19990229 Ver 1_Complete File_19990312

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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Mazch 2, 2007
DWQ # 99-0229
Forsyth County
CERTIFIED MAIL -RETURN RECEIPT REQUESTED
Mr. Pat Ivery, PE
NCDOT, Division 9
North Carolina Department of Transportation
375 Silas Creek Pazkway
Winstori-Salem, NC 27127
Dear Mr. Ivery:
On Mazch 5, 1999, you requested a 401 Water Quality Certification from the
Division of Water Quality (DWQ) for your project SR 4000 located in Forsyth County.
We wrote you on March 12, 1999 discussing concerns that we have regarding the design
of the project and placing it on hold until those concerns aze addressed. Therefore we aze,
returning your application. Once you have collected sufficient information to have a
complete application (please see our hold letter for the missing information), you will
need to reapply for the DWQ approval. Your file is hereby retired and will not be
reviewed until our eazlier concerns are addressed.
Please contact me at 919-733-5694 if you have any questions or would like to discuss this
matter.
erely,
?~6L ~~
John Hennessy y ;YyG
Transportation and Permitting Unit
cc: DWQ Winston-Salem Regional Office
US Army Corps of Engineers Raleigh Field Office
Central Files
File Copy
NQp~~~hCarolina
Transportation Pertnitiing Unil ~VUlllCQ~~t~J
1650 Mail Service Center, Raleigh, North Carolina 27699-1650
2327 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604
Phone: [phone] FAX [phone] /Internet httol7h2o.enrstate. naus/ncwetlands
An Equal OppodunitylAffirtnative Action Employer- 50 % Recycled110% Post Consumer Paper

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State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
A. Preston Howard, Jr., P.E., Director
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NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
March 12, 1999
Please call Cyndi Bell at 919-733-1786 if you have any questions.
inc r \ ~
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Joh .Domey
Mr. George Teague
NC DOT
515 Camp Road
Salisbury, NC 28147
Dear Mr. Teague:
Subject: Bridge #62-536
DWQ # 990229
Forsyth County
On March 11, 1999, your application fora 401 Water Quality Certification for a
culvert # 536 in Forsyth County was received by the N.C. Division of Water Quality.
The Division will begin to review the project for eventual decision. However, please be
aware that beginning Januazy 1, 1999 that the N.C. General Assembly passed legislation
requiring payment of a fee of $200.00 for this project. The 401 Certification cannot be
issued until this fee is paid. Presently the Department of Transportation and Environment
and Natural Resources are developing a process so these fees will not have to be paid
separately for each project. We anticipate that this agreement will be finalized early in
1999. However until this agreement is completed we will not be able to complete our
action on your request. Until that time, your application will remain on hold as
incomplete.
cc: Central Files
Winston-Salem DWQ Regional Office
Raleigh Field Office US Army Corps of Engineers
Cyndi Bell
" ' Domey
Unit 4401 Recdy Creck Road Raleigh, North Carolina 27607
Telephone [phone] FAk # 733-9959
.n Equal Opportunity Affirmative Action Employer ~ 50% retycled/10`Yo post consumer paper
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MAR. 5, 1999
515 Camp Rd.
Salisbury, N. C. 2817
Mr. KEN JOLLY
U. S. Amry Corps of Engineers
6512 FALLS OF THE NEUSE ROAD
RALEIGH, N. C. 27(15
Dear Mr. JOLLY,
The Nonh Carolina Department of Transponation Bridge Maintenance Unit. proposes the following
project for }'our review. We believe This project can be accomplished under Natiomvide # 1~.
COUNTY : FORSYTH COUNTY, CULVERT # 53(
ROUTE S. R. 4000
STREAM : LEAK FORK CREEK
DESCRIPTION : Bridge # 62-536. EXTEND ~l BARREL REINFORCED CONCRETE BOXED
CULVERT (ail 7' X 10' BY 12 ADDITIONAL FEET.
Not located in wetlands.
Less than O.ll I. Acres of Rip Rap fill in waters.
Drainage Arca =~tsq. miles. Average Daily Flow =y_~ C.F.S.
Total CULVERT length in stream = 113 FT He 2 IN
We have attached a site location map . and a sketch of planned activities. A stringent erosion and
sediutentation control program will be implemented during the project constniction and even effort will
be made to complete work in a timely manner.
Our personnel are available to assist with your evaluation of this project . if necessary. Should 7ou -
haveany questions. please call meat 70~{- 639-7515.
Sincerely,
George Teague
Bridge Maintenance Supt.
Attachments.
GLT/des

