HomeMy WebLinkAbout20170249 Ver 1_401 Application_20170317March 2, 2017
US Army Corps of ng�e�
Raleigh Regulato ffi e
Attn: Mr. James L !r[?;-----'�'`
3331 Heritage Trade Drive
Suite 105
Wake Forest, NC 27587
Re: Stephenson Property
Request for NWP 29 & GC 3890
Action ID #SAW 2014-01192
NCDWR NBRRO# 14-189
Sage Project #2017.14
2 0 1 7 0 2 4 9
NC Division of Water Resources
401 & Buffer Permitting Unit
Attn: Ms. Jennifer Burdette
512 N. Salisbury Street
Raleigh, NC 27604
On behalf of the owners, Stephenson Heirs, please find attached a complete application and
supplemental information requesting written concurrence from the US Army Corps of Engineers
(USACE) and North Carolina Division of Water Resources (NCDWR) that the activities associated
with the residential development may proceed under Nationwide Permit (NWP) 29 and the
associated General Certification (GC) 3890.
Project Summary and Purpose
The proposed Stephenson Property (Project) involves the development of a 133.74 -acre parcel
bisected by Woods Creek Road. The (Project) is located immediately southwest and northwest
of the intersection of Woods Creek Road and Old Holly Springs Apex Road in the Town of Holly
Springs, NC. The Project is a proposed residential development of single-family homes and will
contain twelve internal roads, five stormwater BMP devices, as well as other utilities (sewer, water,
electricity, etc.) required for a residential development. The Project will have sewer service that
ties into existing municipal lines located to the south of the Project. The required stormwater plan
is being reviewed by the Town of Holly Springs and will consist of five BMPs located along the
southern property line. The project will provide additional housing to meet the current demand in
the area.
Project History
The Project site was likely farmed in the distant past but has been wooded for at least the past 40
years. A wetland and stream delineation was completed in 2014 and the delineation approved by
Mr. James Lastinger of the USACE during a field visit and a preliminary jurisdictional
determination (AID SAW -2014-01192) was issued on December 30, 2016. Mr. James Graham
(formerly of the NCDWR) made stream determinations during a field meeting held on May 22,
2014 and his determinations are reflected in his letter issued on June 24, 2014 (NBRRO#14-189).
The determinations made by Mr. Lastinger and Mr. Graham are reflected on the attached impact
maps.
Stephenson Property Page 1 of 2
Avoidance and Minimization
Proposed roads were aligned so as to avoid impacts to streams and wetlands. In most cases, lots
were also positioned so as to avoid lot fill in wetlands and streams. Open space was provided
around drainages containing jurisdictional streams and wetlands. Retaining walls are being built
around portions of wetlands to further avoid impacts. Lot fill is being requested at the upper portion
of some drainages were a sewer line is being installed immediately "downstream" (See Wetland
Impact Locations 1 and 3). Due to the site using a gravity sewer some locations of the sewer line
are fixed given the topography of the site as well as the property lines. The temporary impacts
associated with Wetland Impact Location 2 result from the installation of a sewer line that cannot
be moved further north and still be able to serve the southern portion of the cul-de-sac located to
the east; and cannot be moved further south due to the necessary location of a stormwater BMP.
Temporary impact areas will be returned to original grade and the original topsoil will be replaced.
Project Impacts
Proposed impacts will result from sewer lines and lot fill. The portion of the Project located north
of Woods Creek Road does not propose any impacts. Temporary wetland impacts resulting from
the installation of sewer line in three locations will total 0.0298 acre. Permanent proposed wetland
impacts associated with lot fill above two of the proposed sewer crossings will total 0.0198 acre.
Proposed permanent lot fill impacts to an isolated stream will total 141 linear feet. The Project is
not within a NCDWR regulated buffered basin therefore no buffer impacts are proposed. The
Town of Holly Springs does require riparian buffers and any proposed impacts to them will be
reviewed by Holly Springs staff.
Mitigation
No mitigation has been proposed due to permanent stream impacts being less than 150 LF and
permanent wetland impacts being less than 0.1 acre. The Project is not within a NCDWR
regulated buffered basin therefore no buffer mitigation is proposed.
If you have any questions, please call me at (919) 559-1537.
Sincerely,
Sean Clark, PWS
Sage Ecological Services, Inc.
Attachments:
Pre -construction Notification (PCN) Application Form
Agent Authorization Form
Figure 1-USGS Site Vicinity Map
Figure 2 -Soil Survey Site Vicinity Map
Impact Maps (5 sheets)
Check for $240.00 for 401 -processing fee (NCDWR only)
Stephenson Property Page 2 of 2
o�0F w ATF99
Office Use Only:
Corps action ID no. SAW -2016-
01126
DWQ project no.
Page 1 of 10
PCN Form — Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1 a.
Type(s) of approval sought from the Corps:
® Section 404 Permit ❑ Section 10 Permit
1b.
