20120677 Ver 1_401 Application_20120712

20120677
DATE July 7 2012
TO DWQ Buffer Authorization Reviewer
FROM John R Davis Jr LSS
RE PCN s for wooden piers at Holt Lake Smithfield NC
Mr J C Bright has had some conversations with Mr Martin Richmond DWQ
representative in the Raleigh Regional office and with Mr Thomas Brown
U S Army Corps of Engineers office about construction of two piers for
residences at Holt Lake I am working with David Revoir engineer with Appian
Consulting Engineers to obtain permits Holts Lake was formed by a dam on
Black Creek The dam is only about 1 mile west of the Neuse River Not sure of
water classification because website is not working
We understand that since we will not be doing any filling or grubbing in wetlands
only driving pilings and constructing mostly by hand that we do not need a 404
permit We understand that water dependent structures such as piers are
allowable in the riparian buffers No parking lots etc will be constructed in the
riparian buffer only the wooden walkways The impact that these walkways and
piers will have in the riparian buffers will be minimal All high value trees will
be avoided in the buffer The walkways are pervious so rainfall will move
through the boards to tree roots
The pilings at the 1300 Country Club Road site will most likely be installed into
auger borings in high ground and the ones at 1146 Country Club Road will most
likely be driven into wet soils Please look over these applications and call me if
you have any questions at 919 818 5087mb
Thanks John Davis
1(IL 1 0 2012
DENR wATER QUALITY
'etlands A e.._.. _ .

W ATF9
O T
201 20677
Office Use Only
Corps action ID no
DWQ project no
Form Version 13 Dec 10 2008
Page 1 of 10
PCN Form — Version 1 3 December 10 2008 Version
Pre - Construction Notification PCN Form
A Applicant Information
1
Processing
la
Type(s) of approval sought from the
Corps
El Section 404 Permit ❑Section 10 Permit
lb 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 ® 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 ❑ 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
® No
1 g
Is the project located in any of NC s twenty coastal counties If yes answer 1 h
below
❑ Yes
® No
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2
Project Information
2a
Name of project
1146 Country Club Pier
2b
County
Johnston
2c
Nearest municipality / town
Smithfield
2d
Subdivision name
Holt Lake
2e
NCDOT only T I P or state
project no
n/a
3
Owner Information
0�2
3a
Name(s) on Recorded Deed
Sammy Jackson
3b
Deed Book and Page No
1832/28 pENR ATER
Branch
3c
Responsible Party (for LLC if
applicable)
Sammy Jackson
3d
Street address
1130 Country Club Road
3e
City state zip
Smithfield NC 27577
3f
Telephone no
3g
Fax no
3h
Email address
Page 1 of 10
PCN Form — Version 1 3 December 10 2008 Version

4
Applicant Information (if different from owner)
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 no
4h
Email address
5
Agent/Consultant Information (if applicable)
5a
Name
John R Davis Jr
5b
Business name
(if applicable)
Soil Horizons Inc
5c
Street address
285 Dreamcatcher Trail
5d
City state zip
Youngsville NC 27596
5e
Telephone no
919 818 5087
5f
Fax no
919 554 2363
5g
Email address
soilhorizons @gmad com
Page 2 of 10
PCN Form — Version 1 3 December 10 2008 Version

June 29 2012
RE AGENT AUTHORIZATION FORM
As owner concerning the above referenced property I do hereby authorize and give permission
for J C Bright, Appian Consulting Engineers and Soil Horizons , to represent or act as an
agent on my behalf and apply for a preconstruction notification or permit and allow the US
Army Corps of Engineers and NC Division of Water Quality or any other regulatory agency to go
on the property for such purposes as necessary to perform the Job tasks
Name / Title
Sammy G Jackson
1130 Country Club Road
Smithfield NC 27577
919 934 4839
Date

1146 Country Club Road, Smithfield, NC - Google Maps
Address 1146 Country Club Rd
Google Smithfield, NC 27577
Page 1 of 1
Site Vicinty Road Map
https://maps.google.com/maps?f--q&source=s—q&hl=en&geocode=&q=l 146+Country+Clu... 7/5/2012

Holt Lake
Jackson and Adams
Address:
1146 Country Club Road
er:
Smithfield, NC 27577
Owner:
Sammy Jackson
County:
Johnston County
NC Pin:
167212- 86.5668
Address:
1 0 Co Club R ad
5
er:
Cr
SnCo
ki
County.
Joy
NC Pin:
16 7

Proposed Pier Sketch
Address:
1146 Country Club Road
Smithfield, NC 27577
Owner:
Sammy Jackson
County:
Johnston County
NC Pin:
167212 -86 -5668
Latitude 35.470008
Longitude - 78.399832
�+ir7lnlriliw
CONSULTING ENGINEERS, PA
CIVII, MUNICIPAL d STRUCTIIRAI- ENGINEERS
COMPREHENSIVE ENVIRONMENTAL. SERVICES
P -O. box 7966 • Raay M—M. NC 27604
Phanc (M) 972 -770;4
Eax.(252)9'72 -7676
v 'aPPIanengi "en.cnm

B Project Information and Prior Project History
1 Property Identification
1a Property identification no (tax PIN or parcel ID)
167212 86 8668
lb Site coordinates (in decimal degrees)
Latitude 35 47002 Longitude 78 399864
(DD DDDDDD) ( DD DDDDDD)
1c Property size
1 55 acres
2 Surface Waters
2a Name of nearest body of water (stream river etc ) to
proposed project
Holts Lake
2b Water Quality Classification of nearest receiving water
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 is part of a single family residential community on Holts Lake The proposed private pier will serve one residence
3b List the total estimated acreage of all existing wetlands on the property
0 2 Acres
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
0
3d Explain the purpose of the proposed project
Construction of a 5 wide elevated wooden pier on wooden piles to access public waters
3e Describe the overall project in detail including the type of equipment to be used
Construction of a 5 wide elevated wooden pier on wooden piles in existing path through the woods no removal of trees
stumps or shrubs is required no placement of fill is required
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 pasty
Comments
El Yes ❑ No Unknown
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 ® Unknown
5b If yes explain in detail according to help file instructions
6 Future Project Plans
6a Is this a phased project?
❑ Yes ® No
6b If yes explain
Page 3 of 10
PCN Form — Version 1 3 December 10 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
1 a Which sections were completed below for your project (check all that apply)
❑ Wetlands ❑ Streams tributaries ® 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
2b
2c
2d
2e
2f
Wetland impact
Type of jurisdiction
number —
Type of impact
Type of wetland
Forested
(Corps 404 10
Area of impact
Permanent (P) or
(if known)
DWQ —non 404 other)
(acres)
Temporary T
W1 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 ❑ P FIT
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
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
3b
3c
3d
3e
3f
3g
Stream impact
Type of impact
Stream name
Perennial
Type of jurisdiction
Average
Impact
number
(PER) or
(Corps 404 10
stream
length
Permanent (P) or
intermittent
DWQ — non 404
width
(linear
Temporary (T)
(INT)?
other)
(feet)
feet)
S1 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S2 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S3 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S4 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
3h Total stream and tributary impacts
31 Comments
Page 4 of 10
PCN Form — Version 1 3 December 10 2008 Version

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 individually list all open water impacts below
4a
4b
4c
4d
4e
Open water
Name of waterbody
impact number —
(if applicable)
Type of impact
Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary T
01 ❑P ❑T
02 ❑ PEI T
03 ❑P ❑T
04 ❑P ❑T
4f Total open water impacts
4g Comments
5 Pond or Lake Construction
If pond or lake construction proposed then complete the chart below
5a
5b
5c
5d
5e
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or purpose
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
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)
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
® Neuse ❑ Tar Pamlico ❑ Other
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b
6c
6d
6e
6f
6g
Buffer impact
number —
Reason
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary T
impact
required?
61 ®P ❑ T
Pier
Holts Lake
® No
30 x5 = 150 sf
20 x5 = 100 sf
B2 ❑P ❑T
❑Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
150 sf
100 sf
61 Comments No removal of trees stumps or shrubs is required no placement of fill is proposed
Page 5 of 10
PCN Form — Version 1 3 December 10 2008 Version

D Impact Justification and Mitigation
1 Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
The elevated wooden pier will be constructed in an existing path through the woods no tree stump or shrub removal is
required Total disturbance is approximately 250 sf
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
The elevated wooden pier will be constructed by hand
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
projects
❑ Mitigation bank
El Payment to in lieu fee program
❑ Permittee Responsible Mitigation
3 Complete if Using a Mitigation Bank
3a Name of Mitigation Bank n/a
3b Credits Purchased (attach receipt and letter)
Type
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
❑ warm ❑ cool ❑cold
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 3 December 10 2008 Version

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 ® 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
PCN Form — Version 1 3 December 10 2008 Version

E
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1
Diffuse Flow Plan
la
Does the project include or is it adjacent to protected riparian buffers identified
® 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
Comments Proposed wooden pier to be elevated above existing grades No
® Yes ❑ No
change is proposed to runoff through the riparian buffer
2
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
(wooden slatted deck proposed is
considered pervious) /o
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
If this project DOES NOT require a Stormwater Management Plan explain why Less
than 0 5 ac disturbed
Approximately 250 sf will be disturbed by this project
2d
If this project DOES require a Stormwater Management Plan then provide a brief narrative
description of the plan
® Certified Local Government
2e
Who will be responsible for the review of the Stormwater Management Plan?
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3
Certified Local Government Stormwater Review
3a
In which local government s jurisdiction is this project?
Johnston County
❑ Phase II
3b
Which of the following locally implemented stormwater management programs
❑ NSW
❑ 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)
❑ 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 3 December 10 2008 Version

F
Supplementary Information
1
Environmental Documentation (DWQ Requirement)
la
Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes
® No
use of public (federal /state) land?
lb
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)?
1 c
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 (15A NCAC 2H 0500) Isolated
Wetland Rules (15A NCAC 2H 1300) DWQ Surface Water or Wetland Standards
❑ Yes
® No
or Riparian Buffer Rules (15A NCAC 2B 0200)?
2b
Is this an after the fact permit application?
❑ Yes
® 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
® 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 3 December 10 2008 Version

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 ❑ No
habitat?
5b Have you checked with the USFWS concerning Endangered Species Act
❑ Yes ❑ No
impacts?
❑ Raleigh
5c If yes indicate the USFWS Field Office you have contacted
❑ Asheville
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 WIII 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
❑ Yes ❑ No
status (e g National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
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 floodpla(n determination?
1164 / Oav+ r T
7_0'/)
Applicant/Agents Printed Name
Applicant/Agent sZignature
Date
(Agents signature is valid only if an authorization letter from the applicant
is provided )
Page 10 of 10
PCN Form — Version 1 3 December 10 2008 Version