20020095 Ver 1_COMPLETE FILE_20020122

4 ?
Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Division of Water Quality
May 16, 2002
DWQ# 02-0095
Rockingham County
Andrew P. Strader
5322 Eckerson Road
Greensboro, NC, 27405
SUBJECT: Pre-construction Notification (DWQ Project No. 02-0095)
Sardis Church Subdivision
Rockingham County
APPROVAL of 401 Water Quality Certification
Dear Mr. Strader
You have our approval, in accordance with the attached conditions, to place fill in 50 linear feet of a perennial unnamed tributary to
the Dan River in order to construct a single road crossing accessing Lots 11 and 12 of the Sardis Church Subdivision in Rockingham
County, as described in your revised application received by the Division of Water Quality on January 22, 2002, and in additional
correspondence received May 16, 2002. The stream crossing is to be constructed in accordance with your revised site plan dated May
6, 2002. After reviewing your application, we have decided that this fill is covered by General Water Quality Certification Numbers 3375,
which can be viewed on our web site at http://h2o.enr.state.ne.us/ncwetiands. This Certification allows you to use Nationwide Permit
Number 14 when it is issued by the U.S. Army Corps of Engineers. In addition, you should get any other federal, state or local permits
before you go ahead with your project including (but not limited to) Sediment and Erosion Control, Coastal Stormwater, Non-Discharge
and Water Supply Watershed regulations. Also this approval will expire when the accompanying 404 permit expires unless otherwise
specified in the General Certification.
This approval is only valid for the purpose and design that you described in your application. If you change your project, you must
notify us in writing and you may be required to send us a new application for a new certification. If the property is sold, the new owner
must be given a copy of the Certification and approval letter and is thereby responsible for complying with all conditions. If total wetland
fills for this project (now or in the future) exceed one acre, compensatory mitigation may be required as described in 15A NCAC 2H .0506
(h). For this approval to be valid, you must follow the conditions listed in the attached certification.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You must act within 60 days
of the date that you receive this letter. To ask for a hearing, send a written petition which conforms to Chapter 1508 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 Cyndi Karoly in our Central Office at 919-733-9721.
Attachments
cc: John Thomas, Corps of Engineers Raleigh Regulatory Field Office
Winston-Salem DWQ Regional Office
Central Files
File Copy
Danny Smith
020095
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)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.ne.us/ncwetiands/

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ROCKIPIGHAM COUNTY DEPARTMENT OF
PLANNING AND BUILDING INSPECTIONS
yam. _..
December 19, 2001
Mr. Andrew P. Strader
5322 Eckerson Road
Greensboro, NC 27405
Dear Mr. Strader:
7, T r
t tf
The Rockingham County Technical Review Committee has granted preliminary plan
approval to Sardis Church Subdivision. Conditions are as follows:
1. Show 50ft buffer along stream on northern line of lot 11 and thru lots 11 and 12.
2. Decide on a new name for road.
3. Need Entrance permit from DOT. (Remove easement, record release documents
as required).
4. Show zoning districts of adjoining property.
5. Lots 9 and 16 access from private road.
6. Add 1Oft Utility Easement to private road.
7. Need to notify per procedures required Army Corp for stream crossing, (need
copy for our file).
Please call our office if you have further questions.
Respectfully, //. ,,
W?
Matthew Warren
Rockingham County Planning Department
Rockingham County Governmental Center `
371 NC 65, Suite 100 - PO Box 105 - Wentworth, NC 27375-0105
Building Inspections [phone] Planning and Zoning [phone]
STATEMENT
PRICE CONSTRUCTION CO., INC.
Grading • Septic Tanks Installed • Stone • Basements a Specializing in Trailer Parks
4tMop Phone [phone] or 349-7661
Reidsville, N. C. 27320 / / 3 U o r
M

Quantity WSCRiPT10N Amount

A

Accounts not paid within 30 days will be charged I V2% Finance Charge each month,
which is 18% Annual Percentage Rate. %X j;,. _i
t
f
o
MARTIN & WFTI?7
Clearing & Grading Inc.
2000 Mollie Mooney Road Roxboro, NC 27573
Office: 336-599-4502' Fax: 336-599»4502
October 16, 2001
Attn: Phil Strader
A. P Strader
5322 Eckerson Rd
Greensboro, NC 27405
Reference: Sardis Church Subdivision
Sardis Church Rd Madison, NC
Dear.Mr. Strader
MARTIN & LOFTIS CLEARING & GRADING Inc. proposes to furnish material, equipment
and labor for Burn Stumps, Erosion Control, Grading Road and iaydown 6" stone ABC on the
above referenced project for the total lump sum price of
$ 30,000.00
Our quote includes a detailed breakout of these items as per the following:
Clearing and bearing stumps in slope
Temporary construction entrance
Temporary sediment trap
Stone Ater & Stone check darn
Temporary ditch and seeding
Grading to balance site
Dress out Road
Fine grade sub-grade
lane grade stone ABC
Laydown and compact 6" ABC
Unit Prices:
Rock Mass Excavation (ripper) $ 35.001cy
Rock Mass .Excavation (blasting) $ 90.00/cy
Trench Rock Excavation (blasting) S 120.00/cy
Excavate unsuitable soil and haul off-site S 10.00/Cy
Replacement with compact fill from off-site S 16.001cy
Pd wdso:60 TOW 9T '??0 z0Si?66S9L2 : 'ON 9NONd S1iJO1 H1idUw : WOdJ
\0?U. `ryQG
o ?
Michael F. Easley
Governor
William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D., Acting Director
Division of Water Quality
April 16, 2002
CERTIFIED MAIL:
Return Receipt Requested
Andrew P. Strader
5322 Eckerson Road
Greensboro, NC, 27405
SUBJECT: Pre-construction Notification (DWQ Project No. 02-0095)
REQUEST FOR ADDITIONAL INFORMATION
Site Visit Results
Sardis Church Subdivision
Rockingham County
Dear Mr. Strader
The Division of Water Quality has reviewed your Pre-construction Notification Application for the discharge of fill
material into approximately 90 linear feet of an unnamed perennial tributary to the Dan River, Roanoke River Basin, Class
WS IV, Rockingham County. Insufficient evidence is present in our files to conclude that your project must be built as
planned in waters and/or wetlands in accordance with 15A NCAC 2H .0506. Therefore, unless modifications of the proposal;
are made as described below, we will have to move toward denial of your 401 Certification as required by 15A NCAC 2H
.0507(e) and will place this project on hold as incomplete until we receive this additional information. We are requesting (by
copy of this letter) that the U. S. Army Corps of Engineers place your project on administrative hold.
Further, during a site visit conducted by Mrs. Cyndi Karoly of the Central Office of the Division of Water Quality, it was
noted that approximately 45 feet of stream had already been filled and a culvert placed in the remaining stream segment.
Also, a subsequent DWQ file review confirmed that no 401 Water Quality Certification or authorizations had been issued for
the subject tract. Accordingly, the site visit and file review confirmed the following violations: 1) failure to obtain a 401 Water
Quality Certification and 2) stream standard violation for removal of best usage.
Item 1: Preclusion of Best Usage
Approximately 45 linear feet of an unnamed tributary to the Dan River had been impacted by the installation of a culvert
and the fill of the stream feature. This activity has resulted in a stream standard violation. Specifically, 15A NCAC 2B
.0216 (2) states that preclusion of best usage, which include a water supply for drinking, culinary, or food-processing
purposes, aquatic life propagation, biological integrity, wildlife, and secondary recreation, represents a water quality
standard violation.
Item 2: 401 Water Quality Certification
The Central Office has confirmed that state-issued 401 Water Quality Certification had not been received for the
installation of the stream crossing. A 401 Water Quality Certification is required for the above-mentioned stream impacts
pursuant to 15A NCAC 2H .0500.
This office requests that you respond, in writing, within 20 days of receipt of this Notice. Your response should address
the following items:
(1) Please explain/detail when stream impacts occurred and the extent of the activities that occurred on the subject
site.
(2) Please discuss the above violations and how you intend to achieve compliance.
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)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/myetlands/
Page.2 of 2
(3) With respectto the pre-construction notification submitted (the 401 Water Quality Certification and the request for `
stream impacts), please provide information detailing why you did not properly secure a 401 Water Quality
Certification prior to going forward with impacting the stream. Also, please note, it is the opinion of this office that
one crossing, rather than two, is sufficient for this subdivision. This desing would minimize impacts to the stream.
There appear to be no site constraints which would preclude the use of a shared driveway by the two properties,
such that the driveway could be split into two driveways after the stream is crossed. Accordingly, please detail in
your response your intentions by providing clear plans to minimize stream impacts and to abate impacts that have
occurred thus far.
(4) If changes noted in item 3 above are unacceptable, please provide a clear account detailing why. This is
necessary in order for this office to determine/ensure your compliance with Water Supply Watershed regulations.
Please respond, in writing, both to this Office, care of Cyndi Karoly, 2321 Crabtree Blvd., Raleigh, NC 27604-
2260 within 20 days of receipt of this letter outlining your intent to proceed with this project or withdraw your
application. Also, please note that the above mentioned violations or future violations are subject to the possible
assessment of civil penalties of up to $25,000.00 per day, per violation.
If you have any questions regarding this matter, please contact Mr. Danny Smith of the Central 401/Wetlands Unit
Office at [phone] or Cyndi Karoly at [phone].

ney
:rvi or, 401/V1/etla ds U t
cc: John T. Thomas, USACE Raleigh Regulatory Field Office
Cyndi Karoly, Central 401/Wetlands Unit
Danny Smith, Central 401/Wetlands Unit
WSRO - Larry Coble
020095
VIA rFRQ ? _. - ^
Michael F. Easley
?O G Governor
] -i William G. Ross,Jr.Secretary
Department of Environment and Natural Resources
Kerr T. Stevens
Division of Water Quality
Dion of Water Quality
Departlrient of Bvyk-nmental and Natural Resources.
W--Jands1401 Unit
Location: 2321 Crabtree Boulevard, Suite 250 Raleigh, NC 27604-2260
Mailing Addres=- 1650 htilSenfice Center R2[eigh, NC 27699-1650
Contact lnfrAm2tion_ karat 919-733-1786 Fax: [phone]
Fax To: 1 Fax Number: 3- 3K - 6
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Company_ D= E: 1/ ?16 Z
From: rnone: ?/q 733
No. Of Pal inclugimg cv ---
Notes or special iristucaor,=-:
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Raleigh, NC 27604-2250

Michael F. Easley
Governor
UJ William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D., Acting Director
Division of Water Quality
April 16, 2002
CERTIFIED MAIL:
Return Receipt Requested
Andrew P. Strader
5322 Eckerson Road
Greensboro, NC, 27405
SUBJECT: Pre-construction Notification (DWQ Project No. 02-0095),.
REQUEST FOR ADDITIONAL INFORMATION
Site Visit Results
Sardis Church Subdivision
Rockingham County
Dear Mr. Strader
The Division of Water Quality has reviewed your Pre-construction Notification Application for the discharge of fill
material into approximately 90 linear feet of an unnamed perennial tributary to the Dan River, Roanoke River Basin, Class
WS IV, Rockingham County. Insufficient evidence is present in our files to conclude that your project must. be built as
planned in waters and/or wetlands in accordance with 15A NCAC 2H .0506. Therefore, unless modifications of the proposal.
are made as described below, we will have to move toward denial of your 401 Certification as required by 15A NCAC 2H
.0507(e) and will place this project on hold as incomplete until we receive this additional information. We are requesting (by
copy of this letter) that the U. S. Army Corps of Engineers place your project on administrative hold.
Further., during a site visit conducted by Mrs. Cyndi Karoly of the Central Office of the Division of Water Quality, it was
noted that approximately 45 feet of stream had already been filled and a culvert placed in the remaining stream segment.
Also, a subsequent DWQ file review confirmed that no 401 Water Quality Certification or authorizations had been issued for
the subject tract. Accordingly, the site visit and file review confirmed the following violations: 1) failure to obtain a 401 Water
Quality Certification and 2) stream standard violation for removal of best usage.
Item 1: Preclusion of Best Usage
Approximately 45 linear feet of an unnamed tributary to the Dan River had been impacted by the installation of a culvert
and the fill of the stream feature. This activity has resulted in a stream standard violation. Specifically, 15A NCAC 2B
.0216 (2) states that preclusion of best usage, which include a water supply for drinking, culinary, or food-processing
purposes, aquatic life propagation, biological integrity, wildlife, and secondary recreation, represents a water quality
standard violation.
Item 2: 401 Water Quality Certification
The Central Office has confirmed that state-issued 401 Water Quality Certification had not been received for the
installation of the stream crossing. A 401 Water Quality Certification is required for the above-mentioned stream impacts
pursuant to 15A NCAC 2H .0500.
This office requests that you respond, in writing, within 20 days of receipt of this Notice. Your response should address
the following items:
(1) Please explain/detail when stream impacts occurred and the extent of the activities that occurred on the subject
site.
(2) Please discuss the above violations and how you intend to achieve compliance.
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)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/ncwetlands/
Page.2 of 2

(3) With respect to the pre-construction notification submitted (the 401 Water Quality Certification and the request for
stream impacts), please provide information detailing why you did not properly secure a 401 Water Quality
Certification prior to going forward with impacting the stream. Also, please note, it is the opinion of this office that
one crossing, rather than two, is sufficient for this subdivision. This desing would minimize impacts to the stream.
There appear to be no site constraints which would preclude the use of a shared driveway by the two properties,
such that the driveway could be split into two driveways after the stream is crossed. Accordingly, please detail in
your response your intentions by providing clear plans to minimize stream impacts and to abate impacts that have
occurred thus far. q
(4) If changes noted in item 3 above are unacceptable, please provide a clear account detailing why. This is
necessary in order for this office to determine/ensure your compliance with Water Supply Watershed regulations.
Please respond, in writing, both to this Office, care of Cyndi Karoly, 2321 Crabtree Blvd., Raleigh, NC 27604-
2260 within 20 days of receipt of this letter outlining your intent to proceed with this project or withdraw your
application. Also, please note that the above mentioned violations or future violations are subject to the possible
assessment of civil penalties of up to $25,000.00 per day, per violation.
If you have any questions regarding this matter, please contact Mr. Danny Smith of the Central 401/Wetlands Unit
Office at [phone] or Cyndi Karoly at [phone],
ey
r, 401 / Wetla ds U t
cc: John T. Thomas, USACE Raleigh Regulatory Field Office
Cyndi Karoly, Central 401/Wetlands Unit.
Danny Smith, Central 401/Wetlands Unit
WSRO - Larry Coble
020095
s
Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No.
r ,
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank. n =,R
L Processing
1. Check all of the approval(s) requested for this project:
? Section 404 Permit 2
? Section 10 Permit 2 2002
Q] 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: 401
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: W
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
IL Applicant Information
1. Owner/
1 \ QlllV. .G/ /?1 L?
Mailing A dress: 6ri ;2 2 154 -e-M YO i2J l??te? Lake 1116 2744o
Telephone Number: 3W 4&1 z s Fax Number: Sam
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
T... Q ..C 1 '1
IM 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 11 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. Name of oroiect: 5?120/s GIJI?Q LN SccBp/r// f /?? Z-o 7
2. T.I.P. Project Number or State Project Number (NCDOT Only): ,Q
3. Property Identification Number (Tax PIN):
4. Location
County: R o C440", Nearest Town:
Subdivision name (include phase/lot number): S,4?Q/s G???u S1?66/u/f/o ?? t %7f
Directions to site (include road numbers, landmarks, etc.): T.4'? ur_ z2.o .votiTN Aolko X,
3 Le i, Noti ry ffF i?7b?6?71`.J w iThl N.c- hw'r CY . 7WT" Lt'Il,-T (wad 7) o&-
IA?D/f G,t1- 4D, 4vZ //zP) Go 21 2-4 / lce TA,e'C tr oN Ole rvirw Loop, ,t7 0?
O,.rd~ SAD 7o t.v0
5. Site coordinates, if available (UTM or Lat/Long): S-f U1 Fs
(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:
2- L14(4N7' Go?S -Al&W Y'6D/yis/----"
7. Property size (acres): 2 3• I 4-^2.,7 ( 2 1- r7J
8. Nearest body of water (stream/river/sound/ocean/lake): 71540-TY"T to JdAl- - JI/Mi --
9. River Basin: 0,41? Q/?t/E? ,
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/mos/.)
TL...... 4 ,.r 1
10. Describe the purpose of the proposed work: 2 11,11147f lR/?ifl?r? y J Tb S. F. 1-47S
11. List the type of equipment to be used to construct the project: B4oi-, o t1, gR- ,- t7-4 4,0,Ma,
12. Describe the land use in the vicinity of this project: AkA?4?-- 1?6D1 y1 Sl Q -?
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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
Nb
VL 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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
in_ -- 17 _-C I It
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody

(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
PZA

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation N`,4
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 ? 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. ,
&j;4 y"a G?sJ f)2,c A, T- ?Oce-&--f //,so ;/-V /N.??J D'?g
a
VIII. Mitigation
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 egtW to one acre of impacts to
freshwater wetlands or greater than or equal to 150 lir>carTees total impacts to perennial
streams. 111.
71...x.. A ..r 11
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No k .
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)
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 15A NCAC 2B .0233
(Neuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No If you answered "yes", provide the following information:
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* ( Impa t
square et) Multiplier Required
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
f)r.? I i ?F?R

XI.
XH.
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.
Stormwater (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.
s'Qo s f Aa5e w171V A"D??v?? ? C,0111-ox f- o' Fat- eve-IV 4o?
Sewage 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.
S&71G 71dNr f "c!? L^ T
XHL Violations (DWQ Only)
Is this site in violation of WQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No KU
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).
_/ f0.p?
Applicant/Agent's Signature / Date
(Agent's signature is valid orfjy if An authorization letter from the apphcarlt is-provided.)

1. Wetland Impacts
Wetland Impact Area of Lop
es within Distance to
Site Numbe
indicate on ) mar Type of Impact* Impact 100 year Floodplain** Nearest Stream Type of Wetland***
(acrecl i..e, i... ... _
* 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 FEMA-approved local floodplain maps. Maps are available through the FEMA Ma
online at http:/hvww.fema eov. P Service Center at 1-800-358-9616, or
*** List a wetland type that best describes wetland to be impacted (e-g-, freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland, beaver pond,
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stream Impacts, including all inter
Stream Impact Length of
Site Number Type of Impact* Impact
ndicate on ma inear feet)
?Y `// de ay S'o
7 1r/ 7
mittent and perennial streams
Average Width
Stream Name** of Stream
Before Im ct
//7

Perennial or
Intermittent?

" List each impact separately and identify temporary im
dams e(separatel ach a list im
y pacts due to both structure and fl mclude, but are not limited to: culverts and associated rip-rap,
stabilization activities (cement wall, rip rap, crib flooding), relocation (include linear feet before and after, and net loss/gain),
Proposed, plans and files showing wall, gabions, etc.), excavation, ditching/straightening, the linear footprint for both the original and relocated streams must be included. cluuded. relocation is
Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed trib
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-96 6,t or online at
www.uses soy. Several intemet sites also allow direct download and printing of USGS maps (e.g., )x"mvtomzone com,
www.mapauest com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:- 90
T...-.. 0 -r , It
k9 UNITED STATES
DEPARTMENT OF THE INTERIOR
GEOLOGICAL SURVEY
80°00' 590000mE 591 592 n MARTINSMADIVA .7 Ml. 5056 N NN
593 57 30 594 MADSO N l.7 ML 595 (MAYODAN)
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%DEPARTMENT OF THE INTERIOR
`F.
GEOLOGICAL SURVEY
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1
Date:I
To: ?RRO Steve Mitchell Project Name
?FRO Ken Avedde DWQ Project umber
?WaRO Deborah Sawyer CountyC? i ,
QWiRO Joanne Stesnhuis
I-DVIVSRO Jennifer Frye .....(??? r _
OARO Mike Parker
?MRO Psfe CoNnAl
From: Telephone (919) 733-
The file attached is being forwarded to you for your evaluation. Please call if you need
assis',=rce_
Cj Stream Length impacted
Stream de;..=rmbla5orr
[l Wetland determirz-t on and distance to blue-line surface waters on USGW topo maps
??iar/avoklarice issues OIL GC old l/ f
Cl Bt -rer Pdes (Netse, Tar-Pamilco, Catawba, Randleman)
Pond W
© A on P.a=tios
C1 Dig
CIAxe the s;Telam and orwetiand mitigation sites available andd viable?
Q Is the Tic-- o cx stmt with pre-application-meetings?
n?
?CmuM an¢ac?co?cernsZ
t :.? 2tw
711
? rr
.
-

Date: 13 / 0°2 ,
To: ?RRO Steve Mitchell Project Name c > A'e
?FRO Ken Averitte DWO Project umber d ?J
?WaRO Deborah Sawyer County
EIWRO Joanne Steenhuis --:
/SRO Jennifer Frye LARO Alike Parker
?MRO P21e Cohn
From: J?GSc. Telephone (919) 733-
The file attached is being forwarded to you for your evaluation. Please call if you need
assis'?.?r?_
r-I Stream tencth i npacted
C Stream deierminabon
Ci Web and de==anir;abon and distance to blue-line surface waters on USGW topo maps
- ? j
Olggii ni orifavoedar3ce issues p?L GG ?lJ U?
EJ BUffrer Piles (Ne'_-,=_, Tar-Pamilco, Catawba, Randleman)
G Pond
El Aogal3cin FZatjos
G s
I Are the s;' trWi=n awd or wetland mitigation sites available and viable?
Lyrames for aazrracy }f /? . ° ?: 1% G
Q Is the appBc.__on corisistent with pre-application meetings? _
F.- K ti. ?^.i=? .?`r! -..?f.s.2•"? ai wY Eel:
S? *i'•a ,+liV??YlfCi? -?_ _ ? ?.??i' ? ? .?" .T^.. 'h^' ?. ?ni.?`- L??"?* ?y ;LT ? J._?
f- '- a ? ?r+u?c..?-viY: X• .t ? - shF 4.? yti.-?i '.... ? ? .-. .-L•.n..-+Y ?
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Meg.
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C ? '? ??is?i? `3 ?.? ?ly-T+.. ? r r_1llAa ? ti?•p,

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9 UNITED STATES
DEPARTMENT OF THE INTERIOR
.(GEOLOGICAL SURVEY
MA
80,00' 5900001,, E 591 i 592 593 57'30" 594 RT/NSMADISON 1.7 M1 595 (MAYODAN)
36°22'30" 1-7
W.oo211an \ \ // 704 f
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Office Use Only:
USACE Action ID No.
DWQ No.
Form Version October 2001

iI -;
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/4q?at?er than
leaving the space blank.
1. Processing O,,
1. Check all of the approval(s) requested for this project: _._ I
? Section 404 Permit JAN 2 ? Section 10 Permit 2
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: 401
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: ?
IL Applicant Information
1. Owner/AmlicanUnformati
Mailing Address: h'.
Telephone Number: JA Fax Number:
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
"- -- c -r 1 n

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 11 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. Name of project: S''W I S GNl?,2 GN SccBO/?I f /?? L o 7 `j f142
2. T.I.P. Project Number or State Project Number (NCDOT Only): AYA
3. Property Identification Number (Tax PIN):
4. Location
County: R o C-144 AA. Nearest Town: M M/ So A
Subdivision name (include phase/lot number): 5?M'13 C4VU,&c,y 51r64iuiJ1o ?? c a7I
Directions to site (include road numbers, landmarks, etc.): Mke utr_ z20 ,vo/,rA/ 4,01A o X
3 &i, /NotirN .r, i??Tb?3?7/`.J t„W N.e,. h'wY SY . 7,012-' Le2l-T Cwej 7) OA-
.4koli G, l- 4 , Ise j/2-Y) Go '` 2_4 14 /c.rs Vle' AT oN 1W.-rvirw La V, 17 0/-?
-
/,trdn7e' A-oAp 7b `4WJ , ' '
5. Site coordinates, if available (UTM or Lat/Long): Se&- a J Fs 4d "o
(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:
2 b4c-4N7 Z_0Tj -Re-W
7. Property size (acres):
2 3. 1 4c2.xs ( 2 4-.71
8. Nearest body of water (stream/river/sound/ocean/lake): 7.410 u- Ze, -r ?? D?•tL IM
9. River Basin: A00,iy' Q% LIVE -
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/map-/.)

