20011894 Ver 1_COMPLETE FILE_20011228

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January 25, 2002
Ms. Dorothy M. Rietze
3027 Wynfield Mews Lane
Louisville, KY 40206
Subject:
Retaining Wall
Jackson County
DW Q# 011894
APPROVAL OF 401 Water Quality Certification
Dear Ms. Rietze,
You have our approval, in accordance with the attached conditions and those listed below, to fill approximately 0.006 acres of lake bottom
to construct a retaining wall at Lot 8 Glen Pointe on Thorpe Lake in the Little Tennessee River Basin, Jackson County based on your
revised application dated December 20, 2001. After reviewing your application, we have decided that this activity is covered by General
Water Quality Certification Numbers 3280. This certification allows you to use General Permit Number 30 when the Corps of Engineers
issues it. 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, Coastal Stormwater, Non-Discharge and Water Supply Watershed regulations. This approval
will expire when the accompanying 404 or CAMA permit expires unless otherwise specified in the General Certification.
This approval is only valid for the purpose and design that you described in your revised application except as modified below. If you
change your project, you must notify us and you may be required to send us a new application. If the property is sold, the new owner must
be given a copy of this 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)
(6) and (7). This approval shall expire when the corresponding Nationwide Permit expires or as otherwise provided in the General
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 Dave Penrose at 919-733-9502.
Wmn e, h.D.
cc: Corps of Engine ers Asheville Field Office
Asheville DWQ Regional Office
File copy
Michael F.-Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Division of Water Quality
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)
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
January 9, 2002
DWQ #01-1894
Jackson County
CERTIFIED MAIL- RETURN RECEIPT REQUESTED
Ms. Dorothy Rietze
PO Box 276
Glenville, NC 28736
Dear Mr. Rietze:
On December 28, 2001, the Division of Water Quality (DWQ) was notified by receipt of your application regarding your
plans to fill waters for the purpose of stabilizing the shoreline of your lot on Lake Glenville in Jackson County. Approval from
DWQ is required to disturb these areas. Please provide seven copies of the following information and refer to the DWQ
number listed above in your reply. In particular as described in 15A NCAC 2B.0502, we will require you to locate all streams
and ponds on the property and provide a site plan, which shows the location and area of fill.
Please call me at [phone] if you have any questions or would require copies of our rules or procedural materials.
This project will remain on hold as incomplete in accordance with 15 A NCAC 2H .0505 (c). The processing time for this
application will begin when this information is received. If we do not hear fromyou within three (3) weeks of the receipt of this
letter, we will assume that you no longer want to pursue this project and will consider it withdrawn.
Sincerely yours,
rny
Cc Fayetteville DWQ Regional Office
Wilmington Corps of Engineers
Central Files
File Copy
Scotty Schmidt
Wetlands/401 Unit 1650 Mail Service Center Raleigh, NC 27699-1650 Ph: [phone] Fax: [phone]
NMENR
Customer Service
1 800 623-7748

Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No. Q 1 18 OA
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I. Processing
1. Check all of the approval(s) requested for this project:
Section 404 Permit
ection 10 Permit ?.
401 Water Quality Certification
F] Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: l-, p
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: EJ
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: E
II. Applicant Information
1. Owner/Applicant Information
Name: ?Do r!' K M. Q i Ct zz,e
Mailing Address: P.o • r?o X 17b
Csl.ar??111e.. N G 3 8' -r 3 (o
a? 3oa7 10 n e ?1'Jaws Ln
Lo?ti3ri//cam/ S4oAoe. u? 2 - 89/-8'919 7E
Telephone Number: 8'x8'-- *r 4.3 - a47 3 Fax Number:
E-mail Address: 0ri etae 60 m.5n. coal
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: , ep#y Ski m f d 7' - .0&=efjo-n ego ? /1 G GU a rk,_,
Company Affiliation: rite cl' f S S o c-.
Mailing Address: o
vi /UG S ?
star
Telephone Nuns er:? a q---3 -- / 31o Fax Number: FAX- ?4 3 - ®?®®
E-mail Address:
Page 3 of 12
III.
Project Information
Attach a Xicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than l I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Nine of project:
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: .TA e/6 o-A Nearest Town: (fu /la cy`iee-
Subdivision name (include phase/lot number): G/en /`0o %n to /df
Directions to site (include road numbers, landmarks, etc.):
Al A/or'tbi? Rd r-r. A0 J. 5- m;A_i 4 i o 6 y Rrg 3 on • 74,-/1 ri eeA f en ?a //s Co ?e oed . /elf oh La Ke 3rt? z,

,,_,i ?onns s ett?f -- _-to//ouJ LaKe 13/Gtze 76 CGtlel¢3olc -house t1- ZT
5. Site coordinates, if available (UTM or Lat/Long):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
io,2-A
4e.
7
6. Describe the existing land use or condition of the site at the time of this application:
/?oir?mwna..- ?Leairin? ??p -e-??03iar? ?Ar+?h?un?- u+2cferrnining o?
7. Property size (acres):
As'
8. Nearest body of water (stream/river/sound/ocean/lake): o n. LACke- Glen vi Jae- (Note - this must be one of North Carolin&:,§ seventeen designated major river basins. The
River I1asin imp is available at l?111r//l?'r?.r1u.;;latc.ur.tis/adniinlnril?;;i.)
9. River Basin:
Page 4 of 12
10. Describe the purpose of the proposed work: 4 6a Md- At ro C- /e " A ;,n /n a cua //
-/!6 ?-fa v r- ra5%a-m a -P it rtd d e c /f -L-
11. List the type of equipment to be used to construct the project: 5j
12. Describe the land use in the vicinity of this project: i ndi v d u a../ vrQ,aeifi? Owne-rs
,- IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, alone with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list tiny) describe the impact in Section Vlll below. If additional '-pac(- i:, Heeded For
listing or description, please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on snap)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identity temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fa
excavation, flooding, ditching/drainage. etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agcncy's (FEMA) Flood Insurance Rate Maps
(FIRM), or FItMA-approved local Floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616. or
online at http://www•.feina.go%.
*** List a wetland type that best describes wetland to be impacted (e-g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams *A-
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wail, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
ww•w.usgs.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., ww•w•.topozonc.cont,
www.mapqucst.com. etc.).
Cumulative impacts (linear distance in feet) to all streams on site:_____._
Page 6 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Area of Type of Waterbody
Open Water Impact Name of Waterbody (lake, pond, estuary, sound,
Site Number Type of Impact* Impact if applicable)
(acres) ( bay, ocean, etc.)
(indicate on map) B 1

