19991001 Ver 1_COMPLETE FILE_19990910

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Kerr T. Stevens, Director 101?W'A
Bill Holman, Secretary
4 •
NC ENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
September 21, 1999
W. D. Lusk
Route 4 Box 322
Marion NC 28752
Dear Mr. Lusk:
Re: W. D. Lusk and Jerry Boyd project
McDowell County
DWQ # 991001
The Division of Water Quality has reviewed your submittal for a 404/401 Permit for commercial
development at NC 221 and NC 70 in McDowell County. Your application was not complete since a) a location map
was not included, b) the existing stream location is not shown on the site plan, and c) the nearest stream must be on
the application form. Please provide information regarding the location of your project. This information is needed
by DWQ in order for us to decide whether this project is approvable.
Please respond with three weeks of the date of this letter by sending us the appropriate information. If
we do not hear from you in three weeks, we will assume that you no longer want to pursue this project and we will
consider the project as withdrawn.
I can be reached at 919-733-1786 if you have any questions. Until this information is received, I will
request (by copy of this letter) that the Corps of Engineers place this project on hold. Also, the project will be placed
on hold for our processing due to incomplete information (15A NCAC 2H.0507(a)(4)). Your processing time will
begin once we receive a complete application.

Attachment
cc: Asheville DWQ Regional Office
Wilmington District of Corps of Engineers
Asheville Field Office Corps of Engineers
File Copy
Central Files
)incerely,
R. Dorney
r Quality Certi7,t Program
991001.hld
Division of Water Quality - Non-Discharge Branch
4401 Reedy Creek Rd., Raleigh, NC 27607 Telephone [phone] FAX # [phone]
An Equal Opportunity Affirmative Action Employer - 50% recycled/10% post consumer paper
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
Kerr T. Stevens, Director
1 P?3'A
NC ENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
August 31, 1999
Kerri Sheehan 4t- 10f
Odom & Associates Wo
1506-2 East Dixon Boulevard
Shelby, NC 28152
Dear Ms. Sheehan:
On August 19, 1999 the Division of Water Quality received your request for a 401
Certification for fill and piping a stream. Your application is being returned since
payment was not received with the application. In order for DWQ to review and process
your request, you must send a check in the amount of $200.00 made payable to the N.C.
Division of Water Quality.
If you have any questions, please call Cyndi Bell at 919-733-9721.
iPDnR. ,
orney
y
PAYMENT
RECENED
Wetlands/401 Unit 4401 Reedy Creek Road Raleigh, North Carolina 27607
Telephone [phone] FAX # [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post consumer paper
(dual & ossociafes
)m and Associates Engineering, Inc.
1506-2 East Dixon Boulevard
O 13n??? Shelby, North Carolina 28152
[phone]
-1 ?oa Fax: [phone]
August 13, 1999
Mr. John Domey
Div. of Environmental Mgt.
NCDENR
4401 Reedy Creek Rd.
Raleigh, NC 27606
REF: PRE-CONSTRUCTION NOTIFICATION APPLICATION
Dear Mr. Dorney;
Enclosed, please find 7 copies of referenced application and necessary drawing. Please contact
David Odom at the following address if you have any questions.
Odom & Associates
David Odom
1506-2 E. Dixon Blvd.
Shelby, NC 28152
[phone]
Thank You,
Ke 'Sheehan

DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT (k):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET).
PLEASE PRINT.
1. OWNERS NAME : VU D LG(s L?- c? ?J e r rv? p?jN p(,
2. MAILING ADDRESS: 6QX -?o
SUBDIVISION NAME:
CITY: /ii1?llri0 STATE: A IC, ZIP CODE: 1 S, WC MAILING ADDRESSSNABOVE) : Ft L4 0,;LI U/ ft LO??AME (IF DIFFERENT FROM 5DTVI 3. TELEPHONE NUMBER (HOME) : EO?&) 7a y - 3a 3a (WORK) :