10. Describe the purpose of the proposed work: 2 114P,471" 0-t ilkid-w r J Tb S. F. 1-47S
11. List the type of equipment to be used to construct the project: B,GC"otl, L o,0140-
12. Describe the land use in the vicinity of this project: A4?A-d L 1?6D1 V) 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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
VL 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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
"..... '7 r 1't
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody
(if
applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.
PIA

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation ?-/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 ? 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.
G,2?va?wAYJ uscl to G4-sf f/Za7J , T ,ecc,&-O 0,0
VIII. Mitigation
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 imps to
freshwater wetlands or greater than or equal to 150 linear'fe;tA df total impacts to perennial
streams.
n..._., n ..r 1 1%
IX. Environmental Documentation (DWQ Only)
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)
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 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No 0 If you answered "yes", provide the following information:
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
tigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
" ii ?fiR

XI.
XH.
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.
Stormwater (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.
S-F /Joa5e W17W 101,4Z111xJ,,1AY ?i4Q?iLoX. foo f-o?` C;OG/V LoT
Sewage 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.
XM. Violations (DWQ Only)
Is this site in violation of I?WQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No Do
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).

Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
n,.,.., 1'I -r 1 '%
I - Wetland Impacts
Wetland Impact Area of Located within
Site Number Type of * Distance to
Impact Impact 100 year Floodplain** Nearest Stream
indicate on map) rarrmcl ,----,__ Type of Wetland***
List each impact separately and identify temporary impacts Impacts include, but are not limited to: mechanized cl
excavation, flooding, ditching/drainage, etc. For dams, eanng, grading, fill,
** 100-Year floodplains are identified through the Federal Emergency enc? impacts due to both structure and fl ding.
(FIRM), or F'EMA-approved local flood lain ma g Y Management Agency's (FBMA) Flood Insurance Rate Maps
online at httn://www.fema eov. p Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland, beaver pond,
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 ImFma Site Numape o fp* of
Average Width Perennial or
ndicate on )?a Str
eam Name** of Stream Intermittent?
linear feet) Before Im ct lease
v7 7
7 0'12
4- 4(Z -I
" List each impact separately and identify temporary Y Pommy impacts
dams ( . Impacts include, but are not limited to: culverts and associated rip-rap,
separately list impacts due to both structure and flstabilization activities (cement wall, crib w OOd?), relocation (include linear feet before and after, and net loss/gain),
rip-rap, all, gabions, etc.), excavation, ditching/ straightening proposed, Plans and profiles showing the linear footprint for both the on mg/ , etc. If stream relocation is
Stream names can be found on USGS to hic ma If a ? and relocated streams must be included
downstream named stream into which ittffl s . USGS name, ps. list as UT (unnamed tributary) to the nearest
?'?'wu _ses gov. Several intemet sites also allow maps are available through the USGS at 1-800-358-9616, or online at
NN-VW-manauest com, etc.). direct download and printing of USGS maps (e.g., u.wW-topozone com,
Cumulative impacts (linear distance in feet) to all streams on site: ?0 ?
n...-.. 0 ..r I,%

Office Use Only: p on October 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 JAN 2 2 2002
1. 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:
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. O
N
M
Telephone Number:.W 4&Z 2,3 ?s Fax Number: Sow
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
n- c ..r 1 '%
M. 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 11 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. Name of nroiect: .5' Xt 01S G11h,2 LN Scc801v1f /-,-, Z- 0 7 `Z //I
2. T.I.P. Project Number or State Project Number (NCDOT Only): ,4
3. Property Identification Number (Tax PIN):
4. Location
County: k oG/?,4 Nearest Town:
Subdivision name (include phase/lot number): S'Wl$ Opu,&?,,cl S1?66/N/f/o-? t v7f /; ?/2
Directions to site (include road numbers, landmarks, etc.): 7,444 Os- ZT O ,volgrV A01A o x
3 A o, Po A. r& nr- iyMLS901?. wiTN N.C, flit e 6'S' . 7?eV-e" Le'r--T e'We:;72 o^r
x.4koif e-W- 4g, J/2-4) Go A? /L&-f T*e- A T. oN Q/c?T??rw lao?, e?7. o/'?
/Rt0/17e 40.4 7,, 4rND
5. Site coordinates, if available (UTM or Lat/Long): S6-/< a 1 Fs 44,oO
(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:
I- 114c4N7 L.o7 S - ,ycz?
7. Property size (acres):
2 ,3, 1 A-c 2.ds ( 2 1--7!
8. Nearest body of water (stream/river/sound/ocean/lake): P-/+G u- ZKIT /'A OAV },?I?1/!7--
9. River Basin: 0,41r- 41 ,Ve'7-'
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
Tl--- L ..l t'1
10. Describe the purpose of the proposed work: 2 A16474' eAt ?dZd-W r.J Tb S. F. 1-437S-
11. List the type of equipment to be used to construct the project: S,40A' I/o e, co,02.
12. Describe the land use in the vicinity of this project: XuXdL- f?GD/ yl S1 Q -?
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.
.,vp?/??
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
k) b
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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
7L.- IF ..C 1 It
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody

(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation ti//p
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 ? 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.
/itlil 'wAYJ UsL4 to f7lazAu T .Oc.c.crSf ,d4,tr-f;I-V zwoew, OF
VIII. Mitigation
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 egtW to one acre of impacts to
freshwater wetlands or greater than or equal to 150 li'fe& of total impacts to perennial
streams. 111.
T--- n ..r I%
IX.
X.
Environmental Documentation (DWQ Only)
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 ?
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 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes El No 0 If you answered "yes", provide the following information:
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
t)
(square fee
Multiplier
Required
1 3
2 1.5
Total
* Zone I extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
fv ?z i i ?Zf 4R

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)
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.
ro- ;J- No'45 e 6VI7)/ /o' DZ1vdJ,1A r 011 -x f. 0 ?o -?C_ F*/- a6N ?a T
XH. Sewage 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.
S& 71c, 7aNr' f /J/L.0/?F/??? t'4'?? T
XM. Violations (DWQ Only)
Is this site in violation of I?WQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No 0
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).

Applicant/Agent's Signature / - Date
(Agent's signature is valid only if an authorization letter from the appiicarit is-provided.)

I. Wetland Impacts
Wetland Impact
Distance to
indicate on map) Area of Located within
Site Number Type of Impact* Impact 100-year Floodplain** Nearest Stream Type of Wetland***
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearin ,
excavation, flooding, ditching/dramage, etc. For dams, separately list impacts due to both structure and flooding. g Smog, fill,
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FMM), 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&ww.fema goy.
*'* List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland, beaver pond,
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 Type of Lnpact* ?Im of Average Width Pere m
Site eon 1 Stream Name** of Stream Intermittent?
linear feet Before Im lease
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 stricture and flstabilization activities (cement wall, rira ,crib O°ding), relocation (include linear feet before and after, and net loss/gain),
Proposed, laps and p- P wall, gabions, etc.), excavation, ditchfiVstraigh?
P profiles showing the linear footprint for both the original and relocated streams must be iint,11i d? relocation is
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 gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone com,
w w.mapauest com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: /CEO ?
n..._„ 0 ..c 1
3p vi
]PW
3DIA83S NOIIVA83SN00 IIOS
38nllnowov 30 1N3WidVcl]Q 'S'n

p `3
Office Use Only: Foi nn'N siono?col?jooi
USACE Action ID No. DWQ No. k4 J"
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
L Processing
JAN 2 22002
1. 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: /
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: 4
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 o
Name:
Mailing A dress:6;-

Telephone Number: ZM 4,& 1a I i.t;' Fax Number: 5all-e _
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Tl_ __ c ..r 1 It
M. 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 11 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. Name of project: SACKS CIIJA t LN Scc80/?// f /?? Z -a7 `Z f /I
2. T.I.P. Project Number or State Project Number (NCDOT Only):A11A
3. Property Identification Number (Tax PIN):
4. Location
County: k ???i??/??C Nearest Town: /??r ?/ S9 ^J
Subdivision name (include phase/lot number): 45 GF/w&., Al Tu6f1/1//J/6 ?? L o7J
Directions to site (include road numbers, landmarks, etc.): Ma," ur_ z2o ,vo/,7N VIAo x-
I ;* ), Notirv ffF itlIMLSe2?I`„/ w1711 ,v.c„ AlwY 6'S' . 7?0-e" Le9t-T C..C-37) oV-
x.Sx-D1I e-W' 4D. 4S-,,2 Z2-4) Go -? 2-? M 14,,-r X*e' AT. o,., /Ve T y/tw L;-I17 Ottd~ ko.4_47 lea E'Njo .,
5. Site coordinates, if available (UTM or Lat/Long): Seff U f FS A1Q,?
(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:
2 vii c4N7 L0 7 S - Alew ??60/yif /? ?
7. Property size (acres): 2 3, I pc2.?s ( 2 1..-71
8. Nearest body of water (stream/river/sound/ocean/lake): 7?,d u- 7-0r41` L OW,,V- 61m_
9. River Basin: 441? Q% ?e'lx-
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)

