20120805 Ver 1_401 Application_20120812

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. I �Z PLAN NO.
STREET ADDRESS:
Please print:
Property Owner:1
Property Owner:
PARCEL ID: 113-�00-
69/
The undersigned, registered property owners of the above noted property, do hereby authorize
(3eaL'1oj s)yly,04 of 1 v I
(Contractor / Agent) (Name of nsulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone: S12 - -? 3 ,6-1-1
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date:

0 00' W AiF9oG
201 2080 5
Office Use Only -
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Page 1 of 10
PCN Form — Version 1.4 January 2009
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
1b. Specify Nationwide Permit (NWP) number: 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):
❑ 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
[] 401 Water Quality Certification — Express Q�Riparian Buffer Authorization
1e.
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
1 g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes o
1h.
Is the project located within a NC DCM Area f Environmental Concern (AEC)?
RYes ❑ No
2.
Project Information /
2a.
Name of project:
2b. County:
(�
2c.
Nearest municipality / town:
2d.
Subdivision name:
�' �01ve'c
2e.
NCDOT only, T.I.P. or state project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
3b.
Deed Book and Page No.
0 q0 00
3 c.
Responsible Party (for LLC if
applicable):
D
3d. Street address:
3e.
City, state, zip:
3f.
Telephone no.:
�f'Q c- _ P1 02 7 �O
3g.
Fax no.:
ww wqx
3h.
Email address:
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:
EAgent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
y) n
4d. Street address:
C>
4e. City, state, zip:
4f. Telephone no.:
r
4g. Fax no.:
(Cr _ S
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

B.
Project Information and Prior Project History
1.
Property Identification f Doc)
1a.
Property identification no. (tax PIN or parcel ID):
I I =
1 b.
Site coordinates (in decimal degrees):
I Latitude: S" Longitude:
1 c.
Property size:
acres „
2.
Surface Waters
2a.
Name of nearest body of water to proposed project:
CJ
2b. Water Quality, Classification of nearest receiving water:
77 O'�' - t"'al iyS' t-,�
2c.
River basin:
r,{
3.
Project Description
3a.
Describe the existing conditions on the site ano the general land use in the vicinity of the project att•the time of this 1
application: -T l 1 � Y) l �E' M l'�I �t 'Nil SC CSY) ► T
Y? G II (�
I,�?e, c�xx� Ike r S Y�. 0', '� 9� on
be �� � o
3b.
List the total estimated acreage of all existing wetlands on the property: j ({? ,
3c.
List the total estimated linear feet of all existing streams (intermittent and perennial) on the pr perty: r /
3d. Explain the purpose of the proposed project:
ly, d aV►, tA FOD/ �' V' Imo' l� (J 1
3e.
Describe the overall project in detail, including the type of equipment to be used:
--Q17 r(DAOd Ck,
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?
9KYes ❑ No ❑ Unkn wn
,
Comments: ��► j k �.
4b.
If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c.
If yes, who delineated the jurisdiction
Name (if known): C�
I reas�
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?
LrJ Yes El No ❑ Unknown
5b.
If yes, explain in detail according to "help file" instructions. C' I d CIS ►�� )�� ��� i ��
V '^mot
6.
Future Project Plans
6a.
Is this a phased project?
❑ Yes tKo
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 (ch k all that apply):
El Wetlands El 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
Choose one
Choose one
Yes/No
-
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:
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
Choose one
S2 -
Choose one
S3 -
Choose one
S4
Choose one
S5 -
Choose one
S6 -
Choose one
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form — Version 1.4 January 2009

Page 5 of 10
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 indivii ualfy list all open water impacts below.
4a.
4b.
4c
4d
4e.
Open water
Name of waterbody
impact number
Permanent (P) or
(if applicable)
Type of impact
Waterbody
Area of impact (acres)
Temporary T
type
01
Choose one
Choose
02 -
Choose one
Choose
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water impacts
4g. Comments:
S. 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:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ 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 miti ation, then You MUST fill out Section D of this form.
6a. Project is in which protected basin?
euse ❑ Tar - Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
6f.
Zone 1
6g.
Zone 2
number —
Permanent (P) or
mitigation
impact
impact
Temporary
required?
(square
(square
feet )
feet
61
Yes/No
B2 - a/
., Pn�ta `,{AYE
Ye o
L7
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.
S 15 6 Oo
1 b. Specifically describe measur s taken to void or mi imize the proposed impacts through construction techniques.
ccx CW." .
2. Compensatory Mitigation f Im acts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
❑ Yes o
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
❑
Mitigation bank
2c. If yes, which mitigation option will be used for this
project?
❑ 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:
F4Compomments:
lete 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
Choose one
square feet
4c. If using stream mitigation, stream temperature:
4d. Buffer mitigation requested (DWQ only):
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
u