~} - _.
DEM ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT # ):
PRE-CONSTRUCTION NOTIFICATIONS APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1) NOTIFICATION TO THE CORPS OF ENGINEERS
2) APPLICATIONS FOR SECTION 401 CERTIFICATION
3) COORDINATION WITH THE N. C. DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORtvt TO THE APPROPRIATE
FIELD OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET), SEVEN
(7) COPIES SHOULD BE SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT
(SEE AGENCY ADDRESSES SHEET). PLEASE PRINT.
I. OWNERS NAME: NORTH CAROLINA DEPARTMENT OF TRANSPORTATION
2. MAII.ING ADDRESS: BRIDGE MAINTENANCE UNIT
S 1 S CAMP RD.
SALISBURY, N.C. 28147
PROTECT LOCATION ADDRESS. (INCLUDING SUBDMSION NAME) _FORSYTH COUNTY.
NEAR WINSTON-SALEM. N. C. ON SR 4000 OVER LEAK FORK CREEK
TELEPHONE NUMBER (HOME)_N/A
(WORK) 704-639-7555
4. [F APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS.
AND PHONE NO.
GEORGE L. TEAGUE
BRIDGE MAINTENANCE SUPERINTENDENT
515 CAMP RD.
SALISBURY, N.C. 28147
704-639-7555
5. LOCATION OF WORK (PROVIDE A MAP. PREFERABLY A COPY OF USGS TOPOGRAPHIC
MAP OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY:_FORSYTH NEAREST TOWN OR CITY:_WINSTON-
SALEM
SPECIFIC LOCATION, (INCLUDING ROAD NUMBERS, NAMES, LANDMARKS, ETC.): 0.2
MILES SOUTH OF JCT OF SR 16R6 AND SR 4000 OVER LEAK FORK CREEK ON SR 4000

f).
6. IMPACTED OR NEAREST STREAM/RIVER: LEAK FORK CREEK
RIVER BASIN: YADKIN
2.
7a. IS PROJECT LOCATED NEAR WATER CLASS[FED AS TROUT. TIDAL SALTWATER (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-I OR WS-Il)? YES O NO (X) IF YES, EXPLAIN:
7b. IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES O NO (X )
7c. IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES). WHAT IS THE LAND USE PLAN (LUP) DESIGNATION?
N/A
Aa. HAVE ANY SECTION 40A PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROPERTY? YES O NO (X) IF YES, PROVIDE ACTION LD. NUMBER OF THE
PREVIOUS PERMIT AND ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF
101 CERTIFICATION):
Sb. ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE
FUTURE? YES O NO (X) IF YES, DESCRIBE ANTICIPATED WORK:
9a. ESTIMATED TOTAL NUMBER OF ACRES IN TRACT OF LAND: "I ~~ SC • M.
9b. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
10a. NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: 0 EXCAVATION: 0
FLOODING: 0 OTHER: 0
DRAINAGE: 0 TOTAL ACRES TO BE IMPACTED: NONE
IOb. (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION):

i~
LENGTH BEFORE: N/A FT. AFTER: N/A FT.
WIDTH BEFORE (BASED ON NORMAL HIGH WATER CONTOURS):N/A
WIDTH AFTER: N/
AVERAGE DEPTH BEFORE: N/A FT. AFTER: N/A FT.
3.
IOb. (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE [N CHANNEL:
CHANNEL EXCAVATION: X CONSTRUCTION OF A DAM/FLOODING:
11. IF CONSTRUCTION OF A POND IS PROPOSED. WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? N/A
WHAT IS THE EXPECTED POND SURFACE AREA? N/A
I2. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF bIECHANICAL
EQUIPMENT TO BE USED (ATTACH PLANS: 8'/" X I I" DRAWINGS ONLY):_EXTEND
EXISTING 4 BARREL 7' X Ill' CULVERT BY I2 (NEW OVERALL LENGTH WILL BE l43'2")
-(WIDTH ALONG CENTER LINE OF ROADWAY IS 48'5" )
13. PURPOSE OF WORK: TO EXTEND EXISTING CULVERT BY 12' .
I4. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS. (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS):
N/A
l~. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE (USFWS)
AND/OR NATIONAL MARINE FISHERIES SERVICE (NMFS) (SEE AGENCY ADDRESSES

