20130709 Ver 1_401 Application_20130713

Quible
Quible & Associates, P.C. PO Drawer 870
ENGINEERING • ENVIRONMENTAL SCIENCES • PLANNING • SURVEYING
SINCE 1959
June 27, 2013
Roberto Scheller
NC Division of Water Quality
943 Washington Square Mall
Washington, NC 27889
Re: Nationwide 18 Permit Request 1
Old North State Trust, LLC
Lot 2 Dennis Perry Parcel
Kitty Hawk, Dare County, North Carolina
Mr. Schaller:
-
"Hawk NC 27949
Phone: 252 - 2613300
Fax: [phone]
2 0 1 3 0 7 0 8 Web: qulble.com
@C�L�aL
JUL 0 8 2013
Please find enclosed a Pre - Construction Notification form and associated documentation for a property currently
owned by North State Trust, LLC. This is an existing subdivision known as Hickory Ridge Phase 2 and the
proposed fill that requires this PCN is required to provide adequate septic setbacks, building pads and driveway
access. The Section 404 Wetlands line was confirmed on November 20, 2012 by you.
The mitigation plan includes a payment to either the Great Dismal Swamp Restoration Bank (if allowed) or the
North Carolina Ecosystem Enhancement Program sufficient to offset 0.10 acres of non - riparian Section 404
impacts at a ratio of 2:1 (mitigation to impacts).
Enclosed is the following:
• Nationwide 18 Site Plan
• PCN Application
• Agent Authorization Letter
• USGS Vicinity Map
• Mitigation Bank/NC EEP Acceptance Letter (to be forwarded)
• Copy of the $240 Processing Fee Check to NCDENR
• Section 404 Delineation Plat
Please do not hesitate to contact the undersigned at 252.261.3300 if you have any questions or requests for
additional information.
Sincerely,
Qui iates, P.C.
arr us
cc: Josh Pelletier, USACE
Anne Burdette, NCDWQ

Quible
Quible & Associates, P.C.
ENGINEERING • ENVIRONMENTAL SCIENCES • PLANNING • SURVEYING
SINCE 1959
June 27, 2013
Josh Pelletier
US Army Corps of Engineers
P.O. Box 1000
Washington, NC 27889
Re: Nationwide 18 Permit Request
Old North State Trust, LLC
Lot 2 Dennis Perry Parcel
Kitty Hawk, Dare County, North Carolina
Mr. Pelletier:
P.O. Drawer 870
Iatty Hawk NC 27949
Phone: 252 -261 -= Fmc. 252 -261 -1260
Web: qufble.com
Please find enclosed a Pre - Construction Notification form and associated documentation for a property currently
owned by North State Trust, LLC. This is an existing subdivision known as Hickory'Ridge Phase 2 and the
proposed fill that requires this PCN is required to provide adequate septic setbacks, building pads and driveway
access. The Section 404 Wetlands line was confirmed on November 20, 2012 by you.
The mitigation plan includes a payment to either the Great Dismal Swamp Restoration Bank (if allowed) or the
North Carolina Ecosystem Enhancement Program sufficient to offset 0.10 acres of non - riparian Section 404
impacts at a ratio of 2:1 (mitigation to impacts).
Enclosed is the following:
• Nationwide 18 Site Plan
• PCN Application
• Agent Authorization Letter
• USGS Vicinity Map
• Mitigation Bank/NC EEP Acceptance Letter (to be forwarded)
• Copy of the $240 Processing Fee Check to NCDENR
• Section 404 Delineation Plat
Please do not hesitate to contact the undersigned at 252.261.3300 if you have any questions or requests for
additional information.
Sincerely,
W tes, P.C.
cc: Glenn Jungen
Anne Burdette, NCDWQ
Roberto Scheller, NC DWQ

