20200943 Ver 1_Determination Request_20200722

Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Name:*
Is this a transportation project?*
What type of request is this?*
Owner Information
Town of Apex - West Chatham Street Waterline
r Yes r No
r% Buffer r IP Stream Determination
r Isolated Wetland r Stream
Check all that apply.
Name on the Recorded Deed:* Town of Apex
Responsible Party: Jose Martinez, P.E.
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 919-249-3434
How would you like to received your determination?*
F 141
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
Yes
c'
Attach agent authorization letter:* ChathamSt_BufferDeterminationReques... 6.71MB
FDF only
Agent/Consultant Information
How would you like to receive your r IJSPS
determination letter?* r Email
Name of Agent:* Preston Butler
Company Name:* Carolina Ecosystems, Inc
Email Address:* [e-mail]
Project Information
Has anyone form DWR done a previous site visit?*
C, --
r No
r Other unknown
Date of Visit:

Site Information
Nearest Highway/Street:*
West Chatham Street
Nearest Town:*
Apex
Nearest Named Stream:*
Big Branch
River Basin:*
Cape Fear
County:*
Wake
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
aick the upload button or drag and drop files here to attach document
Rif file type only
TOPO map look up: https://viewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
dick the upload button or drag and drop files here to attach documnt
Rif file type only
Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
Please provide the Latitude and Longitude for physical location for the determination that. If you have a
physical address you can look up the Latitude and Longitude by typing in an address or filling out the
information manually.
Choose below how you would like to provide this information.
r Address Lookup
r Manually
Latitude: 35.7321
Longitude: 78.8553
M isc attachments: pdf or lace file types only
By digitally signing below, I certify that:
• I have given true, accurate, and complete information on this form;
o I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act")
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the "Determination Request' form."
Signature
r�l`ir"..vr�pwrf` Raaxmr_ �sr ir/�k,.vnr �rSsn�Fr
Date Submitted: 7/22/2020

Initial Review
ID#* 20200943
Version* 1
Do you want to send for review?* F Yes f No
Select Reviewer:* Rob Ridings:eads\rgridings
Select Regional Office:* Central Office - [phone]