SHEET) REGARDING THE PRESENCE OF ANY FEDERALLY LISTED OR PROPOSED FOR
LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL HABITAT IN THE
PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED:_NO (ATTACH RESPONSES FROM THESE
AGENCIES.)
l6. YOU ARE REQUII2ED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) (SEE AGENCY ADDRESSES SHEET) REGARDING THE PRESENCE OF HISTII2IC
PROPERTIES IN THE PERMIT AREA WHICH MAY BE AFFECTED BY THE PROPOSED
PROJECT. DATE CONTACTED: NO
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OR THE USE OF
PUBLIC (STATE) LAND? YES O NO (X) (IF NO, GO TO 18)
4.
l7. a. IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACT? YES O NO (X )
U. b. IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE? YES O NO ( )
IF ANSWER TO 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE
STATE CLEARINGHOUSE TO DIVISION OF ENVIRONMENTAL MANAGEMENT REGARDING
COMPLIANCE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADIMINSTRATION, 116 WEST JONES STREET, RALEIGH.
NORTH CAROLINA 27603-8003, TELEPHONE NO. 919-733-6369.
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION [F
PROPOSED ACTIVITIES INVOLVES THE DISCHARGE OF EXCAVATED MATERIALS
INTO WETLANDS:
a. WETLANDS DELINEATION MAP SHOWING ALL WETLANDS, STREAb1S, LAKES
AND PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS l~. 18,
2I, 26, 29, AND 38). ALL STREAMS (INTERMITTENT AND PERMANENT) ON THE
PROPERTY MllST BE SHOWN ON THE MAP. MAP SCALES SHOULD BE I" = 50'
OR 1" = 100' OR THEIR EQUIVALENT.
b. IF AVAILABLE, REPRESENTIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED
BY PROJECT.
c. IF DELINEATION WAS PERFORMED BY A CONSULTANT. INCLUDE ALL DATA
SHEETS RELEVANT TO PLACEMENT OF THE DELINEATION LINE.
d. ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
e. ~1'I-IAT IS LAND USE OF SURROUNDING PROPERTY? SHOPPING CENTER
f. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
N/A

g. SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATLRS OF TFIE U.S. MAY NOT BE IMPACTED PRIOR TO:
I) ISSUANCE OF A SECTION d04 CORPS OF ENGINEERS PERMIT,
2) EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF ENVIRONMENTAL
MANAGEMENT (WATER QUALITY) CERTIFICATION, AND
3) (TN TFIE TWENTY COASTAL COUNTIES ONLY) A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT \VITII TI IE NORTIi CAROLINA COASTAL
MANAGEMENT PROGRAM.
OW 'S / _ S SIG ATURE DATE
(AGENT'S STGNATURE VALID ONLY IF AUTHORIZATION
LETTER FROM THE OWNER IS PROVIDED (IRg.) )
5,
AGENCY ADDRESSES
ENDANGERED SPECIES
U.S. FISH AND WILDLIFE SERVICE
RALEIGH FIELD OFFICE
P.O. BOX 13726
RALEIGI-I, N. C. 2761(,-3726
TELEPf-ZONE 919-R56-d520
NATIONAL MARINE FISHERIES SERVICE
HABITAT CONSERVATION DIVISION
FIVERS ISLAND
BEAUPORT. N.C. 2R5IG
TELEPHONE 919-72R-5090
U.S. FISH AND \VILDLIFE SERVICE
ASIIVILLE FIELD OFFICE
160 ZILLICOA STREET
ASHVILLE, N.C. 25RI11
TELEPHONE h2R-665-1125
HISTORIC RESOURCES
STATE 1-IISTORIC PRESERVATION OFFICE
N. C. DIVISION OF ARCHIVES AND HISTORY
109 EAST JONES STREET
RALEIGH, N.C. 27601
TELEPHONE [phone]
STATE REGULATORY AGENCIES

MR. JOHN DORNEY.
DIV. OF ENVIRONMENTAL MANAGEMENT
N. C. DEPARTMENT OF ENVIRONMENT,
HEALTH, AND NATURAL RESOURCES
4401 REEDY CREEK ROAD
RALEIGH, N. C. 27607
TELEPHONE [phone]
6.
CORPS OF ENGINEERS FIELD OFFICES:
RALEIGH REGULATORY FIELD OFFICE
U.S. ARIvfY CORPS OF ENGINEERS
6512 FALLS OF THE NEUSE ROAD
RALEIGH. N. C. 276li
TELEPHONE [phone]
ASHE Vll.LE REGULATORY FIELD OFFICE
U.S. ARMY CORPS OF ENGINEERS
li l PATTON AVE. ROOM 143
ASHEVILLE, N. C. 28801-5006
TELEPHONE [phone]
WASHINGTON REGULATORY FIELD OFFICE
U.S. ARMY CORPS OF ENGINEERS
P.O. BOX 1000
WASHINGTON. N.C. 27889-1000
TELEPHONE [phone]
WILMINGTON REGULATORY F[ELD OFFICE
U.S. ARMY CORPS OF ENGINEERS
P.O. BOX 1890
MR. STEVE BENTON
DIV.OF COASTAL MANAGEMENT
N.C. DEPARTMENT OF
ENVIIiONMENT, HEALTH, AND
NATURAL RESOURCES
P.O. BOX 27687
RALEIGH, N. C. 27611-7687
TELEPHONE [phone]
FAX [phone]

