HomeMy WebLinkAbout20090753 Ver 2_401 Application_20120612pwg•� .��
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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
1/
Pre - Construction Notification (PCN) Form
A
Applicant Information
1
Processing
la
Type(s) of approval sought from the Corps
® Section 404 Permit ❑ Section 10 Permit
1 b Specify Nationwide Permit (NWP) number / or General Permit (GP) number
1c
1 d
Has the NWP or GP number been venfied by the Corps? ❑ Yes ® No
Type(s) of approval sought from the DWQ (check all that apply)
[:1401 Water Quality Certification - Regular ❑ 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*7
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 ® No
1g
is the project located in any of NC s twenty coastal counties If yes answer 1h
below
® Yes ❑ No
1 h Is the project located within a NC DCM Area of Environmental Concern (AEC)
❑ Yes S No
2
Project Information
2a
Name of project
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2b
County
r,..l
2c
Nearest municipality / town
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2d
Subdivision name
IV A
2e
NCDOT only T I P or state project no
3
Owner Information
3a
Name(s) on Recorded Deed
[V C3 5 fL a � � 7 v d 7- V S f-
3b
Deed Book and Page No
0 uc. j� � 0 p , j / J
3c
Responsible Party (for LLC if
applicable)
I %
r' "-/ V S i/V ;✓� i� L> U /V f K, r s A ` Dix(, Al
3d
Street address
C> a, y 9
3e
City state zip
L15 f,
3f
Telephone no
V -3 - Glor,
3g
Fax no
/ S 3 -- _2 t] 2
3h
Email address
K d UM C' br u M S G t:> lv�> �-
Page 1 of 10
PCN Form - Version 1 4 January 2009
1/
4
Applicant Information (if different from owner)
4a
Applicant is
❑ Agent
® Other specify VOL u v -, r ��� J 5 / Cz
4b
Name
c� '
^
F& a J + 1 A T O t
4c
Business name
(if applicable)
4d
Street address
(�
U &I
4e
City state zip
UL �°
(9vr Al 1-- Aj ,% z%5 7
4f
Telephone no
f '� /v
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4g
Fax no
7i✓ -
76, 3 °- S 3 3 f
4h
Email address
3 r& c
b (> b N° v o v S c, v C v
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
B
Project Information and Prior Project History
1
Property Identification
la
Property identification no (tax PIN or parcel ID)
1b
Site coordinates (in decimal degrees)
Latitude 3 7 36 n/ Longitude
1c
Property size
C 1— acres
2
Surface Waters
2a
Name of nearest body of water to proposed protect
To ,v iv re e- K
2b
Water Quality Classification of nearest receiving water
TO i L� �
2c
River basin Cti /J Fe2 o f
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
I N g � t �G. L7 ��. t7 Ci L..
-h 5 /� rL /a car f y
3b
List the total estimated acreage of all existing wetlands on the property
3c
3d
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
Explain the purpose of the proposed project To '411c, "" nits S C, 4' c, 4 A n,4
3e
Descnbe the overall project in detail including the type of equipment to be used �C' fc:, vv-,IL q v d w u,
`7f ✓i-v !'e3 / c? 4p,V .,,a( -- T 5h y�4y /� .S iL k1 '3 V, /1 iN� r[ /A V �C
of _ boc, K 1) o( E), l A'( 7 I A
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?
❑ Yes ❑ 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)
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 ❑ No ® 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 14 January 2009
C Proposed Impacts Inventory
1 Impacts Summary
1 a Which sections were completed 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
Wetland impact
number
Permanent (P) or
—Temporary
2b
Type of impact
2c
Type of wetland
2d
Forested
2e
Type ofjunsdiction
Corps (404 10) or
DWQ (401 other)
2f
Area of
impact
(acres)
W1 1"
Choose one
Choose one 120 .-lei L,
Oe /No
��(iL�J�� j
W2 P
Choose one
Choose one � 0t el
Yes,
l
W3
Choose one
Choose one
Choose one �J ��f f J �i
fe§lNo
4/
W4
Choose one
Yes /No
W5
Choose one
Choose one
Yes/No
W6
Choose one
Choose one
Yes /No
2g Total Wetland Impacts
10 Oio
2h Comments
3 Stream Impacts 4
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
Choose one
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
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 indiv ually list all open water impacts below
4a
4b
4c
4d
4e
Open water
Name of waterbody
impact number
(if applicable)
Type of impact
Waterbody
Area of impact (acres)
Permanent (P) or
type
Temporary T
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 the complete the chart below
5a
5b
5c
5d
5e
Pond ID number
Proposed use or
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
purpose of pond
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f Total
59 Comments
5h Is a dam high hazard permit required?
E] Yes [] No If yes permit ID no
51 Expected pond surface area (acres)
51 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 basm*7
❑ Neuse Tar Pamlico Catawba [:] Randleman ❑ Other
6b
6c
6d
6e
6f
6g
Buffer Impact
Reason for impact
Stream name
Buffer
Zone 1
Zone 2
number—
mitigation
impact
impact
Permanent (P) or
required?
(square
(square
—Temporary T
feet )
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
1 a Specifically describe measures taken to avoid or minimize the proposed impacts in designing pro ect
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1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
E Q C h SC f vI, W // he /C ," OA &y sc, n1 ,V r S h,
Vv(, ie,- 00gf -j"t l %it?ur x�� d11 a // I—C?Me9 v t) -1 h � A
-Se l,4 FCC (f ' L d i { N ca C7 (f V e4
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 ® 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
prolecO
❑ Mitigation bank
❑ Payment to in lieu fee program
❑ Permittee Responsible Mitigation
3 Complete if Using a Mitigation Bank
3a Name of Mitigation Bank
Type Choose one Quantity
3b Credits Purchased (attach receipt and letter) Type Choose one Quantity
Type Choose one 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 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 mitigation 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
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
la
Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules?
❑ Yes ® 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 beef 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 governments 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?
❑ 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 1 4 January 2009
F
Supplementary Information
1
Environmental Documentation (DWQ Requirement)
1a
Does the project involve an expenditure of public (federal /state /local) funds or the
® Yes
❑ No
use of public (federal /state) land?
lb
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
letter)
❑ Yes
❑ No
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
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
4
Sewage Disposal (DWQ Requirement)
4a
Clearly detail the ultimate treatment methods and disposition (non discharge or discharge) of wastewater generated from
the project or available capacity of the subject facility
�proposed
V o 1/
Page 9 of 10
PCN Form — Version 14 January 2009
5 Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this protect 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 ❑ No
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 protect 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 protect 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?
8 Flood Zone Designation (Corps Requirement)
-T 8a Will this protect occur in a FEMA designated 100 year floodplain?
❑ Yes ® No
8b If yes explain how protect meets FEMA requirements
make the floodplain determination
8c What source(s) did you use to ma ?
(3 ruv> vl G K &( ,tt vfy
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
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