4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: ' ?n?, ?, LL45
k k_ N, P ox !r3l)-2• A[A,+7i on , NG a?7 5 a
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTOG PHY WITH SCALE):
COUNTY: c-tmw,e I NEAREST TOWN OR CITY: ?,1?`/QVI
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
/V

1
6. IMPACTED OR NEAREST STREAM/RIVER: on k fy&o(\
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [-?,] IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ] NO [-/,]
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ ] NO [-?, ] IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: _ zo
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: 0
l
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: nhg EXCAVATION: f /n
FLOODING: p-IA OTHER:
DRAINAGE: A0 TOTAL ACRES TO BE IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION): /
LENGTH BEFORE: ?/l, FT AFTER: FT
WIDTH BEFORE (based on normal high water contours): a FT
WIDTH AFTER: FT
(2)
AVERAGE DEPTH BEFORE: 0,5 FT AFTER: O. 5-
STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL:
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
x
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? /i/A
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 81-" x 11" DRAWINGS ONLY):
Ell and P ?Oi?y SI r?arr?
FT
13. PURPOSE OF PROPOSED WORK: CarnmC--r"c,c, I

14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (I CLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
Nliq
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE? FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE 0 ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPE IES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED P OJECT.
DATE CONTACTED (ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIR D TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ ] (IF NO, GO TO 18)
a. IF YES, DOE THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES [ ] NO [ )
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINIST TION STATE CLEARINGHOUSE? YES [ ) NO [
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DI ISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVI ONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRE TOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? Comm er(,IaI
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? i???j
g. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.
?J/- ) :,- /95
(0, OWNER'S/AGENT'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
,i,
=N
-------•/
I ?
,\ r

DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET)
PLEASE PRINT.
1. OWNERS NAME: ?U b•(,1(S? ?l?rrv? p?jN p(,
2. MAILING ADDRESS:
SUBDIVISION NAME:
CITY: 00 STATE: AIC, ZIP CODE
PROJECT LOCATION ADDRESS, CLUDING SU D VISIONAME
MAILING ADDRESS ABOVE): ((
af7'?) a
(IF DIFFERENT FROM
3. TELEPHONE NUMBER (HOME) : &) dY- 3c RR (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR ESPO SIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: t()_ 0, tI/15IZ
k IL 144 60 A e'3 a! 0, jwjon/
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: M C, n/? oe NEAREST TOWN OR CITY:
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
/V
I .
A.
6. IMPACTED
OR NEAREST STREAM/RIVER
RIVER BASIN:
uAkm,)(?
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALI4Y WATERS (HQW), OUTSTANDING RESOURCE WATERS
(WS-I OR WS-II) ? YES [ ] NO [?] IF YES, EXPLAIN:
7b. IF THE PROJECT IS' LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ] NO [-/, ]
7c. IF THE PROJECT IS'[ LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 004 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ J NO [? ] IF YES, PROVIDE ACTION I. D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND:
0
9B. ESTIMATED TOTAL UMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: 0
(ORW), WATER SUPPLY
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: WA EXCAVATION: Iv'n
FLOODING: )A OTHER: 14
DRAINAGE: (00 TOTAL ACRES TO BE IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION): /
LENGTH BEFORE: ?y u FT AFTER: S?f ?O FT
WIDTH BEFORE (based on normal high water contours): a FT
WIDTH AFTER: ?L- FT
AVERAGE DEPTH BEFORE: `J FT AFTER: (D. _57 FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: k
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? nJ /A
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 8V' x 11" DRAWINGS ONLY):
F'J I and n?v??J sfr?G?
13. PURPOSE OF PROPOSED WORK: CoMMC 1 r , • I
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS) :
N//4
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPECIES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED PROJECT.
DATE CONTACTED: (ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ ] (IF NO, GO TO 18)
a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES [ ) NO [ )
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINISTRATION STATE CLEARINGHOUSE? YES [ ) NO [
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? CaMAle(c,aAI
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? i?%rg
g. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.
/'-) // /';q /
OWNER'S/AGENT'S SIGNATURE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
/) ;- /95
DATE
r

