20220254 Ver 1_DWR Stream Determination_20220215

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
DANNY SMITH
Director
NORTH CAROLINA
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Express Buffer Applicability / Stream Origin
Determination Request
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
1 a. Name(s) on Recorded Deed
Robert & Tami Barnett
1 b. Responsible Party (for LLC)
1 c. Mailing Address
977 Florida Ave. Oviedo FI. 32765
1d. Telephone Number
407-467-5957
le. Email address
[e-mail]
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
176 Mt Carmel Church Rd Pikeville NC 27863
3. Agent / Consultant Information
3a. Agent/ Consultant Name
Cameron Mitchell
3b. Company
Cameron Mitchell Homes, Inc
3c. Mailing address
993 Vail Rd Pikeville NC 27863
3d. Telephone no.
919-920-0918
3e. Email address
[e-mail]
4. Project / Site Information
4a. Name of project
Barnett
4d. River Basin
4b. County
Wayne
4e. Lat/Long
4c. Nearest Named Stream
4F. Number
Stream Calls
5. Project Description (attach plan if available)
New Construction (Custom Home)
6. Has anyone from DWQ visited the
site?
Y
N
No
Staff Name:
Date of visit:
7. Does DWR staff have permission
to access this property?
Y
Yes
N
8. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey
If you are unable to locate either of these maps, please contact the DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitigation? Nutrient offset credit?
9. Please return form
to:
Chris Pullinger
943 Washington Square Mall
Washington, NC 27889
Email: [e-mail]
Please contact Chris Pullinger at the Washington R 2) 948-3922 if you have any questions.
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Note: Submittals on Friday after 12:00 pm
Will be stamped as received on the
Next business day
North Carolina Department of Environmental Quality (Division of Water Resources - Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
DANNY SMITH
Director
NORTH CAROLINA
Errwironrraerrla! Qualify
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: Deed Book 3503 Page374-375
LOT NO N/A PLAN NO. PARCEL ID: 3603430501
STREET ADDRESS: 176 Mt Carmel Church Rd Pikeville, NC 27863
Please print:
Property Owner: Robert Barnett
Property Owner: Tami Barnett
The undersigned, registered property owners of the above noted property, do hereby authorize
Cameron Mitchell, of Cameron Mitchell Homes, Inc
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
977 Florida Ave. Oviedo, FL 32765
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Tami Barnett / Robert Barnett Tami Barnett / Robert Barnett
Authorized Print Name Authorized Signature
Date: 2-13-22 Date: 2-13-22
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North Carolina Department of Environmental Quality Division of Water Resources - Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481