20201004 Ver 1_401 Application_20200804

LANDSCAPE ARCHITECTURE - CONSERVATION PLANNING – LOW IMPACT DEVELOPMENT
P.O. Box 8013 - Asheville, NC 28804 – PH. 828-243-6604
www.fuscola.com
1
August 4, 2020

David Brown
USACE Contact for Transylvania County
151 Patton Avenue, Room 208 Asheville, NC 28801

Re: Slusher - Sapphire Farm

Slusher - Sapphire Farm - Project Description

The purpose of this project is to repair existing stream crossings along tributaries on the
property, to enhance the lake edge of Lake Pickens & associated tributaries including the
Thompson River, and to provide an alternate access to an existing cabin site which will be
improved. The proposed enhancements will not only allow the owner better access to different
areas of the property but, more importantly, it will offer an opportunity for habitat
improvement on a variety of levels within the watershed. Lake Pickens itself is a waterbody
created by damming up an unnamed tributary to the Thompson River. Based on our records,
we understand the lake has been in place with its current dam since before 1971. The property
was operated as Camp Buc, a Presbyterian Camp, until sometime around 2015 and was left
unoccupied until Shannon Slusher & his family purchased the property in early 2019. The
property itself is located southwest of Lake Toxaway at 4730 Upper Whitewater Road
Sapphire, NC 29774 on the left after you cross the bridge over the Thompson River coming
from the south.

Mr. Slusher has engaged Stephen Stimson Associates for site overall planning efforts which
include restoration of an old cabin site, a new main house and new barn areas. Also, we have
engaged Anchor QEA of Asheville for dam evaluation and improvement. I am assisting as a
local contact for overall project coordination and permitting.

Since closing, we have been working with Lloyd Raleigh of Helia Environmental to work with
on bog restoration and forest enhancement activities. That work is ongoing and many areas
are in the process of being restored. (See Attachment A for a brief description of the Bog
work.) Also, Mr. Slusher has met with Jacob Rash and Andrea Leslie of the NC Wildlife
Resources Commission to explore options for fish habitat restoration within the lake, the
Thompson River and other tributaries on the property.

This work has been in support of Mr. Slusher’s desire to improve habitat diversity throughout
the property and includes the lake edge improvements and other disturbances we are
requesting approval for herein. The additional work will allow us to implement a program to

LANDSCAPE ARCHITECTURE - CONSERVATION PLANNING – LOW IMPACT DEVELOPMENT
P.O. Box 8013 - Asheville, NC 28804 – PH. 828-243-6604
www.fuscola.com
2
renaturalize the lake to make it feel like more of a natural feature rather than a man-made one.
Also, it will provide improved access for dam maintenance and access to bog restoration areas
below the dam. With these goals in mind, we submit to you our request for Nationwide Permit
approval for the following activities.

A. Starting upstream of the lake, we plan to replace an existing crossing structure that
creates a pool along the unnamed tributary that enters the lake. The proposed activity
will be within the footprint of the existing structure and will maintain a similar profile
to the existing condition but will impound an additional area upstream of the existing
structure.
- For the existing stream crossing and primary weir structure, we will flood an
additional area upstream of the crossing. This will result in 61 linear feet of stream
disturbance due to flooding and will result in the addition of 0.06 Ac of open
water.

B. Within the lake and dam area, we are proposing to modify the dam and vary the lake
edge to create larger areas of wetland edge as well as a couple deeper pools for fishing,
swimming and water play. Also, there will be a raised area (currently outside of the
existing lake edge) and small dock along the lake's north edge. It should be noted that
there was an existing boathouse and dock structure at the east end of the lake which
the owner removed in early 2019. The building structure was approximately 1500 sq.
ft. and the dock was approximately 500 sq. ft.
- Lake edge enhancements will impact 0.38 Ac of wetland area and the installation of
a small dock will create 0.0005 Ac of open water impact for the installation of 6 +/-
pilings within the existing lake edge.
- The enhancements will result in a net gain in open water area and wetlands. 4.45
Ac of open water will be provided at project completion and 0.71 Ac of wetland
edge area will be created which will result in a net gain of 1.18 Ac of open water
and 0.33 Ac of wetland area over the current condition.
- Stream impacts associated with the proposed dam improvements will include 40
linear feet of stream disturbance impacted by fill and 48 linear feet of stream
disturbance impacted due to flooding. The feature itself will create 0.20 Ac of open
water. Also, this will include the removal of a 20’ culvert for 20 linear feet of stream
daylighting. The proposed impacts minus the daylighting will result in a total of 68
linear feet of stream disturbance. In addition, a pipe along the proposed wetland
disturbance in this area will be removed, however, we will not be claiming credit for
that.

