20200756 Ver 1_Buffer and/or Stream Determination Request_20200610

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Quality
Express Buffer Applicability / Stream Origin
Determination Request
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
la. Name(s) on Recorded Deed
JOSEPH BOMERSHEIM
Sb. Responsible Party (for L-C)
lc. Mailing Address
124 WARRENS WAY, CHOCOWINITY, NC 27817
Id. Telephone Number
919-989-6062
1 le. Email address NONE
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
CHICOD PITT COUNTY, HWY 43, BESIDE CHICOD SCHOOL
3. Agent / Consultant Information
3a. Agent/ Consultant Name
HAYWOOD PITTMAN
3b. Company
PITTMAN SOIL CONSULTING
3c. Mailing address
PO BOX 1387, RICHLANDS, NC 28574
910-330-2784 3e. Email address [e-mail]
3d. Telephone no.
4. Project / Site Information
4a. Name of project
CHICOD
LANDING
4d. River Basin
NEUSE
4b.County
PITT
4e.Lat/Long
35.460641,77.2692257
4c. Nearest Named Stream
CLAYROOT
SWAMP
4F. Number Stream
Calls
2
5. Project Description (attach plan if available)
PROPOSED SUBDISION
6. Has anyone from DWQ visited the site?
Y
N X
Staff Name:
Date of Visit:
7. Does DWR staff have permission to
access this property?
Y X
N
8. Attach a map of the site Indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey
If you are unable to locate either of these maps, please contact the DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitigation? Nutrient offset credit?
9. Please return form to: Chris Pullinger
943 Washington Square Mall Note: Submittals on Friday after 12:00 pm
Washington, NC 27889 Will be stamped as received on the
Email: [e-mail] Next business day
Please contact Chris Pullinger at the Washington Regional Office at [phone] if you have any
questions.
D_EQ�
Nonh Carolina Department of Environmental Quality (Division of Water Resources- Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Qualify
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
PARCELID: �rGtS
STREET ADDRESS: Ak L_l � G .J C L l t o j)
Please print:
Property Owner: 2��oort-44ww
Property Owner:
The undersigned, registered property owners of the, above noted property, do hereby authorize
%I."/�� 101(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
y1 Q t nJ f GIhU C� 4nell' t _ a 0XI l?
Telephone: 1�1[4-V5 --f6D I
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
�OstpL %yz�+�1-tw_
Authorized Print Name
Date: h ��
—c
lGi&Orized Signature
North Carolina Department of Environmental Quality IDivision of Water Resources- Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

Owner: JOESPH BOMERSHIEM
Address: HWY 43
Location: CHICOD, PITT CO.
_Chiccd Sch
PITTMAN SOIL CONSULTING
PO BOX 1387
RICHLANDS, NC 28574
910-330-2784
PITTMANSOIL(aYAHOO. COM
APPROX SCALE NONE