20240510_Ver 1_More info

AGENT AUTHORIZATION FORM
pitiF:§PIO T LEGAL D SCCU j ION
- ' ivy. _jam _ PLAN NO. PARCEL I®:
Lane., v� Lim
Pease print:
{_ undersicunes k registered properly owners of the above noted property, do hereby authorize
42ri4ractore�f t.A � ou�.T L
I Agent) (Name of consulting firm)
do ;;:cap: an my behalf and take aH actions necewary for the processing, issuance and acceptance of
tb w permit or certification and any and all standard and special condfidons a shed.
lo: esa, r:xo Owe -iees Address (if different than property above),
We hereby card y'ehe above information submitted in -pis app➢ cation is true and accurate to the
Jai iafmr Imohiledge.

5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.):I�l�
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary): r,( NU--T2r t—r ,D,\,�, —]-.%/ <7-\' , A.-e-,-
7. Will work be conducted from land? f711 From water? [l
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
(�
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet land-
ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
also
Temporary impacts (temporary .clearing, construction corridor) in square feet:
) �
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50 feet
landward to be impacted (number of trees, for instance):
oho �.��P-e�•�+�. - _-
11. Signature
By signing below, I, as the project proponent, certify to the following:
The project proponent hereby certifies that all information contained herein is true, accurate,
and complete to the best of my knowledge and belief
The project proponent hereby requests that the certifying authority review and take action on
this CWA 401 certificatioOrequest within the applicable reasonable period of time
!��
Ow nature" Im +l y u.. p-,
j Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources Division of Water Resources
15A NCAC 02B .0233 (8)(b), .0243 (8)(b), .0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2) - Buffer Authorization
FORM: BA 10-2013
Riparian Buffer Authorization Form
A. Applicant Information
1. Project Information
la. Name of project:
A-M
1 b. County:
=' L
1c. Nearest municipality:
o p i✓ - y
1d. Subdivision name:
-1 - �Pb / N
1e. Is the project located in any of North Carolina's twenty coastal counties?
If yes, answer 1f below.
❑ Yes X No
1f. Is the project located within a NC Division of Coastal Management Area of
Environmental Concern (AEC)?
❑ Yes XNo
2. Owner Information
2a. Name on Recorded Deed:
S EP 14 `d• LY NAI M
2b. Deed Book and Page No.
2c. Map Book and Page No.
(include a copy of the
recorded map that indicates
when the lot was created):
143 / 0
2d. Responsible Party
for Corporations):
2e. Street address:
I ( L4 YJ L0 Mal Q-1ZL-1 L E
2f. City, state, zip:
Vt ALL 29 117
2g. Telephone no.:
-
2h. Fax no.:
2i. Email address:
gA7G- L E L Z'- GCS M
3. Applicant Information (if different from owner)
3a. Applicant is:
Agent ❑ Other, specify:
3b. Name:
j,.d(Ce ,qy L1 C- -T� C G-R
3c. Business name
if applicable):
S
3d. Street address:
�jj S 33S
3e. City, state, zip:
/J B
3f. Telephone no.:
3g. Fax no.:
--
3h. Email address:
L� i 7.
4. Agent/Consultant Information (if applicable)
4a. Name:
4b. Business name
if applicable):
4c. Street address:
4d. City, state, zip:
4e. Telephone no.:
4f. Fax no.:
4g. Email address:
FORM: BA 10-2013 Page 1 of 4

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
1 b. Site coordinates (in decimal degrees):
Latitude: Longitude: _gZj c} P
1c. Property size: $7PcILA.,0
acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
A—yu
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
3. Project Description
�the general land use in the vicinity of the project at the time of
3a. Describe the existing conditions on the site and
this application: wy.
3b. Attach an 8'/z x 11 excerpt from the most recent ver ion of the USGS topographic map indicating the location
of the site
3c. Attach an 8'/z x 11 excerpt from the most recent version of the published County NRCS Soil Survey Map
depicting the project site
3d. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3e. Explain the purpose of the proposed roject: 5
�.
aoL, �
3f. Describe the overall project in detail, including the type of equipment to be used:
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 priorphases) in thepast?
❑ Yes No ❑ Unknown
Comments:
4b. If yes, who delineated the jurisdictional areas?
Name (if known):
Agency/ Consultant Company:
Other: �~
4c. 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 priorphases) in thepast?
ElYes Z No D Unknown
5b. If yes, explain and detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? El Yes
6b. If yes, explain.
FORM: BA 10-2013 Page 2 of 4

