20021712 Ver 1_COMPLETE FILE_20021022

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October 29, 2002
Forsyth County
DWQ Project #: 02-1712
APPROVAL of 401 Water Quality Certification with ADDITIONAL CONDITIONS
Todd Harris
3426 Dixiana Lane
Pfafftown, NC 27040
Dear Mr. Harris:
You have our approval, in accordance with the attached conditions, to impact 285 feet of stream
for the purpose of creating a pond at 421 Old North as you described in your application dated October
15, 2002. After reviewing your application, we have decided that this fill is covered by General Water
Quality Certification Number 3362, which may be viewed on our website at
http://h2o.enr.state.nc.us/ncwetlands. This certification allows you to use General Permit Number 39
when the Corps of Engineers issues it. In addition, you should get any other federal, state or local
permits before you go ahead with your project including (but not limited to) Sediment and Erosion
Control, Coastal Stormwater, Non-Discharge and Water Supply Watershed regulations. This approval
will expire when the accompanying 404 or CAMA permit expires unless otherwise specified in the
General Certification.
This approval is only valid for the purpose and design that you described in your application
except as modified below. If you change your project, you must notify us and you may be required to
send us a new. application. If the property is sold, the new owner must be given a copy of this
Certification and approval letter and is thereby responsible for complying with all conditions. If total
wetland fills for this project (now or in the future) exceed one acre, compensatory mitigation may be
required as described in 15A NCAC 2H.0506 (h) (6) and (7). This approval shall expire when the
corresponding Nationwide Permit expires or as otherwise provided in the General Certification. For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
1. Upon completion of the project, the applicant shall complete and return the enclosed.
"Certification of Completion Form" to notify DWQ that all the work included in the 401
Certification has been completed. The responsible party shall complete the attached form and
return it to the 401/Wetlands Unit of the Division of Water Quality.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory
hearing. You must act within 60 days of the date that you receive this letter. To ask for a hearing, send
a written petition, which conforms to Chapter 150B of the North Carolina General Statutes to the
Office of Administrative Hearings, P,O. Box 27447, Raleigh, N.C. 27611-7447. This certification and
its conditions are final and binding unless you ask for a hearing.
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/ncwetlands
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
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This letter completes the review of the Division of Water Quality under Section 401 of the Clean
Water Act. If you have any questions, please telephone John Dorney at 919-733-1786 or Jennifer Frye
at our Winston-Salem Regional Office at 336-771-4600.
JRD/bs
Attachments
Sincerely,
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P.E., r for
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cc: Corps of Engineers Raleigh Field Office
Winston-Salem DWQ Regional Office
File copy
Central Files
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OCT 2
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X217 4 s..,?
Pre-Constr notification (PCN) Applicationi?orm
For Section 4lor Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
http://www.saw.usace.army.n-iil/wetlands/Perm _app. htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at http://www.saw.usace.army.mil/wetlands/regtour.htm, or contact one of the field
offices listed on page 3 of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.nc.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for General Certifications is not required, provided
that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet should
contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission .(NCWRC) is required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on page 4 of this application) prior to submittal of the application.
Page 1 of. 12
Coastal Area Management Act (LAMA) Coordination - If the project occurs in any of North Carolina's
twenty coastal counties (listed on page 4) the applicant should contact the North Carolina Division of
Coastal Management (DCM). DCM will determine whether or not the project is within a designated
Area of Environmental Concern, in which case DCM will act as the lead permitting agency. In such
cases, DCM will require a CAMA Permit and will coordinate the 404/401 Permits.
The applicant may also choose to coordinate with the United States Fish and Wildlife Service to ensure
that the proposed project will have no impact upon any endangered or threatened species or critical
habitat as regulated by the Endangered Species Act, and the State Historic Preservation Office, North
Carolina Department of Cultural Resources to ensure that the proposed project will have no impact upon
any properties listed or eligible for listing on the National Register of Historic Places. Compliance with
these regulations is required to be eligible for any Department of the Army permit. The addresses for
both agencies are listed on page 3 of this application.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office. Upon receipt of an application, the
USACE will determine if the application is complete as soon as possible, not to exceed 30 days. This
PCN form is designed for the convenience of the applicant to address information needs for all USACE
Nationwide, Regional or General permits, as well as information required for State authorizations,
certifications, and coordination. Fully providing the information requested on this form will result in a
complete application for any of the USACE Nationwide, Regional or General permits. To review the
