HomeMy WebLinkAbout20130336 Ver 1_Application_20130328
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PCN Form – Version 1.3 December 10, 2008 Version
Office Use Only:
Corps action ID no. _____________
DWQ pro ject no. _______________
Form Version 1.3 Dec 10 2008
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
1b. Specify Nationwide Permit (NWP) number: 1 4 (GC 3886, Riparian Buffer Impacts) 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
1e. Is this notification solely for the record
because written approval is not required?
For the record on ly 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 propose d for mitigation
of impacts ? If so, attach the acceptance letter from mitigation bank or in -lieu
fee program.
Yes No
1g. Is the project located in any of NC’s twenty coastal counties. If yes, answer 1h
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: SR 1 529 (Sulphur Springs Road)
2b. Co unty: Catawba
2c. Nearest municipality / town: Hickory
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state
project no: 17BP.12.R.101
3. Owner Information
3a. Name(s) on Recorded Deed: NC DOT Right of Way
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
3e. City, state, zip:
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
Page 2 of 11
PCN Form – Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: Agent Other, specify:
4b. Name: Mike Holder
4c. Business name
(if applicable): N.C. Department of Transportation, Division 12
4d. Street address: 1710 East Marion Street
4e. City, state, zip: Shelby, NC 28151
4f. Tele phone no.: 704 -480 -9020
4g. Fax no.: 704 -480 -5401
4h. Email address: mholder@ncdot.gov
5. Agent/Consultant Information (if applicable)
5a. Name: Trish Beam
5b. Business name
(i f applicable): N.C. Department of Transportation, Division 12
5c. Street address: 1710 East Marion Street
5d. City, state, zip: Shelby, NC 28151
5e. Telephone no.: 704 -480 -9044
5f. Fax no.: 704 -480 -5401
5g. Email address: pdbeam @ncdot.gov
Page 3 of 11
PCN Form – Version 1.3 December 10, 2008 Version
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): NA
1b. Site coordinates (in dec imal degrees): Latitude: 35.7993 Longitude: - 81.2417
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size: <.1 0 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: Long Shoals Creek
2b. Water Quality Classification of nearest receiving water: WS -V & B
2c. River basin: Catawba
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:
A deteriorating three span bridge to be replaced with a three span bridge . L anduse in the vicinity of the pro ject is
designated forested and urban . Bridge is on a paved secondary road.
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:
1 00 feet
3d. Explain the purpose of the proposed project:
The purpose of the proposed work is to replace the deteriorating bridge for the safety of the travelling public.
3e. Describe the overall project in detail, including the type of equipment to be used:
NCDOT proposes to replace the deteriorating 90 ft x 25 ft three span bridge with a 92.5 ft x 30 ft three span bridge. New
impacts in buffer zones 1 and 2 are necessary for the construction of a t emporary workpad and a permanent driveway .
Approximately 35 feet of permanent riprap bank stabilization will be installed under the bridge on both si des of the stream.
There will be ~35 feet of temporary workpad impacts in the same area as the permanent impacts. The Project will be
constructed using typical heavy equipment (trackhoe, backhoe, etc.)
4. Jurisdictional Determinations
4a. Have jurisdictio nal wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Comments: Jurisdictional stream determination made by
Division 12 DEO.
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 jurisdiction al 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.
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PCN Form – Version 1.3 December 10, 2008 Version
6. Future Project Plans
6a. Is this a phased project? Yes No
6b. If yes, explain.
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PCN Form – Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
1a. 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.
Wetland impact
number –
Permanent (P) or
Temporary (T)
2b.
Type of impact
2c.
Type of wetland
(if known)
2d.
Forested
2e.
Type of juri sdiction
(Corps - 404, 10
DWQ – non -404, other)
2f.
Area of impact
(acres)
W1 P T Yes
No
Corps
DWQ
W2 P T Yes
No
Corps
DWQ
W3 P T Yes
No
Corps
DWQ
W4 P T Yes
No
Corps
DWQ
W5 P T Yes
No
Corps
DWQ
W6 P T Yes
No
Corps
DWQ
2g . Total wetla nd 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.
Str eam impact
number -
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial
(PER) or
intermittent
(INT)?
3e.
Type of jurisdiction
(Corps - 404, 10
DWQ – non -404,
other)
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 P T Riprap Bank
Stabilization
Long Shoals
Creek
PER
INT
Corps
DWQ 15 33
S2 P T Work Pad Long Shoals
Creek
PER
INT
Corps
DWQ 15 36
S3 P T PER
INT
Corps
DWQ
S4 P T PER
INT
Corps
DWQ
S5 P T PER
INT
Corps
DWQ
S6 P T PER
INT
Corps
DWQ
3h. Total stream and tributary impacts 40
3i. Comments:
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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 Oc ean, or any other open water of
the U.S. then individually 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)
O1 P T
O2 P T
O3 P T
O4 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.
Pond ID
number
5b.
Proposed use or purpose of
pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Floode d 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:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
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PCN Form – Version 1.3 December 10, 2008 Version
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?
Neuse Tar -Pamlico Other:
Catawba Randleman
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 T Slope
protection Long Shoals Creek Yes
No 285 110
B2 P T Driv eway
Construction Long Shoals Creek Yes
No 10 585
B3 P T Yes
No
6h. Total buffer impacts 295 695
6i. Comments:
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Existing stormwater pipe to remain to avoid additional buffer impacts.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction tec hniques.
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
2 b. 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 p rogram
Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
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PCN Form – Version 1.3 December 10, 2008 Version
3c. Comments:
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attache d. 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.
6. Buffer Mi tigation (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 req uired, 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:
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PCN Form – Version 1.3 December 10, 2008 Version
E. Sto rmwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? Yes No
1b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: Yes No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of thi s project? 0 %
2b. Does this project require a Stormwater Management Plan? Yes No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: Complies with NCDOT ’s individual
NPDES permit NCS000250 .
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 Manag ement Plan?
Certified Local Government
DWQ Stormwater Program
DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government’s jurisdiction is this project? NA
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 pr ograms apply
(check all that apply):
Coastal counties
HQW
ORW
Session Law 2006 -246
Other:
4b. Has the approved Stormwater Management Plan w ith 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
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PCN Form – Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federal/state/local) funds or the
use of public (federal/state) land? Yes No
1b. If you answered “yes” to the above, does the project require preparation of an
environmental document pursuant to the requirements of the Nati onal or State
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
Yes No
1c. If you answered “yes” to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy o f the NEPA or SEPA final approval
letter.)
Comments:
Yes No
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,
or Riparian Buffer Rules (15A NCAC 2B .0200)?
Yes No
2b. Is this an after -the -fact permit application? Yes N o
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) resu lt in
additional development, which could impact nearby downstream water quality? Yes No
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 ge nerated from
the proposed project, or available capacity of the subject facility.
NCDOT
HAZARDOUS SPILL BASIN CHECKLIST
Division: 12 County: C atawba Project ID :
17BP.12.R.101
River Basin: _ Catawba Bridge No: 27
Route: SR 1 529 Stream: Long Shoals Creek
Water Quality Criteri a :
Yes No
Roadway Criteria :
Route Designation - Yes No
Additional Site Information:
Yes No
Criteria Based Upon NCDOT “Best Management Practices for the
Protection of Surfa ce Waters” (March, 1997).
Stream Crossing Blue Line On USGS
Quad ORW
WSI
WS II,III OR IV, Crossing Within 0.5mi of W.S. Critical Area
Arterial Rural
Arterial Urban
Is a Hazardous Spill Basin Required?