20110018 Ver 1_Initial Interest_20110103

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Form Version 6.2
June 29, 2009
INITIAL INTEREST IN PARTICIPATION IN THE EXPRESS REVIEW PROGRAM
WITHIN THE 401 OVERSIGHT/EXPRESS PERMITTING UNIT
A. Applicant Information
1. Processing
? 401 Water Quality Certification (List NW(s) or GP# verified by Corps: )
? Non-404 Jurisdictional Permit
? Riparian Buffer Authorization
la. Type(s) of actions ? Riparian Buffer Minor Variance
requested: ? Coastal General "Major" Variance
(Check all that apply)
? Stream Determination: _ # Streams
® Non-404 Wetland Determination: 1 # Wetlands
? Stormwater Management Plan Review (fee not additive if combined with 401):
# of Drainage Areas/Project Site
2. Project Information
2a. Name of project: Dixie Forest Road
2b. County: wbam V? o??
2c. Latitude/Longitude: Lat: -78.601 Long: 35.864
2d. River Basin: Neuse
2e. Tax PIN or Parcel ID: 1716-89-7614
2f. Nearest Named Stream: Perry Creek
2g. Water Quality Classification of Nearest Named Stream: NSW
2h. Total project acreage (Stream or wetland determinations may omit this item): (acres)
2i. Total Built Out Imperviousness (Stream or wetland determinations may omit this item): %
2j. Provide a brief description of this project (attach a site plan):
2k. Provide directions from the nearest named town, including street names and/or highway numbers:
• Atlantic Avenue North from downtown Raleigh;
• Proceed 0.25-mile from Spring Forest Road & Atlantic Ave intersection; turn left into site;
Site is located at northwest corner of Atlantic, Dixie Forest, Old Wake Forest, & Litchford Road intersection. Old pond
is located at western end of the property near Millbrook HS student parking lot and track.
Call my cell phone if any problems: 749-8259.
Please attach a map of the site location using USGS 1:24,000 topographic map and a copy of the latest bound
and published County soil survey with the project/site boundaries delineated. A site plan should also be included
for all projects other than stream and wetland determinations.
Initial Interest Form v6.2 Cont.
3. Applicant Information
3a. Applicant is: ? Owner ® Agent ? Other:
3b. Name: Tim Morgan
3c. Business name (if applicable): Evergreen Construction Company
3d. Street address: 7706 Six Forks Road
3e. City, State, zip: Raleigh, NC 27615
3f. Telephone no.: [phone] 3g. Fax no., [phone]
3h. Email address: [e-mail]
4. Agent/Consultant Information (if applicable)
4a. Contact Name: Jay Keller
4b. Company Name: Keller Environmental LLC
4c. Street address: 7921 Haymarket Lane
4d. City, State, zip: Raleigh, NC 27615
4e. Telephone no.: [phone] 4f. Fax no.:
4g. Email address: [e-mail]
5. Proposed Impacts (include both temporary and permanent) [Determination requests may omit this item]
5a. Total 404/401 wetland impacts: (acres) 5b. Total non-404/401 wetland impacts: J (acres)
5c. Total 404 stream impacts: Intermittent: (linear feet) Perennial: (linear feet)
5d. Total non-404 stream impacts: Intermittent: (linear feet) Perennial: (linear feet)
5e. Total riparian buffer impacts: Zone 1: (sq. feet) Zone 2: (sq. feet)
6. Project History and Additional Information
6a. Has any DWQ staff visited the site? ? Yes ® No
If yes, provide staff name: and date of visit:
6b. Does this project require a Stormwater Management Plan (SMP)? ? Yes ® No ? Unknown

6c. Who will be responsible for the review of the SMP? ? Certified Local Gov't:
? DWQ Stormwater Program
? DWQ 401/Express Review Unit
6d. Does this project require approval under SEPA or NEPA? ? Yes ® No ? Unknown
6e. Is this project an after-the-fact application or has a DWQ notice of violation been issued? ? Yes ® No
6f. Does this project include buffer impacts that are "prohibited" in the DWQ "Red Rule Book"? ? Yes ® No
6g. If you are aware of any local controversy concerning this project, provide details in a cover letter. Describe the
controversy and any measures that have been taken with respect to public involvement.
This form must be submitted via email (c/o [e-mail]), faxed (919-733-6893), or hand-delivered to:
Parkview Building, 2321 Crabtree Blvd. Suite 250, Raleigh, NC 27604. Applicants who are selected to participate in the
Express Review Program will be notified via email or fax. Successful applicants will then be instructed regarding detailed
procedures for full application (Note: Submittals of the review packages on Friday after 12:00 pm will be stamped as
received on the next business day).
Please contact Lia Myott Gilleski or Joseph Gyamfi at 919-733-1786 if you have any questions regarding this form.
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Dixie Forest Road
NRCS Soil Survey Map
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