HomeMy WebLinkAbout20110005 Ver 1_401 Application_20110511
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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps: ? Section 404 Permit ? Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ? Yes ? No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
? 401 Water Quality Certification - Regular ? on-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required? For the record only for DWQ
401 Certi ication:
Yes ? No For the record only for Corps Permit:
? Yes ? No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in-lieu fee program.
? Yes ? No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ? No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ? No
2. Project Information
2a. Name of project: to
2b. County: O
2c. Nearest municipality / town:
2d. Subdivision name: C S?
2e. NCDOT only, T.I.P. or state project no/
3. Owner Information
3a. Name(s) on Recorded Deed: ?j
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
3e. City, state, zip: dGV?l? e
3f. Telephone no.: - f -- QQ
3g. Fax no.:
3h. Email address:
J
Page 1 of 10
PCN Form - Version 1.4 January 2009
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: 1A Q / q Z7
5b. Business name
(if applicable): /
(,.L7'sC? //1
! (Oyu .? C.
5c. Street address: y? OQ
5d. City, state, zip: ?G
5e. Telephone no.: - -
5f. Fax no.:
5g. Email address:
Page 2 of 10
I ' /
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): -
1 b. Site coordinates (in decimal degrees): Latitude: Longitude:
1 c. Property size: ss- acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classificati n of nearest receiving water: ALISW
_
2c. River basin:
3. Project Description
3a. Describe the existing conditions on the sit and the genera la ur in tthe/vicinity of.thq proj at t time of t 's
application: ' ell Sr l? /S A Sc, //'f ?q r"?S i G'I E'?1 C, ?a G?Id
ha01 Ac? ?Xl3t'/?q 4 /' VoUis WAp- uer- I d nc?rh
t,v, fkl ,?s ard<11 °tp n e ls. An w6 r WPo , and e? rA H* - eve
A Ie
I- -k r -J r LISD re en rir ?- arr1 G c`?
3b. List the total estimated acreage of all existing w tlands on the property: D? Z
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project: ' {fie CrOM.,), t J C
D S r U ok5 p era p I a der roc,ws?m lAre0S, I{lf-l ((AW401\ s?e? , IWO
r lnoxf-r I a n S e
be. ?scribe the overall project ' de ail, cludin th type of equipment to be u ed: Mt, o?s prt it
Q A
CD rYl l? Ilr1 !'CrVI o tl a { 6 X C?IY1Gt 5-?--1' ?..?-zav?e_S a e r ?'?'Il?ay! t.c? e?0i>IP
6al?k n i 1,i5 ro " Gr?1,l1IC5 ?imai huts- 'c 6 Cy I cQu?+?
4. Jurisdictional Deterinin tions I IF
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past? ? Yes No ? Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? ? Preliminary ? Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ? Yes No ? Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project?
AmA
? Yes
No
6b. If yes, explain.
f
rlit,1 r
U?i?lC
l tcr5 .
Page 3 of 10
PCN Form - Version 1.4 January 2009
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (ck all that apply):
[] Wetlands El Streams - tributaries Buffers ? Open waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary 2b.
Type of impact 2c.
Type of wetland 2d.
Forested 2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other) 2f.
Area of
impact
(acres)
W1 - Choose one Choose one Yes/No
W2 - Choose one Choose one Yes/No
W3 - Choose one Choose one Yes/No -
W4 - Choose one Choose one Yes/No -
W5 - Choose one Choose one Yes/No -
W6 - Choose one Choose one Yes/No
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary m 3b.
Type of impact 3c.
Stream name 3d.
Perennial (PER) or
intermittent (INT)? 3e.
Type of
jurisdiction 3f.
Average
stream
width
(feet) 3g.
Impact
length
(linear
feet)
S1 Choose one
S2 Choose one -
S3 Choose one -
S4 Choose one
S5 Choose one
S6 Choose one
3h. Total stream and tributary impacts
3i. Comments:
Al"
Page 4 of 10
PCN Form -Version 1.4 January 2009
/ .4
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual) list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary 4b.
Name of waterbody
(if applicable) 4c.
Type of impact 4d.
Waterbody
type 4e.
Area of impact (acres)
01 Choose one Choose
02 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If and or lake construction ro ose , then complete the chart below.
5a.
Pond ID number 5b.
Proposed use or
purpose of pond 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required? ? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin? ? Neuse Tar-Pamlico ? Catawba ? Randleman ? Other:
6b.
Buffer Impact
number -
Permanent (P) or
Temporary 6c.
Reason for impact 6d.
Stream name 6e.
Buffer
mitigation
required? 6f.
Zone 1
impact
(square
feet 6g.