temporary impacts. Impacts include, but are not limited to:
flooding, dt°ainagc, bulkheads, etc.
4. Pond Creation Al"A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): [] uplands ? stream D wetlands
Describe the method of construction (e.g., darn/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stonnwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
71 D 46 9
Page 7 of 12
Vlll. Mitigation WA
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic enviromnent are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource fiuietions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ-s Draft Technical Guide for Stream Work in North Carolina, available at
httn•//h-o enr state nc.us/ncwetlands/sti-m,icle.litml.
1. Provide a brief description of the proposed niitia_____ Lion an. The description should provide
as much information as possible, inc u ing, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://ti2o.eiu-.state.nc.u&!wrp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):_
Amount of Non-riparian wetland mitigation requested (acres
Amount of Coastal wetland mitigation requested (acres):
IX. Envir6nmental Documentation (DWQ Only) /V ^-
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No [ 1.
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only) /V
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within lrs .4 NCAC 213 .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (11an l man Rules and
Water Supply l3uifcr RcgL1irc111u1t:;), ur othel. (hlcasc identify
Yes ? No ? If you answered ;`yes", provide the following; information:
Page 9 of 12
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Lone I extends out St) teet perpenmcufar irom near Dank of cnannei. /-one L exrcaus an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 213.0242 or.0260.
XI. Stormwater (DWQ Only) */It
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stortnwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Selvage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes F] No
Is this an after-the-fact permit application?
Yes [] No FS
Page 10 of 12
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
constriction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species. accessibility problems, or other issues outside of the applicant's control).
90/0

Applicant/Agent's Signature Date

tion letter from the applicant is provided.)
i
h
(Agent's signature is valid only if an za
or
aut

US Army Corps O f Engineers Field Offices and County Coverage
levAle Reegugu latory Field Office Alexander Cherokee lredell Mitchell
US Army Corps of Engineers Avery Clay Jackson
Buncombe Cleveland Lincoln Poll:
Rowan
151 Patton Avenue Burke Gaston Macon Rutherford
Room 208
Asheville. NC 28801-5006 Cabarrus Graham Madison Stanley
i
S
271-1854
2
Telephone: Caldwell Haywood McDowell
Henderson Mecklenburg
Catawba wa
n
Transylvania
71-4
Fax:
Fax: .71-4853
(828)
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Anny Corps Of Engineers Alleghany Edgecombe Lee
h
N Stokes
Surry
6508 Falls of the Neuse Road Ashe
Caswell Franklin
Forsyth as
Northampton Vance
Suite 120
NC 27615
h
Ralei Chatham Granville Orange Wake
,
g
Telephone: [phone] Davidson Guilford
lif Person
Randolph Warren
Wilkes
Fax: [phone] Davie ax
Ha
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Martin
Post Office Box 1000 Camden
Carteret* Gates
Green Pamlico
Washington, NC 27889-1000 Chowan Hertford Pasquotank
Telephone: [phone] Craven Hyde Perquimans
Fax: [phone]
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Richmond
Post Office Box 1890 Brunswick
Carteret Hoke
Montgomery Robeson
Wilmington, NC 28402-1890 Columbus Moore Sampson
Telephone: [phone] Cumberland New Hanover Scotland
Fax: [phone]
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 11 of 12

Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No. a 4),
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
i. Processing
.y 1. Check all of the approval(s) requested for this project:
Section 404 Permit
ection 10 Permit
[3401 Water Quality Certification
F] Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: G P
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: El
II. Applicant Information
1. Owner/Applicant Information
Name: ?Do rdb) M.
Mailing Address: P-o - 13o
lsl
t Ac- a r -r
fc an 3o a 7 Gtr n 'e d Al a.w S 6A
60 ?ci3?i / SLo.Zo 6 Sae - 8 9/ -8'97 9 7F
Telephone Number: 8'Aff- 7 4.3 - a47 3 Fax Number:
E-mail Address: 0rl efze (6) M-IfL coat
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: -'Y6a- f y Sci m f 4j D-e?'? ay1 el o ? ?'1 G Gv a r' ?
Company Affiliation: PHI 4 f L S S o c,
Mailing Address: o S.--T
kC- _149 7
Qe2r
Telephone Number: 7 4-5 - / 310Fax Number: YA8 - 74 3 - /.3/-e>
E-mail Address:
Page 3 of 12