WII.MINGTON, N. C. 28402-1890
TELEPHONE [phone]
ATTN.:CESAW-CO-R

MAR. 5, 1979
5I S Camp Rd.
Salisbury, N. C. 2R 147
Mr. JOHN TFIOMAS
U. S. Army Corps of Engineers
6512 FALLS OF THE NEUSE ROAD
RALEIGH, N. C. 27(,15
Dear Mr. THOMAS,
The North Carolina Department of Transponalion Bridge Maintenance Unit, proposes the following
project for your review. We believe this project can be accomplished under Nationwide # 14.
COUNTY : FORSYTH COUNTY, CULVERT # 536
ROUTE S. R. 40110
STREAM : LEAD FORK CREEK
DESCRIPTION : Bridge # 62-536, EXTEND 4 BARREL REINFORCED CONCRETE BOXED
CULVERT (n? 7' X 10' BY 12 ADDITIONAL FEET.
Not located in wcllands.
Less than 11.01. Acres of Rip Rap fill in Waters.
Drninage Arca =~-~`sq. miles. Average Daily Flow=~~1 C.F.S.
Total CULVERT length in slrcam = 143 FT Rc 2 IN
We have mtachcd a site location map , and a sketch of planned activities. A stringent erosion and
scdimenlation control program will be implemented during the project consiniclion and every effort will
be made in contplclc work in a timely manner.
Our personnel arc available m assist with your evaluation of This project , if necessary. Should you
have any questions, please call me al 7lW- (,39-7555,
Sincerely, / ~.
G gc9.. Tcaguc
Bridge Maintenance Supt.
Altachmcnts.
GLT/dcs

MAR. 5, 1999
515 Camp Rd.
Salisbury, N. C. 2K 147
Mr. ERIC GALAM6
W Q CERTIFICATIONS UN[T
P.O. BOX 29535
RALHIGI-I. N.C. 27C2C-0535
Dear Mr. GALAMB,
The North Carolina Department of Transportation Bridge Maintenance Unil, proposes the following
project for your review. We believe this project can be accomplished under Nationwide # 14.
COUNTY : FORSYTH COUNTY, CULVERT it 536
ROUTE S. R. 41100
STREAM : LEAK FORT: CREEK
DESCRIPTION : Bridge # 12-53C. EXTEND 4 BARREL REIMORCED CONCRETE BOXED
CULVERT (r~ 7' X 10' BY 12 ADDITIONAL FEET.
Not located in wetlands.
Less than 11.01 Acres of Rip Rap fill in Waters.
Drainage Arca =~1-esq. miles. Average Daily Plo~e =y~1 C.F.S.
Total CULVERT Icngih in stream = 143 FT ~ 2 IN
1Vc have attached a site location map , and a sketch of planned activities. A stringent erosion and
sedimentation control program will be implenrenicd during the project constniction and every effort will
be made to complete work in a timely manner.
Our personnel are available In assist with your evaluation of this project , if necessary. Should you
have any questions, please call me at 7U4- G39-7551.
Sincerely,
,~~:~a~
George Tcaguc
bridge Maintenance Supt.
Attachnrents.
GLT/des

DEM ID:
ACTION ID:
JOINT APPLICATION FORM FOR
NATIONWIDE PERMITS THAT REQUIRE NOTIFICATION TO THE DISTRICT ENGINEER
NATIONWIDE PERMITS THAT REQUIRE SECTION 401 CERTIFICATION CONCURRENCE
NATIONWIDE PERMITS THAT REQUIRE INDIVIDUAL SECTION 401 CERTIFICATION
WILMINGTON DISTRICT ENGINEER
CORPS OF ENGINEERS
DEPARTMENT OF THE ARMY
P.O. BOX 1890
WILMINGTON, NC 28402-1890
ATTN: CESAW-CO-E
Telephone [phone]
WATER QUALITY PLANNING
DIVISION OF ENVIRONMENTAL MANAGEMENT
NC DEPARTMENT OF ENVIRONMENT, HEALTH,
AND NATURAL RESOURCES
P.O. BOX 29535
RALEIGH, NC 27626-0535
ATTN: MR. JOHN DORNEY
Telephone [phone]
ONE (1) COPY OF THIS COMPLETED APPLICATION SHOULD BE SENT TO THE CORPS OF
ENGINEERS. SEVEN (7) COPIES SHOULD BE SENT TO THE N.C. DIVISION OF
ENVIRONMENTAL MANAGEMENT. PLEASE PRINT.
1. OWNERS NAME: IV~ ~ • ~~~~• o~ Tf~,nS Por~c,"II ~ (\
2. OWNERS ADDRESS: S I S Carv,n R~aU
3 • OWNERS PHONE NUMBER ( HOME ) : N ) F~ ( WORK) : ~10y1 (,3~1 - ~ S S5
4. IF APPLICABLE:
PHON
5
AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL. ADDRESS.
6. NAME OF CLOSEST STREAM/RIVER: I-ra~ . FDCF ~,Y~c~

