20010561 Ver 1_COMPLETE FILE_20010416

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Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Kerr T. Stevens
Division of Water Quality
April 19, 2001
DWQ# 01-0561
Pitt County
Danny Wilson and Earl Wilson
423 Riverpath Lane
Grimesland, NC 27838
APPROVAL of 401 Water Quality Certification
Dear Sirs:
You have our approval, in accordance with the attached conditions, to place fill in 0.1 acres of waters of the Tar River
in order to construct a road on your property in Pitt County, as described in your application received by the Division of
Water Quality on April 16, 2001. After reviewing your application, we have determined that this fill is covered by General
Water Quality Certification Number 3287. This Certification allows you to use Nationwide Permit Number 39 when it is
issued by the U.S. Army Corps of Engineers. In addition, you should get any other federal, state or local permits before you
go ahead with your project including (but not limited to) Sediment and Erosion Control, Non-Discharge and Water Supply
Watershed regulations. Also this approval will expire when the accompanying 404 permit expires unless otherwise
specified in the General Certification.
This approval is only valid for the purpose and design that you described in your application. If you change your
project, you must notify us and you may be required to send us a new application for a new certification. If the property is
sold, the new owner must be given a copy of the Certification and approval letter and is thereby responsible for complying
with all conditions. If total wetland fills for this project (now or in the future) exceed one acre, compensatory mitigation may
be required as described in 15A NCAC 2H .0506 (h). For this approval to be valid, you must follow the conditions listed in
the attached certification.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You must act
within 60 days of the date that you receive this letter. To ask for a hearing, send a written petition which conforms to
Chapter 150B of the North Carolina General Statutes to the Office of Administrative Hearings, P.O. Box 27447, Raleigh,
N.C. 27611-7447. This certification and its conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If you have
any questions, please telephone John Dorney at 919-733-9646.
Sincerely,
r . Stevens
Attachment
cc: Corps of Engineers Washington Field Office
Washington DWQ Regional Office
Central Files
File Copy
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
010 711 1 7..f_ /..1.......\ 010 711 8001 ff-N k. f, 1/k), ..... .. 4,f, - -1--t I,. A,I
Z??c i,? , 010 5 6 A 00
N 3 4 d-15 0 D' U.S. ARMY CORPS OF ENGINEERS •??
E d M6 OD Wilmington District
Action ID: 0 (? 1 y County: 1
r
Notification of Jurisdictional Determination
Property owner/Authorized Agent U A n n ?A ) l lS b h Ak\,r,? t o r t U ISOh
Address ?ia3 V-f r,n?a`l, Lie,
Telephone Number 62 5 'a) -2,5 2 2
T
Size and I pcatiion of Pro erty(waterbody, Highway Aname/number towns, etc.) / n
l?cCt°5S ?'ca?AcC Y? 7r P I V e L06,17ezf' 3 m i e s n or't' W e,4 6?
?A ?a L LLA, n.Ac ?-L ?-Lo . --T-;4 r lK V P r-1.
Indicate Which of the following apply:
• Ther are wetland on the abov described roperty w ich we str gly suggpt should l;? delineaVd and
su eyed. The s rveyed wetl nd lines m st be veri " d by our aff befo
Ju re the Corps will make a final
?sdictional d erminat Y
ion n our Pr crtY.
• Becaof the size o our proper and our pros nt workload, ur identificatio nd delineation your
wi1approval s cannot be • ccomplishe in a timely nner. You y wish to emplo a consultant to btain a vy6
mmely deline ion of the tlands. One our consult, t has flagged a tland line on th property,
Ctaff will re iew it, and,' it is accurat we strongly commend that u have the line surveyed for
fiby he Corps. e Corps will of make a fi 1 jurisdictional termination on your property
wan app wed surve .
H"w The wetlands on your lot have been delineated, and the limits of Corps jurisdiction have been explained
to you. Unless there is a change in the I w or our published regulations, this determination may be relied
upon for a period not to exceed t y?ss from the date of this notification.
