20201151 Ver 1_Determination Request_20200709

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
Name on the Recorded Deed:*
Parcel #23396
f Yes r No
r Buffer
r Isolated Wetland
Check all that apply.
A. T. Venters Properties, LLC
r IP Stream Determination
FJ Stream
Responsible Party: Leo Allen Venters
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 252-327-8100
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:* 20-075 - Parcel 23396 - Signed Agent
241.49KB
Authorization Form.pdf
PDF only
Agent/Consultant Information
How would you like to receive your f USPS
determination letter?* r Email
Name of Agent:* Igor Palyvoda
Company Name:* Baldwin Design Consultants, PA
Email Address:* ipalyvoda@baldwindesignconsultant
s.com
Project Information
Has anyone form DWR done a previous site visit?*
f Yes
r No
f Other

Date of Visit:
Site Information
Nearest Highway/Street:* 7023 County Home Road
Nearest Town:* Ayden
Nearest Named Stream:* Fork Swamp
River Basin:* Neuse
County:
Pitt
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
aickthe upload button or drag and drop files here to attach document
20-075 - Parcel 23396 - USGS Topo
238.92KB
Maps.pdf
Rfr 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.
aick the upload button or drag and drop files here to attach documnt
20-075 - Parcel 23396 - Pitt County Soils
237.97K6
Map.pdf
Ftlr 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
f Manually
Project Look Up Address
Latitude
Street Address
7023 County Home Road
Address Line 2
City
Ayden
Fbstal / Zip Code
28513
35.4660728
Longitude:-77.34100719999999
State / Frovince / f;bgion
NC
Country
US

M isc attachments: 20-075 - Parcel 23396 - Pitt County OPIS
190.96KB
Map.pdf
pdf or lace file types only
By digitally signing below, I certify that:
• I have given true, accurate, and complete information on this form;
• 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
Date Submitted:
Initial Review
ID#*
Version*
Do you want to send for review?*
Select Reviewer:*
Select Regional Office:*
7/9/2020
20201151
1
r Yes r No
Chris Pullinger:eads\rcpullinger
Washington Regional Office - [phone]

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.
PLAN NO.
PARCEL ID: 23396
STREET ADDRESS: 7023 County Home Road, Ayden, NC 28513
Please print: A. T. Venters Properties, LLC
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Igor Palyvoda of Baldwin Design Consultants, PA
(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):
4202 Westhaven Avenue, Ayden, NC 28513
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: 7 ' ' Z_ Date:

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