10. Describe the purpose of the proposed work: 2 PP P47t' 1,)1Q ?eZdfieY J Tb ,S'. F. 1-10'7S-
0
11. List the type of equipment to be used to construct the project: B.CG,? 661, ?i? t?4 c,,4Q6iL-
12. Describe the land use in the vicinity of this project: X,,Ad4- f?6Ol yt 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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
VL 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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
n..-..17 _r I,%
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody

(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ean, etc.)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation N`,4
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 ? 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. ,
?,Q7vtt'G?AYI &5cl fQ GA'-°3I fT?ia?/!t/ T iOGCI?Sf /?4 ?//? /lY• b r? D?'
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater. tbian or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linearfeift -4of total impacts to perennial
streams. 11,
-- a 7 _Ir
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No Al
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)
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 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify I )?
Yes ? No '4 If you answered "yes", provide the following information:
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* ( Impac t)
square Multiplier Rimed
tigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
"? 4t rf1R

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)
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.
3`0o S-f Aa5 e 6VI71 /v' DZi yxy./i4 ? ?,yQ?ti o x o Zo?? Ffl? acq I- 7
XH. Sewage 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.
XIM Violations (DWQ Only)
Is this site in violation of IZWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No 0
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).
_/,v .0,-?,
Applicant/Agent's Signature
(Agent's signature is valid of
if do authorization letter from the appiicatit is-Provided.)
il--- 11 -rill
1. Wetland Impacts
Wetland tnmp) Area of Located within
Site Numbe
'indicate Distane to
oType of Impact* Impact 100 year Floodplain** Nearest Stream Type of Wetland***
farrP.0 ... _
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized cl
excavation, flooding, ditching/drainage, etc. For dams,, grading, fill,
100-Year floodplains are identified through the Federal list 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 httn://%vww.fema y.
• ` List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland beaver pond,
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 Len 1 Site Number Type of Impact* of ** Average Width perennial or
ndicate on ma Pa Stream Name" Of Stream Intermittent?
linear feet Before Im ct lease
27 #1/ ,El (le d o ' 7 iV ?.cva?L
4c, .1
7 0'12 (.ivdy-wu d'?C?.?.?i?4L
List each impact separately and identify temporary im
dams (separately list -hMimts -
impacts due to both structure and fl include, but are not limited to: culverts and associated rip-raA
stabilization activities cement ooding)> relocation (include linear feetstraibefore and after, and net loss/gain),
(cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/
Proposed, Plans and profiles showing the linear footprint for both the original etc. ff stream relocation is
Stream names can be found on USGS to 1? and relocated streams must, included Stream has downstream named stream into which it flows. USGS maps are available thro name, list as SG (unnamed tributary) to the nearest
(e.w16, or online at
www.us s or. Several intemet sites also allow direct download and printing ? of the USGUSGS S at maps (e.g., 1-800-358-
WWW.maoauest com, etc.). ., www.top ozone cony,
Cumulative impacts (linear distance in feet) to all streams on site:- 90 ?
il--- 0 -r III
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U.S. DEPARTMENT OF AGRICULTURE
SOIL CONSERVATION SERVICE
Office Use Only: Form Version October 20oi
USACE Action ID No. DWQ No. l'
If any particular item is not applicable to this project, please enter "TXbt Applicable" or "N/A" rather than
leaving the space blank.
L Processing
1. Check all of the approval(s) requested for this project:
? Section 404 Permit JAN2
? Section 10 Permit
M 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested:
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: ?
11 Applicant Information
1. Ownet
Name:
Mailin
Telephone Number:.W 4AI2,31s Fax Number: So,np
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
rl . C ..r 1
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 11 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. Name of project: 5*,44015 C-14141c,N SccBp/?/ f /?? L o 7 `1, //I
2. T.I.P. Project Number or State Project Number (NCDOT Only): ld
3. Property Identification Number (Tax PIN): _ _71t //3 !? f T
4. Location
County: k o C-M4 , Nearest Town:
Subdivision name (include phase/lot number): S,??D/S Gflo ?,u S1F6/1/u/s/o .? Z o 7.t
Directions to site (include road numbers, landmarks, etc.): 1,44e 40s_ z2o .vo/,rN W,01 -o x
3 & ), /ox rN aF it/71XSC077?-A-) W IThl N.C- Nor Y SY . ?.?'? Lt'7? T Cw? 7? oN
Al- /_D. 4nt Go 2-7 M /C.c-S TA,?e AT onM //Z 7wew Loop, ,l7 0?
x.41-Dlf e,
0,.10n7e Ao AD 7,, e-'.vD
5. Site coordinates, if available (UTM or LatlLong): U f Fs and 4
(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:
yAc4NT L.o]'S -,vct? ??60?yi1?..•
7. Property size (acres): 2 3. 1 4c2d5 ( 2- I--7.1
8. Nearest body of water (stream/river/sound/ocean/lake): 74444-?VOT f- DAV- A 0y
9. River Basin: 4An/ Q% l/!?n-
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/mVs/.)
T.. IC ..r 7 •,
,)/QydZdOY f Tb S. F. 1-.-7S,
10. Describe the purpose of the proposed work: 2 IK1114 7f J /
11. List the type of equipment to be used to construct the project: tsoe6/, F-1
12. Describe the land use in the vicinity of this project: X -A-dt- I?6Ol ??SIQ
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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
N?
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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
n..-,. -s ..r i It
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)

# List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation 1/14
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): ? uplands ? 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. ,
,0 Z n!¢'&-j A ? ,F us tl yQ f22,a pu T AG G e-Tf i(Ia d1 ?/ /N'i7?'?`? Q ?
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater, tban or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linearfeiot 4 total impacts to perennial
streams.
n--- n ..r ,'?
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No ,V
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)
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 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify - )?
Yes ? No 0 If you answered "yes", provide the following information:
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
feet)
(square
Multiplier
Required
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 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 2B .0242 or.0260.
XI. Stormwater (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.
m oo S-f_ Aloe W17N /D " eZI Va-&IA r ?i4Q?rLoX f.0 Lo?G? arw 4.
XII. Sewage 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.
.Si-07/G Ze&&- f /12. lA,,,c t,?5 &wcl? U T
XUL Violations (DWQ Only)
Is this site in violation of I?WQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No 0
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).
4z 6"t,44 /- 62
Applicant/Agent's Signature Date
(Agent's signature is valid only if do authorization letter from the appiicaiit is-,provided.)
T--- 1 '1 -V I,%
I. Wetland Impacts
Wetland Impact Area lartracl of Located within
Site Number Type of Impact* Impact Distance to
indicate on ma 100 year Floodplain** Nearest Stream Type of Wetland***
P)
List each impact separately and identify temporary impacts Impacts include, but are not limited to: mechanized clim ,
** excavation, flooding, ditching/drainage, etc. For dams, separately pa g grading, fill,
100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplam maps. Maps are available through the FEMA Map Service Center at 1_800-358-9616, or
online at h../hvww.fema eov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland, beaver pond,
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stre
Stream Impact
Site Number
ndicate on map
07
'
o 7 >w/2
am Impacts, including all inter
Length of
Type of Impact* Impact
ear feet
? Nl' l?dY S'o '
miittent and perennial streams
Average Width
Stream Name** of Stream
Before Im
/?7 -AIe_ A:.,---w .?