• Ther are no we ands prey t{the ove describe property which/are subject " the permit
req rements of ection 404 f the Clew ater Act (33 SC 1344). Unl s there is a c ange in the law
or r publishe regulation , this deter nation may be died upon for eriod not to )exceed three years
fr m the date f this notif' ation. ll
• he Unkoject is loca d in one of th 20 Coastal Co nties. You s?buld contact th?nearest Ste Office of
Co• tal Manager?t to determiytheir requirents. «< //
Placement of dredged or fill material in wetlands on this property without a Department of the Army
permit is in most cases a violation of Section 301 of the Clean Water Act (33 USC 1311). A permit is
not required for work on the property restricted entirely to existing high ground. If you have any
qu stions re ar in the Corps of Engineers regulatory pro ram lease con a t 11 rasa ?s i ? ek
Property owner/Authorized Agent ?ignature
Project Manager Signature
Date
Expiration Date a - L? 1? " ad 016
SURVEY PLAT OR FIELD SKETCH OF DESCRIBED PROPERTY AND THE WETLAND
ELINEATIION FORM MUST BEA TT?H? TO THE YE LOW (F?LE) CO,?Y O?THI? FORM.
g5,s 0 , ? Vh ? q i k) g;, Gt reA f n?nyl e- c r e r?,? o`? ? , s Q S
CESAW Form 566 CS?f -e I M A k i W U 1 l).) ?ct V ! 1 V???t l G? , 7 i j e%w U , 4 1 1 " % S a r e
NOTIFICATION, OF ADMINISTRATIVE APPEAL OPTIONSANDPROCESS AND
REQUEST:FOR APPEAL
A licant: , File Number: abvll D / Date: c? IoW
Attached is: See Section below
INITIAL PROFFERED PERMIT (Standard Permit or Letter of permission) A
PROFFERED PERMIT (Standard Permit or Letter of permission) B
PERMIT DENIAL C
APPROVED JURISDICTIONAL DETERMINATION D
PRELIMINARY JURISDICTIONAL DETERMINATION E
SECTION
I - The following identifies your rights and options regarding an administrative appeal of the above
decision. Additional information may be found at http://usace:army.mil/inet/functions/cw/ceewo/r
or
eg
Corps regulations at 33 CFR Part 33 L _
A: INITIA L PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights
to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the permit.
• OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request that
the permit be modified accordingly. You must complete Section II of this form and return the form to the district engineer
.
Your objections must be received by the district engineer within 60 days of the date of this notice, or you will forfeit your right
to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your objections and may: (a)
modify the permit to address all of your concerns, (b) modify the permit to address some of your objections, or (c) not modify
the permit having determined that the permit should be issued as previously written. After evaluating your objections
the
,
district engineer will send you a proffered permit for your reconsideration, as indicated in Section B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Pernut, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights
to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the permit.
• APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and conditions therein, you
may appeal the declined permit under the Corps of Engineers Administrative Appeal Process by completing Section II of this
form and sending the form to the division engineer. This form must be received by the division engineer within 60 days of the
date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process
by completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.
D: APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the approved JD or
provide new information.
• ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify the Corps within 60 days of the
date of this notice, means that you accept the approved JD in its entirety, and waive all rights to appeal the approved JD.
• APPEAL: If you disagree with the approved JD, you may appeal the approved JD under the Corps of Engineers Administrative
Appeal Process by completing Section II of this form and sending the form to the division engineer. This form must be received
by the division engineer within 60 days of the date of this notice.
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps
regarding the preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an
approved JD (which may be appealed), by contacting the Corps district for further instruction. Also you may
provide new information for further consideration by the Corps to reevaluate the JD.
SECTION II - REQUEST FOR APPEAL' or OBJECTIONS TO AN INITIAL PROFFERED PERMIT'
REASONS FOR APPEAL OR OBJECTIONS: (Describe your reasons for appealing the decision or your objections to an
initial proffered permit in clear concise statements. You may attach additional information to this form to clarify where your reasons
or objections are addressed in the administrative record.)
ADDITIONAL INFORMATION: The appeal is limited to a review of the administrative record, the Corps memorandum for the
record of the appeal conference or meeting, and any supplemental information that the review officer has determined is needed to
clarify the administrative record. Neither the appellant nor the Corps may add new information or analyses to the record. However,
you may provide additional information to clarify the location of information that is already in the administrative record.
