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Home My WebLink About20120395 Ver 1_401 Application_20120412C4 WAr��4G a < 20120395 Office Use Only Corps action ID no DWQ project no Form Version 14 January 2009 Page 1 of 10 PCN Form - Version 1 4 January 2009 Pre - Construction Notification (PCN) Form A Applicant Information 1 Processing 1a Type(s) of approval sought from the Corps Section 404 Permit ❑ Section 10 Permit 1 b Specify Nationwide Permit (NWP) number �q or General Permit (GP) number 1c Has the NWP or GP number been verified by the Corps? ❑ Yes ❑ No 1d Type(s) of approval sought from the DWQ (check all that apply) yX 401 Water Quality Certification – Regular ❑ Non 404 Jurisdictional General Permit ❑ 401 Water Quality Certification – Express ❑ Riparian Buffer Authorization 1e Is this notification solely for th ere cord because written approval is not required? J For the record only for DWQ 401 Certification ❑ Yes I Z(No For the record only for Corps Permit ❑ Yes N�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 3.,No 1g Is the protect located in any of NC s twenty coastal counties If yes answer 1 h below ❑YesVo 1 h Is the project located within a NC DCM Area of Environmental Concern (AEC) ?,, ! ❑ Yes 19vo L2 ;Protect Informattort \� 2a Name of project C AMEt-O T *1001245 DAM 2b County STOP -S5 2c Nearest municipality / town pNN el U Pl 2 2d Subdivision name C 4ASLCT WCOM pF 2e NCDOT only T I P or state project no �R�k C3—Owner Information 3a Name(s) on Recorded Deed CKNF71LOT E 3b Deed Book and Page No jf�jp g 3c Responsible Party (for LLC if applicable) GN�FiLcr TE KIAPPOST S T 1r\/E bC�u'TWELL 3d Street address 527 CDof�T 3e City state zip 6hEEtJ580130 2.740 7 3f Telephone no $i>-2 -4045 3g Fax no 3h Email address Page 1 of 10 PCN Form - Version 1 4 January 2009 Page 2 of 10 Applicant Information (if different from owner) 4a Applicant is ❑ Agent ❑ Other specify 4b Name 4c Business name (if applicable) 4d Street address 4e 04y, state zip -4f - i ne no 4g Fax no 4h Email address Agent/Consultant Information (if applicable) 5a Name WiLLiANA E.. MITCA EUL 5b Business name (if applicable) I'll -i—tw M%TCJt16w k5c oc 5c Street address , gp�j_G Ae>RW6o'D Cwpg 5d City state zip tie.. 27455 5e Telephone no G _ 940 _ 00 O 5f Fax no 5g Email address Page 2 of 10 B Project Information and Prior Project History 1 lzzzProperty Identification 1a Property identification no (tax PIN or parcel ID) Co 00<o462,20 1b Site coordinates (in decimal degrees) Latitude N'%a° Z3' 3 Longitude V4 $p° 121 10 1c Property size LA + acres 2 C$urface Water 2a Name of nearest body of water to proposed protect M11— ,, 02ic-S6 2b Water Quality Classification of nearest receiving water G(A<C 2c River basin F)bNi-JOYE �Zfj�O 3 CPi!oject De`sc`ription 3a Describe the existing conditions on the site and the general land use in the vicinity of the protect at the time of this application RUF)AL) F;�Stvl ilpv Sul3V1V1S�0�1 Ab,1 PPRo��P,fi( ScaT1-lrFis✓D OF`) VACANT 3b List the total estimated acreage of all existing wetlands on the property 3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property�,t�tiJ�1 3d Explain the purpose of the proposed protect 3e Describe the overall protect in detail including the type of equipment to be used 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? ErYes ❑ 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) Y jam, C>A 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 'EZNo ❑ Unknown 5b If yes explain in detail according to help file instructions 6 Future Project Plans 6a Is this a phased project? ❑ Yes 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) ❑ Wetlands Y Streams — tributaries3 [j 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 Choose one-(��4oa- , r-o. Choose one r Ye 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 p 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 , f S1 Choose one �— et) w gig S2 Choose one S3 Choose one S4 Choose one S5 Choose one S6 Choose one 3h Total stream and tributary impacts 31 Comments = Page 4 of 10 PCN Form — Version 1 4 January 2009 1 4 *open Water Impacts If therrb are proposed impacts to lakes ponds estuaries tributaries sounds the Atlantic Ocean or any other open water of the U S then indivii ually 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 Pond or Lake Construction If nd or lake construction proposed the 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 51 Expected pond surface area (acres) 5j Size of pond watershed (acres) 5k Method of construction uffer 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 mite ation then vou 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 B1 Yes /No B2 Yes /No B3 Yes /No B4 Yes /No B5 Yes /No B6 Yes /No 6h Total Buffer Impacts 61 Comments Page 5 of 10 D Impact Justification and Mitigation 1 Avoidance and Minimization la Specifically describe measures taken to avoid or minimize the proposed impacts in designing protect 1b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques 2 Compensatory Mitigation for Impacts to Waters of the U S or Waters of the State 2a Does the protect 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 protect? ❑ Mitigation bank ❑ Payment to in lieu fee program ❑ Permittee Responsible Mitigation om lete 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 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 14 January 2009 E Stormwater Management and Diffuse Flow Plan (required by DWQ) 1 Diffuse Flow Plan la Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules? ❑ Yes k No 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? % 2b Does this project require a Stormwater Management Plan? ❑ 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 2e Who will be responsible for the review of the Stormwater Management Plan 3 Certified Local Government Stormwater Review 3a In which local government s jurisdiction is this project? 3b Which of the following locally implemented stormwater management programs apply (check all that apply) ❑ Phase II ❑ NSW ❑ USMP ❑ Water Supply Watershed ❑ Other 3c Has the approved Stormwater Management Plan with proof of approval been attached El Yes ❑ No 4 DWQ Stormwater Program Review 4a Which of the following state implemented stormwater management programs apply (check all that apply) []Coastal counties ❑HQW ❑ORW ❑Session Law 2006 246 ❑Other 4b Has the approved Stormwater Management Plan with proof of approval been attached? ❑ Yes ❑ No 5 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 Page 8 of 10 PCN Form — Version 14 January 2009 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 ❑ Yes ❑ 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 15 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 NO F Supplementary Information 1 Environmental Documentation (DWQ Requirement) la Does the protect involve an expenditure of public (federal /state /local) funds or the ❑ Yes `o use of public (federal /state) land? 1 b If you answered yes to the above does the protect require preparation of an environmental document pursuant to the requirements of the National or State ❑Yes ❑ No (North Carolina) Environmental Policy Act (NEPA/SEPA)? 1c 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 ❑ No or Riparian Buffer Rules (15A NCAC 2B 0200)? 2b Is this an after the fact permit application? XYes ❑ No 2c If ou answered yes to one or both of the above questions provide an explanation of the violation(s) 5VIT LMc2 W k -MtA '5SP OF Fo%""MST, FD Ob (Mt.,L .9 �p LN MSS 1 -9.90 5 j, GPif`AT� 5MA.Lj_ 6Mt0V0V M6t-i F-OCK pijh M5b`5 Uf_.jAUjAVV DV= ANA( VW& DK S�DIM�( Cb�Cul.- R- �GUt�TIoNS /R��vtCZt�M1�"t5 3 Cumulative Impacts (DWQ Requirement) 3a Will this protect (based on past and reasonably anticipated future impacts) result in E] Yes ONO 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 Sewage Disposal (DWQ Requirement) 4a Clearly detail the ultimate treatment methods and disposition (non discharge or discharge) of wastewater generated from the proposed protect or available capacity of the subject facility Page 9 of 10 PCN Form — Version 14 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 'RNo 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 Histonc or Prehistonc 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 f 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-E] Yes XNo 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 z0a CDat CApphcanUAgent s Signatures (Agents signature is valid only if an authorization letter from the applicant is provided Page 10 of 10 � 1 T Av R�� cr l i C o0 E' w ro n a y o lD oy 3 o a I D o o 3 ? `G v �• v 1 , i' _. 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