20120518 Ver 1_401 Application_20120512

20 1 205 1 8
305 W Wilson Creek Drive
Trent Woods NC 28562 7537
May 18 2012
NC DENR — Division of Water Quality Wetland
401 Unit
2321 Crabtree Boulevard Suite 250
Raleigh NC 27604 2260
Re PCN Application for Sediment Removal
Dear Staff
Attached is my PCN Form with sketch attached for permit approval and issuance I am
coordinating with Dominion Shoreline Management to insure that I am compliant with their
rules and policies
Your prompt attention to my request will be greatly appreciated If you have any questions
please call me at 252 676 0088 or email me at iggihusar@verizon net
Sincerely
Ihor W Husar
Attachment
PCN Form with Sketch �5
MAY 252012

20120518
Office Use Only
o Corps action ID no
DWQ protect no
Form Version 13 Dec 10 2008
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 3 or General Permit (GP) number
1 c Has the NWP or GP number been verified by the Corps? LM tees ❑ No
1 d Type(s) of approval sought from the DWQ (check all that apply)
❑ 4ul Water Quality Certitcation — Regular [j Non 404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
le Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification
❑ Yes ® No
For the record only for Corps Permit
® Yes ❑ No
If 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
El Yes No
1g Is the protect located in any of NC s twenty coastal counties If yes answer 1 h
below
❑ Yes ® No
1h Is the protect located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ® No
2 Protect Information
2a Name of protect
Removal of Accumulated Sediment
2b County
Warren
2c Nearest municipality / town
Littleton
2d Subdivision name
Twin Oak Shores
2e NCDOT only T I P or state
protect no
3 Owner Information
3a Name(s) on Recorded Deed
Ihor W and Barbara A Husar
3b Deed Book and Page No
Deed Book 865 Page 703 Plat Book 18 Page 5
3c Responsible Party (for LLC if
applicable)
3d Street address
186 Twin Oaks Lane
3e City state zip
Littleton NC 27850 8345 t
252 676 0088
3f Telephone no
3g Fax no
252 633 4131
3h Email address
iggihusar @verizon net RENR
wotge ®►anrn 1
Page 1 of 10
PCN Form — Version 1 3 December 10 2008 Version

4 Appucant information (if different from owner)
4a Applicant is
❑ Agent ❑ Other specify
4b Name
4c Business name
kif appiicably)
-
4d Street address
4e City state zip
4f Telephone no
4g Fax no
4h Email address
5 Agent/Consultant Information (if applicable)
5a Name
5b Business name
(if applicable)
5c Street address
5d City state zip
5e Telephone no
5f Fax no
5g Email address
Page 2 of 10
PCN Form — Version 1 3 December 10 2008 Version

B Project Information and Prior Project History
1 Property Identification
1a Property identification no (tax PIN or parcel ID)
K2C131
Fib
Latitude 36 312132 Longitude
Site coordinates (in decimal degrees)
77 572050
(DD DDDDDD) ( DD DDDDDD)
1c Property size
1 5 acres
2 Surface Waters
2a Name of nearest body of water (stream river etc ) to
Lake Gaston
proposed p oject
2b Water Quality Classification of nearest receiving water
2c River basin
Roanoke River Basin
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
Water access to boat dock obstructed by sediment
3b List the total estimated acreage of all existing wetlands on the property
None
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
None
3d Explain the purpose of the proposed project
Accumulated sediment removal in front of boat dock
3e Describe the overall project in detail including the type of equipment to be used
Excavate and remove 12 cubic yards of sediment using barge mounted excavator
4 Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
El Yes ®No El Unknown
project (including all prior phases) in the past
Comments
4b If the Corps made the jurisdictional determination what type
❑ preliminary ❑ Final
of determination was made?
4c If yes who delineated the jurisdictional areas?
Agency /Consultant Company
Name (if known)
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
® Yes ❑ No ❑ Unknown
this project (including all prior phases) in the past?
5b If yes explain in detail according to help file instructions
GP #200520849 issued 25 May 2005 Expired 31 December 2010
6 Future Project Plans
6a Is this a phased project*
❑ Yes ® No
6b If yes explain
Page 3 of 10
PCN Form — Version 1 3 December 10 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
la Which sections were completed below for your project (check all that apply)
❑ Wetlands ❑ Streams tributaries ❑ Buffers
Z Gpcn 6vaterb ❑ Pond Cunstrucuun
2 Wetland Impacts
If there are wetland impacts proposed on the site then complete this question for each wetland area impacted
2a
2b
2c
2d
2e
2f
Wetland impact
Type of Jurisdiction
number —
Type of impact
Type of wetland
Forested
(Corps 404 10
Area of impact
Permanent (P) or
(if known)
DWQ —non 404 other)
(acres)
Temporary T
W1 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g Total wetland impacts
2h Comments Not Applicable
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
3b
3c
3d
3e
3f
3g
Stream impact
Type of impact
Stream name
Perennial
Type of Jurisdiction
Average
Impact
number
(PER) or
(Corps 404 10
stream
length
Permanent (P) or
intermittent
DWQ — non 404
width
(linear
Temporary (T)
(INT)?
other)
(feet)
feet)
S1 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S2 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S3 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S4 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
3h Total stream and tributary impacts
31 Comments Not Applicable
Page 4 of 10
PCN Form — Version 1 3 December 10 2008 Version

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
4b
4c
4d
4e
Open r a +e
I "Jame of v aterbody
impact number —
kif appucabie)
Type oi impdut
Aate, body type
Area uf mpac' (acres,
Permanent (P) or
Temporary T
01 ®P ❑ T
Lake Gaston
Dredging
Lake
500 sq ft
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
4f Total open water impacts
4g Comments 2100 cubic feet (See attached sketch)
5 Pond or Lake Construction
If pond or lake construction proposed then complete the chart below
5a
5b
5c
5d
5e
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or purpose
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f Total
5g Comments Not Applicable
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
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
❑ Neuse ❑ Tar Pamlico ❑ Other
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b
6c
6d
6e
6f
6g
Buffer impact
number —
Reason
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary T
impact
required?
B1 ❑P ❑T
El Yes
❑ No
B2 ❑P ❑T
❑Yes
❑ No
B3 ❑P ❑T
F1 Yes
❑ No
6h Total buffer impacts
61 Comments Not Applicable
Page 5 of 10
PCN Form — Version 13 December 10 2008 Version

D Impact Justification and Mitigation
1 Avoidance and Minimization
la Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
Minimum amount of sediment will be removed to allow pontoon boat acces to dock from open water on lake Coordination with
the Dominion Shoreline Management Authority to follow their rules and Dolicies to mitigate shoreline disturbance
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Specifications from the Dominion Shoreline Management Authority will be applied to the terms and conditions of the sediment
removal contractor
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 *c 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
Quantity
3c Comments Not Applicable
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
❑ warm ❑ cool ❑cold
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 Not Applicable
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 3 December 10 2008 Version

E Stormmwater Management and Diffuse Flow Plan (required by DWQ)
1 Diffuse Flow Plan
la Does the prnjert iprli frig nr is it adjacent to protected riparian buffers identified
I
within one of the NC Riparian Buffer Protection Rules?
❑ Yes IJZ No
1 b If yes then is a diffuse flow plan included? If no explain why
Comments
❑ Yes ® No
2 Stormwater Management Plan
2a What is the overall percent imperviousness of this project?
%
2b Doe s this protect require a S +o mm a+er Management Plar'
❑ ves ® No
2c If this project DOES NOT require a Stormwater Management Plan explain why Open water sediment removal
2d If this project DOES require a Stormwater Management Plan then provide a brief narrative description of the plan
i
❑ Certified Local Government
2e Who will be responsible for the review of the Stormwater Management Plan?
❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3 Certified Local Government Stormwater Review
3a In which local government s jurisdiction is this project?
Not Applicable
❑ 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
4a Which
(check
of the following state implemented stormwater management programs apply
all that apply)
❑ 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 13 December 10 2008 Version

F
Supplementary Information
1
Environmental Documentation (DWQ Requirement)
10
Does the project involve an expenditure of public (federal/sta +e /Iocnl) funds or +he
use ion public (fede, ai / *tote) .and?
LJ Yes
Z No
lb
h yolu answered yes tv Lhe above goes the piolect 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 yolu answered yes to the above has the document review been finalized by the
State Clearmq House? (If so attach a copy of the NEPA or SEPA final approval
letter)
❑ Yes
❑ No
Comments Not applicable
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 Rlparian Buffer Rules (15A NCAC 2B 0200)?
2b
Is this an after the fact permit application?
❑ Yes
® 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
El Yes
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
Not applicabbe
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
Not Applicable
Page 9 of 10
PCN Form —Version 1 3 December 10 2008 Version

5 Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this project occur in or near an area with federally protected species or
❑ Yes ® No
habitat?
❑ Yes ® No
5b Have you checked with the USFWS concerning Endangered Species Act
impacts?
❑ Raleigh
5c If yes indicate the USFWS Field Office you have contacted
❑ Asheville
5d What data sources dia you use to determine whether yuur site wouid impact Endangered Species or Des gnated Critical
Habitat?
Not Applicable
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?
Not Applicable
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 ® 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?
Not Applicable
8 Flood Zone Designation (Corps Requirement)
8a Will this project occur in a FEMA designated 100 year floodplain?
❑ Yes ® No
8b If yes explain how project meets FEMA requirements
8c What source(s) did you use to make the floodplain determination? Not Applicable No structure will be build in floodplain
This is an open water sediment removal project
s May 2012.
Applicant/Agents Printed Name
Date
Applicant/Agents Signature
(Agents signature is valid only if an authorization letter from the applicant
is provided
Page 10 of 10
PCN Form — Version 1 3 December 10 2008 Version

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