7. RIVER BASIN: ~ q a~'~ v~
8. IS THIS PROJECT LOCATED IN A WATERSHED CLASSIFIED AS TROUT, SA, HQW, ORW,
W5 I, OR WS II? YES [ ] NO [)(]
9. HAVE ANY SECTION 404 PERMITS BEEN
PROPERTY? YES [ ] NO
IF YES, EXPLAIN.
PREVIOUSLY REQUESTED FOR USE ON THIS
CX]
10. ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
N~N~
2/3/92
LOCATION OF PLANN D WORK (ATTACH MAP).
COUNTY: Fo< ~~
NEAREST TOWN OR CITY: W'~nr on- Soc cYV~
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.): ~,a m ,\ r
So~,.~~ ~ 3~ ~C <R IC,~C a.,,~ SRUaao ~..~s„ I en\~ ,.~-

-2-
11. NUMBER OF ACRES OF WETLAND IMPACTED BY THE PROPOSED PROJECT:
FILLED: C~
DRAINED: O
FLOODED: C\
EXCAVATED: p
TOTAL IMPACTED: ~~0(\I ~
12. DESCRIPTION OF PROPOSED
n r, i i ~
(ATTACH PLANS):
1,y ~~ ~ ~nc ~l
. ~,~ a ~ 4 5(~ 5 rr
R,k~~ c-~ , ~ a
u
C
13. PURPOSE OF PROPOSED WORK
~co ~~.\~~~ -~k,~\;~~ ~u\v~r~ ~Y lay
14. STATE REASONS WHY THE APPLICANT BELIEVES THAT THIS ACTIVITY MUST BE
CARRIED OUT IN WETLANDS. ALSO, NOTE MEASURES TAKEN TO MINIMIZE WETLAND
IMPACTS. N I A
15. YOU ARE REQUIRED TO CONTACT THE U.S. FISH AND WILDLIFE SERVICE
(USFWS) AND/OR NATIONAL MARINE FISHERIES SERVICE (NMFS) REGARDING THE PRESENCE
OR ANY FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED
SPECIES OR CRITICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE
PROPOSED PROJECT. HAVE YOU DONE SO? YES [ ] NO [)(].
RESPONSES FROM THE USFWS AND/OR NMFS SHOULD BE ATTACHED.
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA WHICH
MAY BE AFFECTED BY THE PROPOSED PROJECT?
HAVE YOU DONE SO? YES [ ] NO [~Q
RESPONSE FROM THE SHPO SHOULD BE ATTACHED.
17. ADDITIONAL INFORMATION REQUIRED BY DEM:
A. WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, AND LAKES ON
THE PROPERTY.
B. IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PROJECT.
C. IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
D. IF A STORMWATER MANAGEMENT PLAN IS REQUIRED FOR THIS PROJECT, ATTACH
COPY.
E. WHAT IS LAND USE OF SURROUNDING PROPERTY? S~o~~~ng Czv~'fCY'
F. IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
L~1 ~~,~, 3 -S~-yY
OWNE ~S~ ATURE DATE

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Department of Transportation >~- C.,,1 V ~t• # S 3 (~
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George L. Teague LJI~ S R y ~ ~~ ~
Bridge Maintenance Superintendent ~~~tl. 1
515 Camp Rd. [phone] F o c s y~~ C U
Salisbury, NC 28147 'e..,.rO Faz [phone]
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North Carolina
Department of Transportation
Division of Hiehways
George U. Teague
Bridge Maintenance Superintendent
Sly Camp Rd. ~d~ [phone]
Salisbury, NC 28147 kt Pax [phone]
f -' .'
11. ._'1
nAVID ~EWIS
[,v,lver~
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WILSON, JIB.
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