20121093 Ver 1_Complete File_20121205 (2)

Beverly Eaves Perdue
Governor
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E.
Director
Dee Freeman
Secretary
C? Stream Origin /Buffer Applicability Determination
Applican wner's Name (c Toration /individual who is legally responsible for the pr rty and its compliance:
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Applicant /Owner Address: �-5 --)H�� C X n / tp'
Applicant's phone number: �5�- 5fs= 453 � Fax umber: a��} r %,T 3 �L t
Applicant's email address:
Consultant /Contact person Name (if applicable):
Consultant address (if applicable):
Consultant's phone number:
Consultant's email address:
Name of Project:
Nearest Named stream + River Basin (from USGS
Please provide a brief description of this project (hakch site plan
IVED
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DWQ -WAR'
Please attach a map of site location indicating project boundaries usigg USGS 1:24,000 topo map and NRCS county soil survey.
Location of project site - please include reference to the county, nearest named town and highway number:
Has any DWQ staff visited the site? , if yes, please provide DWQ staff name,
visit:
and date of
This form may be submitted via email ([e-mail]), faxed (252- 946 - 9215), mailed or hand - delivered to:
943 Washington Square Mall, Washington, NC 27889. (Note: Submittals of the review packages on Friday after 12:00 pin will
be stamped as received on the next business day).
Please contact Amy Adams at 252- 948 -3917 if you have any questions regarding this form.
North Carolina Division of Water Quality Internet: www.newaterquality.org
943 Washington Square Mall Phone: [phone] One
Washington, NC 27889 FAX [phone] NorthCarolliina
An Equal Opportunity /Affirmative Action Employer— 50% Recycled /10% Post Consumer Paper Nldulrallff

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