Q:\2010\PlOO50\drowings\:110050—NAT18dwg 6/21/2013 11.03 AM TStokely
LEGEND NOTES
j� 1. OWNER OLD NORTH STATE TRUST, LLC
EXISTING
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PROPOSED LOT 3 PROPOSED LOT 2 PROPOSED LOT 1
49,153.55 Sq.Ft. I 47,890.32 Sq.Ft. I 57,819.48 Sq.Ft.
1.13 Acres 1.10 Acres 1.33 Acres
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PROPOSED LOT 3 PROPOSED LOT 2 PROPOSED LOT 1
49,153.55 Sq.Ft. I 47,890.32 Sq.Ft. I 57,819.48 Sq.Ft.
1.13 Acres 1.10 Acres 1.33 Acres
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201 NORTH FRONT STREET
SUITE G103
WILMINGTON, NC 28401
CONSULTANT- QUIBLE & ASSOCIATES, P.0
P 0. DRAWER 870
KITTY HAWK, N C. 27949
PROPERTY INFORMATION: LOT 2, DENNIS A. PERRY ESTATE
P C. F, SL 36
D.B 1911, PG 406
PIN- 9865 -06 -39 -8525
TOTAL PARCEL AREA* 154,863 SQ.FT (3 56 ACRES)
TOTAL UPLAND AREA 70,107 SQ.FT. (1.61 ACRES)
TOTAL WETLAND AREA: 84,756 SQ.FT. (1.95 ACRES)
TOTAL COASTAL WETLAND AREA- 65,043 SQ.FT. (1.49 ACRES)
THIS MAP IS NOT A CERTIFIED BOUNDARY SURVEY AND HAS
NOT BEEN REVIEWED BY A LOCAL GOVERNMENT AGENCY FOR
COMPLIANCE WITH ANY APPLICABLE LAND DEVELOPMENT
REGULATIONS. THIS MAP SHALL NOT BE USED FOR SALES OR
CONVEYANCES
BOUNDARY INFORMATION SHOWN AS PER P.0 F, SL 36;
BOUNDARY SURVEY BY SEABOARD SURVEYING & PLANNING, INC.
SIGNED AND DATED 5 -22 -03 BY W. C. OWEN
WETLAND DELINEATION AS SHOWN PERFORMED BY QUIBLE AND
ASSOCIATES, PC.
SURVEY DATE: 01 -28 -2013
THERE MAY BE ADDITIONAL JURISDICTIONAL WATERS ON THE
PROPERTY THAT ARE NOT DEPICTED ON THIS PLAT
yy APPROXIMATE
COASTAL 404 PEnAAM `R G0A5TAL PenANDS
►�T•21 LIMIT5 BASFD ON FIELD
Y REVIEN WITH DG 4
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VICINITY MAP
(*ITTY HAW -V
COASTAL )18=7LAND AREA:
1,47033 SgFL
0.03 Acres
IP
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SALLY' A BROTTON
LE5LIE M. BARRA
PARCEL Z DENNIS A FBW E5TA7E
P.C. C, 5L NB
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273.54' -- N 09 ° 05'
----- 20'FA5FMENT - - - --
'� 42 �1 I P.C. F, SL. 36' DC
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GURRI TUCK SOUND 4
PROJECT I COPYRIGHT © 2013 ����"
QUIBLE & ASSOCIATES, P.C. NATIONWIDE 18 FILL PLAN .�`'.�1�1 C A P �� ♦�
P10050 THIS DOCUMENT IS THE PROPERTY OF QUIBLE ��� ♦iQuible SINC£ 1959
ASSOCIATES, PC ALL RIGHTS ARE �,•`•�ESS /0 z ♦
DRAWN BY RESERVED. ANY REPRODUCTION OF THIS OR LOT DENNIS A. PERRY ESTATE o y :;
POSSESSION WITHOUT PRIOR PERMISSION OF �* �L & Associates P.C.
TAS QUIBLE & ASSOCIATES, P C. WILL CONSTITUTE P.0 A SL. JV : Q !
VIOLATION OF COPYRIGHT LAWS VIOLATION SEAL ° ENGINEERING • CONSULTING • PLANNING
CHECKED BY WILL BE SUBJECT TO LEGAL ACTION ATLANTIC TOWNSHIP DARE COUNTY qr L-4 g-ENVIRONMENTAL SCIENCES ' SURVEYING
WDE IF THIS PLAN OR PLAT IS NOT SIGNED AND NORTH CAROLINA 1:1, 13 NC License #: C -0208
SEALED BY A LICENSED PROFESSIONAL THEN ♦♦ C'0' �� PO Drawer 870, Kitty Hawk, NC 27949
THIS PLAN OR PLAT SHALL BE CONSIDERED 0 50 100 ♦ L,' •• �•
6-21-13
AND L B SALES ED LAND CONVEYANCES •_ ♦ ♦ ♦, ♦ ♦I �• /WIL Lf- ? -' Phone: , E -Mail: : (25) 261-1260 u be.00m PRELIMINARY AND NOT A CERTIFIED DOCUMEN RWEE!E"
GRAPHIC SCALE IN FEET 1 50 •..,.___....• a

