20170300 Ver 1_Buffer Determination Request_20170316

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RECEIVED/NCDEWRIDWR
NCDENR
MAR 16 2017
North Carolina Department of Environment and Natural Resot*QP%L,u,it re�ionai
Division of Water Resources
Operatio,13 Section
Washing'o%n �. insm,
Pat McCrory Water Quality Programs
III
Governor Thomas A. Reeder
Secretary
Director
5b. County
Stream Origin/Buffer Applicability Determination
Additional Requested Information
Required Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
1 a. Name(s) on Recorded Deed
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1 b. Responsible Party (for LLC)
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1c. Mailing Address
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1d. Telephone Number
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1e. Email Address
5b. County
2. Location of Project Site - please in de the county, nearest named town and highway number:
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3. Has anyone from DWQ visited the site?
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Staff Name
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Date of Visit?
Please attach a map of the site indicatingproject boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.
If you are unable to locate either of these maps, please contact the Regional Office for assistance.
Additional Requested Information
4. Agent/Consultant Information (if applicable)/'G-,-IM C, b
4a. Name, Company
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4b. Mailing address
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4c. Telephone no.
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5. Project and Site Information L'P pr- Tap ut,' 25Z 6
5a. Name of project
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5b. County
5c. Nearest Named Stream
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5d. River Basin
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5e. Provide a brief description of this project (attach site plan if available
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Please attach a map of the site indicatingproject boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.
If you are unable to locate either of these maps, please contact the Regional Office for assistance.
Please return form to: Anthony Scarbraugh
943 Washington Square Mall Note: Submittals on Friday after 12:00 pm
Washington, NC 27889 will be stamped as received on the
Fax: [phone] next business day.
Email: anthony.scarbraugh(cDncdenr.gov
Please contact Anthony Scarbraugh at [phone] if you have any questions.
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3-D RopoQuade Copyright � 1999 DeLorme Yarmouth, ME 04096 Source Data: USGS a 500 ft Sc=1e: 1 : 12,800 Detail: 14-0 Datum: 41GS84

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