20071145 Ver 1_Buffer Determination Request_20070703

• INITIAL INTEREST IN PARTICIPATION IN THE EXPRESS REVIEW PROGRAM
WITHIN THE 401 OVERBITE/EXPRESS PERMITTING UNIT
September 1, 2004
Version 3
Applicant Na
Applicant Address:

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Fax number: ~-( ~'-]~
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Consultant Name (if applicable): ~ ~" `-'
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Consultant address (if applicable): 7~ O 8 DENR:WATERQUAIITY
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Consultant's phone number:
Fax number:
Consultant's e
Type of action requested under the Express Review Program (check all that apply):
^ 401 Water Quality Certification ^ Stream Origin Determination
^ Isolated Wetland Permit # of Determinations Requested
^ Riparian Buffer Approval ~ Intermittent/Perennial Determination
^ Stormwater Management Plan ~ # of Determinations Requested
^ Mitigation Plan
^ Stream ^ Wetland ^ Buffers (check all appropriate)
Name of Project: T~V ('0.~~~. County:
Total project acreage: ~~ (acres) Total builnnt out__imp'e/rvious area: '~ (0~7~ (acres)
Nearest named stream (from USGS topo map): ~a~S ~--~f`~'~_ I~-
Please provide a brief description of this project (attach site plan if available)``: t~~
Applicant's phone number: ~-2" x-7(0 1

Please attach a map of site location using USGS 1:24,000 map and county soil survey.
Location of project site -please include reference to the county, nearest name town and highway number:
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Proposed impacts:
Acres of 404 wetlands:
Acres of isolated wetlands:
Linear feet of streams:
Linear feet of isolated streams:
Square feet of protected stream buffers:
Has consultant or applicant attended any DWQ-sponsored training sessions in the past two years? If so, please list
which ones. ~`~'C"
Has any DWQ staff visited the site? n o , if yes, please provide DWQ staff name, and
date of visit:
Which other environmental permits from other agencies will be needed for this project? Please list the permits and
issuing agencies below:
Does this project require approval under the State Environmental Policy Act or National Environmental Policy Act?
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Is this project an After-the-fact application or has this project received a previous Notice of Violation from DWQ?
No
Does this project require approval of a Variance from the NC Environmental Management Commission? . 1~
Are you aware of any local controversy concerning this project? If so, please describe the controversy and any
measures that have been taken with respect to public involvement.
This form must be submitted via email (Go 401 exoress(~ncmail.net), faxed (919-733-6893) or hand-delivered to the Parkview Building, 2321
Crabtree Blvd., Raleigh, NC 27604. Applicants who are selected to participate in the Express Review Program will be notified via email or fax
within 2 days. Successful applicants will then be instructed regarding detailed procedures for full application (Please Note: Submittals of the review
packages on Friday after 12:00 pm will be stamped as received on the next business day).
Please contact Cynthia Van Der Wiele at 919-715-3473 if you have any questions regarding this form.
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