20140242 Ver 1_Stream Call Request_20140311

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Charles Wakild, P.E.
Governor Director
Stream OriginBuffer Applicability Determination
John E. Skvarla III
who is legally responsible for the property and its compliance):
Applicant/Owner Address:
Applicant's phone number: Fax number:
Applicant's email address: �h c- Q SN W8 ,
Consultant/Contact person Name (if applicable):
Consultant address (if applicable):
Consultant's phone number:
Consultant's email address:
Fax number:
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Name of Project: S �� Q_ �A.z, -.uv County: &QQ,1SQ
Nearest Nameo � C_p strre + A �RPirver_ r =S%= );
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Please provide a brief description of tthis project (attach site plan if
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 - please iin�nc�llu��de reference to the county, nearest named town and highway number:
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Has any DWQ staff visited the site ?� if yes, please provide DWQ staff name, and date of
visit:
This form may be submitted via email (roberto.scheller @ncdenr.gov), 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 Roberto Scheller at 252- 948 -3940 if you have any questions regarding this form.
Water Quality Regional Program
943 Washington Square Mall
Washington, NC 27889
Internet www wwaterqualitv.ore
Phone: [phone]
FAX [phone]
An Equal Opportunity/Affimtalive Action Employer— 50% Recycled/10% Post Consumer Paper

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