IN,
-- I \
F- vs$?4?10>
DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET).
PLEASE PRINT.
1. OWNERS NAME: W d•(,kS?- ?J?rrr1 p?jN p(,
2. MAILING ADDRESS:
CITY
SUBDIVISION NAME:
)00 STATE: /? / V/61 ZIP CODE:
a(f "715 a
PROJECT LOCATION ADDRESS, INCLUDING SU DTVISIO] NAME
MAILING ADDRESS ABOVE): ftcA
(IF DIFFERENT FROM
3. TELEPHONE NUMBER (HOME) : (W) 7dY- 3aR (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR ESPO SIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: UJ. t), ?LA5?
y k' g, box ea?a /1k&yi on , NG a 5 a
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTOG PHY WITH SCALE):
COUNTY: M c' oa weI NEAREST TOWN OR CITY:
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
7y
t . I
6. IMPACTED OR NEAREST STREAM/RIVER: 08 knu (?
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [-/,,] IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ] NO [-/,]
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ ] NO [-?' ] IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: _ /0
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: 0

10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: r /'4 EXCAVATION:
FLOODING: p-)A OTHER:
DRAINAGE: (00 TOTAL ACRES TO BE IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION): /
LENGTH BEFORE: ? /L' FT AFTER: FT
WIDTH BEFORE (based on normal high water contours): a FT
WIDTH AFTER: ?L- FT
AVERAGE DEPTH BEFORE: Q, S FT AFTER: ?• s FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: k
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? A)I1+
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 8V' x 11" DRAWINGS ONLY):
I and .0'
13. PURPOSE OF PROPOSED WORK: CrWmFf-". "-s'

14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPECIES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED PROJECT.
DATE CONTACTED: (ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ I (IF NO, GO TO 18)
a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES ( ) NO ( ]
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINISTRATION STATE CLEARINGHOUSE? YES [ ] NO [ J
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].
a
f
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? Comm erc,Ul
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? ,?j,?j
g. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.
0B//----
OWNER'S/AGENT'S SIGNATURE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
?) ;?- /99
DATE

IN,
=N \
\,N

DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT M):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET)
PLEASE PRINT.
1. OWNERS NAME: W. d.tks ? JQr r? at
2. MAILING ADDRESS: &x 3a3-
CITY
SUBDIVISION NAME:
STATE: A IC, yIC, ZIP CODE
PROJECT LOCATION ADDRESS, NCLUDING SU D VISIO] NAME
MAILING ADDRESS ABOVE):
aI7r5 'ol_
(IF DIFFERENT FROM
3. TELEPHONE NUMBER (HOME): (P8) 7a ? - 3a 3a (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR ESPOS,IBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: L(), 0, L=uM
VL W4 fox !5?0 /1W-ion., Nc ar?5 a
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTOG PHY WITH SCALE):
COUNTY: M C., a w I NEAREST TOWN OR CITY: jha-,k-l&"W
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
?v
6. IMPACTED OR NEAREST STREAM/RIVER: uf\km"a(?
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [?] IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ] NO [-/, ]
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ ] NO ['?' ] IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION) :
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: _ f V
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: 0
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: W4 EXCAVATION: lv?n
FLOODING: ?JA OTHER: /
DRAINAGE: Mp TOTAL ACRES TO BE'
E IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION):
LENGTH BEFORE: t (, FT AFTER: FT
WIDTH BEFORE (based on normal high water contours): FT
WIDTH AFTER: OA- FT
AVERAGE DEPTH BEFORE: 0.•5 FT AFTER: ?•,s FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: X
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? nJ lA
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 8V' x 11" DRAWINGS ONLY):
Ffl and P ?O iO? s fr?G?
13. PURPOSE OF PROPOSED WORK: Comm c- c-, Ck I
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS) :
N/iq
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPECIES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED PROJECT.
DATE CONTACTED: (ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ ] (IF NO, GO TO 18)
a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES [ ) NO [ )
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINISTRATION STATE CLEARINGHOUSE? YES [ ) NO ( )
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? comnle('c,al
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? i?ffj
q. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.