C. Below the dam, we are proposing to add an ATV access drive to access an existing
cabin site to the southwest. This access drive will allow us to reduce the width of the
access across the dam to a path to make the lake feel more natural and provide
additional area for edge habitat creation. Finally, it will provide better access to the
downhill side of the dam for maintenance effort. The development of this access drive
will result in stream and wetland impacts but will ultimately create improved habitat by

LANDSCAPE ARCHITECTURE - CONSERVATION PLANNING – LOW IMPACT DEVELOPMENT
P.O. Box 8013 - Asheville, NC 28804 – PH. 828-243-6604
www.fuscola.com
3
allowing better future access for dam maintenance and bog restoration and
management activities.
- Wetland impacts include 0.10 Ac of wetland impact due to the construction of the
ATV access drive.
- Stream Bank Stabilization along the Thompson River will allow us to stabilize the
bank edge along the Thompson River where the existing outfall enters the river. This
work will result in 75 linear feet of stream bank stabilization in this area.
- A proposed boardwalk crossing a wetland/bog. Wetland impacts include 0.001 Ac
of wetland impact for pilings associated with the proposed boardwalk.
- Other crossings will be accomplished through the use of fords and bridges.

D. Thompson River improvements include the introduction of a rock vane structure and
streambank work to create a pool upstream of the proposed structure. The crest
elevation of the vane structure would sit just below the bank full height of the channel.
- Impacts for the structure itself would be 15 linear feet including a ladder type
feature on the downstream side to promote fish passage.
- Stream Bank Stabilization along the Thompson River at this location will allow us
to modify and stabilize stream banks along the channel edge upstream of the
proposed vane structure. This work will result in 100 linear feet of stream bank
stabilization and disturbance of 0.005 Ac of wetland in this area.

E. In addition to the impacts proposed above, we are planning for the restoration of
existing wetland/bog complexes within the project area. This area is roughly 20 acres
and generally consists of a 90% shrub layer. We are working with Lloyd Raleigh of Helia
Environmental to transition these areas closer to a 50% shrub layer, 3.4 acres of which,
was completed in 2019. With this request, we would like to plan for the installation of
18” +/- grade changes within the incised areas of the drainages through the wetland
and potentially flashboard risers to help keep wet areas flooded. Also, efforts will be
made to grade out or remove unnatural hummocks and high areas. We are requesting
permit approval to perform restoration activities within the 20.76 Acres of
wetland/bog complexes within the project area.

Our proposed overall disturbance/enhancement will result in the following Nationwide Permit
Requests:
1) Total Stream Channel Disturbance 144 LF under NWP 27
2) Total Wetland Disturbance 0.385 Ac under NWP 27
3) Total Stream Bank Stabilization 175 LF under NWP 27
4) Total Open Water permanent impact of 0.0005 Ac under NWP 29
5) Total Wetland Disturbance 0.001 Ac under NWP 29
6) Total Wetland/Bog Restoration 20.76 Ac under NWP 27
Mitigation Proposal:
a. New wetland area of 0.68 Ac for a net gain of 0.31 Ac of wetland , nearly 2:1
mitigation for the proposed wetland disturbance around the lake.