POINT OF CONTACT FOR UESTTONS OR INFORMATION:
If you have questions regarding this decision and/or the appeal If you only have questions regarding the appeal process you may
process you may contact: also contact:
Mr. Henry Wicker, Regulatory Specialist Mr. Arthur Middleton, Administrative Appeal Review Officer
Washington Regulatory Field Office CESAD-ET-CO-R
Post Office Box 1000 U.S. Army Corps of Engineers, South Atlantic Division
Washington, North Carolina 27889 60 Forsyth Street, Room 9M15
252 975-1616, ext. 25 Atlanta, Georgia 30303-8801
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any government
consultants, to conduct investigations of the project site during the course of the appeal process. You will be provided a 15 day
notice of any site investigation, and will have the opportunity to participate in all site investigations.
Date: Telephone number:
Signature of appellant or agent.
DIVISION ENGINEER:
Commander
U.S. Army Engineer Division, South Atlantic
60 Forsyth Street, Room 9M15
Atlanta, Georgia 30303-3490
THIS PACKET OF INFORMATION
IS PROVIDED TO ASSIST YOU
IN COMPLETING THE PRE-
CONSTR CONSTRUCTION NOTX FI CATX ON
(PClV) FORM THAT IS REQUIRED
BY THE U.S. ARMY CORPS OF
ENGINEERS AND THE NORTH
CAROLINA DIVISION OF
ENVIRONMENTAL MANAGEMENT
WHEN APPLYING FOR CERTAIN
NATIONWIDE PERMITS
AUTHORIZED BY THE U.S.
ARMY CORPS OF ENGINEERS
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 T1C DIVISION OF COASTAT, 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:
2. MAILING ADDRE
SUBD ISION NAME: /t/ o'ne
CITY: STATE: /IC. ZIP CODE: ?? /9377
PROJECT LOCATIO ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE): 5'? m e
3. TELEPHONE NUMBER (HOME) : S ` .. O (WORK) :
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER : 4204 e-
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOT AY WITH SCALE):
COUNTY: NEAREST TOWN OR CITY:
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.) 4 3 3
Lve54 o:?- rYirne i.Xyne/ fLS flLnUl1 R 'urn /Qi??f
vo f o S ?'o!J S. ? f ti y? f_ ?? 9/v, n i4a? Q ?u f / ,8/vc.?
2A-O,9j,vn1- /l o?1 ?Y7? Cc/i I?;(?C' 4? ?'?C c S /Q! ls?Pv,?a!! h
6. IMPACTED OR NEAREST STREAM/RIVER: ? Y 'R ( V e
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 [ J NO [yCJ IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ J 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 [ J NO [XJ 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 [ J NO [IJ IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: 3
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: Q'/ EXCAVATION:
FLOODING: OTHER:
DRAINAGE: 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: FT
AVERAGE DEPTH BEFORE: FT AFTER: FT
(2) 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:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? /? o n -ei
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS : 81/2" x 11" DRAWINGS ONLY) : C'N/J 5-7' r,. rT 3 6 U ' X /2
, reevs Ro#/ 7`0 li fh v r-oueI
3g11,c CZrv i- FA e' .7 v,e -/ ,®r
13. PURPOSE OF PROPOSED WORK: ??' /r (Cr fs 12 to R P r f y
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
_ /a I fir V`i l/ y V •? CCC?S i! It a YQ /???
_. ' X i? S 7` ; N C Ac- l In tS 0 Asl D /y P q ?i 6 a a i o 'p e Y 'f ?1
Ne rG /I 6o•- hcl*S d P,v Wezf aS P of rOwl
15. 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:
16. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ x 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 [
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, 1302 Marl Service Center, RALEIGH, NORTH CAROLINA 27699-1302,
TELEPHONE [phone].
17. 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? F4 r 4q if- 17f ?? ht 6p?-
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
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/II S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
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W'3 4?1156 D U.S. ARMY CORPS OF ENGINEERS '?:o -T3
M :3--:.