minimum amount of information that must be provided for a complete PCN for each USACE
Nationwide permit, see Condition 13, 65 Fed. Reg. 12893 (March 9, 2000), available at
http://www.saw.usace.army.mil/wetlands/nwpfinalFedReg_pdf. Processing times vary by permit and
begin once the application has been determined to be complete. Please contact the appropriate
regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated
as optional. Incomplete applications will be returned. Submit seven collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet cumulative impacts to
streams, then a fee of $200 is required. If either of these thresholds is exceeded, then a fee of $475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be stapled to the front of the application package. For more
information, see the DWQ website at http://h2o.ehnr.state.nc.us/ncwetlands/fees.html. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office.. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,.
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Page 2 of 12
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office
US Army Corps of Engineers
151 Patton Avenue
Room 208
Asheville, NC 28801-5006
Telephone: [phone]
Fax: [phone]
Raleigh Regulatory Field Office
US Army Corps Of Engineers
6508 Falls of the Neuse Road
Suite 120
Raleigh, NC 27615
Telephone: [phone]
Fax: [phone]
Washington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1000
Washington, NC 27889-1000
Telephone: [phone]
Fax: [phone]
Wilmington Regulatory Field Office
US Army Corps Of Engineers
Post Office Box 1890
Wilmington, NC 28402-1890
Telephone: [phone]
Fax: [phone]
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
US Fis
US Fish and Wildlife Service
Raleigh Field Office
Post Office Box 33726
Raleigh, NC 27636-3726
Telephone: [phone]
Alexander Caldwell Haywood McDowell Swain
Alleghany Catawba Henderson Mecklenburg Transylvania
Ashe Cherokee Iredell Mitchell Union
Avery Clay Jackson Polk Watauga.
Buncombe Cleveland Lincoln Rowan Yancey
Burke Gaston Macon Rutherford
Cabarrus Graham Madison Stanley
Alamance Franklin Nash Surry
Caswell Forsyth Northampton Vance
Chatham Granville Orange Wake
Davidson Guilford Person Warren
Davie Halifax Randolph Wilkes
Durham Johnston Rockingham Wilson
Edgecombe Lee Stokes Yadkin
Beaufort Currituck Jones
Bertie Dare Lenoir
Camden Gates Martin
Carteret* Green Pamlico
Chowan Hertford Pasquotank
Craven Hyde Perquimans
Anson Duplin Onslow
Bladen Harnett Pender
Brunswick Hoke Richmond
Carteret Montgomery Robeson
Columbus Moore Sampson
Cumberland New Hanover Scotland
North Carolina State Agencies
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
h and Wildlife Service / National N
US Fish and Wildlife Service
Asheville Field Office
160 Zillicoa Street
Asheville, NC 28801
Telephone: [phone]
Pitt
Tyrrell
Washington
Wayne
*Croatan National Forest Only
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
[arine Fisheries Service
National Marine Fisheries Service
Habitat Conservation Division
Pivers Island
Beaufort, NC 28516
Telephone: [phone]
Page 3 of 12
CAMA and NC Coastal Counties
Division of Coastal Management
1638 Mail Service Center
Raleigh, NC 27699-1638
Telephone: [phone]
Fax: [phone]
Beaufort Chowan
Bertie Craven
Brunswick Currituck
Camden Dare
Carteret Gates
NCWRC and NC Trout Counties
Hertford Pasquotank
Hyde Pender
New Hanover Perquimans
Onslow Tyrrell
Pamlico Washington
Western Piedmont Region Coordinator Alleghany Caldwell Watauga
3855 Idlewild Road Ashe Mitchell Wilkes
Kernersville, NC 27284-9180 Avery Stokes
Telephone: [phone] Burke Surry
Mountain Region Coordinator Buncombe Henderson Polk
20830 Great Smoky Mtn. Expressway Cherokee Jackson Rutherford
Waynesville, NC 28786 Clay Macon Swain
Telephone: [phone] Graham Madison Transylvania
Fax: [phone] Haywood McDowell Yancey
APPLICATION FORM BEGINS ON PAGE 5. PLEASE DO NOT SUBMIT PAGES 1 - 4.
Page 4 of 12
Office Use Only: Form Version May 2002
USACE Action ID No. DWQ No.
(if any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
1. Processing
1. Check all of the approval(s) requested for this project:
? Section 404 Permit ? Riparian or Watershed Buffer Rules
ction 10 Permit ? Isolated Wetland Permit from DWQ
? 401 Water Quality Certification
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. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: p,0 1, s-
Mailing Address: 302 6 LA/ 1 f
r_? A !/GS A/, / 7,0 4.2
Telephone Number:1336NZZ t4F79 Fax Number:
E-mail Address: °.a?°r?s Dar
2. Agent/Consultant 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:
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 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: "00/V.o
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN): ??/f Z4?
4. Location
County: Y71 -1 Nearest Town: /- ro}?,?Oeay
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.): D it/!i' L
5. Site coordinates, if available (UTM or Lat/Long):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Property size (acres): .157 eleels '
7. Nearest body of water (stream/river/sound/ocean/lake):
8. River Basin: Y,6-01elAl , el t?
(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.ne.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: i-o IA/ LAV.D
10. Describe the overall project in detail, including the type of equipment to be used: 67.- -
.44ne z z4eil!' . "-,e/t A 111 ?`ir?EiVSio?ys ,° /eZ D
AIioT? E' 20P ` Z $ :5?' Lei 7f4 / ?Iee n yzzG D,-- ".,-7
.?.??SC?. °??`fF.2.. O? /lOT rrlT. /f/?_' , ?° ?T.D, i°/!°?" .P/ s? ?
STD, ?•?ct.e , /?/Gt •??Y. 3EE •??/.yc`?? a ?L!/ro .BY
.STD. EpuiP.??•vT,Do ZE,?.? d? ?d?EP??R .t/£.Q .
11. Explain the purpose of the proposed work:
Tv .Bu/c,o 4 s,n,O-4eAi tAD.
i
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.
N 1.5Z
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.
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.
Page 7 of 12
1. Provide a written description of the proposed impacts: / '04 L Ess AVIXV e.
FD Q -2 gs- ` ./ H`E G ox 0lY--v Al hlf.2 f_ 9zo s W .Pe/',ks /e. r,