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 M 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.
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).
y
14-;
J
I, t
.o lil
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
dyes �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. -T ,
Iy✓tro:I` G-'� np nevi( 40
[]Yes �o
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b. Does this project require a Stormwater Mana ement Plan?
❑,Yes VNo
m
2c. If this project DOES NOT require a Stormwater Managee n, explain why: C kb-r-
C1*
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
. IL/)q
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 roeect?
❑ Phase II
3b. Which of the following locally- implemented stormwater management programs
❑ NSW
apply (check all that apply):
❑ USMP
n 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 of the following state - implemented stormwater management programs apply
❑HQW
❑ORW
(check all that apply):
[]Session Law 2006 -246
[]Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
[] Yes ❑ No
attached?.
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)
1 a. Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes El 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
❑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
or Riparian Buffer Rules (15A NCAC 213 .0200)?
2b. Is this an after - the -fact permit application?
❑ Yes o
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
additional development, which could impact nearby downstream water quality?
n Yes blqo
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 1.4 January 2009

S. 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 ❑ 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 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)?
❑ Yes ❑ No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
B. Flood Zone Designation (Corps Requirement)
-T 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?
Applicant/Agent's Printed Name
Date
pplicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
Page 10 of 10

SCIR1'EM RS OsLEAMR'
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ASSOCIATES. AND /OR AGENTS SHALL NOT BE LIABLE FOR USE OF THIS SURVEY BY
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IMPERVIOUS CALCULAAONS
HOUSE -1048 SF
INCLUDES PORCH, STEPS
CONCRE7F 4J6 SF
INCLUDES SIDEWALK, DRIVEWAY
TOTAL IMPERVIOUS AREA -1484 SF
PERCENTAGE OF IMPERVIOUS AREA -6.65%
NOTE.
DOCUMENT OR/GNALLY
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LEGEND
THIS WAS ISSUED AND
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NUMBER L -2855, ONS- 29-12 REV. 8 -2h12 THIS
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DOCUMENT. THE ORIGINAL STGVED AND SEALED
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BARBOUR SURVEYTNa P. A. 213 SOUTH SECOND
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STREET, SMITHFIELD, NORTH CAROUNA 27577.
JIMMY C. BARBOUR
c-J709
21J South Second Street
P. O. eox z6
SM/�nLqD NC 27577
919 989 -6542 PHONE [phone] FAX
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REVISED 8 -24 -2012
BRANCH WAS DETERMINED TO BE
CTV -CABLE TV PEDESTAL
ADDED 50' RIPARIAN BUFFER
A 50" RIPARIAN BUFFER BY LAUREN
EB- ELECTRICAL TRANSFORMER BOX
WITHERSPOON WITH THE NC DEPT.
R/W- -RIGHT OF WAY
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RALEIGH, NC 27616
AREA BY COORDINATE METHOD
SURREY FOR'
tote of North Carolina, JOHNSTON County
certify that this mop was drown under pe supervision
From on actual survey made under my supervision (deed
ascription recorded in Deed Book9740 Page 1900 ar
ther referenced source BM 1994, PG 1688,-that the ratio
f precision or positional accuracy is I.-10,000+ and
hat this map meets the requirements of THE
✓B 9740, PG 1900
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D�L.�O/ // /AH ����� ty
PARCEL /D NO
1737008218
URVEYED BY
RM
LOT 12
REMINGTON PARK PHASE 1
AS RECORDED IN BOOK of MAPS 1994, PAGE 1688
FIELD BOOK
137
TANDARDS of PRACTICE for LAND SURVEYING in North
orolina (21 NCAC 56. 1600) Th1s297H day of MAY 2012.
IC
DA TE 5 -17 -2012
NEUSE T�
WAKE COUNTY
NC
RAWN BY
CSS
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JIMMY C. BARBOUR
c-J709
21J South Second Street
P. O. eox z6
SM/�nLqD NC 27577
919 989 -6542 PHONE [phone] FAX
_
CALE
1 ° -40
mmy C. Barbour, Professional Land Surveyor
Number 2855
WG NO.
12 -070