20210971 Ver 1_Determination Request_20210524

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:*
Bill Michel 09986 Allen RD
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 :
17 Buffer
r Isolated Wetland
Check all that apply.
Thomas Andrews, Norma Andrews
17 IP Stream Determination
r Stream
Ashton Alexander Properties,LLC
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 301-674-0977
How would you like to received your determination?*
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
Project Information
Has anyone form DWR done a previous site visit?*
Date of Visit:
Site Information
Nearest Highway/Street:* Dickinson Ave
Nearest Town:*
Greenville
Nearest Named Stream:* Green Mill Run
River Basin:* Tar -Pamlico

County: *
Pitt
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Gickthe upload button or drag and drop files here to attach docurrent
Bill Michel 09986.pdf
Rif file type only
707.43KB
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 docurrent
Bill Michel 09986 Soils.pdf 856.19KB
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: 35.590967
Longitude: -77.434816
Misc attachments: pdf or krre 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
Date Submitted:
Initial Review
.......................................................
ID#* 20210971
Version* 1
Do you want to send for review?* C' Yes r No
Select Reviewer:* Chris Pullinger:eads\rcpullinger
5/24/2021

Select Regional Office:*
Washington Regional Office - [phone]

OFIF
111IS
MEONME MIME
https://gis.pittcountync.gov/opis/
5/24/2021, 1:12 PM

https://gis.pittcountync.gov/opis/
5/24/2021, 1:13 PM