20240618 Ver 1_Determination Request_20240423

Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Name:*
Is this a transportation project?*
Is this request for a mitigation site?
What type of request is this?*
Owner Information
[e-mail]
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
IP Stream Determination
Stream
Name on the Recorded Deed: * Graydon Paul Jackson, Jr. & Barbara Jackson Dennis
Responsible Party : Pivotal Housing Partners
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: [phone]
Email Address: * [e-mail]
m
How would you like to received your determination?*
Is there an agent or consultant responsible for the request?*
Yes
No
Project Information
Has anyone form DWR done a previous site visit?*
Date of Visit:
Site Information
..............................................................................................................................................
Nearest Highway/Street: *
Old Fire Tower Rd - SR 2235
Nearest Town: *
Greenville, NC
Nearest Named Stream:*
Fork Swamp
River Basin: *
Neuse

County: *
Pitt
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach document
Quad Map PN 11770.pdf 225.79KB
Pdf file type only
TOPO map look up: https://viewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
Click the upload button or drag and drop files here to attach document
Soil_Report PN 11770.pdf 696.65KB
Pdf file type only
Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
Please provide the Latitude and Longitude for physical location for the determination that. If you have a physical
address you can look up the Latitude and Longitude by typing in an address or filling out the information
manually.
Choose below how you would like to provide this information.
Address Lookup
Manually
Latitude: 35.564
Longitude:-77.357
Misc attachments: Sheet C2_ExistingConditions.pdf 339.88KB
pdf or kmz file types only
By digitally signing below, I certify that:
o I have given true, accurate, and complete information on this form;
d 1 agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act)
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Determination Request' form."
Signature
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Date Submitted: 4/23/2024
Initial Review
.................................................
ID#* 20240618
Version * 1
Do you want to send for review?* Yes No