20091072 Ver 1_401 Application_20091009

~ 1 !
~ a 1317 a ulrtain p~N ~ 11 Perk 17 Mourrtain ® Park
N 67°26'57" E / 3 $ 0.2 Miles to SR 1306 Zephyr 4 1418 1315
69.19' / E~ " " .a ~ a a LINE TABLE N 67°26'57" E ~ / Pat Nixon Road - , 13~6~93d1 A 1419 / ~ ~
DISTANCE 25.52' / x 1!2"REBAR ' .g 1 14 LINE BEARING ry 3
L1 N 67°39'38" E 63.70' 112 REBAR(f) ~ / ~ a 1540 • 1315 'm Gum
23.96 / / X530 s L2 N 66°52'39" E 108.18 ~ ~ 25.04' ~ , e , r Orchard Church
' ~ x~ 1516 131s / /25.05 i ~ ~ 1314 1315
USGS MONUMENT "i i " 0 1315 ,e 1 1301 10
" " . t 1/2 REBAR t 136 HLZ (1969) 1 NIR i 5 .1
ertical Control / • ~ 1 w ~ 1312 ~ N ) , / ~ a ~ N z~ ~ 1313
/ / ~ ~ 3 -107-x- ~ r
/ .....5~ ~ t ° ~ 1307 , ° E.:::'::~~:~::::.:.~ . ~ ~ ~ ~ ~ , ~ WILKES IT t3 1 ~
°TIE LINE" g''$.:.. ~ . 24.47 ~ x o ~ c, ~ ro ra ° ~ " / 61 ~ ~ .~i t cn COUNTY T S 01 4154E ~ \ ~ , r?
' PAVED Pt)BLIC ROAD 22.92' ~ ~ 3g2/ ` } ~ \ z, - 20 / 3B ~ 1 NIR N` t ~s^~ % w ~ ~ , SORRY s ~SURRY
(60 RNV Shown•Nof Per Record) ~ 4 , ~ ~ . ` \ Pro a Line is with the Centerline / • x ~ (GRASS FIELD) COUNTY COUNTY
nted 2 ? o, , , r..., (Points in Centerline are Not Monume ) ~~`I~ , ~ w w , w , te`
1`S• / v, ~ . :t::~:. ~ i-a ~ State ~Q V • ~ ° ` t~77, i ~ (GRASS FIELD) (~gd mad
~ ~ m x ~ ~ (No Scale) e 19.30 r?~ , ~
. ~ ~ ~ ~ C
line ~ "A" ~ GEAR AXLE found on ~ ~ PARCEL m, (0.8'subsurface) N w fi~ N
" 1 f co° o°
~ ' 1/2 REBAR(f) x ~ (GRASS FIELD)
w e t~
o ~9 ,A5 ~ ~ N 21 33 41 W ~ to 1A 30.17'
_ ~ PAR EL "A" N 1
0 ~ b'°-- n ~ ~ p z a. TAX ID#4954-00-28 5978 X X45
o ° 1 1434 a Q CHRISTOPHER CARTER N 211A' ~
p'° 2 1"NIR
w o et ux t 1 DB IoIO PG 38s X x a
x
1"NIR t ~ ~ TAXID#4954-00-38-2699 99
~ x ~ x' x ~~J%; ° THOMAS MATTHEW FREED FED
~ et tcx
B~" DB 1144 PG 550
z
0
TAX ID#4954-00-18-8469 ~ ~
O W (GRASS FIELD) ELLIS C. HAMBY and N o?
DEBRA H. GARNER
DB 659 PG 824
w
a~
0