LANDSCAPE ARCHITECTURE - CONSERVATION PLANNING – LOW IMPACT DEVELOPMENT
P.O. Box 8013 - Asheville, NC 28804 – PH. 828-243-6604
www.fuscola.com
4
Efforts have been made to avoid and minimize disturbances as part of our work as well. With
the lake area, we will be transforming the lake edge into a more sinuous curvilinear edge with a
greater variety of habitat opportunities. While there will be wetland disturbance associated
with this work, we will be creating additional wetland and increasing the total to provide more
wetland at project completion. The impacts in this area will be temporary and we are
confident the resulting wetland edge will be higher quality that what’s currently there. The
increased flooded area behind the proposed weir structures above and below the lake will
disturb stream channel but will create additional open water. Also, the pool area may be used
as a collection point to divert water around the work area while under construction. The ATV
below the dam access road was pulled as close to the base of the dam as possible to minimize
impacts to the wetland below. Establishment of the access will help prevent future disturbance
by allowing access to the base of the dam for maintenance activities. Other disturbance on the
site are proposed for purposes of habitat improvement for flora and fauna which will
ultimately promote diversity and a healthy ecosystem.
With regard to additional approvals, proposed vertical construction will require typical
building permits from Transylvania County. The full extent of the proposed land disturbing
activity has not been determined but any proposed activity greater than one acre of
disturbance, including the lake area, will require erosion control approval by the North
Carolina Department of Environmental Quality – Land Quality Section (NCDEQ). Due to its
location along a designated trout waters, we are requesting a trout buffer variance from the
NCDEQ - Land Quality Section as well. Due to the difference in permit review timelines, the
NCDEQ trout buffer variance and erosion control permit requests will be submitted separate
of, but contingent upon, receiving approval for the proposed disturbances requested herein.
Work will commence as soon as all required permits are in hand. Equipment to be used will
be traditional construction equipment, including bulldozers, trackhoes and excavators for the
sitework and traditional construction equipment for erecting any structures.
Additional information will be provided upon request.
Thank you,
/s/ Matthew J. Fusco 08/04/2020
Matthew J. Fusco
Enclosures
DWR
mrlslon of Water Resources
Pre -Construction Notification (PCN) Form
April 11, 2020 Ver 3.1
Initial Review
Has this project met the requirements for acceptance in to the review process?*
r Yes
r No
Is this project a public transportation project?*
C Yes r No
Change only if needed.
BIMS # Assigned
20201004
Is a payment required for this project?*
r No payment required
r Fee received
r Fee needed - send electronic notification
Reviewing Office *
Asheville Regional Office - [phone]
Information for Initial Review
1a. Name of project:
Slusher - Sapphire Farm
1a. Who is the Primary Contact?*
Matthew Fusco
1b. Primary Contact Email:*
[e-mail]
Date Submitted
8/4/2020
Nearest Body of Water
Lake Pickens along an unnamed tributary to the Thompson River onsite
Basin
Savannah
Water Classification
Thompson - C,TR
Site Coordinates
Latitude: Longitude:
35.085-83.017
A. Processing Information
County (or Counties) where the project is located:
Transylvania
Is this a NCDMS Project
r Yes r No
Is this project a public transportation project?*
r Yes r No
1a. Type(s) of approval sought from the Corps:
W Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Version#*
1
What amout is owed?*
IT $240.00
r $570.00
Select Project Reviewer*
Kaylie Yankura:eads\kyankura
1c. Primary Contact Phone:*
[phone]
1b. What type(s) of permit(s) do you wish to seek authorization?

W Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?
r Yes r No
Nationwide Permit (NWP) Number:
Nationwide Permit (NWP) Number:
NWP Numbers (for multiple NWPS):
1d. Type(s) of approval sought from the DWR:
W 401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
r Individual Permit
27 - Restoration
29 - Residential Developments
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
For the record only for Corps Permit:
F- 401 Water Quality Certification - E)press
r Riparian Buffer Authorization
1f. Is this an after -the -fact permit application?*
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
Acceptance Letter Attachment
1h. Is the project located in any of NC's twenty coastal counties?
r Yes r No
1j. Is the project located in a designated trout watershed?
r Yes r No
B. Applicant Information
1d. Who is applying for the permit?
r Owner 9 Applicant (other than owner)
le. Is there an Agent/Consultant for this project?*
r Yes r No
2. Owner Information
2a. Name(s) on recorded deed:
Wachhund Land Company, LLC
2b. Deed book and page no.:
879/344
2c. Responsible party:
Shannon Slusher
2d.Address
Street Add-
3 Stansbury Drive
Address Line 2
City
Asheville
Fbstal / Zip Code
28803
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
State / Rovince / legion
NC
Country
USA
2f. Fax Number:
r^ Yes r No
r^ Yes r No

