20201999 Ver 1_3 - PCN Form North Park Site (Rev)_20210121

39
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:
Michelle Measday
5b. Business name
(if applicable):
ECS Limited
5c. Street address:
9001 Glenwood Avenue
5d. City, state, zip:
Raleigh, NC 27617
5e. Telephone no.:
919-861-9821 (o) or 919-441-2437 (c)
5f. Fax no.:
N/A
5g. Email address:
[e-mail]
Page 2 of 10

B.
Project Information and Prior Project History
1.
Property Identification
1a.
Property identification no. (tax PIN or parcel ID):
0918-00-52-8553.000
1 b.
Site coordinates (in decimal degrees):
Latitude: 36.450695 Longitude:-78.948643
1 c.
Property size:
26.14 acres
2.
Surface Waters
2a.
Name of nearest body of water to proposed project:
Mitchell Creek
2b.
Water Quality Classification of nearest receiving water:
C
2c.
River basin:
Roanoke
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:
The site consists of primarily open, wooded land. Surrounding areas consist of commercial properties, single-family residences, wooded land and
utility right-of-way.
3b.
List the total estimated acreage of all existing wetlands on the property: 0.704
3c.
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 2,885
3d. Explain the purpose of the proposed project:
See Appendices
3e. Describe the overall project in detail, including the type of equipment to be used:
See Appendices
4.
Jurisdictional Determinations
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?
❑X Yes ❑ No ❑ Unknown
Comments:
4b.
If the Corps made the jurisdictional determination, what type
of determination was made?
❑X Preliminary ❑ Final
4c.
If yes, who delineated the jurisdictional areas?
Name (if known): Mr. Jonathan Grubb
Agency/Consultant Company: ECS Limited
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
SAW-2020-01317
5.
Project History
5a.
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑Yes ❑X No ❑ Unknown
5b.
If yes, explain in detail according to "help file" instructions.
6.
Future Project Plans
6a.
Is this a phased project?
❑ Yes ❑X No
6b.
If yes, explain.
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 (check all that apply):
❑X Wetlands ❑X 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 T
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 P
Fill
Riverine Swamp Forest
Yes
Corps
0.0061
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:
0.0061
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 (T)
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 P
Culvert
UT Mitchell Creek
PER
Corps
4
95.86
S2 P
Stabilization
UT Mitchell Creek
PER
Corps
4
70
S3 P
Fill
UT Mitchell Creek
INT
Corps
3
32
S4
Choose one
S5 -
Choose one
S6
Choose one
3h. Total stream and tributary impacts
197.86
3i. Comments:
A culvert is required to cross the unnamed tributary to Mitchell Creek to allow access to upland portions of the site for industrial development. The
culvert accounts for 95.86-LF of impact to the channel, 70-LF accounts for rip -rap aprons required for stabilization at the end of the culvert and 32-LF is
impacted to a small channel to the unnamed tributary. Total stream impacts/loss of waters are 127.86-LF.
Page 4 of 10
PCN Form — Version 1.4 January 2009

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 individually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary (T)
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 pond or lake construction proposed, 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 0 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 any 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 (T)
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet)
B 1
Yes/No
B2
Yes/No
B3
Yes/No
B4
Yes/No
B5
Yes/No
B6
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D.
Impact Justification and Mitigation
1.
Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
See Appendices
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
See Appendices
2.
Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a.
Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes ❑X 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
El Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3.
Complete if Using a Mitigation Dank
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 Making 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.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Mules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
Yes 0 No
buffer mitigation?
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

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
❑ Yes X❑ No
within one of the NC Riparian Buffer Protection Rules?
1 b.
If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2.
Stormwater Management Plan
2a.
What is the overall percent imperviousness of this project?
24 %
2b.
Does this project require a Stormwater Management Plan?
❑X Yes ❑ No
2c.
If this project DOES NOT require a Stormwater Management Plan, explain why:
2d.
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
The site is subject to review by the City of Roxboro and Person County under "The Falls Watershed, Water Supply Watershed and NPDES Phase II
Stormwater
Ordinance for New Development." The stormwater management plan will be reviewed by a professional engineer on behalf of Person
County.
2e.
Who will be responsible for the review of the Stormwater Management Plan?
City of Roxboro/Person County
3.
Certified Local Government Stormwater Review
3a.
In which local government's jurisdiction is this project?
❑X Phase II
❑ NSW
3b.
Which of the following locally -implemented stormwater management programs
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c.
Has the approved Stormwater Management Plan with proof of approval been
El Yes X❑ 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):
N Session Law 2006-246
❑ Other:
4b.
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑X No
attached?
5.
DWQ 401 Unit Stormwater Review
5a.
Does the Stormwater Management Plan meet the appropriate requirements?
❑X Yes ❑ No
5b.
Have all of the 401 Unit submittal requirements been met?
❑X Yes ❑ No
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
❑X Yes ❑ No
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
El Yes ❑X No
(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
❑ Yes ❑ No
letter.)
Comments:
2.
Violations (DWQ Requirement)
2a.
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
❑Yes ❑X No
or Riparian Buffer Rules (15A NCAC 213 .0200)?
2b.
Is this an after -the -fact permit application?
❑Yes ❑X No
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
❑Yes ❑X No
additional development, which could impact nearby downstream water quality?
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 project, or available capacity of the subject facility.
Wastewater
will be handled by City of Roxboro/Person County
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
❑X Yes ❑ No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑X Yes ❑ No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
See Appendices.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ❑X No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NOAA Essential Fish Habitat Mapper
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
❑ Yes ❑X No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
See the attached NCSHPO GIS imagery.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?
❑ Yes ❑X No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
FEMA FIRM Map Service Center GIS viewer and attached figures.
Michelle Measdayxe�s
12/18/2020
Applicant/Agent's Printed Name
Date
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
Page 10 of 10