?7 OZ) Wilmington District m -. ,
M "
Action ID: aQ 109 County: 1 o i
Notification of Jurisdictional Determination
>r
Property owner/Authorized Agent U A n h V ?A J (?S a In A *-,c ,J--Q r t 1,?I [Soy,
Address -013 Ve r-,n Ip Lan
'a g
IZIephone Number. C,25_T,j 7 - 3D 2
Size and Xcation ofPerty(waterbody, High`yay?lname/number town etc.) AcC `tom /?4r /°CIv r 12iYP?Y 3 - reS nor ?A eS?C o? rImeS1W?J
_ 4 o 4 -lno. I. i4 r IK v p. ??.
Indicate Which of the following apply:
• Ther are wetland on the abov described roperty w rch we str gly sugg?t should delineavd and
su eyed. The s rveyed wetl nd lines in
st be verif' d by our aff befoc
Ju t the Corpdill make a final
sdictional d ermination n Your property.
• BecauY of the size o our proper and our pres nt workload, ur identificatio and delineation your
wetla scan not be ccomplishe i n a timely nner. You n)AY wish to emplo a consultant to btain a
mor timely deline ion of the tlands. One our consult t has flagged a tland line on th property,
Cor s staff will re iew it, and, ' it is accurat we strongly 54commend that u have the line surveyed for
fin 1 approval by he Corps. c Corps will of make a fi 1 jurisdictional 46termination on your property
A l w' hout an app ved surv
e .
• The wetlands on your lot have been delineated, and the limits of Corps jurisdiction have been explained
to you. Unless there is a change in the I w or our published regulations, this determination may be relied
upon for a period not to exceed t yeas from the date of this notification.
• Ther are no we ands pres r tg
ovc describe property whit are subject the permit
req r- in nts of ection 404 f the Cleter Act (
33 SC 1344). Unl . s there is a c ange in the law
or r publishe regulation , this deter on may be eked upon for Irp
eriod not to )exceed three years
fr in the date f this notif' ation. ll
• e oject is loca d in one of th 20 Coastal Co ntics. You suld contact th/nearest St?te Office of
Co tal Manager?t to determi?their rcquirents.
Placement of dredged or fill material in wetlands on this property without a Department of the Army
permit is in most cases a violation of Section 301 of the Clean Water Act (33 USC 1311). A permit is
not required for work on the property restricted entirely to existing high ground. If you have any
qu stions re ar in the Corps of Engineers regulatory program lease con a t,.
C'
1aa?75- ?.5Property owner/Authorized Agent?ignature

Project Manager Signature
Date ?-) - ":? I - C?0 1 . 0 Expiration Date a - aI - ;?() 016
SURVEY PLAT OR FIELD SKETCH OF DESCRIBED PROPERTY AND THE WETLAND
ELINEATION FORM MUST BE ATTA,rr? HE TO THE YELLOW (F LE) CO Y %T1H FORM.
ASJS D? Qe`?P,i-VhrrY i?;K The W?t1f?Qr?A i'Yle. C./fi`teh? c`WiS CtS
CFSAW ForthW l S?Jf \ -e
1 fu 1 L^ p G? V ! l ? 7 `I U) p
tt 6 Y? t? 1."' e6 l/ {fix (?S ar e.
O 92

Oth??fl . /? dI F !MINIS,,
IO'
M • rF
Q
?Ty?
Applicant: File Number: abo?16)(
1 D
114
Attached is: ate:
See Section below
INITIAL PROFFERED PERMIT (Standard Permit or Letter of permission) A
PROFFERED PERMIT Standard Permit or Letter of permission) B
PERMIT DENIAL C
APPROVED JURISDICTIONAL DETERMINATION D
PRELIMINARY JURISDICTIONAL DETERMINATION E
SECTIONrhThe following identifies your niAs and options-,r
egarding mr administratrve;.appeal of the above
r
decision..?ddifional` information may be found at http:// usacearniycmiVinet/functions/cw/cecwo/reg or
Co s re ulations at 33 CFR'Part331.
A: INITIAL PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights
to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the permit.
• OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request that
the permit be modified accordingly. You must complete Section II of this form and return the form to the district engineer.
