20140592 Ver 1_Stream Call Request_20140609

NCDENR
North Carolina Department of Environment and
Division of Water Resources
Water Quality Programs
Pat McCrory Charles Wakild, P.E.
Governor Director
Applicant/Owner's Name
Applicant/Owner Address:
Applicant's phone number:
Applicant's email address:
Natural Resources
Stream Origin/Buffer Applicability Determination
Consultant/Contact person Name (if applicable):
Consultant address (if applicable):
Consultant's phone number:
Consultant's email address:
John E. Skvarla III
who is legally responsible for the property and its compliance:
N
Fax number:
Fax number:
Name of Project: l C�(\_ __P( &o—a County:' ����
NeaLesLt Named stream + River Basin (from USGS topographic map):
Please provide a brief description of this project (attach site plan if available):
Please attach a map of site location indicating project boundaries using USGS 1:24,000 topo map and NRCS county soil survey.
site - Tease include reference to the county, nearest named town and highway number:
Has any DWQ staff visited the site?__, if yes, please provide DWQ staff name,
visit:
and date of
This form may be submitted via email ([e-mail]). 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.ncmater(lualitv.org
Phone: [phone]
FAX [phone]
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