Specify Nationwide Permit (NWP) number: 29 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
® Yes
❑ 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
1 e.
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
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2.
Project Information
2a.
Name of project:
Stephenson Property
2b.
County:
Wake County
2c.
Nearest municipality / town:
Holly Springs
2d.
Subdivision name:
2e.
NCDOT only, T.I.P. or state
project no:
N/A
3.
Owner Information
3a.
Name(s) on Recorded Deed:
H&B Stephenson Family LLC
3b.
Deed Book and Page No.
013290 / 02541
3c.
Responsible Party (for LLC if
applicable):
Richard C. Stephenson (rep of Stephenson Heirs)
3d.
Street address:
105 Charlemagne Court
3e.
City, state, zip:
Cary, NC 27511
3f.
Telephone no.:
919-459-2187
3g.
Fax no.:
N/A
3h.
Email address:
res@stephenson-law.com
Page 1 of 10
PCN Form — Version 1.4 January 2009
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:
Sean Clark
5b. Business name
(if applicable):
Sage Ecological Services, Inc.
5c. Street address:
3707 Swift Drive
5d. City, state, zip:
Raleigh, NC 27606
5e. Telephone no.:
919-559-1537
5f. Fax no.:
5g. Email address:
sclark@sageecological.com
Page 2 of 10
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
0730-82-6440
1 b. Site coordinates (in decimal degrees):
Latitude: 35.677803° N Longitude: 78.869105° W
1c. Property size:
133.74 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
Big Branch
2b. Water Quality Classification of nearest receiving water:
C
2c. River basin:
Cape Fear River Basin (HUC 03030004)
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: The majority of the property has been . Immediately adjacent properties are similarly wooded and/or pasture
or agricultural fields. Residential developments exist north and south of the project area.
3b. List the total estimated acreage of all existing wetlands on the property: +/- 1.38 acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: +/- 2,294 LF
(includes 141 LF of isolated intermittent stream)
3d. Explain the purpose of the proposed project:
The purpose of the proposed project is to construct a residential subdivision and associated utilities to meet the demand
in the Holly Springs area.
3e. Describe the overall project in detail, including the type of equipment to be used:
The overall project is a single-family residential subdivision with residential streets and utilities that will connect to
existing adjacent streets and utilities in the area. The proposed impacts result from sewer line crossings and lot fill.
Heavy equipment typically used for utility installation projects (e.g. back hoes, bull -dozers, etc) will be utilized.
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?
® Yes ❑ No ® Unknown
Comments:
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): Chris Flowers & Phil Beach
Agency/Consultant Company: SEPI Engineering &
Construction Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
AW2014-
A site meeting was held with Mr. James Lastinger of the USACE and a PJD was issued on 12/30/2016 (AID SAW-2014-
01192).
01192). A stream determination site meeting was held with Mr. James Graham (formerly of NCDWR) in June 2014 and
the determination letter NBRRO# 14-189 dated 6/24/2014 summarizes the determinations.
6. 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 1.4 January 2009
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) or
Area of
Permanent (P) or
(if known)
DWQ (401, other)
impact
Temporary (T)
(acres)
Wetland Impact 1
Fill
Headwater
Yes
Corps
0.0131
P
wetland
Wetland Impact 1
Excavation
Headwater
Yes
Corps
0.0052
T
wetland
Wetland Impact 2
Excavation
Headwater
Yes
Corps
0.0226
T
wetland
Wetland Impact 3
Fill
Headwater
Yes
Corps
0.0067
P
wetland
Wetland Impact 3
Excavation
Headwater
Yes
Corps
0.0020
T
wetland
Choose one
Choose One
Choose one
Yes/No
-
0
2g. Total wetland impacts
0.0496
2h. Comments: permanent fill impacts will total 0.0198 acre and temporary impacts will total 0.0298 acre.
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 stream
Impact
number
(PER) or
width
length
Permanent (P) or
intermittent
(feet)
(linear
Temporary (T)
(INT)?
feet)
Stream Impact 1
(P)
Fill
UT to Big
Branch
INT
DWR
4
141
3h. Total stream and tributary impacts
141
3i. Comments: Permanent impacts of 141 LF (968 ft2) to an isolated intermittent stream.
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
impact number -
waterbody
Type of impact
Waterbody type
Area of impact
Permanent (P) or
(if applicable)
(acres)
Temporary T
01 Choose one
Choose One
Choose
4f. Total open water impacts
0
4g. Comments: There are no open waters within the project boundaries.
Page 4 of 10
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)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
Choose One
P2
Choose One
6f. Total
0
0
0
0
0
0
0
5g. Comments: This project does not propose Pond or Lake construction
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:
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)
6h. Total buffer impacts
0
0
6i. Comments: The proposed project is not within a drainage basin that has riparian buffers regulated by NCDWR.