Your objections must be received by the district engineer within 60 days of the date of this notice, or you will forfeit your right
to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your objections and may: (a)
modify the permit to address all of your concerns, (b) modify the permit to address some of your objections, or (c) not modify
the permit having determined that the permit should be issued as previously written. After evaluating your objections
the
,
district engineer will send you a proffered permit for your reconsideration, as indicated in Section B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights
to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the permit.
• APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and conditions therein, you
may appeal the declined permit under the Corps of Engineers Administrative Appeal Process by completing Section II of this
form and sending the form to the division engineer. This form must be received by the division engineer within 60 days of the
date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process
by completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.
D: APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the approved JD or
provide new information.
• ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify the Corps within 60 days of the
date of this notice, means that you accept the approved JD in its entirety, and waive all rights to appeal the approved JD.
• APPEAL: If you disagree with the approved JD, you may appeal the approved JD under the Corps of Engineers Administrative
Appeal Process by completing Section II of this form and sending the form to the division engineer. This form must be received
by the division engineer within 60 days of the date of this notice.
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps
regarding the preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an
approved JD (which may be appealed), by contacting the Corps district for further instruction. Also you may
provide new information for further consideration by the Corps to reevaluate the JD.
THIS PACKET OF INFORMATION
IS PROVIDED TO ASSIST YOU
IN COMPLETING THE PRE-
CONSTRUCTION NOTIFICATION
(PCN) FORM THAT IS REQUIRED
BY THE U.S. ARMY CORPS OF
ENGINEERS AND THE NORTH
CAROLINA DIVISION OF
ENVIRONMENTAL MANAGEMENT
WHEN APPLYING FOR CERTAIN
NATIONWIDE PERMITS
AUTHORIZED BY THE U.S.
ARMY CORPS OF ENGINEERS
rn
'70 ?
c7 -?
rn
? rn
rn ?'
o -?
DEM ID:
NATIONWIDE
CORPS ACTION ID:
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:
2. MAILING ADDRE
SUBD I S I ON NAME : d ''L e
CITY: STATE: C- ZIP CODE:
PROJECT LOCATIO ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE) : ,??YY1 P.
3. TELEPHONE NUMBER (HOME): S` 7:T 17 o (WORK) : ?RS ,.
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER:
-r
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOT RA?IiY WITH SCALE):
COUNTY: ??"! NEAREST TOWN OR CITY: ITYI /qh w
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.) /-3!V LcJ?
r, ?r' S / PS"T O ?r r i rn P 5' ?? n ?? f'L`> ?1??? ! 1 AJ -tai-'n
I / .c??D f: ! l
V o f S "0-?- f ail Y r? ::f-I ?? ???>? n /QC1 n Q 14
y ?',?? ?7. h
6. IMPACTED OR NEAREST STREAM/RIVER: 5 Y jog P ?
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS `lRQUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [)C] IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ] NO (V']
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 ['9] 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: ?:5 '/ <LdeC
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: © i/ EXCAVATION:
FLOODING: OTHER:
DRAINAGE: 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: FT
AVERAGE DEPTH BEFORE: FT AFTER: FT
(2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION:
CHANNEL ELEVATION:
OTHER:
PLACEMENT OF PIPE IN CHANNEL: X
CONSTRUCTION OF A DAM/FLOODING:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED DRAINING
TO THE POND? /?/D 7'• -6
WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL EQUIPMENT
TO BE USED (ATTACH PLANS: 8V2" x 11" DRAWINGS ONLY) : roil 5-11 r.. tT 3 610 Y I2 ?
?9?cPss R-o-#/ to /i fh 9 ro,ite 1
Bul/elozr- ? FA t-.7 uj¢i or
13. PURPOSE OF PROPOSED WORK : / y t'CC sS j7 ! d p P ?- -f Y
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
//o oak er (,i1 Ay 7' dCfrsS L!; ?h a roC,O'Ncr•
Sfi -`NC fCCrjS ?aAol o.? NP:q?i bar prop?v7?+/
hcl, s a5 e o-f ro y/
15. 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:
16. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [ x 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 [ )
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, 1302 Marl Service Center, RALEIGH, NORTH CAROLINA 27699-1302,
TELEPHONE [phone].