III.
Project Information
Attach a Xjeinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than I I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. NWne of proj
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number ("Tax PIN):
4. Location
County: a a/60-A Nearest Town:
Subdivision name (include phase/lot number): C /en Ao %n f';e- /e f` 8
Directions to site (include road numbers, landmarks, etc.):
Al Alorton 2d lo 'f ? J. 5- i";A-i -,4 %ohy .aP- ryzon . Turn riq`?;
T_ A.. iii ?...e r% o A ?a //_? ?. ?Q /i e l /Q on La ke
4111 oc11 Lake 13' /Ge z e fo C u lde3 e, c - /IOU I e ?t .ZT
5. Site coordinates, if available (UTM or Lat/Long):
(Note - if project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
0?o,2yb
21e.
7
6. Describe the existing land use or condition of the site at the time of this application:
f?oinmwne.r d.Q.airinQ ? ??? .eresic» iOr+?h?u».?- u?'taFt./"I?i?irto? o?
ba,n K
7. Property size (acres): 1-5
8. Nearest body of water (stream/river/sound/ocean/fake): o n LACke. 61envi Ae-
9.
River Basin:
(Note - this must be one of North Carolina'§ §eventeen designated major river basins. The
River Basin trial) is available at l?itlr//1??'it.e?11.:ita[c.nc.u:;/adnrii?/nri1?:./.)
Page 4 of 12
10. Describe the purpose of the proposed work: -/& Aau 1`1 a ro C- /e r-e -14 in An a ZW4
A :5-favor Aemb6;i2-m C5-f- ba..n le ez "U rtd d e c % a I-e
11. List the type of equipment to be used to construct the project:
?s es, i
12. Describe the land use in the vicinity of this project: indiY;d "-Lt./ vro?/t4 acdners
... IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the iinpict in Section V111 below. If additional ::liaw i:. needed For
listing or description, please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on snap)
Type of Impact* Area of
impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill.
excavation, flooding, ditching/drainage. etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year tloodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FVMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-353-9616, or
online at http://www.feina.ao?.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams //?
Stream Impact
Site Number
(indicate on map)
Type of Lnpact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and aRer, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USES topographic maps. ll' a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
ww.v.uses.sov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.tonozonc.com,
www.mapuucst.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on
Page 6 of 12
Estuaries, Sounds, Atlantic Ocean and any
3. Open Water Impacts, including Lakes, Ponds,
other Water of the U.S.
en Water Impact
Site Number Type of lir?pact*
ndicate on map)
/
Area or Name of Waterbody
Impact (if applicable)
List each impact separately and identify temporary impacts. Impacts
flooding, drainage, bulkheads. etc_
VII.

but are not
(lake, pond, estuary, sound,
bay, ocean, etc.) _
to: fill, excavation.
4. Pond Creation /V/14
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): EJ uplands ? stream 0 wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Page 7 of 12
V111. Mitigation VA
DWQ - In accordance with 15A NCAC 2I-I .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
-> including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource fiuictions and values by creating, restoring, enhancing, or preserving similar
functiins and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
htII2://Ii-)o.eiir.state.iie.us/ticwetlands/sti-i-n(-,ide.htmi.
1. Provide a brief description of the proposed mitia_ tion an. The description should provide
as much information as possible, h c u ing, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitig on proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.( ' j., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://li2o.enr.st ite.iic.us,/wrp/iiidex.litm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following infornation:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):_
Amount of Non-riparian wetland mitigation requested (acres
Amount of Coastal wetland mitigation requested (acres):
IX. Envir6nmental Documentation (DWQ Only) N^--
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land? ?/
Yes ? No L g'
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
Y. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only) of
It is the applicant's (or agent's) responsibility to detennine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within >xNCAC 213 .0233
(Neuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (MaN man Rules and
Water Suplfly Buffer Reyuiruucaits), ur utkl (I)lutst; idClttily
Yes ? No ? If you answered "yes", provide the following' information:
Page 9 of 12
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone t extends out 30 Peet perpendicular from near nanK of cnannel. /-one z extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 213.0242 or.0260.
XI. Stormwater (DWQ Only) /S//t
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss storinwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Se`vage Disposal (DWQ Only) /v
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No [g''
Is this an after-the-fact permit application?
Yes [] No U/
Page 10 of 12
I
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
go/a
ApplicantlAgent's ignature v
ti
i
h
n letter from Date
the applicant is provided.)
(Agent's signature is valid only if o
za
or
an aut

US Army Corp s Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
lk
P
US Army Corps of Engineers
n Avery
Buncombe
Clay
Cleveland
o
Jackson
Lincoln Rowan
151 Patton Avenue
? Burke Gaston Macon Rutherford
Room 208
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
i
S
Telephone: [phone] Caldwell
Catawba Haywood
Henderson n
wa
McDowell
Mecklenburg Transylvania
Fax: [phone]
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
Stokes
US Army Corps Of Engineers Alleghany Edgecombe
nklin
F Lee
Nash Surry
6508 Falls of the Neuse Road Ashe
Caswell ra
Forsyth Northampton Vance
Suite 120
NC 27615
h
Ralei Chatham Granville Orange Wake
g
,
Telephone: [phone] Davidson Guilford
f Person
h
Randol Warren
Wilkes
Fax: [phone] Davie ax
Hali p
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Martin
Post Office Box 1000 Camden
rteret*
C Gates
Green Pamlico
Washington, NC 27889-1000 a
Chowan Hertford Pasquotank
Telephone: [phone] Craven Hyde Perquimans
Fax: [phone]
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
hmond
Ri
Post Office Box 1890
NC 28402-1890
Wilmington Brunswick
Carteret Hoke
Montgomery c
Robeson
,
Telephone: [phone] Columbus Moore Sampson
Scotland
Fax: [phone] Cumberland New Hanover
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 1 l of 12
Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No. -?
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
I . Check all of the approval(s) requested for this project:
Section 404 Permit
Section 10 Permit
[401 Water Quality Certification
Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: /_- P )'7? »•'?':'.?
f
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: E
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here:
II. Applicant Information
1. Owner/Applicant Information
Naive: -_Do r j%h ?' . Q i e"M z e ? ??-?e??
Mailing Address: P.o • 13o X 2-7(0
fsla..r???I1{ . ?t ? a r? -r 3 ?
uh 3-a 7 ZO n A41,) /YJaw s 6A
Go,C i Z 1, //c , / SL o .7-4 6 u`-e 2 - 8 9/ -8' 97 9 7k
Telephone Number: S"-- 7 St.3 - aIV 7 3 Fax Number:
E-mail Address: J ri etze LO M.Sn. corm
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: Sc_,.2> h1ri Ski m t d -/- - e-" do/r2 e1 zcv o rk,
Company Affiliation: nt 1 c? t Assoc-,
Mailing Address: 160 o S?
rr/o?,?i /o _ RIC- -4 S 7 ? 4a
Pap'
Telephone Number:? 4_5 - / 3/a Fax Number: 57,98'- `74 3 -- /-3/0
E-mail Address:
Page 3 of 12
III. Project Information
Attach a ieinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than I I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
NWme of project:
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
county: _ 7A e.16 o-n Nearest Town: (fu /16 JAJJe-e_
Subdivision name (include phase/lot number): C /en 000o ;n te. /d f 0 8
Directions to site (include road numbers, landmarks, etc.):
Al A1or'to.7 R.4 (? /o'f'? 3.S ir?i/es ?6 %oby Rry.3on . 7a- -4 ri,
T_ A.. $2 ri .A ?` err ?a //s e ?Q X ? e4 /¢4f On lee 13/.eC z
24 4a Ln: t r?tlrf -- -ors//ouJ Lake T3f?tze * Cu/c1eSaC - `loutie .ft -Z-7
5. Site coordinates, if available (UTM or Lat/Long):
(Note - if project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this appl
l dineowne..- aad rin?t ? v'aO ¢re5io» jorvble.,n-j- tA.-to
7. Property size (acres)
/. 5
8. Nearest body of water (stream/river/sound/ocean/lake): o n tocke 61env; l/6-
9. River Basin:
(Note - this must be one of North Carolinq'$ seventeen designated major river basins. The
I?Illr//1?'u.e?u.:;latc.nc.u:;/atlnrin/n?,?ir.:/.)
River Basin mil) is available at
fOn-o
2 -D2.
7
Page 4 of 12
10. Describe the purpose of the proposed work: -7& 6a Mld a ro e- /e- "7?6 ;A le) a 4y4
ra5ia-y a ba.? /e a -oc crtd d o e- /< a Pt! -L,
11. List the type of equipment to be used to construct the project: s? e
12. Describe the land use in the vicinity of this project: indi ?id Xa..l ?ro,aeilz, owners
.,. IV. Prior Project History
If jurisdictional detenninations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules. .
V. Future Project Plans
Are any additional pen-nit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list ant) describe the impact in Section V111 below. If additional i-: 11ce ed For
listing or description, please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on trap).
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill.
excavation, flooding, ditching/drainage. etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Ratc Maps
(FIRM), or FWA-approved local Floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http:/hvww.fcana.ov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams 1X// -
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap. crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. 11'a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
wavw.usgs.Qov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozonc.cona,
www.mapLiticst.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on
Page 6 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S . ?ITI