OWNER'S/AGENT'S SIGNATURE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
) 1 99
DATE
Y ? s -
,
=N \
1 \
??? per, /

DEM ID:' CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT )k):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE- ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET).
PLEASE PRINT.
1. OWNERS NAME: ?1J d.(5? J?rrv? p?jN pL
2. MAILING ADDRESS: 62x 3L3 L?-
SUBDIVISION NAME:
CITY: STATE: /? / C, ZIP CODE: '17 r5 a
PROJECT LOCATION ADDRESS, CLUDING SU D VISIOI NAME
MAILING ADDRESS ABOVE):
(IF DIFFERENT FROM
3. TELEPHONE NUMBER (HOME) : (PO 7aY- 3a 3a (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR ESPOr? S?IBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: Q5 K
9 I ti, prox ?,?2• /tk& -i on N? a??5 a
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: mc-uwal NEAREST TOWN OR CITY:
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
"7v

6. IMPACTED OR NEAREST STREAM/RIVER: uf) K m'a?
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO ['?,] IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ] NO [-?',]
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ ] NO [? ] IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: ! O
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: 0
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: t/4 EXCAVATION: 'v/A
FLOODING: OTHER: ??
DRAINAGE: I?I?? TOTAL ACRES TO BE'
E IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION): /
LENGTH BEFORE: FT AFTER: t{f ?O FT
WIDTH BEFORE (based on normal high water contours): FT
WIDTH AFTER: FT
AVERAGE DEPTH BEFORE: 0..5 FT AFTER: 0.5 FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: >C
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? A)//$
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 8%f x 11" DRAWINGS ONLY):
III and AID"
13. PURPOSE OF PROPOSED WORK: Crr?mc Cc " c.

14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
N/lq
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPECIES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED PROJECT.
DATE CONTACTED:
(ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ ] (IF NO, GO TO 18)
a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES [ ] NO [ ]
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINISTRATION STATE CLEARINGHOUSE? YES [ ] NO [ ]
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].

18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? commelr(,Gll
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? ??/,?j
g. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.

OWNER'S/AGENT'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
-M
f? \
7E
______?

10

DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT $):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET)
PLEASE PRINT. pp 22,,'' /
1. OWNERS NAME:
2. MAILING ADDRESS: &x C3 C-)-
SUBDIVISION NAME:
CITY: (0 STATE: /? / y C ZIP CODE: 7
PROJECT LOCATION ADDRESS, CLUDING SU D'VISIOI NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
3. TELEPHONE NUMBER (HOME) : (k&) 7d? - 3a 3a (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR ESPOr? S?IBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: t(), 0, L=g5K
V k, W, box ?e3aa, /11&6 -I on , NG a 5 a
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTO_ ('Gg npwz WITH SCALE)
COUNTY: r?V i)??'?- AJ NEAREST TOWN OR CITY:
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
"70
6. IMPACTED OR NEAREST STREAM/RIVER: _ 0A km"p(`
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [-?,] IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC) ? YES [ ] NO ]
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ ] NO [? ] IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: _ /0
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE: 0
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: CIA EXCAVATION: Iv?n
FLOODING: P-IA OTHER:
DRAINAGE: NIA TOTAL ACRES TO BE IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION):
LENGTH BEFORE: FT AFTER: FT
WIDTH BEFORE (based on normal high water contours): FT
WIDTH AFTER: ?L- FT
AVERAGE DEPTH BEFORE: 0.5 FT AFTER: ?• s FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: X
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? A) /A
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 8'r x 11" DRAWINGS ONLY):
I and p "O",
13. PURPOSE OF PROPOSED WORK: ComMC?? .I
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
N/lq
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPECIES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED PROJECT.
DATE CONTACTED: (ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ ] (IF NO, GO TO 18)
a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES [ ) NO [ )
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINISTRATION STATE CLEARINGHOUSE? YES [ ] NO [ ]
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? Comm e('c*Ul
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? i?%?
g. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.