17. 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? F4t r nI ii? s ?' / i? h1 6 pr
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
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'SIjgW 'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED (18G.))
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.. US. ARMY CORPS OF ENGINEERS
?7 Da Wilmington District M H?Z
j M
Action ID: ;00 091 County:
Notification of Jurisdictional Determination
Property owner/Authorized Agent
Address
Telephone Number_ (, s s 7-3o!2
Size and Location of Property(waterbody, Highvyaygname/number, town: etc.)
Indicate Which of the following apply:

1. ?1--?h vY1 p. ? l lde
• Ther are wetlaZrmim on the abov described roperty w ich we str gly suggpt should delineatdd and
su eyed. The eyed wet! nd lines in st be verif d by our aff before the Corpdwwill make a final
ju sdictional d tio n on your pr erty.
nt workload, ,bur identificatio nd delineation your
• Becaus of the size o our proper and o/ny
wetla s cannot be ccomplishe in a timer. You n)dy wish to emplo a consultant to btain a
mor timely deline ion of the Hands. Or consult t has flagged a Hand line on th property,
Cor s staff will re lew it, and, ' it is accurrongly 5,66commend that u have
the line surveyed for
fin 1 approval by he Corps. e Corps wile a fi 1 jurisdictional termination on your property
hout an app ved surve. .
• The wetlands on your lot have been delineated, and the limits of Corps jurisdiction have been explained
to you. Unless there is a change in the 11a w or our published regulations, this determination may be relied
upon for a period not to exceed tears from the date of this notification.
• Ther are no we ands pres t b?5 dies ove descr/beprop erty hia re subject the permit
req rements of ection 404 f the Clea ater Act (3C 344)tere is a c ange in the law
or r publishe regulation , this deter nation may be d upon for eriod not to xceed three years
fr in the date f this notif ation.
• e oject is loca d in one of th 20 Coastal Co nties. You 4uld contact th?nearest St e Office of
Co tal Manage ent to determi?their requireAents. <`<`
Placement of dredged or fill material in wetlands on this property without a Department of the Army
permit is in most cases a violation of Section 301 of the Clean Water Act (33 USC 1311). A permit is
not required for work on the property restricted entirely to existing high ground. If you have any
qu stions re far i the Corps of Engineers regulatory pr ra lease con of t
',
a? a 5 l e 0(?
Property owner/Authorized
Project Manager Signature
Date__ a' I- c o L 0 Expiration Date a A- a0 016
SURVEY PLAT OR FIELD SKETCH OF DESCRIBED PROPERTY AND THE WETLAND
DELINEATION FORM MUST BE ATT?H? TO THE YELLOW (qLE) COPY O wT?FORM.
gSu o? m ?r ?v?. _ The cci? t tneA M4 c7-1 e/nr4 o w?yy /cps
CESAW Form 566 U 4 MlQ
C
1 OCC 92 40")'s a r
'
NOTIFICATION:OF . ADiIIINIS rRA
,I1N'E A_PYU_ML.OPTIONS ANDr
PROCESS A_ND
REQUES' TOR PPE Al i
Alicant: jq SL k , File Number: a6v11 U, Date:
a?a00/
Attached is: See Section below
INITIAL PROFFERED PERMIT (Standard Permit or. Letter of permission) A
PROFFERED PERMIT (Standard Permit or Letter of permission) B
PERMIT DENIAL C
APPROVED JURISDICTIONAL DETERMINATION D
PRELIMINARY JURISDICTIONAL DETERMINATION E
SECTION I Tlie follow in;= identifies your n hl ' aiid optloils'r? in` an ad 4iinistrati? appeal ofthe above
d
is
d
ec
ion
iitional,inforrliation maybe.found at http:usaCe army::miLinet hirictioiisicW; cecwo/red or-
`
: ..Corps re
lations__at 3.3 CFR Part 33 L
A: INITIAL PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights
to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the permit.
• OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request that
the permit be modified accordingly. You must complete Section II of this form and return the form to the district engineer.
