20130100 Ver 1_401 Application_20130201

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20130 100
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 14 January 2009
Pre- Construc ion Notification (PCN) Form
A. Applicant Information
1. Processing
1a. 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. 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 ❑ on -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?
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 in4leu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ ,Yes [R/No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
0,* No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes GrNo 7
2. Project Information
2a. Name of project:,
1 TIE Al -PLC
2b. County:
2c. Nearest municipality I town:'
A ALE-r& "
2d. Subdivision name:,
S% q%ur HrCL -S
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.
�'�— � — - � .--F
,
3c. Responsible Party (for LLC if,
applicable):
3d. Street address:
Al PL
( j -r E
3e. City, state, zip:
R AL . Ill L } 71, 0
3f. Telephone no.:
° j — S a — 7 S—ig it
3g. Fax no.:
3h. Email address:
RD C k 6 P96a (,M 41 L. Co
Page 1 of 10
PCN Form — Version 1.4 January 2009
D

4. Applicant Information (If different from owner)
4a. Applicant is:
Agent ❑ Other, specify:
4b. Name:
SD £ FS oil
4c. Business name
(if applicable):
R 5 r D FA)M#4L REM IFOr S
4d. Street address:
SD 11 $Tt)IvE H,r� -L
4e. City, state, zip:
R14L A) O
4f. Telephone no.:
AQI _ p 3 u
4g. Fax no.:
4h. Email address:
zd£ C O
S. 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
71a. Property identification no. (tax PIN or parcel ID):;
17 A6 16 11/40 - Doa
1b. Site coordinates (in decimal degrees):
Latitude: Longitude
1c. Property size: 151 r x Ito
. `!q acres,
2. Surface Waters
2a. Name of nearest body of water to proposed project:
SHELLY L 4KE-
2b. Water Quality Classification of nearest receiving water.
2c. River basin:
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:
one i yh4 l) aF 140t)si-
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: I Yb
3d. Explain the purpose of the proposed project:
3e. Describe the overall project in detail, including the type of equipment to be used:
#PEA) RA-r -� S l g' 1= oarPR=&)T-- ROOF* aQtLk Ftx)",+T '
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: STREAM OA/ A
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:
I 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?
es []'No ❑Unknown
5b. If yes, explain in detail according to "help file" instructions.
3:NTERX0P- REf1D()A-TrDK)s
6. Future Project Plans MOO F
6a. Is this a phased project?,
❑ Yes o
6b. If yes, explain.
Page 3 of 10'
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (ch 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 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

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 indivv dually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
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.
58.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(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 mitigation, then youMUST fill out Section D of this form.
CProject is in which protected basin .
euse [] Tar-Pamlico ❑Catawba [3 Randleman ❑Other:
6b.
Buffer Impact
number—
Permanent (P) or
�Tem ra )
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
�quired?
6f.
zone 1
impact
((square
(feet )j
6g.
Zoonne�2
impact)
(square
'feet
B1
o
I
t�
B2
Yes/No
B3 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
40
6i Comments;
Page 5 of 10

D. Impact Just9flcation and Mitigation
1. Avoidance and Mlnlmization
1a. proposed impacts in designing pn�ject.
MTECT=Or) iFRo M E Kr STZA)& �+oL)SE_
1 b.. S� pea cally describe measures taken to avoid or minimize the pro posed impede through construction techniques.
RJEMI)JAL PROM SLTE OF ALL— so =LL RErV101JE10 Foe JFboTrAyhS
54P,015 + (214P )W iUTrA)eP
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
project?
❑ Mitigation bank
❑Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
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:
S. 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 DWG
Will the project result in an impact wiMin a protected riparian buffer that requires
`buffer mitigation ?) — —
„„�
� o
6b. If yes, #%en identify the square feet of impact to each tone of the riparian buffer that req mitigation. e
amount of mitigation required.
Zone
U
Reason for impa�
C ".L—
Total impact
(square feet))
Multiplier
U
(Required mitiga —bti n
((square feet)1
Zone 1
3 (2 for Catawba)
Zone
iRONr jwaF -
10
1.5
6f.,Total buffer mitigation requined�
6g. ')f buffer mitigation is requin+d, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
jpermittee 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. mouse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
des ❑ 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.
np
O AI:A ) 6U ir�S A WJA V
Yes ❑ No
rA%T`U v EGkTA~Txo r✓
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
ova
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 brief, 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 government's jurisdiction is this project?
❑ Phase II
3b. Which of the following locally - implemented stormwater management programs
❑ NSW
❑ USMP
apply (check all that apply):
[� 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
❑HQW
4a. Which of the following state - implemented stormwater management programs apply
❑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?
S. 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)
la. Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes ❑ No
use of public (federal/state) land?
1b. 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 (NEPAISEPA)?
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), isolatel
'Weiland Rules (15A NCAC 2H .1300), DWO Surface Water or Weiland Standards,
❑ Yes GM<O
for Riparian-Buffer-Rules (15A NCAC 2B-.0200)-?)
2b. , s this an after - the -fact permit applicati on?
-
❑Yes No)
.__
`2c. If you answered 'y -s to one or both of the above questions; provide an explanation
f the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. WII this project (based on past and reasonably anticipated future impacts) result in
❑ Yes No
ladditional 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 proposed project, or available capacity of the subject facility.
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. 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)
8a. Will this project occur in a FEMA- designated 100 -year floodplain? -T-0
Yes ❑ No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make th floodp in dete ' ion
/
J'�q
gm, Jr
plicanUAgerWs Printed Name
7
(ApplicanUAgent's Signature)
C(iijWs signetwe is varal only N an sulhof ftn
— (leper from the leant is zed.
Date%
Page 10 of 10

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Rockafellow Addition
PLOT PLAN SCALE: I"= 40' DATE: 01 /21/2013
PROPERTY OF
✓AMES H McOOUGALD a WIFE
NEAR RALBON, N. G
., SCALE �.
JOHN Y. PHELPS, JR.
6 4 174 REGISTERED SURVEYOR
P/W RALIEIGH , N. C.
ines es n s
creating great places to live
119 E. Hargett St, Suite 300, Raleigh, NC 27601
RAA 0=0 AA97 . 040 09A QCMA . ......, �...1+a11....,..1 ....:...... ......,,

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rockafellow, brenda Q
L
Field
Value
PIN
1706169400 000
•
Real Estate ID
0066245
lvlap Name
170609
Owner
ROCKAFELLOW, BRENDA R
Mailing Address
1115 TEMPLE ST
1
Mailing .Address
RALEIGH NC 27609 -4345
2
Deed Book
07092
Deed Page
0650
Deed Date
0713111996
Deeded
0.5
Acreage
Assessed
$113,014
Building Value
Assessed Land
$94,000
Value
Total .Assessed
$207,014
Value
Billing Class
INDIVIDUAL
Property
LO45 CHESTNUT HILLS EST SUB
Description
Heated Area
1343
Site .Address
1115 TEMPLE ST
City
Raleigh
Township
HOUSE CREEK
Year Built
1974
Total Sale Price
$136,000
IVI
® �®' P.