mot W ATF9O�
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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.0 November 2008
Pre - Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps:
®Section 404 Permit ❑Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 18 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 ❑ Non -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 in -lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in -lieu
fee program.
® Yes
❑ No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
® Yes
❑ No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2. Project Information
2a. Name of project,
Old North State Trust, LLC
2b. County:
Dare
2c. Nearest municipality / town:
Kitty Hawk
Dennis Perry Estate
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state
project no:
UU
3. Owner Information
3a. Name on Recorded Deed:
Old North StateTrust, LLC
3b. Deed Book and Page No:
DB 1911/ PG 406
3c. Responsible Party (for LLC if
applicable):
Mr. Glenn Jungen
3d. Street address:
201 N. Front Street, Suite G103
3e. City, state, zip:
Wilmington, NC 28401
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
gjungen @twiddy.com
Page 1 of 11
PCN Form — Version 1.0 November 2008 Version

Section A. Applicant Information, continued
4. Applicant Information (if different from owner)
4a. Applicant is:
® Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
Warren D. Eadus
5b. Business name
(if applicable):
Quible & Associates, P.C.
5c. Street address:
P.O. Drawer 870
5d. City, state, zip:
Kitty Hawk, NC 27949
5e. Telephone no.:
(252) 261 -3300
5f. Fax no.:
(252) 261 -1260
5g. Email address:
weadus @quible.com
Page 2 of 11
PCN Form — November 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
986506398525
1b. Site coordinates (in decimal degrees):
36.0681566'N - 75.7389457'W
1c. Property size:
3.56 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
Currituck Sound
proposed project:
2b. Water Quality Classification of nearest receiving water:
SB
2c. River basin:
Pasquotank
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:
Single Family Residential. Nearby properties include single family residential homesites and undeveloped wetlands and
uplands.
3b. List the total estimated acreage of all existing wetlands on the property:
1.95 ac.
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
0
3d. Explain the purpose of the proposed project:
The purpose of this notification is for impacts associated with the fill of 0.10 acres of wooded Section 404 wetlands to
meet on -site septic system setbacks and for building pads and driveway access as shown on a proposed subdivision of
the property. The lot can be subdivided and meet the local ordinacne as shown. However, in order to subdivide into
three buildable lots it is necessary to fill 0.10 acres as depicted on the attached site plan and described herein.
3e. Describe the overall project in detail, including the type of equipment to be used:
Proposed residential building construction and associated grading will require minor wetland impacts. Equipment
includes bulldozers, backhoes and dump trucks (and other conventional equipment as necessary).
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
® Yes ❑ No ❑ Unknown
project (including all prior phases) in the past?
4b. If the Corps made the jurisdictional determination, what type
® Preliminary ❑ Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas?
Agency /Consultant Company: Quible & Associates, P.C.
Name (if known): Warren Eadus
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Field confirmed by Josh Pelletier on November 20, 2012.
S. Project History
5a. Have permits or certifications been requested or obtained for
El Yes ®No El Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
NA
6. Future Project Plans
6a. Is this a phased project?
® Yes ❑ No
6b. If yes, explain.
The lot will be subdivided as shown and sold as three lots or homes will be constructed and then sold.
Page 3 of 11
PCN Form - Version 1.0 November 2008 Version