Fen Water Impact Area of
Name of Waterbody Type of Waterbody
(lake, pond, estuary, sound,
Site Number Type of linpact* Impact
(acres) if applicable)
(
bay, ocean, etc.)
indicate on map) ?

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dreugmg.
flooding, drainage, bulkheads, etc.
4. Pond Creation 11A If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands [] stream [i wetlands
Describe the method of construction (e.g., dam/embankinent, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts. Page 7 of 12

Vlll. Mitigation VA
DWQ - In accordance with 15A NCAC 2I-I .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environnient are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http•//li2o enr state ilc.us/iicwetisiiids/striTi,.ide.htmi.
1. Provide a brief description of the proposed mitia____ lion plan. The description should provide
as inuch information as possible, ii- u ing, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at httu•//h20.err.state.nc.us`wrp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):-
Amount of Non-riparian wetland mitigation requested (acres
Amount of Coastal wetland mitigation requested (acres):
IX. Envirdnmental Documentation (DWQ Only) WA_
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No [ t?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only) Of
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and trust be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15?? NCAC 213 .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Igan? man Rules and
Water Su1.)l)ly Buffer RCiluiruttuil:;), 01'01110' (1AWSC identify
Yes ? No ? If you.answered "'yes", provide the following 4nformation:
Page 9 of 12
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone I extends out 30 feet perpend]War from near banK of cnannec, Gone L extenus an
additional 20 feet from the edge of "Lone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B.0242 or.0260.
XI. Stormwatcr (DWQ Only) f?-
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Sewage Disposal (DWQ Only) /V ?PF
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes F] No
Is this an after-the-fact permit application?
Yes [] No [L'
Page 10 of 12

XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
IXO/°
Pitt
Tyrrell
Washington
Wayne
Applicant/Agent's ignat le v Date'
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
\? k ?
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
US Army Corps of Engineers Avery Clay Jackson Poll:
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville.. NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: (828)'-771-4858 Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombe Lee
h
N Stokes
Surry
6508 Falls of the Neuse Road Ashe
Caswell Franklin
Forsyth as
Northampton Vance
Suite 120
NC 27615
h
Ralei Chatham Granville Orange Wake
g
,
Telephone: [phone] Davidson Guilford
f Person
h
Randol Warren
Wilkes
Fax: [phone] Davie ax
Hali p
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Martin
Post Office Box 1000 Camden
Carteret* Gates
Green Pamlico
Washington, NC 27889-1000 Chowan Hertford Pasquotank
Telephone: [phone] Craven Hyde Perquimans
Fax: [phone]
Wilmington Regulatory Field Office Anson Duplin Onslow
US Arny Corps Of Engineers Bladen Harnett Pender
Richmond
Post Office Box 1890 Brunswick
Carteret Hoke
Montgomery Robeson
Wilmington, NC 28402-1890 Columbus Moore Sampson
Telephone: [phone] Cumberland New Hanover Scotland
Fax: [phone]
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 11 of 1.2

Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No. Q 1 i Q V 9 4
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I. Processing
.4 I . Check all of the approval(s) requested for this project:
Section 404 Permit
,Section 10 Permit L
401 Water Quality Certification
Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: /GP 3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: n
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here:
II. Applicant Information
1. Owner/Applicant Information
Naive: -_Do ro-Fk 4 M. Q i ctz e C ?e? dare-?
Mailing Address: F-6-13-ox ;,_74c
fsl a re?ill? , N c .2
s (o
ati 3az7 ZV n .e d Il'1aws Ln
Lo?ci?ri//c? Lej?
SLo?o6 u?2- ?9/-8'979 ?f?'
Telephone Number: 8'"- 1 q 3 - A47 3 Fax Number:
E-mail Address: W ri et=e CeD Haan. corn
2. Agent Infonnation (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: Sc?ff0 Soh m t - o-e??crr d 4l /1 CI
Company Affiliation: .??./? ryt) c? L Assoc, Mailing Address:D
Pao'
®
Telephone Number: ? 7 43 /310 Fax Number: KAX - ?I¢ 3 - ®31
E-mail Address:
Page 3 of 12
III.
Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than l I by 17-inch format;
however. DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
Nine of project:
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number ("fax PIN):
4. Location
County: -)-a e./6O-n Nearest Town:
Subdivision name (include phase/lot number): G/en 10o %n to /of 0 8
Directions to site (include road numbers, landmarks, etc.):
Al Al., r7-,,,7 Rd (fir. /o-7 m /eg 4 1ob?ySoh. Turn r;gh;
T_ h.. 1;1 i...c , oA f .,n ,Ca //s lc ?e_ 10.4 Jo P- dn Lalee ?/CC z.
2W ?oitnit ?aiir? 4611ou1 G.aA6e 13,-,e&7_e Y6 -e- -Z-7
Site coordinates, if available (UTM or Lat/Long):
(Note - if project is linear, such as a road or utility line, attach a sheet that separately
coordinates for each crossing of a distinct waterbody.)
lists the
PXoa-A
2),e.
7
6. Describe the existing land use or condition of the site at the time of this application:
homwWne.r d?airin4? ? p ¢?'esian ior+?h?ems- us?eFerntinirtq o?
b 4,A K
7. Property size (acres): 1-5
3. Nearest body of water (stream/river/sound/ocean/lake): o n. U'ke Glen vi f
9. River Basin:
(Note - this must be one of North Carolinq's §eventeen designated major river basins. The
1?it??://li''i?.cn?.:;ta[c.nc.us/,icln?in/n?;i1?:>/.)
Rivcr Bashi iuap is available at
Page 4 of 12
10. Describe the purpose of the proposed work: 4 AaMd- A ro C- /e v-e 7?t in In a ura
?-fa o oM5;e a 4--n lie arourtd e- /< 'M P-e -t-,
11. List the type of equipment to be used to construct the project:
12. Describe the land use in the vicinity of this project: indiY,;d ".a 1 vrov?fz. ewners
- IV. Prior Project History
If jurisdictional detenninations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at. the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section Vill hclow. If additional '-Jmcr i'.: llcedcd For
listing or description. please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on map)
Type of Impact* Area of
impact
(acres) Located within
100-year Floodplain**
(yeshto) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill.
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FWA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://wv,w.feina.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams /!//4'
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and alter, and net loss/gain),
stabilization activities (cement wail, rip-rap, crib wall, gabions, etc.), excavation, ditching/s(raightening, etc. If stream relocation is
proposed, plans and profiles showing (lie linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USES topographic maps. 11'a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
wwtiv.us>;s.Qov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozonc.coni,
www.maPquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:________ _.,
Page 6 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.

Open Water Impact Area of
Name of Waterbody Type of Waterbody
(lake, pond, estuary, sound,
Site Number Type of Impact* Impact if applicable)
(
bay, ocean, etc.)
(indicate on trap)
(acres)
i ?
5- l /
?d
, +. but are not li mited to: fill, excavation, dredging.
* List each impact separately anu ju-1-u ,. ?..r .° ° *-------
flooding, drainage, bulkheads, etc.
4. Pond Creation IVIA
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): 0 uplands [] stream 0 wetlands
Describe the method of construction (e.g., dam/embankinent, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stotmwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce itnpacte o
Page 7 of 12
VIII. Mitigation WA
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http•//h2o enr state nc us/iicwetlaiids/strmt-,ide.html.
Provide a brief description of the proposed mitia_tion an. The description should provide
as much information as possible, inc u ing, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at htip:/,1,26.enr.state.nc.uc!wrp/index.httn. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Envir6nmental Documentation (DWQ Only) 11A_
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes [] No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes F ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes F-1 No
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only) /V
it is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 1.*,NCAC 213 .0233
iman Rules and
(Neuse), 15A NCAC 213 .0259 (Tar-Paimlico), 15A NCAC 213 .0250 (Man,?,
Water Supply 13ulTi ?' Pc yuircutc tts), w other (hlc:asc: identify
Yes F No n If you answered "yes", provide the following; information:
Page 9 of 12
Identify the square feet and acreage of impact to each zone of the riparian buffers. 11' buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
zone t extenus out su ieet perpenmcufar from near Dank of eftannec. /-011C L emenuS an
additional 20 feet front the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 213.0242 or.0260.
XI. Storinwater (DWQ Only) &/I
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Sewage Disposal (DWQ Only) A
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes F] No
Is this an after-the-fact permit application?
Yes [] No [?;/
Pagc 10 of 12

XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
0
Applicant/Agent's ignature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
U
Asheville Regulatory Field Office Alexander Cherokee lredell Mitchell
US Army Corps of Engineers Avery Clay Jackson Poll:
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Anny Corps Of Engineers Alleghany Edgecombe Lee
h
N Stokes
Surry
6508 Falls of the Neuse Road Ashe
Caswell Franklin
Forsyth as
Northampton Vance
Suite 120
NC 27615
h
Ralei Chatham Granville Orange Wake
,
g
Telephone: [phone] Davidson Guilford
if Person
h
Randol Warren
Wilkes
Fax: [phone] Davie ax
Hal p
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Martin
Post Office Box 1000 Camden
Carteret* Gates
Green Pamlico
Washington, NC 27889-1000 Chowan Hertford Pasquotank
Telephone: [phone] Craven Hyde Perquimans
Fax: [phone]
Wilmington Regulatory Field Office Anson Dupiin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Richmond
Post Office Box 1890
Box
28402-1890
Wilmington Brunswick
Carteret Hoke
Montgomery Robeson
,
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page I 1 of 12