3. Applicant Information (if different from owner)
3a. Name:
Matthew Fusco
3b. Business Name:
Fusco Land Planning & Design, PLLC
3c.Address
Street Address
P.O. Box 8013
Address Line 2
(Sty
State / Province / Pegion
Asheville
NC
Postal / Zip Code
Country
28814
USA
3d. Telephone Number:
3e. Fax Number:
[phone]
3f. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Matthew J Fusco
4b. Business Name:
Fusco Land Planning & Design, PLLC
4c.Address
Street Address
P.O. Box 8013
Address Line 2
city
State / Province / Fbgion
Asheville
NC
Postal / Zip Code
Country
28814
USA
4d. Telephone Number: 4e. Fax Number:
[phone]
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
2-Slusher-Sapphire_Farm_Agent_Authorization_Form.pdf 707.49KB
C. Project Information and Prior Project History
1. Project Information
1b. Subdivision name:
(d appropriate)
1c. Nearest municipality/ town:
Sapphire
2. Project Identification
2a. Property Identification Number:
2b. Property size:
7590-98-1632
461.28
2c. Project Address
Street Address
4730 Upper Whitewater Road
Address Line 2
(Sty
State / Rmime / Fegim
Sapphire
NC
Postal / Zip Code
Country
2774
Transylvania
3. Surface Waters

3a. Name of the nearest body of water to proposed project:*
Lake Pickens along an unnamed tributary to the Thompson River onsite
3b. Water Resources Classification of nearest receiving water:*
Thompson - C,TR
3c. What river basin(s) is your project located in?*
Savannah
3d. Please provide the 12-digit HUC in which the project is located.
030601010104
4. Project Description and History
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:*
See Project Narrative
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
r Yes r No r Unknown
4d. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for DWR)
3-Slusher-Sapphire_ Farm _USGS_Map.pdf 1021.86KB
4e. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site. (for DWR)
4-Slusher-Sapphire_ Farm_Soil_Report.pdf 1.48MB
4f. List the total estimated acreage of all existing wetlands on the property:
20.76
4g. List the total estimated linear feet of all existing streams on the property:
42,040
4h. Explain the purpose of the proposed project:*
See Project Narrative
41. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
See Project Narrative
4j. Please upload project drawings for the proposed project.
15-200731 ACOE PERMIT SET.pdf 39.59MB
16-200731 11 X1 7 Record_ACOE PERMIT SET.pdf 35.13MB
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
r Yes r No r Unknown
Comments:
Lloyd Raleigh of Helia Environmental has delineated wetlands and streams on the property
5b. If the Corps made a jurisdictional determination, what type of determination was made?
r Preliminary r Approved r Not Verified r Unknown r N/A
Corps AID Number:
SAW-2020-00113
Sc. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Lloyd Raleigh
Agency/Consultant Company: Helia Environmental
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made bythe Corps or DWR
May 14, 2020 Site Visit, June 4, 2020 Approved
5d1. Jurisdictional determination upload
14-SAW-2020-00113 Slusher Property PJD.pdf 1.95MB
6. Future Project Plans
6a. Is this a phased project?*
r Yes r No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity?

D. Proposed Impacts Inventory
1. Impacts Summary
Ia. Where are the impacts associated with your project? (check all that apply):
W Wetlands W Streams -tributaries r Buffers
W Open Waters r Pond Construction
2. Wetland Impacts
2a1 Reason (?)
2b. Impact type * (?)
2c. Type of W.
2d. W. name*
2e. Forested *
2f. Type of
2g. Impact
Jurisdicition*(?)
area
WS,W6,W7
Lake Edge
T
Isolated Wetlands
Wetland due to lake
Both
0.380
Enhancement
flooding
(acres)
W9,W11
ATV access Road
P
Bog
Wetland due to historic
No
Both
0.101
road construction and
(acres)
floodplain area w high
voter table
W1
Bank Stabilization and
P
Isolated Wetlands
Wetland area adjacent
Both
Rock Vane at the
to Thompson River
r_1
F�]_
Thompson River
2g. Total Temporary Wetland Impact 2g. Total Permanent Wetland Impact
0.380 0.106
2g. Total Wetland Impact
0.486
2h. Comments:
Wetlands along the lake edge established over time due to the impoundment. We have Google images dating back to 1993 showing the dam and a
narrative history of Camp Buc that describes the dam being rebuilt prior to 1971. We understand that mitigation for these wetland areas is not
required. However, we are proposing to reestablish a wetland edge in areas along the perimeter of the modified lake edge. We expect the total
additional wetland area to be approximately 0.68 Ac
3. Stream Impacts
3a. Reason for impact (?)
3b.lmpact type *
3c. Type of impact*
3d. S. name*
3e. Stream Type *
3f. Type of
3g. S. width *
3h. Impact
❑
(?)
Jurisdiction*
length*
S1
S5 - Impacts due to floodin
P 9
Permanent
Flooding
9
S5 - Pool and Weir
Perennial
Both
3
61
improvements
Average (feet)
(linearfeet)
S2
S6 - impacts due to fill for
P
Permanent
Flooding
9
S6 - Dam Improvements
P
Perennial
Both
2
68
dam improvements
Average (feet)
(lir�rfeet)
S3
Thompson River
Temporary
Other
Thompson River
Perennial
Both
18erage(feet)
15
Avnearfeet)
(li
31. Total jurisdictional ditch impact in square feet:
0
31. Total permanent stream impacts:
129
31. Total stream and ditch impacts:
144
3j. Comments:
4. Open Water Impacts
31. Total temporary stream impacts:
15
4a. Site # 4af. Impact Reason 4b. Impact type 4c. Name of waterbody 4d. Activity type �1149. Waterbody type 4f. Impact area
Lake edge
enhancements
T
Lake Pickens
Reshaping
Lake
0.00
4g. Total temporary open water Impacts:
0.00
4g. Total open water impacts:
0.00
4h. Comments:
4g. Total permanent open water impacts:
0.00