Your objections must be received by the district engineer within 60 days of the date of this notice, or you will forfeit your right
to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your objections and may: (a)
modify the permit to address all of your concerns, (b) modify the permit to address some of your objections, or (c) not modify
the permit having determined that the permit should be issued as previously written. After evaluating your objections, the
district engineer will send you a proffered permit for your reconsideration, as indicated in Section B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all rights
to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the permit.
• APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and conditions therein, you
may appeal the declined permit under the Corps of Engineers Administrative Appeal Process by completing Section II of this
form and sending the form to the division engineer. This form must be received by the division engineer within 60 days of the
date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process
by completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.
D: APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the approved JD or
provide new information.
• ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify the Corps within 60 days of the
date of this notice, means that you accept the approved JD in its entirety, and waive all rights to appeal the approved JD.
• APPEAL: If you disagree with the approved JD, you may appeal the approved JD under the Corps of Engineers Administrative
Appeal Process by completing Section II of this form and sending the form to the division engineer. This form must be received
by the division engineer within 60 days of the date of this notice.
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps
regarding the preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an
approved JD (which may be appealed), by contacting the Corps district for further instruction. Also you may
provide new information for further consideration by the Corps to reevaluate the JD.
THIS PACKET OF INFORMATION
IS PROVIDED TO ASSIST YOU
IN COMPLETING THE PRE-
CONSTRUCTION NOTIFICATION
(PCN) FORM THAT IS REQUIRED
BY THE U.S. ARMY CORPS OF
ENGINEERS AND THE NORTH
CAROLINA DIVISION OF
ENVIRONMENTAL MANAGEMENT
WHEN APPLYING FOR CERTAIN
NATIONWIDE-PERMITS
AUTHORIZED BY THE U.S.
ARMY CORPS OF ENGINEERS
c
m
c m
m z
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:
2. MAILING ADDRE
SUBD ISION NAME: /U d n e
CITY: STATE: ZIP CODE: ?X 773-7
PROJECT LOCATIO ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE): 5-'m
3. TELEPHONE NUMBER (HOME): S` 5,' - 25 o (WORK): S
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL,
ADDRESS, PHONE NUMBER:
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP OR
AERIAL PHOT RAY WITH SCALE): /J
COUNTY: NEAREST TOWN OR CITY: /fin
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.) i l'c2'w-N
a,p24k s P T ?? t r 1' ?Y» P 5' ?? rAC? L f7?d ! / C fGl t? J 1 ?l Li/i T
goo s p ?,-?, Z

6. IMPACTED OR NEAREST STREAWRIVER: /a_ 1- R ( y e ?
RIVER BASIN:
7a. IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TRQUT, TIDAL SALTWATER
(SA), HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER SUPPLY
(WS-I OR WS-II)? YES [ ] NO [ Y,) IF YES, EXPLAIN:
7b. IF THE PROJECT IS LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL MANAGEMENT
ARE OF ENVIRONMENTAL CONCERN (AEC)? YES [ ) NO [`t j]
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 [ XI IF YES, DESCRIBE ANTICIPATED WORK:
9A. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND:
9B. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
10A. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: EXCAVATION:
FLOODING: OTHER:
DRAINAGE: 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: FT
AVERAGE DEPTH BEFORE: FT AFTER: 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? d ri
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'h" x 11" DRAWINGS ONLY) : C'e/J s7R i, eT' 3 6 49 ol X 12
/iCCP SS ?• 7`o L2 %f?i 9 ?'dur?p
8QI/ G10Zf' I- FA l'R t/A-/Ayr
13. PURPOSE OF PROPOSED WORK:d CC[?Sf i G ?e7
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
it. e, ?1??y d C?C'is /mil ? Si??! !l YOaiy/
h?CC r tS 'ge o/ e r 'Z 6 r J- s OP e ;-)'-V

15. 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: k 1ev`
16. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF PUBLIC
(STATE) LAND? YES [ ] NO [;4] (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, 1302 Marl Service Center, RALEIGH, NORTH CAROLINA 27699-1302,
TELEPHONE [phone].
17. 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? f
cZ i' lyt i £ a'?" 'f- o A" O P Y-
i
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
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/PI 'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER.IS PROVIDED (18G.))
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