16e6~9 A.C ES+I-
Notes: _ 1. AREA CALCULATED BY THE COORDINATE METHOD.
2. THE PROPERTY SHOWN HEREON IS SUBJECT TO ANY
PRIOR EASEMENTS RIGHTS OF WAY,AGREEMENTS, RESTRICTIVE 112"REBAR(t) ° 1 r
COVENANTS, ORDINANCES, REGULATIONS, etc., WHICH MAY OR
MAY NOT BE OF RECORD AND WHICH MAY NOT BE SHOWN HEREON.
3. THE NORTH INDEX OF THIS PLAT IS RELATIVE TO DEED BOOK 1010, POINT in a 30" WHITE OAK ata
PAGE 394 IN WHICH THE DESCRIPTION WAS OBTAINED FROM A SURVEY fence line intersection and located 6 r 6 ID PL DATED JANUARY 21 2002. ° o " ~ " 5g' ~ 9
BY HENRY MONROE HOBSON, S ~ N 84 5245 W -1.43 from a 1!2 5 ~ ~ 4. POINTS WITHOUT NOTATION ARE POINTS IN THE CENTERLINE OF SR 1307 °31`®g TAX ID#4954-00-38-2699
Rebar found on line. 3g AND ARE NOT MONUMENTED. ~ THOMAS MATTHEW FREED et uu~ ~ 4 j O C T 9 2009
DB 1144 PG 550
D~tdR • SAT 375.05' ASNdDStc DENR - WATER QUALITY WETLANDS AND STOR PATE K BRANCH
f N 84°5 '4 "
. 2.5 W .NORTH CAROLINA _ .
SORRY COUNTY
TAX ID#4954-00-27-9469 PLAT OF SURVEY FOR:
I, Stanrick B. Damell, PLS, certify that this plat was drawn and an FRANK S. CABS et ux
actual survey made under my supervision {deed description recorded in ' DB 1018 PG 1001
Book ~ Pa a as noted • that the boundaries not surve ed are clears indicated 9 J~ Y Y FIELD CREW FIELD BOOK
asdrawn #romthe information found in Book & Pa a as noted; that the ratio of I STATE ZONED FIELD WORK G.1~ F FIELD CREW 9 TOWNSHIP COUNTY precision as calculated is 1:10,000+; that the information shown hereon is true BRYAN SORRY N.C. RA 10115(08 and 1116 ~~8 SBD,SCD,RC BD,SCD,RDT 15122 (EDC)
urated to the best of m knawled a and belief. Witness m on final TiE LINES and FORMER PROPERTY LINES ~ RRS=RAILROAD SPIKE {s)=set, (t)=found and acc Y 9 Y 9 _ _ _ _ . _ ~ NIP=NEW IRON PIPE DRAWN BY CHECKED BY TAX ID #
signature, registration number and seal this lob day November, A.D., 2008. - ADJOINERS PROPERTY LINES PROJECT # of:4954-00-28-5978 08-141-A
0 NIR=NEW IRON REBAR SBD SSD Remainder of:4954-00-28-7656; Portion of:4954-00-28-5 0 - - - - RIGHT OF WAY AND EASEMENT LINES
Q°~~ar,~G~ I'~S ~ EIS=EXISTING IRON STAKE PROPERTY LINES SURVEYED REFERENCES J
Surveyor Registration Number L-4488 o EIP=EXISTING IRON PIPE - X - x - x - X - x -FENCE _ Remainder of: STAfVRiCd~ ,~N CAF~® ~ C1L-CENTERLINE Deed Book 1010 Pa a 394 PROVERBS 3:5 STANRiCK E. DARNELL, PLS
Ig BUILDING LINE ~ PP=POWER POLE ~
F~ssr Portion ofi QQ
~ ~ I, Stanrick B. Damell, PLS, certify that this survey is of - • ~ - ~ ~ ~ - - • -AERIAL UTILITY LINE ~ TP=TELEPHONE POLE Deed Book 1010 Page 388 E NORTH CAROLINA
an existin parcel of sand and does not create a new a TELEPHONE PEDESTAL NORTh SEAL g street or change an existing street. {G.S. 47-30(f1(11 ~.1.~ ! PROF PROFESSIONAL
L-44~~ ~ GRAPHIC SCALE ~ wELL L,4ND VLAND SURVEYOR
N v ® ~ e LS - o -m o 0' 100' 200' 300' l ~ 9 c~' v ~ > o - L-4488
9 ~ st>r~re~ ~ PROPERTYADDRE$S: 285 ADAMS RIDGE ROAD ~ ~ Surveyor Registration Number L-4488 Date ~S PF' 1691 MOUNTAIN PAE#K RD STATE ROAD, N.C. 28676
CK g,O
® 1 inch = 100 Horizontal Feet STATE ROAD,NC 28676 TELE: [phone]

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l ~ /
~ Jp A In r
/ ti
~ 1 ~ ~ ~ .~"Glyd~ C. P,~ ~E1t~ _
0 / I DE's C~~ M. ~ R
i ~ ` ate ~ ~ H _r'~ ~ _ _
ey' M ~J
d ~-cau KBE SNa~1N....__:.
/ ~
rv ~ , . l _izz2, o ~ / /
~ ~ ~ r 4 3z:,~_____ ~ ~ / j
D4t~ ~L~ 1Z3 ,b Q~, t
~ / j ' _ ~ ~ ~ ~ f ~
s ~ ~ ~ i ` Seedln mixture ~ R / ~ d~ r~ g t
~ w c ~ -a ~ ~ ~ i ~ J C f ~ - ~ / ~ ~.:1~ Species Rate Ibls J Tall #escue Rate (Iblacre)
. 1 ~ / ~ ~ 80 b~, bGY~a~L I~oS,~l _ ~ ( ~SL iZ _ / / / v ~ Serue le t I I _ ~ a spedeza 20 80 20
_ Przo Q~r~ `r r fir . i ~ - _ / ~ ~Q 4v Kobe lespedeza 10 Y S i ~ 10
_ / - _ / / ~
Y ~ i ~ ~ 0 , t ~ Seeding n®tes t / ~ ~ / 1~~ Q,~ ~ ~ 1. After Aug.15 use Unscarified sericea seed.
~ I / ~i ` 2. Where r / Q ` periodicmowin is annedoraneata Hcea seed.
~ ~ e 9 pl ppear ~ i ~ / / ~ ~ a ~ sericea and increase Kobe lespedeza to 40 Ibiacre. d or a neat appearance is desired, omit ?za to 40 lb/acre.
/ ; ~ ~ , / t,0 ~4~ : L 3. To extend spring se®ding dates into June, add i; into June, add 15 lb/acre hulled Ber-
! / „ l if ~ mudagrass. However, after mid•Apr. it is preferable ~ ~ ~ ~ ~ j cover. pr. it is preferable to seed temporary
ti U' j ~ ti v
~ / / / ~ i r~~A=~ v~ Nurse plants _
Dr3:1~I~ tom( , ~ ~ z, ti~~A~„ f - Between Ma 1a F~ tl / ~ , rJ~F`".,,. ~ y nd Aug.15, add 10 Ib/acre ~e~nar 10 Iblacre GeBnan millet or 15 Ib/acre
<~~;f ` i4tr'~~ r ~ P / ~ ~ Sudan rase. Prwr to Nfa 1 or afte / , 9 y rAug.t5add401t ~ 1 Aug. 15 add 40 Ib/acre rye (grain).
/ I J ! ~ l,/ ~ • ~ / f ~ ~ / Seedling dates
i ~ ~ / Sest Po I t 1 ssl Possible
f C / ~ ( / Fati: Au . 25 - Se .15 i ~ 9 Pt Aug. 20 - Aug. 20 - Oct. 25
~ ~ ~ I Late winter: f I / Feb. 15 - FAar. 29 Feb.1- A~ i / Feb. 1 - Apr. 15
/ i ~ ~ ~ Fall is best for tall fescue and late winter for les ez winter for lespedezas. Overseeding of
'G~ ` r~U ~ Kobe e /j ~ / I s edeza over fall- I ~ti ~ ~ : ~ , ~ / p seeded tall fescue !s very of ~ 1 / / 11 fescue is very effective.
~ 0 f / / ( Soil amendments
~ ~ ~ A pl lima and fertilizer acxordin to soil to is , _ / / / / / ~ p Y g s , or to soil tests, or apply 4,000 lb/acre
~ f / / ground agricultural limestone and 1,000 Ib/acre 10-10 ,000 Ib/acre 10-10-10 fertilizer.
/ / / ~ , / l „ / I /
1 I ~ ~ ~ A 14 OOIb I / / ~ / r ~ pp y ,0 /acre grain straw or equivalen4 cover
~ ' ,w. ~ ~ / / f - mulch.Anchorstrawbytadungw~thas halt, nettin of i ~ P equivalent cover of another suitable asphalt, netting, or roving or by crimp-
A~~,G / ~ / in g, ~ ! ~ ~ g with a muk:h anchorin tool. A dis ' I ~ r,.- / ~ / g k wrth blades set sk with blades set nearly straight can
' . / / be used as a mulch anchorin tool. / / ~ g / ~
~ ~ s / , Maintenance
' ~ ~ / / ~ Refertil¢e ' ~ ~ / / m the second year unless growth is fully ss growth is fully adequate. May be
~ ~ l`, ~ ~ mowed once or twice a ear, but mowin is not neces: ~ / ~ Y g ~ 1 / wing is not necessary. Reseed, fertil-
/ ~ ~ / / ize, and mulch damaged areas immediately. f , ~ ~ I / , ij ~ l I ediately.
t / ~ I l ~ ti ` f j / / Refer to Appendix 8.02for botanical names. iI names.
r / ~ 1
Arf ~ / ~ ~ , J - ~ / ~
~ f i ~ r
/ ~ r d ~ 1 ( , h~ ~ 1 / i
r .,1 ` I { / _ 1 ~ i
n, ~ ~ / ~ - _
'f'~;~ Ip~ d-,~~- 3~ ~r~ f ; ~J_2~~ ~ ~.o~ peM~t:f..~d! 42:34-.v' ' ~ .J l
T4fO?~a.S M T'C•H F u~ / - t"a'~ eNE~~ ~ka~L __t~1.~~_ t:2:3~-.~". f j ' ~ ~ .
° WG_114q P~ _ _ / C~:S~tw pC~T: r~F ~~_lzv.~Y~-~~,~.a~ :~~?t<YN~'+~ ~ ~~c f / - ~ ~
~ ~ f ~ :rJ_1 _ ErL1"-FrfZ~t~IC:N-:_ _ ~.s.:A ¢CA - uSG . UM.3?_. f ~ f ' USA. M': /V 15 _1Na j_ rZ_- _ _
/ ~ I l.N . 7aLL CO rZ.l.~ f.r~ tL -Ar3r~G r?.~ 1
/ ~ ~-~fl ALL DIS°[UlZ73C-+~:. ~~,=1~y. _ t
~a ~ I ~ ~ ~ ~ ~ t ~ I ~
~ ~ ~ , I + t ~
1 r~
~ ~ t nJ ~ N fJ(~ ~ THIS IS N4T A BOUNDRY SURVEY. ~ ~ ~ ~ ~
This plan was prepared from portions of a previous survey ~ ~4 ~ ~ yy ! ~ t m I 15 IY1 pd N D -~orz , I
prepared by Stanrick J3. Darnell, PLS, Dated 10 day 1 ~ ~ ~ _ i
November, A.D., 2008. ~ ~ ~ B t ~ G; ~ R t~t~ i a t~ _ ~_t~Y~~ lit _ Co of the surve is attached. i ~
PY Y rv i _ _ _ _ _ _ ~ A. _ _ _ e ~ t 1'~1 ~ ~i' , f~~ U. t~17~1.1~_ . P~.t,~. _rz e~.~ c~
1
~r 1 ;j'Ir~t~. r?t=AgS¢-rho-Zv-.~iQ7w
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tZ~t~l,~i~t.12i3r.o~. Dt'a loll p4. 3 ~ _ p. C~ ! T
Z4- Zo'q
s t
O C T 2909
DENR - WATER QUALITY
wETLANDS AND STOR?AWATER BRANCH

of wArFq
o?rr pG Office Use Only:
I.JU?J?: r 0 8 1 0 7 2 Corps action ID no.
o DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. V-Tti
Applicant Information ??--
1. Processing
I a. Type(s) of approval sought from the Corps:
I

Section 404 Permit ? Section 10 Permit
k-11
1b. Specify Nationwide Permit (NWP) number: W-?, or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ( "(es ? No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
JW,401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ
401 Certification:
E] Yes RNo For the record only for Corps Permit:

? Yes ['?No
1 f. 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 1?;„ No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below. ? Yes *0
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ?-r
2. Project Information
2a. Name of project:
2b. County: j .? rZ1Z
2c. Nearest municipality / town:
2d. Subdivision name: ?7.4
2e. NCDOT only, T.I.P. OF state project no:
3. Owner Information
3a. Name(s) on Recorded Deed: a C t4l
3b. Deed Book and Page No. m
3c. Responsible Party (for LLC if
applicable):
t z
3d. Street address: l 4 y1 m;. IRS Z 41 T
3e. City, state, zip:

Vi/ L5 U IC/ L!?n 11
<
3f. Telephone no.: L
3g. Fax no.: .?

3h. Email address: UM - WATER QtjALITy
---? WETLANDSAND
A5$
Aln
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. AgentlConsultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): t a,2 4=9_41.4 0 Z°- ! i7f'
1 b. Site coordinates (in decimal degrees): Latitude: Longitude:
1 c. Property size: l f0. acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
3. Project Description p%a,2M &2 t4 V
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:
A /L--V ZILL -
3b. List the total estimated acreage of all existing wetlands on the property: pct ,z
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 4,0e2
3d. Explain the purpose of the proposed project:
t
.
'I in uding the type of equipment to b used: 6- U.azk` l^ CL IA ft
?3e. Describe th over II project in d t
a L L. J . YX. i
2R,?
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 riot phases) in the past? t?ces ? 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): Agency/Consultant Company:
Other: 5L.60,, V?? M CL
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
a44-
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ?Yes Mo ? Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes 14-No
6b. If yes, explain.
Page 3of10
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):
q VWetlands [1?treams - 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 impact Type of wetland Forested Type of jurisdiction Area of
number Corps (404,10) or impact
Permanent (P) or DWQ (401, other) (acres)
Temporary
-
W1 - Choose one Choose one ?i?L.. Yes - V 03
W2 - Choose one ?-f C Choose one Yes o - L? . d
W3 - Choose one Choose one Yes/No -
W4 _ Choose one Choose one Yes/No -
W5 - Choose one Choose one Yes/No -
W6 - Choose one Choose one Yes/No -
2g. Total Wetland Impacts: I Q. 0-1
2h. Comments:
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 (PER) or Type of Average
t Impact
length
number intermittent (I NT)? jurisdiction ream
s
Permanent (P) or width (linear
feet)
Temporary (T) (feet)
215
S1 - Choose one 1 -
S2 - Choose o4e 0 ? j fl l - - ?0? ??-"•
S3 - Choose one - -
S4 - Choose one - "
S5 - Choose one - -
S6 - Choose one - -
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form -Version 1.4 January 2009

4. Open Water Impacts
estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
ponds
osed impacts to lakes
ro
If th
,
p
ere are p ,
the U.S. then individual) list all open water impacts below.
4
4a. 4b. e.
4c. 4d.
Open water Name of waterbody
(if applicable) Type of impact Waterbody Area of impact (acres)
b
er
impact num type
Permanent (P) or
Tem ora T
01 Choose one Choose
02 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed, then complete the chart below. 5e

5a. 5b.
Pond ID number Proposed use or .
5c. 5d.
Wetland Impacts (acres) Stream Impacts (feet) Upland
(acres)
purpose of pond
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
__ p e?(r Ae-
?Choosee one
P2
5f. Total:
5g. Comments:

5h. Is a dam high hazard permit required? [E] Yes No If yes, permit ID no:
5i. Expected pond surface area (acres): 0-34
5j. Size of pond watershed (acres): P. Y p

5k. Method of construction:
1y p
j pin
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 an impacts require mitigation, then ou MUST fill out Section D of this form.
6a. Project is in which protected basin? ? Neuse ? Tar-Pamlico ? Catawba ? Randleman ? Other:
6b. 6c.
Buffer Impact Reason for impact 6d. 6e. 6f. 69.
Stream name Buffer Zone 1 Zone 2
mitigation impact impact
number- required? (square (square
Permanent (P) or feet feet
Temporary T
131 Yes/No

-
132 Yes/No
133 Yes/No

64
- Yes/No
Yes/No
65
-
Yes/No
136
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10
A
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically escnbe measures taken to avoid or minimizg the proposed impa is irk designin project.

? !-'\0. ?c1 S GIYI C? e c r?PL?i sQ C? s ;
eC_a? ?0 n?__i,?t? Z
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes o
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this
project? ? Mitigation bank
? Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:

3b. Credits Purchased (attach receipt and letter) Type: Choose one
Type: Choose one
Type: Choose one Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Makin a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6of10
PCN Form -Version 1.4 January 2009
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 Yes No
buffer mitigation?
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.

Z 6c.
Reason for impact 6d.
Total impact
Multiplier 6e.
Required mitigation
(square feet)
one (square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
6g
.
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
PanP 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan [] Yes
1 a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Ri arian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why. 0 Yes
2. Stormwater Mana ement Plan V
2a. What is the overall percent imperviousness of this project? []Yes
2b. Does this project require a Stormwater Management Plan?
2c. If this project DOES NOT require a Stormwater Management Plan, explain why.
1)4,No
25?qo

2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
anagement Plan?
2e. Who will be responsible for the review of the Stormwater M
3. Certified Local Government Stormwater Review
3a. In which local overnment's jurisdiction is this ro ecV ? Phase ll
? NSW
stormwater management programs USMP
Water Supply Watershed
3b. Which of the following locally [] -implemented Other:
apply (check all that apply):
roved Stormwater Management Plan with proof of approval been ?Yes ? No
3c. Has the app
attached?
4. DWQ Stormwater Pro ram Review ?Coastal counties
?HQW
-implemented stormwater management programs apply ?ORW
4a. Which of the following state []Session Law 2006-246
Other:
(check all that apply)
Yes ? No
roved Stormwater Management Plan with proof of approval been
4b. Has the app
attached?
5. DWQ 401 Unit Stormwater Review Yes [] No
5a. Does the Stormwater Management Plan meet the appropriate requirements?
Yes ? No
O
5b. Have all of the 401 Unit submittal requirements been met?
Page 8 of 10 2009
PCN Form -Version 1.4 January
F. Supplementary Information
i. tnvironmental Documentation (DWQ Requirement)
f
1 a. Does the project involve an expenditure of public (federal/stateAocal) funds or the
use
f
bli
f
d
l/
?Yes ?N
pu
o
c (
e
era
state) land? o
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 ONO
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above
has the document review been finalized b
the
,
y
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ? Yes ® No
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
additional development, which could impact nearby downstream water quality? ?Yes ? No
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.
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PCN Form -Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat? Yes No
?
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? ? Yes ? No
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?
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?
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
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
? Yes ? No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
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:
8c. What source(s) did you use to make the floodplain determination?
r ?b?fp'Qy
Applicant/Agent's Printed Name Applicant/Agent's nature
(Agent's signature is valid on if an authorization
letter from the applicant is provided.) Date
Page 10 of 10

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