20210641 Ver 1_Determination Request_20210326

Stream Origin/Buffer Applicability Determination
Please note: fields marked with a red asterisk * below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Name:*
MASON LUMBER COMPANY SUBDIVISION
Is this a transportation project?* f Yes r No
Is this request for a mitigation site?* f Yes No
What type of request is this?*
Owner Information
Name on the Recorded Deed:*
Responsible Party :
Telephone Number:
r Buffer
r Isolated Wetland
Check all that apply.
WILLIAM PAGE TRUST
17 IP Stream Determination
17 Stream
WILL PAGE
(for LLC, Corporations, businness, agency, etc.)
252-946-8159
How would you like to received your determination?*
Email Address:*
[e-mail]
Is there an agent or consultant responsible for the request?*
(
Attach agent authorization letter:*
Agent/Consultant Information
agent auth.pdf
FL7F only
How would you like to receive your r USPS
determination letter?* C' Email
Name of Agent:*
Company Name:*
Email Address:*
Project Information
MARIE PEEDIN
INNER BANKS ENGINEERING, PC
MUPEEDIN@IBXENG INEERING. CO
M
Has anyone form DWR done a previous site visit?*
38.63KB

f Yes
✓ No
f• Other
UNSURE, PREVIOUS DEVELOPMENT WAS UNDER
ANOTHER OWNER
Date of Visit:
Site Information
.............................................................................................................................................................................................
Nearest Highway/Street:* US 264 AND GRIMES ROAD
Nearest Town:*
Nearest Named Stream:*
River Basin:*
County: *
Beaufort
WASHINGTON
TRANTERS CREEK/ CHERRY RUN
Tar -Pamlico
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach docurrent
ditch call map.pdf
Rif file type only
111.99KB
TOPO map look up: https://viewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
Click the upload button or drag and drop files here to attach docunent
NRCS MAP.pdf 1.77MB
Rif file type only
Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
Please provide the Latitude and Longitude for physical location for the determination that. If you have a
physical address you can look up the Latitude and Longitude by typing in an address or filling out the
information manually.
Choose below how you would like to provide this information.
f Address Lookup
C' Manually
Latitude:
Longitude:
Misc attachments:
35.56833
77.08
pdf or Ivre file types only
By digitally signing below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act")
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act");

o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Determination Request' form."
Signature
r
Date Submitted:
Initial Review
.......................................................
ID#* 20210641
Version* 1
Do you want to send for review?* C' Yes r No
Select Reviewer:* Robert Tankard:eads\rbtankard
Select Regional Office:* Washington Regional Office - [phone]
3/26/2021

AGENT AUTHORIZATION
For Mason Lumber Yard Subdivision
I, Will Page, Jr , certify that I am a trustee of the William H Page Trust which own the
property identified as Tax Parcel 5676-07-3128, and thus give permission to Inner Banks
Engineering, PC to provide information for the development of the project.
Signature:
I, (, viskl+nc A. Ciskwat
Date: 34/
, a Notary Public for the State of rk , County of
, do hereby certify that W 1 111 Y1 Q tait fr•
personally appeared before me this \ 4 day of
Mia CIA �++''1'120 Zl and acknowledge the due execution of the authorization.
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