20061073 Ver 1_Application_20060830

APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT ~ OMB APPROVAL NO. G710-0003
(33 C; R 3261 Expires December 31, 2004
The Public burden fior this collection cf information is sestimated tc average 10 hours per response, although the majcrity of applications should requite
us or less. This includes the time for reviewing instructions, searching existing data sources, gathering and maintaining Lhe data needed, and
feting and reviewing the collection of information- Send comments regarding this burden estimate or any other aspect of this collection of
intormation, including suggestions for reducing this burden, to Bepartment of Defense, Washington Headquarters Servics Directorate of Information
Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302; and to the Office of Management and Budget,
Paperwork Reduction Project (0310-00031, Washington, DC 20503. Respondents should be aware that notwithstanding any other provision of taw,
no person shall be subject to any penalty for failing to comply with a collection of infermation if it does not display a currently valid OMB control
number. Ptease DO NOT RETURN your form to either of those addresses. Completed applications must be submitted to the District Engineer having
jurisdiction over the location of the proposed activity.
PRIVACY ACT STATEMEN T
Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection ,Research and
Sanctuaries Act, s3 USC 1413, Section 103. Principal Purpose: Information provided on this form will be used in evaluating the aopiication.for a
permit. Routine Uses; This information may be shared with the Department of Justice and other federal, state, and local government agencies.
Submission of requested information is voluntary, however, if infiormation is not provided the permit application cannot be evaluated nor can a permit
be issued.
One set of original drawings or good reproducible copies which sho:v the location acid character of the proposed activity mud fle attached to this
application (see sample drawings and instructions) and be submitted to the District ~ngineer having jurisdiction over the loca~ion of the proposed
activity. An application that is not completed in full will be returned. ~ ~, ®~~. ,~~
1. APPLICATION N0. 2. FIELD OFFICE CODE 3. GATE RECEIVEI~~,f~ ..+ ., •;:;a;L4. DATE APPLICATION COMPLETED
~1r J
(ITEMS BELOW "TO BE FILLED BY APPL~~T(DRY RRAN&'1~
5. APPLICANT'S NAME
NC Dept, of Health and Human Serv. `8. AU1~~IORIZED AGENT'S NAME AND TITLE lan$pentrsnotreauiredl
Michelle Clements, PE,~'Project Man.
6. APPLICANT'S ADDRESS 9. AGENT'S ADDRESS
2001 Mail Service Center P.O. Box 7305
Raleigh, NC 27699,2001 Greenville, NC 27834
APPLICANT'S PHONE NOS. W/AREA CODE 10. AGENT'S PHONE NOS. W/AREA CODE
Residence a. Residence
b. Business 919-733-6829 ~ b. Business 252-758-3746
11, STATEMENT OF AUTHORIZATION
I hereby authorize, Michelle Clements to act in my behalf as my agent in the processing of this application and to
rurnish, upon request, supplemental information ink upport of this permit application.
.TURF
12. PROJECT NAME OR TITLE Isee insuudions.
OF
Caswell Center - Tile Campus Ditches
?vocal Contact - Jeru~ing Outlaw, PE - Facility Maintenance Manager
'l3. NAME OF WATERBODY. IF KNOWN rif annlinan~.l ~ 14. PROJECT STREET ADDRESS /it applicable)
UT to Neuse River
15. LOCATION OF PROJECT
Lenoir NC
Caswell Center
2415 W . Vernon Avenue ~ ~ ~ ~ ~ U
Kinston, NC 28504 v
[phone]
COUNTY STATE ~ AUG 3 0 2006
?6. OTHER LOCATION DESCRIPTIONS, IF KNOWN, rs~instrucziansl UENR -WATER QUALITY
35 Deg 16.19'N, 77 Deg 37.84'W, Kinston Township wETI-APIDSANDSTORMWATLRBRI
DIRECTIONS TO THE SITE
''_oject is located on the eastern Rortion of the Caswell Center campus in Kinston, NC
The campus is on the north side of Vernon Avenue (Bus. Hwy 7G), west of vernon Park Mall
at the corner of Vernon Avenue and Hull Road (SR 1557). See Attached vicinity map.
ENG FOR 4345, Jul 57 EDITION OF FEB 84 IS OBSOLETE. {Proponent: CECW-OR3

18. Nature Of AetlVlty lDescripdon of project, include a/1 iear,:res/
See Attac't~ed Sheet
19. Project PLrpOSe (Describe YAe r~san or purpose a; the project, see lna.ructions7
See Attached Sheet
USE BLOCKS 20-22 1F DREDGED AND/OR F{LL MATERIAL IS TG BE DISCHARGED
20. Reason{s} for Discharge
See Attached sheet
21. TVpe(s} of Material Being Discharged and the Amount of Each Tvoe in Cubic Yards
580 CY of sandy fill material
22. Surface Area in Acres of Wetlands or Cther Waters Filled /seeinstrucrionsl
Approximately 0.17 acres of stream will be filled.
23. Is Any Portion of the Work Already Complete? Yes ~ No " IF YES. DESCRIBE THE COMPLETED WORK
24. Addresses of Adjoining Property Owners, Lessees, Etc., Whose ?roperty Adjoins the Waterbody ~If more than can be entered here,
please attach a supplemental fist).
1. Robert L. James Jr. ET ALS - 843 Hardee Road, Suite 814 Kinston, NC 28504
2. Poole Enterprises Inc., - 4206 W. Vernon Avenue, Kinston, NC 28504
(See attached for parcel information)
25. list of Ocher Certifications or ApprovalslDenials Received from other Federal, State or Loca! Agencies for Work Described in This Application.
AGENCY TYPF APPROVA! "~ IrIFNTIFICATIC)N NtIMRFR ne7F Baal lFn na-rr APPRr11fCr1 nnTC ncnn~n
'Would Include but is not restricted to zoning, building and flood plain permits
26. Application is hereby made for a permi*. ar permits to authorize the work described in this application. 1 certify that the information in this
appiicavon is complete and accurate. further certify that I possess the authority to undertake Lhe work described herein or am acting as the
dull a~orized agent o t ap Ic ~~/~ ~ /~ ff~~~
~-
l SI¢~lATjdRE OF APPLICAPlT DATE SIGNATURE OF AGENT DATE
The apdication must be signed by the person who desires to undertake the proposed activity iapplicant} or it may be signed by s duly
authouzed agent if the statement in block 1 S has been filled out and signed.
NC DENR DWQ Stream KB -05-0062 10/21/06
Determination
NC DENR DWQ PCN 6/26/06
401 Wetlands Application
18 L'.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States
:no•.vin_ly and v;,•illfully falsifies, conceals; or covers ug any irlck; scheme; or disg~~ises a material fact or makes ary false, fctitious or
fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or
fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.