Zone 2
impact
(square
feet
4- My z9a V, 60) 1 WS;Jq
62 V
-? pw/i ? / ct
-- Yf5
63 T
a a Ye o
B4 e Yes
B5 Yes/No
B6 Yes/No
6h. Total Buffer Impacts: L7J 7 S ,
6i. Comments:
s C
3k,
Page 5 of 10
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. pecifically describ mea ures taken to avoid or minimize he propped impa s in depigning project Thez. ?tv
rc uGt° i m:?AC -s ny 1`r?h?rJ?jq,nori-ahsorb? S ure am CA C,O-A ?
tar ? ?U?''S r4l`Pd5 ?r'?GrV? 't???5` a??o{ ?bSorfi?h baSG
1 Specifically desc 'be means es taken t avoid or mini ie the proposed impacts through construction techniques.
I P?M? f CC vV ? I tit'{-i ?r? c ?`? ?- tv? GiY1 D r
? in 1l
Ins ?cY1r(?cr ?ivGrfet?,v? la?"Il
2. Com ensato Mitigation for Impacts to Waters of the U.S. or Waters of the Stat
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps
2c. If yes, which mitigation option will be used for this
project? ? Mitigation bank
? Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type: Choose one
Type: Choose one
Type: Choose one Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Makin a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
?i )/
Page 6 of 10
PCN Form - Version 1.4 January 2009
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? Yes tj No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10
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E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified es ? No
within one of the NC Riparian Buffer Protection Rules?
1b. If yes, then iis,.a diffuse flow plan included?)fno, explain why.
L) S e. '0 /:_ r e- /`r-164_1 N A E,Gn 115
Ale ? No
?
,
S? I W a,6?/ hA Q /yor 40 rra _
rt
2. Stormwater Mana eme Plan
2a. What is the overall percent imperviousness of this project? jam %
2b. Does this project require a Stormwater Management Plan? ? Yes A NO
2c. If this project DOES NOT require a Stormwater Management Plan, ex I in why:
T r/A A eR" I_&7a S 5? ?'Lt c? YZ°__ ?u?D?itt G)Ce
2d. If this project DOES require Stormwater Managyment Plan, th n provide a brief, Harr tive description of the plan:
I
4
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t
!1
bbl
wa
14 ?v, l1 lam. sti?e-
2e. Who will be responsible for the review of the Stormwater Management Plan?
J-f
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
? Phase II
3b. Which of the following locally-implemented stormwater management programs ? NSW
? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been []Yes ? No
attached?
4. DWQ Stormwater Program Review
[]Coastal counties
?HQW
4a. Which of the following state-implemented stormwater management programs apply ORW
(check all that apply): Law 2006-246
HSession
[]Other:
4b. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No
attached?
S. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
)e
Page 8 of 10
PCN Form -Version 1.4 January 2009
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the ? Yes 'N0
use of public (federal/state) land?
1 b. 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 ?Yes -E?90
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
l
t
? Yes AV'No
e
ter.)
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
I
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes A
No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ?Yes 4rvo
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
o
?Yes
additional development, which could impact nearby downstream water quality? oc
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed proj
t
, or available capacity of the subject facility.
c
e
'
t,
Page 9 of 10
PCN Form - Version 1.4 January 2009
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? ? Yes No
?
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
? Yes ? No
5c. If yes, indicate the USFWS Field Office you have contacted. -
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes ? No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
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 (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
? Yes ? No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? T ? Yes ? No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
Applicant/Agent's Printed Name Ap licant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant is provided.) Date
Page 10 of 10
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
r I. hereby certify that I own property adjacent to
their property is located at (Name of Property Owner)
lit ipamk?C-0 L -.C\
(Lot, Block, Road, etc.)
CV\0C3- W,
.(Waterbod) (Town and/or County
North Carolina.
The applicant has described to me, as shown below, the development proposed at the
above location. I understand that any construction, must be set back a minimum distance
of fifteen feet (15') from my area of riparian access unless waived by me. The (15')
setback does not apply to the following: bulkheads/riprap, boat ramps, upland boat
basins, utility lines and attendant structures, temporary structures, riprap for wetland
protection, or upland development.
I have no objection to the project as proposed, but do not
wish to waive the (15') setback requirement.
I have no objection to the project as proposed and do wish
to waive the (15') setback requirement.
object to the project as proposed. --- ----
? -- t
DESCRIPTION " RD G OF PROPOSED DEVEi
(To be e by vidual proposing the develop nt)
S?
YJrgdl e? -LL-22it
PRINT OR TY E NAME
Z 5- Z -- ? g G- 6 75-Z
TELEPHONE NUMBER
2/20/2006
S- Z s 1 ?
DA
ACENT RIPARIAN PROPERTY OWNER STATEMENT
is oeat at
(Lot, Block, Road, etc.)
I hereby certify that I own property adjacent to .5 it 0er\
!'fFs?"? 6Z°? e-1-
their nronertv ' 1 (Name of Property Owner)
on C1nocz w. in C_?,oc,:;, U.A?11
(Waterbo y) (Town and/or County
North Carolina.
The applicant has described to me, as shown below, the development proposed at the
above- location. I understand that any construction, must be set back a minimum distance
of fifteen feet (15') from my area of riparian access unless waived by me. The (15')
setback does not apply to the following: bulkheads/riprap, boat ramps, upland boat
basins, utility lines and attendant structures, temporary structures, riprap for wetland
protection, or upland development.
(To be l
H V)
I have no objection to the project as proposed, but do not
wish to waive the (15') setback requirement
I have no objection to the project as proposed and do wish
to waive the (15') setback requirement.
obC- jest to the project as proposed: "-
??ass
?R D "G OF PROPOSED DI
i by ividual proposing the devela
Pew
PRINT OR TYPE NAME
9v loq"7
TELEPHONE DER
2/,20/2006
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