20220356 Ver 1_Determination Request_20220303

Please note: fields marked with a red asterisk * below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Name: * Leggett Road Site
Is this a transportation project?* Yes • No
Is this request for a mitigation site?* Yes • No
What type of request is this?* Buffer IP Stream Determination
Isolated Wetland Stream
Check all that apply.
Owner Information
Name on the Recorded Deed:* Whitehurst, Jennifer Leggett & Leggett, Ruby Diane Lancaster
Responsible Party : (for LLC, Corporations, businness, agency, etc.)
Telephone Number:
How would you like to received your determination?*
USPS Email
Mailing Address:*
Street Address
3613 River Road
Address Line 2
City
State / Province / Region
Washington
NC
Postal / Zip Code
Country
27889-7525
US
Is there an agent or consultant responsible for the request?
Yes
No
Attach agent authorization letter: * Agent Authoriz Form Signed Leggett.pdf 34.57KB
PDF only
Agent/Consultant Information
..........................................................................................................................................................................................................................................................................................................
How would you like to receive your USPS
determination letter?* • Email
Name of Agent: * Gerald Pottern
Company Name: * Mogensen Mitigation Inc
Email Address:* [e-mail]

'roject Information
Has anyone form DWR done a previous site visit?*
Yes
No
Other
Date of Visit:
Nearest Highway/Street: * Leggett Road
Nearest Town: * Washington
Nearest Named Stream:* Maple Branch
River Basin: * Tar -Pamlico
County:
Beaufort
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach document
USGS Topo Leggett-1.pdf 211.17KB
Pdf file type only
TOPO map look up: https:Hviewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
Click the upload button or drag and drop files here to attach document
Soils NRCS+OneMap-1.pdf 188.73KB
Pdf file type only
Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
Please provide the Latitude and Longitude for physical location for the determination that. If you have a physical
address you can look up the Latitude and Longitude by typing in an address or filling out the information
manually.
Choose below how you would like to provide this information.
Address Lookup
Manually
Latitude: 35.5998
Longitude:-77.1023
Misc attachments:
Leggett Parcel N.kmz
DWR Stream ID Form Leggett.pdf
Stream Determin Map-1 Leggett.pdf
pdf or kmz file types only
1.52KB
68.81 KB
222.01 KB
By digitally signing below, I certify that:

a I have given true, accurate, and complete information on this form;
a I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act)
a I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
a I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
a I intend to electronically sign and submit the "Determination Request' form."
Signature
Date Submitted: 3/3/2022
Initial Review
ID#* 20220356
Version *
Do you want to send for review?* Yes No
Select Reviewer: * Robert Tan kard:eads\rbtan kard
Select Regional Office:* Washington Regional Office - [phone]