Office Use Only: f=orm Version April 2001
Jb64
USAGE Action ID No. llWQ No.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
1. Check all of the approval(s) requested for this project: 1- 7
Section 404 Permit
eetion 10 Permit
[ ? 401 Water Quality Certification
F] Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Perinit Number(s) Requested: /6,P 3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here:
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here:
II. Applicant Information
1. Owner/Applicant Information
Name: ?Dc ro-Vk, j M. ! i ct'-z e
Mailing Address: P.o . 13o X X74,
6r1-a.n?111.r- , N G Z 8' -13
to
an 3-0.2 7 10 n A4 1d /Y)¢w 5
64 u.i.1 ?i//cI Ley V 0
.zo6 Sae- 89/-8'979 7E'
Telephone Number: ral8'- 7 4.3 - ay-7 3 Fax Number:
E-mail Address: W r1 etie LeD Mai?. coat
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: SGvf0lci Soh m f 7 0-e ja-n ego/? w a r>?,
Company Affiliation: l.4 f t A S S o c,,
Mailing Address: ?O oX S9
ear
Telephone Nuniber:-a 43 / 310 Fax Number: FAX- ?4 3 - /3/®
E-mail Address:
Page 3 of 12
III. Project Information
Attach a Vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other reaps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
. USACE requires information to be submitted on sheets no larger than I I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
NWne of project:
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4.
AO476
z 2)'e.
7
5. Site coordinates, if available (UTM or Lat/Long):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
?oinmwner' d.¢airingT V70p A-egbs;an _'+!b'uril-- Gertcfei^I?tint+Z? o?
7. Property size (acres): A 5
8. Nearest body of water (stream/river/sound/ocean/lake): o n. L^lke. 611_n vi )/2
9. River Basin:
(Note - this must be one of North Carolinq'.§ Seventeen designated major river basins. The
River Basin map is available at ti11.1)://h2().c?u'
Page 4 of 12
Location
County: . Ta c ?t!s Nearest Town:
Subdivision name (include phase/lot number): G/en Igo %n Y-e /df 4. 8
Directions to site (include road numbers, landmarks, etc.): -
10. Describe the purpose of the proposed work: 4 ,ha Met A ro C- /e Y-e 744 i,, ,'r, a 4V4
-A :5 -& o je ro5ia-n a b 4.r> le of "ctrLd d o c /< a ve -c-
11. List the type of equipment to be used to construct the project: -52k -4 a- 7 i.o -
12. Describe the land use in the vicinity of this project: indiyidua / ?ro,aeil?Z, owne-r-s
.? IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at, the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact ill Section Vlll Mow. If addilional :-pace' i:: nceded for
listing or description, please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodpiain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditchingldrainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FVMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http:/fhvww.1eina.,ov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams Allar
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. if stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USES topographic maps. 11'a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.uscs.aov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozonc.cottt,
wtivw.mnpqucst.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:-_-__ __
Page 6 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact Are;
Site Number Type of Impact* Imp
(indicate on map) (act

lP 6
__A :.1....,:(:, 1nm„nr nni111
L15t cucu uuya..a o..t+..•. ...._ ----
flooding, drainagc, bulkheads, etc.

? or Name of Waterbody
act (if applicable)
es)

Facts. I?npacts include, but are not
Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
to:
4. Pond Creation 11A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): [] uplands 0 stream [] wetlands
Describe the method of construction (e.g., darn/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stonnwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Page 7 of 12
Vlll. Mitigation h (A
1
DWQ - In accordance with 15A NCAC 2I-I .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic envirorunent are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functi6ns and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for strewn restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina. available at
http•//h-o enr state nc us/ncwetlands/strm,,:ide.litmi.
Provide a brief description of the proposed mitia____ Lion an. The description should provide
as much information as possible, inc u rng, but not limited to: site location (attach directions
and/or map, if offsite), affected stream mid river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at lit ip-//h2o.eiir.state.tic.us/wrp/ilidex.him. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Envirdnmental Documentation (DWQ Only) A/^_
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only) /Y
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within t,SA,?„NCAC 213 .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Matn? man Rules and
Water Sul)ltly 13ulfer RcgLJrC111CJ1ts), 01' ut11Cr (l)10-)-C identify -` )"
Yes ? No ? If you answered "'yes", provide the following information:
Page 9 of 12

Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
Lone t extends out Stl teet perpenoicutar from near oanK of Gtamluf; / Onu L u\tunu5 all
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
XI. Stormwater (DWQ Only) / A_
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Selvage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes F] No [g--
Is this an after-the-fact permit application?
Yes ? No LK
Pac 10 of 12
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
constriction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
IXO/a
ApplicantlAgent's ignature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
lteE A Iredell Mitchell
lle Regulatory Field Office Alexander Cherokee
US Army Corps of Engineers Avery Clay Jackson Polk
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] CCald atawba Henderson Mecklenburg Transylvania
Fax: (828) _71-4858
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare
t
G Lenoir
Martin
Post Office Box 1000
NC 27889-1000
ton
Washin Camden
Carteret* es
a
Green Pamlico
,
g
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen
Brunswick Harnett
Hoke Pender
Richmond
Post Office Box 1890
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
otland
S
Fax: [phone] Cumberland New Hanover c
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page I 1 of 12
Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No.,
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I. Processing
1. Check all of the approval(s) requested for this project: E
Section 404 Permit _
Fl$ection 10 Permit
[? 401 Water Quality Certification
Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: /-',P s
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: F]
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: ?D o roEH M - Q i f-I z e
Mailing Address:_ P.o . 13O X X710
GH-e-ryill-e- , N C_ a 8- -r 3
Q„ 3 o a lt1 n 'e d Al ¢cu s Ln
e.ou. / ,y o z o 6 sa - 8 9/ -8' 919 7E
Telephone Number: 8a8'- 140 - aV 7 3 Fax Number:
E-mail Address: JD r; et=- a? M Yn. corn
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.) ,
Name: _5'c Wzi Ski m f 4/ !D-e•Y? ?» e? o / ?'1 G /.u a r k,
Company Affiliation: nt t c4 -f t s S o c.
Mailing Address: o .5-9
Telephone Number: ? 7 43 -- / 310 Fax Number: KAX - ?4 3 - /A/e>
E-mail Address:
Page 3 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than I I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Nitme of project:
9
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: Sa c/?S o-n Nearest Town:
Subdivision name (include phase/lot number): Glen t'e- /d f` 8
Direct?iolns to site (include road numbers, landmarks, etc.):
Al tJorfon I& (Tr. /o J. S Mile1 76 %o by bury -Ion. Turn r;ghfogyb
7. bT ru s c-r, ? aA t en 1Ca //s C-0/4__ R-4 let 417 &-tKe ??cc z.e D'e.
ad -ennis courf -- -?I//emJ La/Ge T3/tcze fo Cal-!"-c_ - house --At 277
5. Site coordinates, if available (UTM or Lat/Long):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
/,eir?mwne,- deairJn?{ ?a yap e-?'esie» Wns-- t,en1 rrnrnina o?
ba.n
7. Property size (acres): A 5
3. Nearest body of water (stream/river/sound/ocean/lake): 5n L Cke- 61envdle.
River Rnsin-
(Note - this must be one of North Carolin4:s Seventeen designated major river basins. The
River Basin vial) is available at l?i1h//li'i?.eni.sla[c.nc.us/,?dniin/n?a1?s/.)
Page 4 of 12
10. Describe the purpose of the proposed work: -? fuild a r'o C- /e Y-e 744 in In a aua
v ?erasia-n, a ba.? /C a ro u.ld d., e- /< a kz!
11. List the type of equipment to be used to construct the project: 5-M1_JA?.-d g-,g
12. Describe the land use in the vicinity of this project: indi yid cca._/ ?ro.,aeY owners
.t IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section Vill Mow. If addilion;?1 ::pacc is needc d For
listing or description, please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on snap)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing. grading, fill,
excavation, flooding, ditching/drainage. ctc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616. or
online at http:/h,.w,,%Jema.gov_
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond.
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams X/A'
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Natne** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and aticr, and net loss/gain),
stabilization activities (cement wall, rip-rap. crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. 11'a stream has no name, list as Uf (untamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usas.Qov. Several internet sites also allow direct download and printing of USGS maps (e.g., w•ww.topozone.cont,
www.mapquest.com. etc.).
Cumulative impacts (linear distance in feet) to all streams on site:___.__ _
............... .
Page 6 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.? Y_L-
J