2. Individually list wetland impacts below: IY114-
Wetland Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

List each impact separately and identity temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year tloodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property: N 1i¢
Total area of wetland impact proposed:
3. _Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
(indicate on ma)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Im act Perennial or
Intermittent?
( leasespecify)
5517 - 6-

List each impact separately and identity temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. 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,
www.mapguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
(indicate on ma)
Type of Impact` Area of
Impact
(acres)
(if Name of ody
applicablecable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)
N

List each impact separately and identity temporary impacts. impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
5. Pond Creation
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.): A-4m E XL'f3ds? .t! T 14',A J_ Drts?,,
„STO. pi?'E el re z r ,,,01,e e- w,V y -SEA ???lEd .Ok/G .
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): wi?Q?/?'E.YyA•?cE?,vi ?i?ii,?ic,?Ta?
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.
,5',E"-5 .4T•9i e- '4?E a p*"/6 8 Y Ae"Vlo r ?i?ssL/.P1l?TE.2s
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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 impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
httj2://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at http://h2o.enr.state.ne.us/wrp/index.htm. If use of
the NCWRP is proposed, please check the appropriate box on page three and provide the
following information:
Amount of stream mitigation requested (linear feet): N1i4
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) 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 (required by DWQ)
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 Al //.t- )?
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* Impact
(square feet) Multiplier Required
Mitigation
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.
Page II of 12
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. ``
lel /.4
XI. Stormwater (required by DWQ)
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.
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XII. Sewage Disposal (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No [D/
Is this an after-the-fact permit application?
Yes ? No Lam"
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).
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Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12

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