20140121 Ver 1_Stream Call Request_20140205

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Charles Wakild, P.E. John E. Skvarla III
Governor Director Secretary
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:
Consultant/Contact person Name (if applicable):
Consultant address (if applicable):
Consultant's phone number:
Consultant's email address:
Fax number:
Fax number:
Name of Project: County: C QN \
Nearest Nam=, r Basin (from USGS topographic map):
Please provide a briefscri lion of this project (attach site plan if available):
Please attach a map of site location indicating project boundaries using USGS 1:24,000 topo map and NRCS county soil survey.
Locatio of project site - lease include reference to the county, ne est named town and hi y numb :
% - C ,,N 1
Has an DWQ staff visited the site? if yes, please provide DWQ staff name,vl and date of
visit: ty
This form may be submitted via email ([e-mail]). 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 72:00 pm will
be stamped as received on the next business day).
Please contact Roberto Scheller at 252- 948 -3940 if you have any questions regarding this form.
Water Quality Regional Program Internet: www.ncwatergualithtora
943 Washington Square Mall Phone: 252 - 946-6481
Washington, NC 27889 FAX [phone]
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