0.0005 o f impacts for pilings in the lake dock did not register above.
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
See Narrative
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
See Narrative
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?
r Yes r No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
We will have a net gain of open water and wetland and stream impacts within the range that would not require compensatory mitigation.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
r Yes r No
If no, explain why:
Not Applicable
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
r Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
r Yes r No
Comments:
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
r Yes r No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)?*
r Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?*
r Yes r No
3b. If you answered "no," provide a short narrative description.
This is a single family private estate. The proposed impacts are for purposes of improving site habitat conditions.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes r Nor WA
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
r Yes r No

5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r Yes r No
5d. Is another Federal agency involved?*
r Yes r No
5e. Is this a DOT project located within Division's 1-8?
r Yes r No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
r Yes r No
5g. Does this project involve bridge maintenance or removal?
r Yes r No
5h. Does this project involve the construction/installation of a wind turbine(s)?*
r Yes r No
r Unknown
Si. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
r Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
FWS IPaC website
Consultation Documentation Upload
5-Slusher-Sapphire_ Farm_IPaC_ Report.pdf 370.75KB
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
r Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
NNOAA Essential Fish Habitat Mapper
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as having historic or cultural preservation status?*
r Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
NC Historic Preservation Office's HPOWEB - Identified Dan Houck house which was onsite and has a survey but has been removed due to disrepair. I
would have been unlikely eligible for historic status per local NCSHPO office.
7c. Historic or Prehistoric Information Upload
13-Slusher-Sapphire_ Farm_ NC SHPO Review Request.pdf
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?*
r Yes r No
8c. What source(s) did you use to make the floodplain determination?*
FEMA Mapping
Miscellaneous
Comments
6.22MB
Miscellaneous attachments not previously requested.
1-Slusher_ Sapphire Farm - ACOE-DWR %rratve.pdf
258.23KB
6-Slusher-Sapphire_ Farm_PB19-109.pdf
215.61 KB
7-Slusher-Sapphire_ Farm_DB321-255.pdf
320.79KB
8-Slusher-Sapphire_ Farm_DB879-340.pdf
129.07KB
9-Slusher-Sapphire_ Farm _NCDENR_Dam _Exemption Letter.pdf
89.36KB
10-Slusher-Sapphire_ Farm_ Southern Appalachian Bog Description.pdf
657.78KB
11-Slusher-Sapphire_Farm—Old Boathouse and Dock.pdf
7.24MB
12-Slusher-Sapphire_Farm_Site Photos-pre.pdf
2.16MB
Signature
*
W By checking the box and signing below, I certify that:

• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN 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 PCN form.
Full Name:
Matthew Fusco
Signature
44A-T r#P,/ J'-PVSCV
Date
8/4/2020

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.
PLAN NO. PARCEL ID:
STREET ADDRESS: 4 7 -30 V Wea W H g V W AT-5 K-- aD—.
5APPItI F2�5 me.., Z$-r�q
Please print: Property Owner: WAG/^
H 4U t.112 LAMP MI*-lL1
Property Owner: �1-�.�ai-1 O IJ ?
The undersigned, registered property owners of the above noted property, do hereby authorize
ty1jt-'--Tr041E .•_i RAS CA of Fu SeZ LAAJD
(Contractor / Agent) (Name of consulting firm) ^, dt1. , ,
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of f 1.
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
3 09014
T��tAvIE
p�}Srl 'VIL .1.tG 28�303
Telephone: " 9014
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date: