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Office Use Only
Corps action ID no
DWQ project no
Form Version 13 Dec 10 2008
Page 1 of 10
PCN Form — Version 13 December 10 2008 Version
Pre-Construction Not>If canon C Form
A Apphcant Information
1
Processing
1a
Type(s) of approval sought from the
Corps
Section 404 Permit ❑ Section 10 Permit
1 $
1 b Specify Nationwide Permit (NWP) number � 1A or General Permit (GP) number
1c
Has the NWP or GP number been verified by the Corps?
❑ Yes No
Id
Type(s) of approval sought from the DWQ (check all that apply)
tK401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 e
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
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 gNo
1 g
Is the project located in any of NC s twenty coastal counties if yes answer 1 h
below
❑ Yes No
1h Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes No
2
Project Information
2a
Name of project
2b
County
LEO TL9 10
2c
Nearest municipality/ town
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2d
Subdivision name
�' 2
2e
NCDOT only T I P or state
project no
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3
Owner Information
3a
Name(s) on Recorded Deed
3b
Deed Book and Page No
y U of S Q �, a�� -eS �-� 145 yvp DQS.Q Z)
3c
Responsible Party (for LLC if
applicable)
3d
Street address
ct
3e
City state zip
v C. �y
3f
Telephone no
3g
Fax no
3h
Email address
5 Q Cu Ol rncj C
Page 1 of 10
PCN Form — Version 13 December 10 2008 Version

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
41' Telephone no
4g Fax no
4h Email address
5 AgentlConsultant 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 — Vernon 13 December 10 2008 Version

B
Project Information and Prior Project History
1
Property Identification
1a
Property identification no (tax PIN or parcel ID)
o�W of
lb
Site coordinates (in decimal degrees)
Latitude 2,S S I Longitude g I
(DD DDDDDD) (DD DDDDDD)
1 c
Property size
tQ g3 acres
2
Surface Waters
2a
Name of nearest body of water (stream river etc ) to
proposed project
�c e r e� ti 1�PC V a c ^ti
2b
Water Quality Classification of nearest receiving water
C
2c
River basing
V p,
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
Q -�60,►tk�
3b
List the total estimated acreage of all existing wetlands on the property
"4 S crc( Q-
3c List the total `estimated linear feet of all existing streams (intermittent and perennial) on the property
3d
Explain the purpose of the proposed project
") b ,4--�
3e
Describe the overa I project 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?
Comments
❑YesNo XUnknown
`
4b
If the Corps made the jurisdictional determination what type
of determination was made
1-1 Preliminary El Final
4c
If yes who delineated the jurisdictional areas?
Name (if known)
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 pasty
Yes j(Vo 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 13 December 10 2008 Version
t14k

C Proposed Impacts Inventory
1 Impacts Summary
1a Which sections were co pleted below for your project (check all that apply)
❑ Wetlands 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
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
W1 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W2 []POT
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P [:IT
❑ 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
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 EPEIT
C���l �'C
C10C1Q
C] I NT
U DWQ
, O�
S2 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S3 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S4 ❑ P ❑ T
❑ PER
❑ Corps
❑ IT
❑ DWQ
S5 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
S6 ❑ P ❑ T
❑ PER
❑ Corps
❑ INT
❑ DWQ
3h Total stream and tributary impacts
31 Comments
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 estuanes 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 water
Name of waterbody
impact number —
(if applicable)
Type of impact
Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary
01 ❑P ❑T
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
4f Total open water impacts
4g Comments
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
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 npanan 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
impact
required
B1 ❑P [IT
El Yes
❑ No
B2 ❑P ❑T
❑Yes
❑ No
B3 ❑P ❑T
❑Yes
❑ No
6h Total buffer impacts
61 Comments
Page 5 of 10
PCN Form — Version 13 December 10 2008 Version

D Impact Justification and Mibgabon
1 Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
S C .OP 1 ­Z11
1b Sp cifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
U Se 01 ti, CLAD :1 6 -
2 Compensatory Mitigation for Impacts to Waters of the U S or Waters off the`State
2a Does the protect require Compensatory Mitigation for
impacts to Waters of the U S or Waters of the State?
❑ Yes
2b If yes mrtigation 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
Quanfity
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
❑ 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
5 Complete rf Using a Perinittee Responsible Mtigation Plan
5a If using a permittee responsible mitigation plan provide a description of the proposed mitigation plan
Page 6 of 10
PCN Form — Version 13 December 10 2008 Version

6 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
buffer mitigation?
❑ Yes ❑ No
6b If yes then identify the square feet of impact to each zone of the riparian buffer that requires mitigabon Calculate the
amount of mitigation required
Zone
6c
Reason for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(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
PCN Form — Version 13 December 10 2008 Version

E
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1
Diffuse Flow Plan
la
Does the protect include or is it adjacent to protected riparian buffers identified
❑ Yes Io
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
Comments
2
Stormwater Management Plan
2a
What is the overall percent imperviousness of this protect?
%
2b
Does this protect require a Stormwater Management Plan?
❑ Yes ❑ No
2c
If this protect DOES NOT require a Stormwater Management Plan explain why
2d
If this protect DOES require a Stormwater Management Plan then provide a brief narrative description of the plan
❑ 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 protect?
❑ Phase it
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
❑ HQW
4a
Which of the following state - implemented stormwater management programs apply
[] ORW
(check all that apply)
❑ Session Law 200 6-246
❑ Other
4b
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
5
DWQ 401 Unit Storm inter Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
513 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
7
Environmental Documentation (DWQ Requirement)
la
Does the project 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 project 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?
❑ 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
❑ Yes
V0
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
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
habitat?
❑ Yeslo
' K
5b Have you checked with the USFWS concerning Endangered Species Act
impacts?
❑ Yes NO
5c If yes indicate the USFWS Field Office you have contacted
❑ Raleigh
❑ Asheville
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 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
status (e g National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
❑ YesNo
/ \\
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?
❑ Yes ❑ No
8b If yes explain how project meets FEMA requirements
8c What source(s) did you use to make the floodpiain determination?
Applicant/Agents Printed Name
C-1A
Date
Applicant/Agent s Signature
(Agents signature is valid only if an authorization letter from the applicant
is provided
Page 10 of 10
PCN Form — Version 13 December 10 2008 Version

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421 landers chapel rpad, lincolnton, nc - Google Maps
Valcese
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Address 421 Landers Chapel Rd
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http://Maps.google.comlmaps?f--q&source=s,_q&hl=-en&geocode=&q=421+landers+chape... 5/28/2012

Gaston County, NC
Office of the Director of Revenue, GIS Division
DisclairrierThe information provided is not to be considered as a Legal
Document or Description. The Map and Parcel Data is believed to be accurate,
but Gaston County does not guarantee its accuracy,
Print Date: 5/2812012
Page I of I
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