Open Water Impact
Site Number
(indicate on in p)

Type of Impact* Area of

Impact
(acres)
Name of Waterbody
(if applicable) 'type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)

?d
?.... « :-h.rle hilt are not li mited to: fill, excavation, dredging,
* List each impact separately anu lu;,11 Y ??•••? ?•? *-------
flooding, drainage, bulkheads, etc.
4. Pond Creation IVIA
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): [] uplands [] stream EJ wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts
Page 7 of 12
Vlll. Mitigation WA
DWQ - In accordance with 15A NCAC 2I-I .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March ), 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic enviromnent are minimal. Factors
-? including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functi6ns and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
htt12•/Ih2o enr state nc us/ncwetlands/strin,,icle.htmi.
1. Provide a brief description of the proposed niitia_ tion an. The description should provide
as much information as possible, inc u ing, but not limited to: site location (attach directions
and/or map, if of(site), affected stream and river basin, type and amount (acreage/linear feet)
of mitiga on proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.(-,., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at httu://h2o.enr.state.rnc.us..Iwrp/index.htrrn. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Envirdnmental Documentation (DWQ Only) W^-
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes n No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes F-1 No F-I
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes F] No
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only) //4
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 1,?&,NCAC 213 .0233
(Neese), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Nan man Rules and
Watcr Supply 13ulfef lteduireniettts), or other (please identify
Yes No If you answered "yes", provide the following; information:
Page 9 of 12
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
Lone I extends out .So ieet perpendicular trom near oanK of cnannet; cone L cxeCnus an
additional 20 feet from [lie edge of 'Lone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Storinwater (DWQ Only) "
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Susvage Disposal (DWQ Only) Af ?1-
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes F] No
Is this an after-the-fact permit application?
Yes [:] No Q-`
Page 10 of 12
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
90/d
Applicant/Agenfs ignature Date
tion letter from the applicant is provided.)
i
h
(Agent's signature is valid only if za
or
an aut

US Army Corp s Of Engineers Field Offices and County Coverage
1
? A Q
Asheville Regulatory Field Office
Alexander
Cherokee
Iredell Mitchell
Polk
US Army Corps of Engineers Avery
Buncombe Clay
Cleveland Jackson
Lincoln Rowan
151 Patton Avenue
1 ?
Burke
Gaston
Macon Rutherford
Room 208
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell
Catawba Heder son Mecklenburg Transylvania
Fax: (
Fax: [phone]
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
Stokes
US Anny Corps Of Engineers Alleghany Edgecombe
anklin
F Lee
Nash Sur y
6508 Falls of the Neuse Road Ashe
Caswell r
Forsyth Northampton Vance
Suite 120
Raleigh, NC 27615 Chatham Granville Orange Wake
Warren
Telephone: [phone] Davidson Guilford
lifax
H Person
Randolph Wilkes
Fax: [phone] Davie a
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare
t
G Lenoir
Martin
Post Office Box 1000 Camden
Carteret* es
a
Green Pamlico
Washington, NC 27889-1000 Chowan Hertford Pasquotank
Telephone: [phone] Craven Hyde Perquimans
Fax: [phone]
Wilmington Regulatory Field Office Anson l