Perennial or
Intermittent?
:?i,Q (,
„,?/,v 4,
List each impact separately and identify temporary impacts- Impacts include, but are not limited to: culverts and assoc{ated riPraP?
dams (separately list impacts due to both structure and flstabilization activities (cement wall, rip-ra , crib flooding) relocation (include linear feet before and after, and net loss/gain),
proposed, plans and P wall, gabions, etc.), excavation, ditching/straightening, showing the linear footprint for both the original and relocated steams be m-cluIf stream ded relocation is
Stream names can be found on USGS topographic maps. If a stream has no name, list as UT est
downstream named stream into which it flows. USGS maps are available through the USGS at?l?-800-3gu9616, or online at
'A'?oV. Seveetc.). ral intemet sites also allow direct download and printing of USGS maps (e.g., w•wW.1oVozone com,
w?vw.manauestcom,
Cumulative impacts (linear distance in feet) to all streams on site:- ?o ?
n..- o ..r I q
U.S. DEPARTMENT OF AGRICULTURE
SOIL CONSERVATION SERVICE
BOP
MdC
MdB
U.S. DEPARTMENT OF AGRICULTURE
SOIL CONSERVATION SERVICE
J4A 2 2 2002
BYP

o
Office Use Only: Form Version October 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.
L Processing
1. Check all of the approval(s) requested for this project: JAN ' awn
? Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: 401
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: K
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
IL Applicant Information
1. O
N
M
Telephone Number:.W 4z^I?.? Fax Number: 50112
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
T- c ..r 1'%
M. 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 11 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. Name ofproject: S'?1Q0/s C14JA t LN SttSV/?/ I /-? Z-o 7 fj //a
2. T.I.P. Project Number or State Project Number (NCDOT Only):k1Q
3. Property Identification Number (Tax PIN):
4. Location
County: k o /?i?'G/?? Nearest Town:
Subdivision name (include phase/lot number): f?M0/s oPiC&C'u
Directions to site (include road numbers, landmarks, etc.): 7,44e, u_r_ zzo .Vox;w Mko x
NoArN,F ir7rLagtW`. wr V ,V-e- NorY CY. 7011` Zer-T Cwe:F7J oV-
e-t1_ ke, &)e. 2-e) Go Al/c.?s 7,*? tT. oN Q/coTvJrw Cool, 17 a/)
5. Site coordinates, if available (UTM or Lat/Long): S61- U164 4d,,O
(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:
Z 114c4,4' Go7S -,vs'W
7. Property size (acres)
23. 1 4C2.ds 12 4.r7J
8. Nearest body of water (stream/river/sound/ocean/lake): 74M 4- 7*00-7' /',-, MV- 4t'
9. River Basin: A4, 1#/ Q% UE1.
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
TI- __ c ..r 1,%
10. Describe the purpose of the proposed work: 2 11.111A7t e1t1 ?dld,Wy J Tb S. F. Lo7S -
11. List the type of equipment to be used to construct the project: BCC,?,1/0 ?, ?tior7 r?G c .?,ap6?
12. Describe the land use in the vicinity of this project: A«-AdL J&ADJ yt S1 Q: --?
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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
iU b
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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
n..-- IF _r 1 It
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody

(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
PIA

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation N`.4
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 ? 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. ,
dt1u?-wA?-f 4tSL4 ro a,-s.r SI"kz r, T AC,as 41a4 1-Ti* 1MJ7e'Zd o)v

VHL Mitigation
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 egtW to one acre of impacts to
freshwater wetlands or greater than or equal to 150 lines'feiA of total impacts to perennW
streams.
n--- A ..r 111
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No 4
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)
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 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify - )?
Yes ? No '4 If you answered "yes", provide the following information:
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* (square Impa t
et) Multiplier Required
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
it ?? 4 i rf i R

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)
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.
?% oe S-f Ai,*e kJ17N /o' dZ1t1ru1A r ?.4O?tioX, fg o Lo^?G Fo/? CdcN Go7
XII. Sewage 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.
&71G 7dtie? f az.41,--F,4r4S &wc/y z-- 7-
XUL Violations (DWQ Only)
Is this site in violation of WQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No 0
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).
_J2? - 0Z
Applicant/Agent's Signature
(Agent's signature is valid of
if do authorization letter from the appilcarlt is-provided.)
n..,.,. ,'% -r ,'l
L Wetland Impacts
Wetland Impact Area of Located within Distance to
Site Number Type of Impact* Impact 100 year Floodplain** Nearest Stream T ***
indicate on map) ra?? ._. ?__. _ ype of Wetland
* List each impact separately and identify temporary impacts Impacts include, but are not limited to: mechanized cl
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.g>g' mil'
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(F'RM)> or FEMA-approved local floodplam maps. Maps are available through the
online at httn://www.fema.gov. FEMA Map Service Center at 1-800-358-9616, or
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland, beaver pond,
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stre
Stream pct
Site Number
g9te on map
a 7 -'°`/2
am Impacts, including all inter
Length of
Al Ile .4
Type of Impact* Impact
ear feet)
/a Ile
mittent and perennial streams
Average Width
AD --A Perennial or
Stream Name** of StF Before ct
//7

Intermittent?

" List each impact separately and identify temporary impacts. Impac
dams (separatel list ' is include, but are not limited to: culverts and associated rip-rap,
y 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/straigh
proposed, plans and profiles showing the linear footprint for both the ong> stream relocation is
Stream names can be found on USGS t ? and relocated streams must beincluded
o flows. c maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which if t flows. US
I=sgs GS maps are available through the USGS at 1-800-358-9616, or online at
?-?oy
wtivzv Several internet sites also allow direct download and printing of USGS maps (e.g., w•ww•tonozone cony,
.manquest com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: ?o ?
n...._ 0 _r I
Md(
MdE
U.S. DEPARTMENT OF AGRICULTURE
SOIL CONSERVATION SERVICE
fsvE1
F4L/JboA.o N•C.,
9ss UNITED STATES
DEPARTMENT OF THE IlgTERIOR
GEOLOGICAL SURVEY
80 00, S90o00m.E 5 5 MARTINSVILLE. VA. 44 M/. 5 5056 /V NW
95
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p '% W_ ood an / 104
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11;
r
Office Use Only: ID G r q* 'on October 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.
L Processing
1. Check all of the approval(s) requested for this project: JAN 2 2 2W2
? Section 404 Permit
Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: 40 /
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: K
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
IL Applicant Information
1. O
N
M
Telephone Number: JA 3 ! ' Fax Number: 501-IQ
E-mail Address:
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
n_ __ c ..r I,%
M. 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 11 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. Name of project: 54401S G/?!? /L GN StcBp/ ?/ s /v,? ?- © 7
2. T.I.P. Project Number or State Project Number (NCDOT Only): A11A
11
3. Property Identification Number (Tax PIN): n ilt /13 2 f/
4. Location
County: R /?i?G/??/?'? Nearest Town: MM15 ^-l
Subdivision name (include phase/lot number): s?-'AQ/s GNU,&,_oc/ Su6lliu/s?o ?? t o 7f Il
Directions to site (include road numbers, landmarks, etc.): 44,ez? u'r- z2 o uoA7N ,4,1A o x
3;*,, /NoAr// frF iwl7L6gt7i--) tv!r/I N-C- fwY CY . 7,02' Le2l-T Cwej7 0,,r-
.fw-ylI e-W° 4.4, 4f)2 Z2-4) Go ? 2..7 M /c.lS T-*e' AT. ON /A -rvitw t;&I, 17 ctw?
5. Site coordinates, if available (UTM or Lat/Long): Se&' U .S Fs mdQ
(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:
2 114c4t- 7 Go7-S
7. Property size (acres,
2 3, 1 Ac2-ds ( 2 1--7J
8. Nearest body of water (stream/river/sound/ocean/lake): 7qJ u- 7WAT /- 4MA!?-
9. River Basin: 4,0.n/ Q% t le?" --
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
7)..__ c ..r III
10. Describe the purpose of the proposed work: 2 IkI PA7L' i4, 4t ?4d-W Y J Tb S. F. 1-47S,
11. List the type of equipment to be used to construct the project:
12. Describe the land use in the vicinity of this project: A x d i-- f?60/ (/1 SlQ
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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
N?
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 VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
71...... 'I ..r 1
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres)
Name p Wateplicabllee) )
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation N`p
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 ? 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. ,
041ile'G?AYJ &j;ef fo G?sI .02,ca"X, r- Ac-&-Tj N? ?'l/7? /N•t"TCd,?J D?
VIIL Mitigation
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 lines'febt of total impacts to perennial
streams.
ll....., a ..r I It
IX. Environmental Documentation (DWQ Only)
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)
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 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify - )?
Yes ? No 0 If you answered "yes", provide the following information:
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*

lmpa t
(square et)

