20100087 Ver 1_Complete File_20110729

FEB _ G 2010
?. Michael F. Easley, Governor
William G. Ross Jr., Secretary
?North Carolina Department of Environment and Natural Resources _ ..
' ? .3 1
Colleen Sullins, Director .
Division of Water Quality
Stream Origin Determination
Applicant/Owner's Name (corporation/individual who is legally
f??? C?? rx If Applicant/Owner Address:
Applicant's phone number:
Applicant's email address:

for the property and its
Fax number: l?C /y `--?7E
3 ;
r r Cromv4wWContact person Name (if applicable): /c
CoR&ultaFA address (if ap licable):
GowAgtaftfls phone number(j-1 ?C? 79':3-2 Fax number:
?Uart's-email address: Co ? 6? L CO L.11 ? Cal fl ?C `
Name of Project: a?[c? County: ?C
Nearest Named stream + River Basin (from USGS topographic map):
Please provide a brief description of this project (attach site plan if available):
1 1 f-1 "T-), . „ a-
&yl? ?? f
Please attach a map of site location indicating project boundaries using USGS
topo map and NRCS county soil survey.

Has any DWQ staff visited the site? A?? if yes, please provide DWQ staff name,
visit:
and date of
This form may be submitted via email (chris.pullingergncmail.net), faxed (252-946-9215), mailed or hand-delivered to:
943 Washington Square Mall, Washington, NC 27889. (Note: Submittals of the review packages on Friday after 12:00 pm will
be stamped as received on the next business day).
Please contact Chris Pullinger at 252-948-3920 if you have any questions regarding this form.
North Carolina Division of Water Quality Internet: h2o.enr.state.naus
943 Washington Square Mall Phone: [phone] One
Wmhineton_NC27RR9 FAX [phone] North C nrolina
Location of project site - please include reference to the county, nearest named town and highway number:

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Property Details:
PIN 08021556 GPIN 669737-7019
GPINLONG 116697-47-7019 NAME1 CITY OF PANTEGO
NAME2 ADDRi
CITY
PANTEGO
STATE NC 21P 27860
PROP ROAD US 264 ACRES 11098
ACCT NUR 34014 MAP SHEET 669740
NBR_BLDG I [ 7 I I DATE
D8 PG LAND VAL 9800
BLDG VAL 177215 DEFR VAL 0
T VAL
TO 187015 NBHD GDE A
NBHD DESC AVERAGE SUB CDE
SUB DESC STAMPS 0
SALE PRICE 0 ZONE
LAND USE DISTRICT
I 08
11
PROP_DESC 1 ACRE +- PANTEGO FIRE DEPT MBL 66971057
EXMPT_PROP EKMPT_AMT 110
ROAD TYPE P
CENSUS BLK
PREVASSESS 0
Dl&, Tr ,- :i8ps a rt .nrormatiun edher in digital OF,.3.dcop}- foun;r! are ,n uvxrerta s0._Ir , :• ;t puh'n: S(,.Vice anal they do nol rriaet yrv._ying aearncy standards Th,s nl,7z::
rala in trra In .r.tory c-f real proper'y ;curd with r Cus u5...az;.u ami is z:..mr.i.e f r; rcxord, ;i needs- olnt; Lmd etne- pubic __?rcls ar.d data Gsers of ar,y map,

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_, ;; cr seauforl assumes no legal responsEbility for Me ?nfermatroi contained en these maps
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