HomeMy WebLinkAbout20140004 Ver 1_401 Application_20131213Ea
20140004
OFW AT O Office Use Only.
Corps actlon ID no
DWQ project no
Form Version 14 January 2009
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Page 1 of 10 C E `' `: 0 2013
PCN Form —Version 1.4 Inulry 2009
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Pre - Construction Notification (PCN) Farm
A.
Applicant Information
1.
Processing
1 a
Type(s) of approval sought from the Corps:
011ection 404 Permit ❑ Section 10 Permit
1 b Specify Nationwide Permit (NWP) number. or General Permit (GP) number-
1 c.
Has the NWP or GP number been verified by the Corps?
es ❑ 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 ❑ 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
If
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 Loo
1g
Is the protect located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes Q'10__*
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes 19- jw
2.
Project Information
2a
Name of project:
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2b. County:
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2c
Nearest municipality / town.
2d
Subdivision name
2e
NCDOT only, T I.P. or state project no*
3.
Owner Information
3a. Name(s) on Recorded Deed.
c
3b
Deed Book and Page No
'
3c
Responsible Party (for LLC if
applicable)*
3d
Street address.
3e. City, state, zip:
3f
Telephone no.:
_ &YZ
3g
Fax no.
3h. Email address:
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Page 1 of 10 C E `' `: 0 2013
PCN Form —Version 1.4 Inulry 2009
f1
�f.
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 -
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
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1a. Property identification no (tax PIN or parcel ID)
1 b. Site coordinates (in decimal degrees):
Latitude: °
��f ongitude.
1c Property size
?
b Cj acres
2. Surface Waters
2a Name of nearest body of water to proposed project*
4 --
2b Water Quality Classification of nearest receiving water:
2c River basin
Yb GZ.
3. Project Description
3a Describe the existing conditions on the site and the general land use
application
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in the vicinity of the project at the time of this
3b List the total estimated acreage of all existing wetlands on the property:
3c List the total estimated linear feet of all existing streams (intermitterit
and perennial) on the property
3d. Explain the purpose of the proposed project:
3e Describe the overall project in detail, including the type of equipment
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to be used.
p r
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?
Comments:
❑ Yes 9.M-01*4 ❑ 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)
Al
O
ency /Consultant Company -
her-
4d If yes, list the dates of the Corps jurisdictional determinations or S
ate 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?
❑Yeso ❑Unknown
5b If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a Is this a phased project?
❑ Yes
6b If yes, explain
Page 3 of 10
PCI 4 Form —Version 1 4 January 2009
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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
Tem ora
2b
ype 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 Z
Choose one
Choose one
Yes /No
W
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
Jev*—
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1
fhea5tror,e�
L "aV� rApe —v—
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' C7
S2
"C' hoos Lro %b-
6.
10
/0
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 1 4 January 2009
D. Impact Justification and Mitigation
1. Avoidance and Minimization
la Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
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lb Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a Does the project require Co �ensatory Mitigation for
impacts to Waters oft S rs of the State
❑Yes ❑ No
2b If yes, mitigate is required by (check all that apply):
❑ DWQ ❑ Corps
2c Xoje which mitigation option will be used for this
�
❑ 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 P ased (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 reques ((DWQ only):
square feet
4e Riparian wetlan itigation requested:
acres
4f Non -npa wetland mitigation requested:
acres
4g Co al (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
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 indiv 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 Z
Choose one
Choose
04
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.
�Iurpose r osed use or
of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P
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
6a. Project is in which protected basin?
❑ 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
Yes /No
B2
Yes /No
B3
Yes /No
B4
Yes /No
B5
Yes /No
B6 -
Yes /No
6h Total Buffer Impacts:
61 Comments
Page 5 of 10
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
within one of the NC Riparian Buffer Protection Rules?
❑ Yes we
lb
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 o
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 government's 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?
E] 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
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 a of the riparian buffer that requires mitigation Calculate the
amount of mitigation required
Zone
6c
Reason for impact
6
Total impact
(square feet)
Multiplier
6e
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
15
6f Total buffer mitigation required:
6g If er 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
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a Does the project involve an expenditure of public (federal /state/local) funds or the
[] Yes Leo
use of public (federal /state) land?
1b 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
re s ❑ No
Wetland Rules (15A NCAC ZH 1300), DWQ Surface Water or Wetland Standards,
or Riparian Buffer Rules (15A NCAC 26 0200)?
2b Is this an after - the -fact permit application?
®.V E] No
2c If you answered 'yes" to one or both of the above questions, provide an explanation of the violation(s)-
'n,.eIs w &S
3. Cumulative Impacts (DWQ Requirement)
3a Will this project (based on past and reasonably anticipated future impacts) result in
El Yes 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) IL-T*
4a Clearly detail the ultimate treatment methods and disposition (non- discharge or discharge) of wastewater generated from
the proposed project, or availa capacity of the subject facility.
Page 9 of 10
PCN Form — Version 1 4 January 2009
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5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this project occur in or near an area with federal) p I
y 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) {
1
6a Will this project occur in or near an area designated as essential fish habitat? I
❑ Yes o �•
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 ❑Yes ❑ No
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 ffoodplain? ❑Yes No
8b If yes, explain how project meets FEMA requirements °
8c. What source(s) did you use to make the floodplain determination?
Applicant/Agent's Printed Name
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
Page 10 of 10
Date