US Anny Corps Of Engineers g
lad n
Brunswick ett
Ham
Hoke Pender

Richmond
Post Office Box 1890
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
tland
S
Fax: [phone] Cumberland New Hanover co
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 11 of 12
.. . - F
Office Use Only: Form Version April 2001
USAGE Action ID No. DWQ NO.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
1. Check all of the approval(s) requested for this project: m
Section 404 Permit
FISection 10 Permit
401 Water Quality Certification
Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: / P
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: E
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: El
II. Applicant Information
1. Owner/Applicant Information
Name: ?D o r&11 M
Mailing Address: P-o . 13
(fSlQ.n?1I1-r_ , Mc, .28--13G
* a • -3 0 a. 7 !.v n 'e e) Ina tv 5 L/t
6OLt o y,; #c , / y j40 a0 6 u? ? - 8 9/ -8' 97 9 71c
Telephone Number: 8a8'- 7 q.3 - A47 3 Fax Number:
E-mail Address: 1) rJ etxe a) man. coat
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: .Saet, #o Soh m f e/ 74' f? 'Cl Zv a 1-
Company Affiliation: ;UAP"114-f L Assoc-.
Mailing Address: o
9Ar
Telephone Numbeer:- 7 43 - / 3? a Fax Number: FAX- -74 3 - 43/®
E-mail Address:
Page 3 of 12
III. Project Information
Attach a Xicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than I I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. NWne of project:
9
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: a e/6 o-n Nearest Town: (fu /1o uJ`ie-e_
Subdivision name (include phase/lot number): Cam-/en Ao;n to /of ` 8
Directions to site (include road numbers, landmarks, etc.):
-Al .4jor7-on Rd /o "l) J. S n+;/eg 76 %o 6 y ary won T rit rrgh?on?b
-sTa "r%aA t on 794//-1 C--;, #e- /2d . /eAt dh Lake 1.3r'tezQ -De.
a.V -Aennis couif - -;G//ou! LaKe T,3/t&ze * C"IcAgOac - house -it Z77
5. Site coordinates, if available (UTM or Lat/Long):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
AaInmwne - U 6 %r3n? lio V-l'ap Cet* an ArWb/4r-*n-0 tw?derl??;ninA o?
ban Ae
7. Property size (acres): /• 5
8. Nearest body of water (stream/river/sound/ocean/lake): o n LA-ke- 6len yi !/e.
River Basin:
(Note - this must be one of North Carolinq'§ §eventeen designated major river basins. The
River Basin final) is available at iilili://lido.e.nral.atc.lir.us/adnEin/nu?i?s/.)
Page 4 of 12
10. Describe the purpose of the proposed work: -? ,6a old. a ro c- /e e-e 7?t Jn i n a ZV4
?raSia'n_ cs -ie ba-+? /C ?t rou.ld d o c /< a
11. List the type of equipment to be used to construct the project: 512-,a-ic-zyy- ?
12. Describe the land use in the vicinity of this project: indi ?id u.a../ pro?e/ owners
- IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional pen-nit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at, the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section V111 below. lFaddilional space in iieedcd For
listing or description, please attach a separate sheet.
Page 5 of 12
1. Wetland Impacts VA
Wetland Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identity temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding ditching/dminage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FkMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://ww ?ti . fc ma.ov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwatcr/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please specify)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and atlcr, and net loss/gain),
stabilization activities (cement wall, rip-rap. crib wall, gabions, etc.), excavation, ditching/straightcning, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., w ww.lopozone.cont,
w%vw.mnpgucst.com. etc.).
Cumulative impacts (linear distance in feet) to all streams on
Page 6 of 12
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S. -CIL
Open Water Impact Area of Name of Waterbody
Site Number Type of Impact* Impact (if applicable)
(indicate on map) (acres) AJ_
I

(lake, pond, estuary, sound,
bay, ocean, etc.)
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation- arcuoing.
flooding, drainage, bulkheads. etc.
4. Pond Creation IVIA
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands 0 stream wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond.
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Page 7 of 12
Vlll. Mitigation WA
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
•- including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource fwictions and values by creating, restoring, enhancing, or preserving similar
functitris and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ`s Draft Technical Guide for Stream Work in North Carolina, available at
httL)://h-o ent state.nc.us/tiewetlands/strm,-icle.htmi.
1. Provide a brief description of the proposed mitia_ Lion an. The description should provide
as much information as possible, inc u ing, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of rritig on proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at huu://1)2o.enr.state.nc.us./wrp/index.htni. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Envir6nmental Documentation (DWQ Only) N
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes n No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes f-I No ?
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes [_? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 1.5*,NCAC 213 .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .0250 (Nano man Rules and
Water' Sul)ply l3uffer Requirelt?etit:;), ur utlter (l?Ica;e ide:titily
Yes F No F] If you answered "yes", provide the following; information:
Page 9 of 12
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
Lone i extenas out su feet perpenatcutar from near nanK Ol cnannel; wnu G uxtlulu5 2111
additional 20 feet froth the edge of "Lone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwatcr (DWQ Only) /y/1_
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
XII. Selvage Disposal (DWQ Only) A
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (I 5A NCAC 2H .0500) or any Buffer Rules?
g--
Yes F] No
Is this an after-the-fact permit application?
Yes [] No L;K
Pa,,c 10 of 12

XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
a
ApplicantlAgent's ignature Date
tion letter from the applicant is provided.)
i
h
(Agent's signature is valid only if an za
or
aut

US Army Corps Of Engineers Field Offices and County Coverage
i U?. ? ? Q
ville Regulatory Field Office
Alexander
Cherokee
Iredell Mitchell
P
lk
US Army Corps of Engineers Avery
Buncombe Clay
Cleveland o
Jackson
Lincoln Rowan
151 Patton Avenue Burke Gaston Macon Rutherford
Room 208
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
271-4854
F
' Catawba H Haywood enderson Mecklenburg Transylvania
ax: (828)
-)71-4858
Fax:
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
Stokes
US Army Corps Of Engineers Alleghany Edgecombe
nklin
F Lee
Nash SurTY
6508 Falls of the Neuse Road Ashe
Caswell ra
Forsyth Northampton Vance
Suite 120
NC 27615
h
Ralei Chatham Granville Orange Wake
,
g
Telephone: [phone] Davidson Guilford
lif Person
h
Randol Warren
Wilkes
Fax: [phone] Davie ax
Ha p
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare
tes
G Lenoir
Martin
Post Office Box 1000 Camden
Carteret* a
Green Pamlico
Washington, NC 27889-1000 Chowan Hertford Pasquotank
Telephone: [phone] Craven Hyde Perquimans
Fax: [phone]
Wilmington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1890
Wilmington, NC 28402-1890
Telephone: [phone]
Fax: [phone]
Anson Duplin Onslow
Bladen Harnett Pender
Brunswick Hoke Richmond
Carteret Montgomery Robeson
Columbus Moore Sampson
Cumberland New Hanover Scotland
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page I 1 of 12