Multiplier

Required
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
fi)R? 4 1 ?F 1'9

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)
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.
S-F_ Notoe WIN 10'e,411vx-&1Ar k f-0 ev G/? I-
XH. Sewage 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.
S?O?IG JOA,?t- f 4-,! 4- T
XUL Violations (DWQ Only)
Is this site in violation of IZWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No L'
Is this an after-the-fact permit application?
Yes ? No 0
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).
_ J/9 . 02-
Applicant/Agent's Signature
(Agent's signature is valid of
if an authorization letter from the applicant is-provided.)
"- -- t't ..C 11
1. Wetland Impacts
Wetland Impact Area of Located within
Site Number Type of * Distance to
indicate on map) Impact Impact 100 year Floodplain** Nearest S!r
eam Type of Wetland***
_ (actpcl List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearin,
excavation, flooding, ditching/drainage, etc. For dams, g 8mdrng, fill,
** 100-Year floodplains are identified through separately list impacts due to both structure and flooding.
ugh
(FIRM) the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
online , at or F W://www.fem&gov. loc al floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
ww.fema.eov.
*** List a wetland type that best describes wetland to be impacted (e-g-, freshwater/saltwater
Carolina Bay, bog, etc.) marsh, forested wetland, beaver pond,
List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:
2. Stre
StreamStream
Site Number
ndioate on map
,7 ?"- - * // -
o 7 r'/2
am Impacts, including all inter
Length of
Type of Impact* Impact
linear feet)
,W d? ay S'o '
mittent and perennial streams
Average Width
P tream Name** of Stream
Before Im ct