Page 5 of 10
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Proposed roads were aligned so as to avoid impacts to streams and wetlands. In most cases, lots were also positioned
so as to avoid lot fill in wetlands and streams. Open space was provided around drainages containing jurisdictional
streams and wetlands. Retaining walls are being built around portions of wetlands to further avoid impacts. Lot fill is being
requested at the upper portion of some drainages were a sewer line is being installed immediately "downstream" (See
Wetland Impact Locations 1 and 3). Due to the site using a gravity sewer some locations of the sewer line are fixed given
the topography of the site as well as the property lines. The temporary impacts associated with Wetland Impact Location
2 result from the installation of a sewer line that cannot be moved further north and still be able to serve the southern
portion of the cul-de-sac located to the east; and cannot be moved further south due to the necessary location of a
stormwater BMP.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Construction fencing will be used to define the construction corridor and prevent any accidental additional impacts. Silt
fencing and temporary basins will also be used to prevent sediment runoff into the streams and wetlands.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
❑ Yes ® No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mitigation option will be used for this
project?
El Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
Type: Choose one
Quantity N/A
Type: Choose one
Quantity N/A
3b. Credits Purchased (attach receipt and letter)
Type: Choose one
Quantity N/A
3c. Comments: N/A
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:
0 linear feet
4c. If using stream mitigation, stream temperature:
Choose one
4d. Buffer mitigation requested (DWQ only):
0 square feet
4e. Riparian wetland mitigation requested:
0 acres
4f. Non -riparian wetland mitigation requested:
0 acres
4g. Coastal (tidal) wetland mitigation requested:
0 acres
Page 6 of 10
4h. Comments: N/A
S. 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 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).
N/A
6h. Comments:
Page 7 of 10
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. 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: The diffuse flow plan is part of the Stormwater Management Plan being
❑ Yes ❑ No
reviewed by the County.
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
39%
2b. Does this project require a Stormwater Management Plan?
® Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: The project requires a Stormwater
Management Plan that will be reviewed by Holly Springs, which is a delegated authority.
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
Stormwater will be directed to 5 stormwater BMPs located on the southern portion of the Site (see attached map).
2e. Who will be responsible for the review of the Stormwater Management Plan?
Town of Holly Springs
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
Holly Springs
® 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
S. 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)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes ® No
use of public (federal/state) land?
1 b. 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
❑ Yes ❑ No
letter.)
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.
The proposed project will tie into offsite regional utility lines located south of the project site.
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?
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?
The NC Natural Heritage Data Base (2017) was referenced and revealed no recorded federally listed species on the
project site or within a 1 -mile radius.
6. Essential Fish Habitat (Corps Requirement)
6a. Will 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?
The proposed project takes place in western Wake County which is not near any coastal or tidal habitat that would
support EFH (i.e. salt marshes, oyster reefs, etc.).
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?
http://gis.ncdcr.gov/hpoweb/ *Records check at the State Historic Preservation Office or the Office of State Archeology
were not performed. No sites are located within the project area. The Shearon Harris Project Houses (WA3715) site is
located approximately 0.25 mile west of the project area. Utilizing the HPOWEB GIS mapping service, no other structures
or sites were mapped within the project area.
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: N/A
8c. What source(s) did you use to make the floodplain determination? NC Flood Risk Information System
(www.fris.nc.gov/fds) FEMA DFIRM Panels #0730 & 0740; Dated May 2, 2006
revised
Sean Clark
%�% Q�
03/02/2017
Applicant/Agent's Printed Name
Date
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization letter from the applicant
isprovided.)
Page 10 of 10
AGENT AUTHORIZATION FORM
All Blanks to Be Filled in By the Current Landowner or Legal Representative
Name: ��..�;;
t
Address: CJS C 4 .c<C Y
f i' 6
Phone:
Email: d`t- .i'v�.av tcK,ti
Project Name/Description: As i '," k: kV. t l
Sage Project# 2017.14
Date: `7
The Department of the Army
U.S. Army Corps of Engineers, Wilmington District
P.O. Box 1890
Wilmington, NC 28402
Attn:
Field Office:
Re: Wetlands and Streams Related Consulting and Permitting
To Whom It May Concern:
I, the undersigned, a duly authorized owner of record of the property/properties identified
herein, do authorize representatives of the U.S. Army Corps of Engineers (Corps) to enter upon
the property herein described for the purpose of conducting on-site Investigations and issuing
a determination associated with Waters of the U.S. subjectto Federal jurisdiction under Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899.1 also hereby
designate and authorize Sage Ecological Services to act on my behalf as my agent in the
processing of permit applications, to furnish upon request supplemental information in support
of applications, etc, from this day forward.
This notification supersedes any previous correspondence concerning the agent for this
project.
Notice: This authorization, for liability and professional courtesy reasons, is valid only for
government officials to enter the property when accompanied by Sage staff. You should call
Sage to arrange a meeting prior to visiting the site. ,
i
Print Name of Landowner or
Legal Representative
f
BY:
Signature of Landowner or Legal
Representative
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