20121117 Ver 1_Complete File_20121214

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. RECEIVED
Dee Freeman
Governor Director
Secretary
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Variance Request Form for Minor Varia�c��s WAR 0
Protection and Maintenance of Riparian Areas Rules Dok-r \-4- I\V7
NOTE: This fonn may be photocopied for use as an original.
Please identify which Riparian Area (Buffer) Protection Rule applies.
Li Neuse River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (15A NCAC 02B
.0233)
u Tar - Pamlico River Basin: Nutrient Sensitive Waters Management
Strategy Protection and Maintenance of Riparian Areas Rule (15A
NCAC 02B.0259)
u Catawba River Basin: Protection and Maintenance of Existing Riparian
Buffers (15A NCAC 02B .0243)
Part 1: General Information
(Please include attachments if the room provided is insufficient.)
1. Applical�J +ms's name (the torpor tion, individual, etc. who owns the property):
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Print Owner /Signing Official (person legally responsible for the property and its compliance)
Name:
Title: pc ✓,vim
Street address:
City, State, Zip: _Cf�OC�c ✓o v; C? 2 j
Telephone:.)�.Y�
Fax: ( ?
Contact person who can answer questions about the proposed project
Name:
Telephone:
Fax:
Email:
Version 4: July 2009

4. Project Name (Subdivision, facility, or establishment name - consistent with project name on
plans, nnspecifications, letters, operation and maintenance agreements, etc.):
1��' lJiE�►Cc, Pi�¢CE IQ OC 4C-7- -"T701V
Project Location:
Street address: 131 lW1,06WCE
City, State, Zip:
County:
_ -_ ......_�.., .. ........
Latitude /longitude: "'t
6. Date property was purchased:..__.. /_ E ZoG�
7. Is your project in one of the 2 oastal Counties covered under the Coastal Area
Management Act (CAMA)? E O .3o Fr
7a. If you answered yes to ques ion 1, in which AEC do you fall (30 ft or 75 ft) ?
7b. What is the total percent of impervious cover that you have proposed within the AEC?
1- j`% (Fill in the blank).
8. Directions to site from nearest major intersection (Also, attach an 8'/z x 11 copy of the USGS
topographic map indicating the location of the site):
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9. Stream to be impacted by the proposed activity:
Stream name (for unnamed streams label as "UT" to the nearest named stream):
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Stream classification [as identified within the Schedule of Classifications 15A NCAC 2B .0315
(Neuse) or .0316 (Tar - Pamlico)] ._- w / .-- __- _e� -_._.
10. Which of the following permits /approvals will be required or have been received already for
this project?
Required: Received: Date received: Permit Type:
CAMA Major
CAMA Minor
401 Certification /404 Permit
On -site Wastewater Permit
NPDES Permit (including stormwater)
®� Non - discharge Permit
Water Supply Watershed Variance
Others (specify)
Part 2: Proposed Activity
(Please include attachments if the room provided is insufficient.)
Description /purpose of proposed activity [Also, please attach a map of sufficient detail (such
as a plat map or site plan) to accurately delineate the boundaries of the land to be utilized in
carrying out the activity, the location and dimension of any disturbance in the riparian buffers
associated with the activity, and the extent of riparian buffers on the land. Include the area
of buffer impact in ft2.]:
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Variance Request Form, page 2
Version 4: July 2009

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2. State reasons why this plan for the proposed activity cannot be practically accomplished,
reduced or reconfigured to better minimize or eliminate disturbance to the riparian buffers:
3. Description of any best management practices to be used to control impacts associated with
the proposed activity (i.e., control of runoff from impervious surfaces to provide diffuse flow,
re- planting vegetation or enhancement of existing vegetation, etc.):
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4. Please provide an explanation of the following:
(1) The practical difficulties or hardships that would result from the strict application of this
Rule.
(2) How these difficulties or hardships result from conditions that are unique to the property
involved.
(3) If economic hardship is the major consideration, then include a specific explanation of the
economic hardships and the proportion of the hardship to the entire value of the project.
........�. ..._ � � d �� .�.� _ _� -.._� _
Part 3: Deed Restrictions
By your signature in Part 5 of this application, you certify that all structural stormwater best
management practices required by this variance shall be located in recorded stormwater
easements, that the easements will run with the land, that the easements cannot be changed or
deleted without concurrence from the State, and that the easements will be recorded prior to the
sale of any lot.
Part 4: Agent Authorization
If you wish to designate submittal authority to another individual or firm so that they may provide
information on your behalf, please complete this section:
Variance Request Form, page 3
Version 4: July 2009

Designated agent (individual or firm): ZA*24S4 I J G &44H, I Z50
Mailing address:
City, State, Zip:
Telephone:
Fax:
Email: �.__...�..._.�.....___.� ....W.._.�...�.�.....� __.
Part 5: Applicant's Certification
I. _._.. m_ _ w/r #-- ._-- .... .. ....... . ... .a__.__w_ ._ _ _.__........ (print or type name of person listed
in Part I, Item 2), certify that the information included on this permit application form is correct,
that the project will be constructed in conform nce with the approved plans and that the deed
restrictions in accordan 7th Part 5 of this f m will be recorded with all required permit
conditions. / / / /
Signature:
Date:
Title:
....._...._f1✓ .. ... ...... _ .......__._...... __ ........
_.e_
Variance Request Form, page 4
Version 4: July 2009