C. Proposed Impacts Inventory
1. Impacts Summary
la. Which sections were completed below for your project (check 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.
2b.
2c.
2d.
2e.
2f.
Wetland impact
Type of jurisdiction
number —
Type of
Type of wetland
Forested
(Corps - 404, 10
Area of impact (acres)
Permanent (P) or
impact
(if known)
DWQ — non -404, other)
Temporary
W1 ®P ❑ T
fill
estuarine scrub
shrub 404/
❑ Yes ® No
® Corps
® DWQ
0.10
non - riparian
W2 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W3 ❑ P [IT
❑ Yes ❑ No
❑ Corps
❑ DWQ
W4 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W5 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W6 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
2g. Total wetland impacts
0.10
2h. Comments: None
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.
3b.
3c.
3d.
3e.
3f.
Stream impact
Type of
Stream name
Perennial (PER) or
Average stream width (feet)
Impact
number -
impact
intermittent (INT)?
length
Permanent (P) or
(linear feet)
Temporary (T)
S1 ❑ P ❑ T
❑ PER ❑ INT
S2 ❑ P ❑ T
❑ PER ❑ INT
S3 ❑ P ❑ T
❑ PER ❑ INT
S4 ❑ P ❑ T
❑ PER ❑ INT
S5 ❑ P ❑ T
❑ PER ❑ INT
S6 ❑ P ❑ T
❑ PER ❑ INT
3g. Total stream and tributary impacts
3h. Comments:
Page 4 of 11
PCN Form — Version 1.0 November 2008 Version

C. Proposed Impacts Inventory, continued
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 individually list all o en water impacts below.
4a.
4b.
4c.
4d.
4e.
Open water -
Name of
impact number
waterbody
Type of impact
Waterbody type
Area of impact (acres)
— Permanent
(if
(P) or
applicable)
Temporary
01 ❑ PC] T
02 ❑ PEI T
03 ❑ PEI T
04 ❑ PEI T
4f. Total open water impacts
4g. Comments:
Page 5 of 11
PCN Form — November 2008 Version

C. Proposed Impacts Inventory, continued
5. Pond or Lake Construction
If pond or lake construction pro osed, then complete the chart below.
5a.
5b.
5c.
5d.
5e.
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or
(acres)
number
purpose of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
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 ou MUST fill out Section D of this form.
6a. '
❑ Neuse ❑ Tar - Pamlico ❑ Other:
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b.
6c.
6d.
6e.
6f.
6g.
Buffer impact
number —
Reason
Buffer
Zone 1 impact (square
Zone 2 impact
Permanent (P)
for impact
Stream name
mitigation
feet)
(square feet)
or Temporary
required?
T
B1 ❑P ❑T
❑Yes El No
B2 ❑ P ❑ T
❑ Yes ❑ No
B3 ❑ P [IT
❑ Yes ❑ No
6h. Total
buffer impacts
6i. Comments:
Page 6 of 11
PCN Form — November 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Fill will be sloped and stabilized; septic system to be located as far as possible from wetlands.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Silt fencing to be maintained until disturbed area is stabilized with grass.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
N
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
p g
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank: Great Dismal Swamp Restoration Bank, LLC
3b. Credits Purchased (attach receipt and letter)
Type non - riparian
Quantity 0.1 acres
3c. Comments: According to GDSRB, credits are available in their Timberlake Bank Service Area. If this is acceptable to
USACE, please condition in the permit. If not, please inform and we will apply for mitigation through NCEEP.
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:
warm, cool, cold
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non - riparian wetland mitigation requested:
0.1
acres
4g. Coastal (tidal) wetland mitigation requested:
acres
4h.. Comments:
5. 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 7 of 11
PCN Form — Version 1.0 November 2008 Version

