20040766 Ver 1_Initial Interest_20040512

INITIAL INTEREST IN PARTICIPATION IN THE EXPRESS PERMITTING PROGRAM
FOR THE 401 WATER QUALITY CERTIFICATION,
ISOLATED WETLAND PERMITTING
OR STREAM ORIGIN DETERMINATION PROGRAMS
February 25, 2004
Version 2
Applicant Name:
Applicant Address: ~ l.5'
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Rood ~e-ve~~r,.e~
Applicant's phone number: 5Jr3 -~-~(c~}' Fax number:
Applicant's email address:
Consultant Name (if applicable): Iv ~9--, ~ ~ b~
Consultant address (if applicable): ~ ~ O8 ~~1~t~~t1`/~ ~'r ~ V`~
~~~Q,~ql.. N C 2?(~I S
Consultant's phone number: ~-'22 ~7 ~'" ~ Fax number: ~1b ` $39J
Consultant's email address:
Type of action requested under the Express Review Program (check all that apply):
^ 401 Water Quality Certification
^ Isolated Wetland Permit ~ ~ ~ n •7 L L
^ Riparian Buffer Approval ~P [.J t7 V
Stream Origin Determination
# of Determinations Requested
Name of Project: ~ ilMU~c~ ~~ ~p'`~-~-~- t ~ 2
Property size (acres) ~ a 5 QC.{2S County: _ v0-~lJ1S~ ~-o
Nearest named stream (from USGS topo map): ~Qa~SR, Qt~-.21(
Please provide a brief description of this project (attach site plan if available):

Please attach a map of site location using USGS 1:24,000 map and county soil survey.
1

Proposed impacts
C~ U ~i ~ r ~s~ Gr~SSi ~ "~
(0~.2~ Ac
~ c-cass;~ G 150
?~ -~0 1
bu.~
f
GC aSS~ r
S~~
Acres of isolated wetlands
Linear feet of streams
Linear feet of isolated streams
Square feet of protected stream buffers
Has consultant or applicant attended any DWQ-sponsored training sessions in the past two years? If so,
please list which ones.
Does this project require approval under the State Environmental Policy Act or National Environmental
Policy Act? IUD
DoesN this Project require approval of a Variance from the NC Environmental Management Commission"
Are you aware of any local controversy concerning this project? If so, please describe the controversy and any
measures that have been taken with respect to public involvement.
This form must be submitted via email (c/o [e-mail]) fax [phone]) or hand-delivered
(Parkview Building, 2321 Crabtree Blvd., Raleigh, NC 27604) within the first three (3) working days of the
month for the first three months of the Express Review Program (until January 1, 2004). Application
procedures after that time will be provided at a later date. Applicants who are selected to participate in the
Express Review Program will be notified via email or fax with one additional working day. Successful
applicants will then be instructed regarding detailed procedures for full application. Unsuccessful applicants
will be queried to determine if they want to be in the following month's selection process or whether they
want to follow the normal application process.
Please contact John Dorney at 919-733-9646 if you have any questions regarding this form.
2
Which other environmental permits will be needed for this project? Please list them below:
Location of project site -please include reference to the county, nearest name town and highway number: