20201780 Ver 1_Riparian Buffer Authorization Request_20201118

Buffer Authorization Application Form
15ANCAC 02B .0233 (8)(b), .0243 (8)(b), .0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2) Buffer Authorization Online Fo
Update 10/23/2018
Original Submittal 11/18/2020
A. Owner/Applicant Information
General Information
Primary Contact Email: *
Who is submitting the application?*
1. Property Owner Information:
la. Name on Recorded Deed:*
1b. Responsible Party:
1c. Mailing Address:*
1d. Telephone:* 713-303-7568
3. Agent Information:
3a. Name:
3b. Company Affiliation:
3c. Mailing Address:
[e-mail]
Rease list the contact person's en -ail for questions or payrrent on this project if needed.
r- Owner
r- Applicant other than Owner
W Agent
Jerry Martin
(for Corporations)
Street Address
4813 Oakwealth Dr
Address Line 2
aty
State / Province / Region
Fuquay Varina
NC
Rzstal / Zip Code
Country
27526
USA
le. Email Address:*
[e-mail]
Street Address
Address Line 2
aty State / Province / Region
Postal / Zip Code Country
3d. Telephone: 3e. Email Address:
3f. Attach a signed and dated copy of the agent Click the upload button or drag and drop files hereto attach docurrent
authorization form. R7FCnly
B. Project Information and Prior Project History
.... ...... ..... ...... ...... ...... ............
1. Project Information
..................................................................................................................................................................................................................................................................................................................................

1 a. Name of Project: *
Martin Grade Stabilization
(Subdivision, facility, or establishrrent narre)
1b. Is this a publicly -funded transportation project?*
r Yes
r No
1d. Subdivision Name: Sunset Lake Subdivision
le. Nearest
Municipality:
1f. Property Size
Fuquay Varina
1.77
acres
1g. County (or Counties) where the project is located:*
1 h. Property ID# Date of Purchase
0668272218 12/12/2016
Tax RN or Parcel id
1 i. Deed Information
Type of Book Book# Page#
-11
Deed 016634 F
78
Map 11 IF
1j. Attach a copy of the recorded map that indicates when the lot was last platted.
Click the upload button or drag and drop files here to attach docurrent
FDF only
1k. How would you like to provide the Latitude and Longitude information?*
r Address Lookup
r Manually
Latitude * 35.6382391
Longitude*-78.7908728
11. Is the project located in any of North Carolina's twenty coastal counties?*
r Yes
r No
2. Surface Waters
2a. Name of the nearest body of water to proposed project:*
Unnamed tributary to Middle Creek (Sunset
Lake)
2b. Water Quality Classification of nearest receiving water:*
2c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:*
300
(linear feet only)
i
3. Project Description:
.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
An eroded gully has formed where surface water runs off of the road and down a
steep bank on the property to the unnamed stream. The land use is existing
residential.
3b. Attach an 8 % x 11 excerpt from the most recent version of the USGS topographic map indicating the location of the site.
Click the upload button or drag and drop files here to attach docurrent
FDF only
3c. Attach an 8 % x 11 excerpt from the most recent version of the published County NRCS Soil Survey Map depicting the
project site.
dick the upload button or drag and drop files here to attach docurrent
FDF only
4. Proposed Activity
Provide a detailed description of the proposed activity including its purpose and include the type of equipment to be used:
Fill in the eroded gully and install a catch basin and HDPE pipe to move water flow
to bottom of slope. The pipe will outlet into a preformed scour hole at bottom of
slope approximately 35' from top bank of stream. A backhoe will be required to
install the pipe and catch basin, and a small compactor will be needed to compact
the soil after installation.
The link to instructions for whats needed in site plans is broken so let me know if
anything needs to be added to site plan.
Attach a site plan as applicable to the project:
Click the upload button or drag and drop files here to attach docurrent
FDF only
5. Jurisdictional Determinations
5a. Have jurisdictional wetlands or stream determinations by the Corps or State been requested or obtained for this
property/project (including all prior phases) in the past?*
f Yes
r No
6. Project History
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
r Yes
r No
7. Future Project Plans
7a. Is this project a phased project?* r Yes
r No
C. Proposed Impacts Inventory
Buffer Impacts
Project is in which protected Basin?*
r Neuse River Basin (15A NCAC 02B.0233)
r Catawba River Basin (15A NCAC 02B.0243)
r Randleman Lake Watershed (15A NCAC 02B.0250)
r Tar -Pamlico River Basin (15A NCAC 02B.0259)
r .Jordan Lake Watershed (15A NCAC 02B.0267)
r Goose Creek Watershed (15A NCAC 02B.0606 & 15A NCAC 02B.0607)

Individually list all buffer impacts below. If any impacts require mitigation, then you MUST fill out Section D of this form.
Site# - Reason Stream Name Buffer Impact* Impact Type * Zone 1 Zone 2
Martin1
Unnamed
Permanent
Allowable
0.00
200.00
lVbp label (e.g. Fbad
(P)
Square
Square
Crossing 1)
F@rmorTenp
Feet
Feet
Total Zone 1 Impacts: 0.00
Total Zone 2 Impacts: 200.00
Total Buffer Impacts: 200.00
Comments:
D. Impact Justification and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project.*
Project will protect downstream waters from continued erosion that is occurring in
the gully. Project has been designed to have the preformed scour hole built as far
from the stream edge as possible.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
The smallest possible equipment will be used during construction. Any disturbed
area besides the scour hole will be immediately reseeded.
E. Diffuse Flow Plan
la. What type of SCM are you providing?*
G Level Spreader
17 Vegetated Conveyance (lower SHWT)
r Wetland Swale (higher SHWT)
r Proposed project will not create concentrated stormwater flow through the
buffer
rJ Other SCM that removed minimum of 30% nitrogen
1b. Describe how diffuse flow will be maintained:*
Project will utilize a preformed scour hole as described in the NCDOT Stormwater
Best Management Practices Toolbox The preformed scour hole will be built where
the ground levels out so that diffuse flow along the edges of the basin can be
maintained.
1 c. Diffuse Flow Documentation* (lick the upload button or drag and drop files here to attach docunent
Preformed ScourHoleChecklist.pdf 712.8KB
FDF only
F. Supplementary Information
Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?
G Yes
r No
A

1b. If you answered "yes" to the above, does the project require preparation of an environmental document pursuant to the
requirements of the National or State (North Carolina) Environmental Policy Act (NEPAISEPA)?
t Yes
r No
Violations
2a. Is the site in violation of DWR Wetland Rules (15A NCAC 02H .0500), Isolated Wetland Rules (15A NCAC 02H .1300), DWR
Surface Water or Wetland Standards, or Riparian Buffer Rules (15A NCAC 02B .0200)?
r'
(-- No
2b. Is this an after -the -fact buffer authorization application?
r^ Yes
r No
G. Additional Information
Please upload any additional information you would like the Division to consider during application review.
Additional Attachments: Click the upload button or drag and drop files here to attach docurrent
FDF only
Additional Comments:
H. Sign and Submit
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')
o 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
o I intend to electronically sign and submit the application form."
Print Name:* Chris Love
Signature
Submission Date: (Auto populated field)
N

Initial Review
Is this accepted into the review process?*
Is this project a public transportation
project?*
ID#*
Version:*
Select Reviewer:
Select Reviewing Office*
Has payment been received?*
O Yes O No
O Yes
O No
20201780
1
Stephanie Goss:eads\szgoss
Raleigh Regional Office - [phone]
C No Payment Needed
r Fee Received
r Need Fee - send electronic notification

North Carolina Department of Transportation
Highway Stormwater Program

PREFORMED SCOUR HOLE CHECKLIST Page 1 of 1
Project: TIP No:
Prepared by: Date: Checked by: Date:
NCDOT Division: River Basin:
City: NCDWR Stream Classification
County: Primary:
CAMA County: Yes No Supplemental:
303(d) Stream: Yes No
Buffer Required: Yes No

PROJECT DESCRIPTION
Check the correct response. Yes No Not
Applicable
Comments/Design
Assumptions
1
Was a field visit made for the
proposed preformed scour hole
site/location?

2
Was the preformed scour hole
positioned outside the roadway
clear recovery zone?

3 Were off-site drainage areas
verified and accommodated?
4
Were adequate ingress and
egress for maintenance provided
within right-of-way?

5
Were different preformed scour
hole locations and orientations
considered to optimize water
quality benefits? Explain.

6
Was topography downgrade of
the preformed scour hole
reviewed for ability to diffuse
flow?

7
Is the PSRM apron shown on the
plans flush with the natural
ground?
8
Is the discharge pipe an allowable
size for use with a preformed
scour hole (15 in. or 18 in.)?

9
Have maximum allowable
discharges based on the Q 10
discharge been verified?

10 Were all design assumptions
documented?

Martin Grade Stabilization
Chris Love 11/18/20
NA
Fuquay Varina
Wake B
NSW
x
x
x
x
x
x
x
18 in pipe
Not a DOT project
x Not a DOT project
x
x