OWNER'S/AGENT'S SIGNATURE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
/) :,- /99
DATE
.
I
01 1
i?
O ,???.1

DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT $):
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATION FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD OFFICE
OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES SHOULD BE
SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT (SEE AGENCY ADDRESSES SHEET).
PLEASE PRINT.
1. OWNERS NAME: VII b.`((5? Jtrr?jNo(,
2. MAILING ADDRESS: 1t 1C, &x
SUBDIVISION NAME: ?
CITY: STATE: A ICI yIC ZIP CODE: (9f7
l ;5a
PROJECT LOCATION ADDRESS, INCLUDING SU D VISIOI NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
3. TELEPHONE NUMBER (HOME) : /c-8) 03a 3a (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR I?ESPOI?SIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER: LI). D, L4 K
k k W, Pao x pia D• hL..&c rj o n, !y L 5 a
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOTOG PHY WITH SCALE):
COUNTY: I Fi-ww l NEAREST TOWN OR CITY:
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
/(J

6. IMPACTED OR NEAREST STREAM/RIVER: _ u8 km'j(?
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [-?Q IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ) NO [-;>4.]
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF COASTAL
COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION:
8a. HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS PROPERTY?
YES [ ] NO [? ] IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND ANY
ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
8b. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES [ ] NO [ ] IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: 0
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WFTLAMDS L00-TED ON PROJECT SITE: 0

10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: WA EXCAVATION:
FLOODING: P-)A OTHER: ??
DRAINAGE: r10 TOTAL ACRES TO BE'
E IMPACTED:
10B. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED, PROVIDE
DISTANCE BOTH BEFORE AND AFTER RELOCATION): /
LENGTH BEFORE: FT AFTER: FT
WIDTH BEFORE (based on normal high water contours): IX FT
WIDTH AFTER: FT
AVERAGE DEPTH BEFORE: 5 FT AFTER: ?• S FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: k
CHANNEL ELEVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? A)14
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: BV' x 11" DRAWINGS ONLY):
F'i•I and ?v? sfr?u?
13. PURPOSE OF PROPOSED WORK: Crmmc ?^?, ,

14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
N/lq
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS) AND/OR
NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES SHEET) REGARDING
THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR
THREATENED SPECIES OR CIRTICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY
THE PROPOSED PROJECT.
DATE CONTACTED: (ATTACH RESPONSES FROM THESE AGENCIES.)
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER (SHPO) (SEE
AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE
PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ ] (IF NO, GO TO 18)
a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL DOCUMENT
PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT?
YES [ ] NO [ ]
b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA DEPARTMENT
OF ADMINISTRATION STATE CLEARINGHOUSE? YES [ ] NO [ ]
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING COMPLIANCE WITH THE
NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE DIRECTED TO MS.
CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH CAROLINA DEPARTMENT OF
ADMINISTRATION, 116 WEST JONES STREET, RALEIGH, NORTH CAROLINA 27603-8003, TELEPHONE
[phone].

18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED ACTIVITY
INVOLVES THE DISCHARGE OF EXCAVATED OR FILL MATERIAL INTO WETLANDS:
a. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES AND PONDS ON THE
PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38). ALL
STREAMS (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON THE MAP.
MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OR 1 INCH EQUALS 100 FEET OR THEIR
EQUIVALENT.
b. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS RELEVANT
TO THE PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. WHAT IS LAND USE OF SURROUNDING PROPERTY? ccmm e('c,ckl
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? nI/?
g. SIGNED AND DATED BY AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE U.S. MAY NOT BE IMPACTED PRIOR TO:
1) ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT, AND
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL MANAGEMENT
(WATER QUALITY) CERTIFICATION.

OWNER'S/AGENT'S SIGNATURE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
?) :,- /95
DATE
4 .
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