C. Proposed Impacts Inventory
1. Buffer Impacts
1a. Project is in which protected basin?
Z%
❑ Neus�an
❑
Tar-
❑ Jordan
a awb
❑ Goose Creek
1 b. Individually list all buffer impacts below. If any impacts require mitigation, then you MUST fill out Section D of
this form.
Buffer impact
number —
Permanent (P)
or Temporary
T
Reason for
impact
Type of impact
(exempt, allowable,
allowable w/
mitigation)
Stream name
Buffer
mitigation
required?
Zone 1
impact
(sq ft)
Zone 2
impact
(sq ft)
B1 ErP T
ED Yes No
S'
B2 P T
Yes ❑ No
B3 ❑P El
El Yes ❑No
B4 ❑ P ❑ T
❑ Yes No
B5 El P 0 T
El Yes El No
B6 0 P 0 T
❑ Yes LJ No
Total buffer impacts
1 c. 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.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction
techniques. -
2. Buffer Mitigation
2a. Will the project result in an impact within a protected riparian buffer that
requires buffer mitigation?
Yes crko
2b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation and
calculate the amount of mitigation required in the table below.
Zone
Reason for impact
Total impact
(square feet
Multiplier
Required mitigation
s uare feet
Zone 1
r.cf) A
3 (2 for Catawba)
Zone 2
_
1.5
Total buffer mitigation required:
2c. If buffer mitigation is required, is payment to a mitigation bank or NC DMS
proposed?
❑ Yes o
2d. If yes, attach the acceptance letter from the mitigation bank or NC DMS.
2e. If no, then discuss what type of mitigation is proposed. 5-z, 67J n
2f. Comments:
FORM: BA 10-2013 Page 3 of 4
M

E. Diffuse Flow Plan
All buffer impacts and high ground impacts require diffuse flow or other form of
❑ Diffuse flow
stormwater treatment. Include a plan that fully documents how diffuse flow will be
❑ Ot i r
maintained. If a Level Spreader is proposed, attach a Level Spreader Supplement Form.
If due to site constraints, a BMP other than a level spreader is proposed, please provide a
plan for stormwater treatment as outlined in Chapter 8 of the NC Stormwater BMP
Manual and attach a BMP Supplement Form.
F. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes <4ST No
use of public federal/state land?
1 b. 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 been finalized by the State
❑ Yes ❑ No
Clearing House? (If so, attach a copy of the NEPA or SEPA final approval letter.)
Comments:
2. Violations
2a. Is the site in violation of DWR Wetland Rules (15A NCAC 02H .0500), Isolated
LJ Yes No
Wetland Rules (15A NCAC 02H .1300), DWR Surface Water or Wetland Standards,
or Riparian Buffer Rules 15A NCAC 02B .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):
p lc ent's Printed Name Applicant/Agen s Sin ft Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Send ONE complete set of this form and accompanying documents to the following:
For government transportation projects sent by
First Class Mail via the US Postal Service:
Amy Chapman
NCDWR — 401 & Buffer Transportation
Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699 - 1617
For all other projects sent by First Class Mail via
the US Postal Service
For government transportation projects sent by
delivery service (UPS, Fed Ex, etc.):
Amy Chapman
OR NCDWR — 401 & Buffer Transportation
Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
For all other projects sent by delivery service
(UPS, Fed Ex, etc.):
Stephanie Goss Stephanie Goss
NCDWR — 401 & Buffer Permitting Branch OR NCDWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699 - 1617 Raleigh, NC 27604
FORM: BA 10-2013 Page 4 of 4