20220834 Ver 1_Determination Request_20190114

Stream Origin/Buffer Applicability Determination
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: * Wayne Pregnancy Center
Is this a transportation project?* Yes • No
Is this request for a mitigation site?* Yes • No
What type of request is this?* Buffer
Isolated Wetland
Check all that apply.
Owner Information
Name on the Recorded Deed: *
Wayne Pregnancy Care Center
Responsible Party : Jonathan Chavous
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 919223-8544
How would you like to received your determination?*
USPS Email
Email Address: *
[e-mail]
Is there an agent or consultant responsible for the request?*
Yes
No
Project Information
Has anyone form DWR done a previous site visit?*
Yes
No
Other
Do not know possibly in 2008
Date of Visit:
Site Information
.....................................................................................
Nearest Highway/Street: *
Nearest Town:*
Nearest Named Stream: *
River Basin:*
US 70 Bussiness
Goldsboro
Stoney Creek
Neuse
IP Stream Determination
Stream

County: *
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
Topo Map[2082].pdf
Pdf file type only
96.37KB
TOPO map look up: https://viewer.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
Soil Map[2081].pdf
Pdf file type only
251.89KB
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
Project Look Up Address: Street Address
3501 E Ash St
Address Line 2
City State / Province / Region
Goldsboro NC
Postal / Zip Code Country
27534 USA
Latitude:
Longitude:
Misc attachments:
By digitally signing below, I certify that:
pdf or kmz file types only
o I have given true, accurate, and complete information on this form;
o 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")
o 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");
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Determination Request" form."
Signature
Date Submitted: 1/14/2019

Initial Review
ID#* 20220834
Version* 1
Do you want to send for review? * • Yes No
Select Reviewer: * Robert Tankard:eads\rbtankard
Select Regional Office: * Washington Regional Office - [phone]

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