D. Impact,Justification and Mitigation, continued
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑ Yes ® No
6b. If yes, then identify the square feet of impact to each zone of the riparian bufferthat requires mitigation. Calculate the
amount of mitigation required.
Zone
Reason for impact
Total impact
(square feet)
Multiplier
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
Total buffer mitigation required:
6c. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6d. Comments:
Page 8 of 11
PCN Form — November 2008 Version

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified
® Yes ❑ No
within one of the NC Riparian Buffer Protection Rules?
1b. If yes, then is a diffuse flow plan included?
❑ Yes ® No
2. Determination if the Project Requires a Stormwater Management Plan
2a. Does the project require a Non -404 Jurisdictional General Permit?
® Yes ❑ No
2b. Is the project subject to General Certification 3704 or 3705?
❑ Yes ® No
3. Determination of Stormwater Review Jurisdiction
3a. Is this project subject to any of the following state- implemented stormwater
® Coastal counties
management programs (check all that apply)?
❑ HQW
If so, attach one copy of the approval letter from the DWQ and one copy of the
❑ ORW
❑ Session Law 2006 -246
approved stormwater management plan.
❑ Other:
3b. In which local government's jurisdiction is this project?
Town of Kitty Hawk
3c. Is this local government certified to implement a state stormwater program?
❑ Yes ® No
If so, attach one copy of the approval letter from the local government and one copy
of the approved stormwater management plan (or one copy of the approved
Stormwater management plan stamped as approved).
4. Information Required for DWQ 401 Unit Stormwater Review
4a. What is the overall percent imperviousness according to the most current site Ian?
< 24 % at max. build out
4b. Does this project contain any areas that meet the criteria for "high density" per
El Yes No
General Certifications 3704 and 3705?
4c. If the site is over 24% impervious and /or contains high density areas, then provide a brief narrative description of the
stormwater management plan.
Site will be less than 24% impervious at build -out as proposed.
4d. Has a completed BMP Supplement Form with all required items been submitted
1:1 Yes No
for each stormwater BMP?
Page 9 of 11
PCN Form — Version 1.0 November 2008 Version

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 (NEPA/SEPA)?
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), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
❑ Yes ® No
or Riparian Buffer Rules (15A NCAC 213 .0200)?
2b. Is this an after - the -fact permit application?
❑ Yes ® No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
❑Yes ®No
additional 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.
On -site septic treatment systems will be installed to serve each proposed lot. The soils have been deemed suitable in the
past for septic (former site of mobile homes). Improvements and repair permits have not been applied for, but will be issued
by Dare County Health Department prior to construction on each proposed lot, as appropriate.
Page 10 of 11
PCN Form — Version 1.0 November 2008 Version

F. Supplementary Information, continued
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
El Y es ®No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑Yes ®No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
El Raleigh
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
NC Natural Heritage Program
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?
Mapping data and field investigation; proposed impact area is not within an area of surface waters.
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
El Yes No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
National Register of Historic Places
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA - designated 100 -year floodplain?
[ Yes ❑ No
8b. If yes, explain how project meets FEMA requirements: This type of fill is allowable with permit in AE and X zones.
8c. What source(s) did you use to make the floodplain determination? NFIP Flood Zone Maps (www.ncfloodmaps.com)
Applicant/Agent's Printed Name
Appli nt/Agent's Signature
(Agent's signature is valid only if an authorization letter from the applicant
Date
is provided.)1
Page 11 of 11
PCN Form — November 2008 Version

Name of Property Ow+negs) Applying for Penraft:
Types of Pemnits sought
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Associates, P.C. lo, act on my behaff for purposes of applying for and obtaining any and all
r1e08888ry pem tt8 for my at:
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