20050041 Ver 1_Initial Interest Form_20050105

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INITIAL INTEREST IN PARTICIPATION IN TIlE EXPRESS REVIEW PROGRAM
WITlllN TIlE 401 OVERSITEIEXPRESS PERMITIING UNIT

September It 2004
Version 3

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05a0041

Applicant Name:
Applicant Address:

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Applicant's phone number: <0. --; ~'\ - ;':X1'-G L,
Applicant's email address:

Fax number: ~\.\-d.1-1--o

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Consultant Name (if applicable): \ <>,:,>,~ -'(("'r> v'" '. '" t)~

Consultant address (if applicable): <;....\- E:- ~

Consultant's phone number: ~'\~ - <..q (") 0 Fax number: ~ '-\ G - q '--\6"1-
Consultant's em ail address: -1 7 \"-~ ,,:, '^ ~r e. '-:.. "-,,,d,,>L co../'> (\A-

Type of action requested under the Express Review Program (check all that apply):

o
o
o Riparian Buffer Approval
o Stormwater Management Plan
o Mitigation Plan
o stream 0 wetland 0 buffers (check all appropriate)

401 Watcr Quality Certification
Isolatcd Wetland Permit

x

o

Stream Origin Determination
~# of Determinations Requested
IntermittentJPerennial Determination
_# of Determinations Requestcd

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Name of Project: :;:, (.. ~ ~t:\...-T

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County:~

Total project acreagc: S"SO (acres) Total built out impervious area: ~ -::; <.)

Nearest named strcam (from USGS topo map): L ., r\ C . ,(>~_

(acres)

Please provide a brief description ofthis project (attach site plan if availablc):

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, N 0 5 2005

Please attach a map of site location using USGS I :24,000 map and county soil survcy.

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" "..,;) I'; 'D ST02JlI~'ATER BRANCH

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Location of project site - please include reference to the county, nearest name town and highway number:

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Proposed impacts:

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Acres of 404 wetlands

Acres of isolated wetlands
Linear feet of streams
Linear feet of isolated streams
Square feet of protected stream buffers

Has consultant or applicant attended any DWQ-sponsored training sessions in the past two years? If so, please list
which ones. c::.X~~~-..... T(" r~"~~ ~

Has any ~~~ staff visited the site? ~ if yes, please provide DWQ staff name, <...-'\(~ '."_ \v..~, '\...c-.A \
date ofvlSlt. ,.,'~ ~~~ <.) t\-\ ,\'-<.. \\.~.....".,",
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Which other environmental permits from other agencies will be needed for this project? Please list the permits and
issuing agencies below:

and

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Does this project require approval under the State Environmental Policy Act or National Environmental Policy Act?
Nv

Is this project an After-the-fact application or has this project received a previous Notice of Violation from DWQ?
~h

Does this project require approval ofa Variance from the NC Environmental Management Commission? No

Are you aware of any local controversy concerning this project? If so, please describe the controversy and any
measures that have been taken with respect to public involvement.

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This form must be submitted via email (c/o 40Iexpress(lV,ncmail.net), faxed (919-733-6893) or hand-delivered to the
Parkview Building, 2321 Crabtree Blvd., Raleigh, NC 27604. Applicants who are selected to participate in the
Express Review Program will be notified via email or fax within 2 days, Successful applicants will then be instructed
regarding detailed procedures for full application (Please Note: Submittals of the review packages on Friday after
12:00 pm will be stamped as received on the next business day).

Please contact Debbie Edwards at 919-733-9502 if you have any questions regarding this form.

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