Perennial or
Intermittent?
A/1,4
t,
i is[ each impact separately and identify temporary im ts. Im > 11 dams (separately list ' impacts due to both structure and P Pacts include but are not limited to: culverts and associated riP-mA
Y flooding), relocation (include linear feet before and after, and net loss/
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditc ' gam)'
Proposed, plans and profiles showing the linear footprint for both the on ?? relocation is
Stream names can be found on USGS topographic ? and relocated streams must be included
flows maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which if t . USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs eov. Several intemet sites also allow direct download and printing of USGS maps (e.g., www.tonozone cony,
WWWmavouest com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: ?o ?
T..._,. 0 ..c 1 rN
M dl
Mdl
U.S. DEPARTMENT OF AGRICULTURE
SOIL CONSERVATION SERVICE
BYP
1j.6 o A.?
F9 UNITED STATES
?0?tiF DEPARTMENT OF THE INTERIOR
GEOLOGICAL SURVEY
80"00' sgpooonE 591 592 593 57 30" 594 5056 IV Nw
o I n - ARTINSMADISON 4i n M4i: 595 (MAYODAN)
36 22 30
r`1 P IFyre y . rP \_ 1 > f {n 1. f'Q i Woodlan 104 `y
1145 • ?'?'1 l (1 ye
,
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,
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?, ,?°° c./ '(` ? ;;? )i`i ??, `? \. "l I _'?\?(? % ? \ ? ?l. /( ) '? 'lll'°o ?' 1 I• b? I In'-- ??..1.
1 ,'600 Thl
eate -
4025000m.
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4024 (f\. - - _ I
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4023
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1900
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29
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17'30" I R8p ? ? I. ( I!f ) • 1 1 \ , .. ?.? \ p m = _ _ , ? . _ _ 1 (. f .II (' ,1 j r 1 ?r
OF WA
O TF9OG
r
o <
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 28, 2002
DWQ # 02-0095Y
Rockingham County
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
Andrew Strader
5322 Eckerson Road
Greensboro, NC 27405
Dear Mr. Strader:
On January 22, 2002, the Divisicri of `w'V er Quality (DWQ) was notified by receipt of your application
regarding your plan to fill streams for tree ?urootse of constructing the Sardis Church subdivision in Rockingham
County. Approval from DWQ is requii-edim disturb these areas. The enclosed application needs to be
completed and returned to us with 7 copies c? tte application, supporting maps and documentation. In
pa-r icular as described in 15A NCAC 27-- X172, we will require you to locate all streams and ponds on the
property and provide a site plan which ciE?ariy sfrows the road crossing. Also please ad ress what stormwater
control measure you plan to use forth` 6--v -iopment (Item XI on the application). Please show these on maps
of suitable scale (for instance 1" = 100 ) so 1rUe can begin to determine your projects' compliance with 15A
MCAC 2H .0500. We are hereby return irig ),Dur application package since we cannot process this incomplete
application.
Please telephone me at 91_0,7S-3--! 786 r you have any questions or would require copies of our rules or
procedural materials. This project will r--7,-din on fiseld as incomplete in accordance with 15A NCAC 2H
.0505(c). The processing time for this ;a:oib ion vAl begin when this information is received. If we do not hear
Tom you by writing within three (3) vv-e-eks we Will assume you no longer want to pursue the project and will
r.Dnsider it withdrawn.
rely,
_0'
Dorney
r Quality Certifi tion Program
CC Winston-Salem DWQ Regk rlrl M6
Raleigh Corps of Engineers
Central Files
File Copy
Wet-WeA1401 unit 1650 Mail SerAce Cep aE+g ? ' 27699-1650 Ph: (919) 7337015 Fax: [phone]
MA
iV CDENR
Customer Service
1 800 623-7748
\O?OF W AT F9pG
Q ?
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
DWQ Project No.: 01 - Q©q 7 County:
F;
Applicant: C " e- JUN -
Project Name: _ _5a- -g l-4uKCk W AIV
TERn?a
Date of Issuance of Isolated Wetland Permit:
/,A - tJ 2
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any subsequent
modifications, the applicant is required to return this certificate to the 401/Wetlands Unit, North Carolina Division of
Water Quality, 1621 Mail Service Center, Raleigh, NC, 27699-1621. This form may be returned to DWQ by the
applicant, the applicant's authorized agent, or the project engineer. It is not necessary to send certificates from all of
these.
Applicant's Certification
hereby state that, to the best of my abilities, due care and diligence was
used in the observation of the construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and specifications, and
other supporting materials.
Signature: d3? U P- Date: -5?" ? / - 02- -
Agent's Certification
I,
used in the observation of the
compliance and intent of the 401
other supporting materials.
Signature:
If this project was designed by a Certified Professional
Date:
I, , as a duly registered Professional (i.e., Engineer,
Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to observe (periodically,
weekly, full time) the construction of the project, for the Permittee hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the construction such that the construction was observed to be built within
substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and
specifications, and other supporting materials.
Signature:
, hereby state that, to the best of my abilities, due care and diligence was
construction such that the construction was observed to be built within substantial
Water Quality Certificati-on and Buffer l Ines, the approved plans and specifications, and
Registration No.
Date
hdi.:' EE~l
N. C. 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)
[phone] (phone), 919-733-6893 (fax), (hftp://h2o.enr.state.nc.us/ncwetiands
Md
Md
U.S. DEPARTMENT OF AGRICULTURE
SOIL CONSERVATION SERVICE
BYF'
~r
CERTIFICATE OF ONERSHIP AND
NOTEi CERTIFICATE OF APPROVAL OF SEVER FI 4L OF SEVER FACILITIES
I i CERVY SHOVIN AND THAT II ( j NA (ARE) THE ON ONt KS) OF THIS SURVEY CREATES A SL~V3104 CF LNG THE Q( WO V1THIN THE AFEA OF A COUNTY OR NIGCVM TTY I HEREBY CERTIFY THAT THE LOTS SHOV THE LOTS SHOVIN ON THIS MAP HAVE PFEPWIiEL N1TI W THE 1E EM
IB LOCAIED IN THE SUIpMSHON dA1ST>ICRON OF ROCKINGHAM THAT NAS AN OROQNNCE THAT REGULATES BEEN EVALUATED IN ACCORDANCE V17H COMM AND THAT i HEREBY ADOPT THIS PLAN OF SUBDIVISION PAFICELS OF LM®. AND RUES FOR SEWAGE TREATMENT AN A E THE APPLICABLE 'LAMS
I WITH AIY (EIRE) FREE CONSENT. ESTA USH HINIMM BALDING (15,A NCAC ISA.1900, EXCEPT AS MOM STAN KY sMla TM FWORI E t AND OISPOSAI SYSTEMS' OF T TREATMENT KEPT AS NOTED. SPECIFICATIONS FOR Y~a~• CMXNM 11pRAMf1
WHACK LIES, AND DEDICATE AU SOREETS ALLEYS, WALKS, EACH LOT ARE AVAILABLE AT THE ROCK j PARKS, AND OTHER SITES AND EASEMENTS TO PUBLIC OR G E FIGNERTSON, PLS L-141 DEPARTMENT OF PUBLIC HEALTH, E AT 7HE ROCKINGHAM COUNTY 1!! IEOCE10MY DWATE ALL
(8 } I I PRIVATE USES AS NOTED. HEALTH. E fm ON THE rx• rAR Mac PRpPEATY,
R\a aort-W-WAY
I I ROCKNGHAM COUNTY EN DATE ox ucc maw" nemm W LM TD MY EASI:7en u.n elce uoatalaRO ozcm AGRFEIENTS OR RIIiAS-W-
LINDA F. KNOTTS I FOR VMYS OF RECORD WCH WERE
I OAR DATE DB.1015-P.1874 ICI F.M. W HYDRANT NO VISIKE AT THE 7W
NOTARY
/ I I
/ I I I a
/
LONNIE CRAY \ \
DB.1017-P.2399
3 ~ Dapm"mx
I i ( , I
_ I i I , ' y IL,b,, eARaa aa~ RD.
(7) i I i E
"Wasn MA}'
I i I , ~ llte° ~ 414% RD srxc
III I a e3?•E FRANCS TILLEY
SEE NAP FOR I I I rare ~L + . II
S mw CHURCH sumum"
R6WRTSI7N I I i - O • \ D8.681-P.685 OVlEI! 6DLANQHAU% W.
s-e-99 I I I I ( - 32 EEIQm1 m ROM
\ NB•41-P.79 I I NC 27405
q?.. / PROPI M LSE TAX MAP NO. 7904(0
Rs N PST a D® REITREWCE: 09.963-PAU
=v
s \
I I I JULIA R. PATTERSON
ANTHONY PEMRIIE\~ DB.683-P.908 s I
5 !1 I
\ I
(6} \ I ISM i s) ~ 11 i ; am UIL .te I
10.697 Ac.
I V I / Lq Ir OAA I S
` N9'03'E (1,051.38) to I imrmm 872 176.17' 277.33' SEE MAP FOR I a T RaNRrs A a 1
KAY TOSH 663.w 24,936.2 Sa.ft. DB.1041-P.1769 °e 2 I m 1 O 30,538.6 Sq.ft.. Nrr DAA o
MM NO. 1 a I
46 Ac. u c N 'COIr9LI0N 8 a ML13-P.16 E O s
w AREA g 4q'1o• m
\ \ \ f P y m 8 doh 54 s69.79 ch. N6452'23•W .46 44'arc 544' 26,78'ac
AN51Uq'32•W 27.40-ac 1 ROBERT M. WALL U 49Fh
DB.1039-P,2593 .64 ac 665.10' Le 121.12- 1Ych 48'w 1e ~ ~rJ ~ ~ y4.94 \ I
766,99') 58979 S 56.14-ore + N7r44'41
(4) x ""6A"o` (50*R^W) (PIVA1E) Y ' CHOCTOW COURT 1.009.22' t1
(7U.53')- (1.134.22') SW42 38 W \
` ` 6 7a 262.36' Le 196.67 199.80' LZ; 103.46' PT, L N14T ' E ~ (1,134.1
m 48'09'552 EE S64JO'S1'E Ls 268Ya~o` \ 5&9,r
(TIE LINE) 26.33'ch, W 1,000 30,541.4 Sa.f. !w 34,188.3 Sq.ft. Z 26.45'ch, Ac. 27,40'ac S75'41'4rE N46139151 28,73'orc ^ a nrA n DNA NIS''44•W 1 rn DMA ~ - ~v c 8 72,60'M, 41.82 40.96'a am 4
83.41' •T~ r c at A 78 22'ac = BAKER
1© 11.506 Ac.
z C, ~V~ 1® ® 36,163.7 Sq.ft. u, ~r
nY
P s 333 84' Nnt 6,m ~ 197,14' 213,93' \
u ~ 243.83' NBTJJ'JS•W (1,425,6Y) « 437.13'
O ~ OI 319. S2' 194.16' R= N87701
V~OG BETTY N. BAKER N8T30 x67.45'
N6779'34
DB.586-P.156
/ VM.OOE-P.567
I
I
I
6etwwa aum 0 I
eWoe" Lma I
I I
CERTIFICATE OF APPROVAL FOR RECGRDMQ MAJOR SUBDIVISON
HERESY CERTIFY THAT THE SU101VISXW PLAT SHOWN HEREON
HAS BEEN FOUND 70 COMPLY 16TH SUBDIVISION REGULATIONS FOR ROCIONOHAM COUNTY. NORTH CAIOIJN& AND THAT SUCH
PLAT HAS BEEN APPROVED ACCORDING TO THE PROCEDURES
FOR APPROVAL OF MAJOR SUBOMSIONS THIS PLAT SIALL BE RECORDED IN THE OFFICE OF 7HE REGISTER OF DEEDS WHIN
30 DAYS OF FINAL APPROVAL PLAT OF SLIRVEY
FOR DEPARTMENT OF PUM9!•10 DATE
CERTIFICATE OF APPROVAL OF REgARED IMPROVENENTB AND BUILDING 61SPECDONS is SARDIS CHURCH SUBDIVISION "
THE LMDERSIONED HIM CERTIFIES THAT THE REQUIRED
L/ lIGIVE E NTS HAVE BEE11 MADE ON THIS PROPERTY w AN ACCEPTABLE MANNER AND N ACCORDANCE VLTH THE CERTIFICATE OF DISCLOSURE. PRIVATE ROADS „PHASE 3"
SPECFlCAIMS OF THE SIR10IMSNIN ORDINANCE OF ROCINIGHAM I (VEJ THE DEVELOPER(S) OF `SARDIS CHUR04 SU13OIV1910F1• HLMTSVU.L.E TVSP. FKXX04344M CO
10117% cARO<aNA COUNTY AND OTHER APpPCANt REO0.ATKW ?EIMBY STATE THAT THE SUMMICH,NQAD% IN SHAW CHURCH
ROCKINOW COUNTY StRO WICH ARE PRIVATE ROAM 0914111" AND MAINTENAFICE NORTH CARQINA OF THE PRIVATE ROADS ARE THE INWOIONLRY OF 7W CUMM
OEPAR1MpNT OF DATE L. G E AOERTSIX CERTIFY THAT THIS PLAT VAS wAVN AND BI/DID w9PECTKW RIGHT OF ACCESS TO PRIVATE RQ$W WOSN SAID SUBDIVISION IS MAY 6. 2802 SCALE 1'= 106'
TIM NY RVERVVEM FROM AN ACTUAL SURVEY MAD Low Din OPIOROI C~RLaDN GUARANTEED TO ALL LOTS BERM BY SUCH ROADS ALL PROVISIONS OF G. S. 136-1029 ABLAIM TO PINVATE ROADS HAVE 1 100 200 300
Nf Sl6ERVTM CM DESCRIPI L REDO N IIOt- PAW , M% THAT THE 1NIU/BNIET MOT SURVEYED BEEN COMPLIED 117N
NE DOW AS YOU LNM TENT TIE NA73D ff PEIC=QN ~ ZR ~ OF NDIM
AS CALCU ATED IS ld8, IM FIAT W A0000 RTIY THAT ~yyN im IN AODTARMRS WM 614766 MEM& WITNESS IY LE DE%VLOM DATE SCALE
1 a CFRT TIFY TH THE NIP FCOUNTY QiI1W SMIIATII Ik1El1p1TlE1 NUNIM AND SEAL D M ALL STATU70W re rw c........s..« .
..r nr caR: FF I= ni OWE]{ --K RI L4.. rvjwn r lwm i wawwn r w
PfOFESSZONAL LAND SLFA4 DR L-1421
XJFVM FEECU R CF MMK IFSASIER OF BMW NOTARY - Pn BOX 384
LXENK MMM L-1141
EDEN, PC 27289 ATWST. PH (336) 627"0498
m AU T/4 KJTY FOOMM E FEEM 11111411111 T Di ~MiO DATE
AND FAVM IN IS
t