20130163 Ver 1_Determination Request_20130220

Beverly Eaves Perdue
Governor
A �
Am ==
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E.
Director
Dee Freeman
Stream Origin/Buffer Applicability Determination
Applicant/Owner's Name (corporation/individual who is legally responsible for the property and its compliance:
Applicant/Owner Address:
Applicant's phone number:
Applicant's email address:
Fax
Consultant/Contact person Name (if applicable): PC-
Consultant address (if applicable): f o , PC&M
Consultant's phone number: u� �� �% / �` �� '7 Fax nu ber:
Consultant's email address: -PI497, P L3dt°r tiro j @ 9, i ry f', (-0Y
Name of Project: /AV-ze County: A _ VED
Nearest �me + River Basin (from USGS topographic map):
FEB 2 0 2013
Please provide a brief de cription of this project (attach site plan if av ilable): li{� 3• o t b3
FCDV D - 1 - C i�R� far. A/S, N
1111
Please attach a map of site location indicating project boundaries using USGS 1:24,000 topo map and NRCS county soil survey.
Location of project site - lease include reference to the county, nearest named town and highway number:
wC1 ►1 Q R"11�0-
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 (amy.adams(a)ncmail.net), 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 pm 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.ncwaterquality.org
943 Washington Square Mall Phone: [phone] One
Washington, NC 27889 FAX [phone] NorthCarohna
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