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500) Isolated
Wetland Rules NCAC 2H 1300) DWQ Surface Water Wetland Standards
EKes
❑ No
(15A or
or Riparian Buffer Rules (15A NCAC 26 0200)?
2b Is this an after the fact permit application?
Mes
❑ No
2c If you answered yes to one r b th of t e above questions provide an ex lanation of the violation(s)
newt � leorec� ian� wos desfroyed 6y APn 1 9011
Sj X Cie re s
fern do
ameoLtilr)ier was SIMpTny C1ean�n up a alisasierand
Dom lekl
P
anaware o cou.sI/ Y 10Ia "Sa
3 Cumulative Impacts (DWQ Requirement)
3a Will this project (based on past and reasonably anticipated future impacts) result in
❑ Yes
R<O
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 14 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
❑ Yes [ to
habitat?
5b Have you checked with the USFWS concerning Endangered Species Act
❑ Yes [w'-
impacts?
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 1"-0
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
❑ Yes 311110,—
status (e g National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
r
7b What data sources did you use to determine whether your site would impact historic or archeological resources?
8 Flood Zone Designation (Corps Requirement) For
8a Will this project occur in a FEMA designated 100 year floodplain?
ffrYes E!rNo
8b If yes explain how project meets FEMA requirements
8c What source(s) did you use to make the floodplain determination?
Vioke Coun 91S
Vo.vid T �"
X'10 �
Lisa 9 loch
Kfsa l <ach
6-9-/A
Applicant/Agent s Printed Name
Applicant/Agent s Signature
(Agents signature is valid only if an authorization
Date
letter from the applicant is provided
Page 10 of 10

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