20140734 Ver 1_401 Application_20140714

L`1
�O� W A T FRIG
Office Use Only:
O
2 0 1 4 0 7 3 4 Corps action ID no. 2013 -02452
o < DWQ project no.
Form Version 1.4 January 2009
Page 1 of 10
PCN Form — Version 1.4 January 2009
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Pre - Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1a.
Type(s) of approval sought from the Corps:
❑X Section 404 Permit ❑ Section 10 Permit
1 b.
Specify Nationwide Permit (NWP) number. NWP -39 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑X Yes ❑ No
1d.
Type(s) of approval sought from the DWQ (check all that apply):
❑X 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑X Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑X No
1f.
Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes ❑X No
1 g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
❑ Yes ❑X No
1h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑X No
2.
Project Information
2a.
Name of project:
Mooresville Industrial Park Expansion
2b.
County:
Iredell
2c.
Nearest municipality / town:
Mooresville
2d.
Subdivision name:
2e.
NCDOT only, T.I.P. or state project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
South Iredell Community Development Corp.
3b.
Deed Book and Page No.
Deed Book 2220 Deed Page 2327 110
3c.
Responsible Party (for LLC if
applicable):
Mr. Robert Carney
3d.
Street address:
151 E. Iredell Avenue JUL
3e.
City, state, zip:
Mooresville, NC 28115 r
3f.
Telephone no.:
704- 662 -6922 7 P_R c
3g.
Fax no.:
704- 664 -0209
3h.
Email address:
robby @edcmooresville.org
Page 1 of 10
PCN Form — Version 1.4 January 2009
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(A.
4.
Applicant Information (if different from owner)
4a
Applicant is
❑X Agent ❑ Other, specify
4b
Name
4c
Business name
(if, applicable)
4d Street address
4e
City, state, zip
4f
Telephone no
4g
Fax no _
4h
Email address
S.
Agent/Consultant Information (if applicable)
5a°
Name
Christina R Raymer
6b
Business name
(if,apphcable)
Professional Service Industries, Inc (PSI)
5c
Street address
5021 -A West W T Harris Boulevard
5d
City, state, zip
Charlotte, NC 28269
5e
Telephone no
704- 598 -2234
'5f
Fax no -
704- 598 -2236
5g
Email address
chnstma raymer @psiusa com
Page 2 of 10

e�zL
1`.46E
B:
Project Information and Prior Project History
1.
Property Identification
9a
Property identification no (tax PIN or parcel ID)
4678287150
lb
Site coordinates (in decimal degrees_)
Latitude 35 61866 Longitude -80778307
1cl
Property °size
297 acres
2.
Surface Waters
2a
Name of nearest body of water to proposed project
Back Creek
2b
Water °Quality Classification of neatest Teceiving water
WS -II, ,HQW
2c
River basin
Yadkin Pee -Dee
3.
Project Description
3a Describe the existing conditions on the,site and,the =general land use in the vicinity of the project at the time of this
application
The property is currently undeveloped land and is surrounded by residential and,agncultural land with an industrial park located north of the property
3b
List the total estimated acreage of all existing wetlands on the property '1 62
3c, List, the total estimated linear feet ofall existing streams (intermittent and perennial) on the property >200
3d Explain the purpose of the proposed project
The overall purpose of the,protect is to provide road access to,the Mooresville Industrial Park Expansion A culvertwdl be placed in an unnamed
tributary to Back Creek (Stream S -1) for the road to cross the stream
3e Describe the,overall project "in detail,'including the type of'equlpment'to be used
The construction of an approximate 3,600 linear foot road will involve, cleanng /grading easements and installation of a 60" concrete culvert,in
intermittent stream S -1 Heavy equipment�such as,haulers, loaders, etc will'be used to clear and grade the easement to install the proposed road
4.
Jurisdictional Determinations
48
Have jurisdictional wetland of stream determinations °by the
Corps or State been requested or obtained for this property /
project (including all prior hases in the past?
ED Yes ❑ No ❑ Unknown
Comments 2013 -02452
4b
If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑X Final
4c
If yes, who delineated the jurisdictional areas?
Name (if known) Tasha McCormick
Agency /Consultant Company USACE
Other .Alan Johnson - NCDENR DWR
4d If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
February 3, 2014
5'.
Project History
5a
Have permits or certifications been requested,or`obtamed for
this project (including all prior: phases) in the past?
❑Yes ❑X ,No ❑ Unknown
5b
If yes, explain in detail according to "help file" instructions_
6.
Future Project Plans
6a
Is this a phased project?
❑X Yes ❑ No
6b If yes, explain
The first phase of the protect consists of an approximate 3,600 linear foot road'that,extends Mooresville Boulevard,across NC 801 Another phase of
the road is planned'to be,added at a later'date However „additional impacts,to streams and wetlands are not being proposed,at this time
Page 3 of 10
PCN Form — Version 1, 4 January,2009

C. Proposed Impacts Inventory
1. Impacts Summary
la Which sections were completed below for your project (check all that' apply)
❑ Wetlands ❑X Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If'there are °wetland impacts proposed on the site, then complete this question for each wetland�area Impacted
2a
Wetland Impact
number
Permanent (P) or
Temporary T
2b
Type oflmpact
2c
Type of wetland
2d,
Forested
2e
Type of jurisdiction
Corps (404,10) or
DWQ (401„ other)
2f
Area of
Impact
(acres)
W1
Choose one
Choose one
Yes /No
-
W2
Choose one
Choose,one
Yes /No;
W3
Choose one
Choose one
Yes /No
W4
Choose one
Choose one
Yes /No
W5
Choose one
Chooselone
Yes /No
W6
Choose one-
Choose,one
Yes /No
2g Total Wetland Impacts:
2h Comments
3. Stream Impacts
If there are perennial or Intermittent stream Impacts (Including temporary Impacts) proposed on the site; then complete this
question for all stream sites Impacted
3a
Stream impact
number
Permanent (P) or
Temporary (T)
3b
Type,of Impact
3c
Stream name
3d
Perennial (PER) or
Intermittent (INT)?
3e
Type of
juhsdicfion
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1 P
Culvert
UT to Back Creek (S -1)
INT
Corps
2
75
82
Choose one
S3
Choose one
S4
Choose one
-
S5
Choose one
S6
Choose one
3h Total stream and tributary impacts
75
31 Comments
Page 4 of 10
PCN Form — Version 1 4-January 2009

!d.
4. Open Water"lmpacts
If therej are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U S then indivii ually list all open water impacts below
4a
Open water
impact number
Permanent (P) or
Temporary T
4b-
Name of waterbody
(if applicable)
4c
Type of impact
4d-
Waterbody
type
4e
Area.of impact (acres)
01
Chooseme
Choose
02,
Choose one
Choose
03
Choose,one
Choose
04
Choose one
Choose
4f Total open water impacts
4g Comments
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below
5a
Pond ID number
5b
Proposed use or
purpose of pond
5c
Wetland Impacts (acres)
5d
Stream Impacts (feet)
5e
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f Total:
5g Comments
5h Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no
51 Expected pond surface area (acres)
5j Size of pond watershed (acres)
5k Method of construction
6. Buffer Impacts (for DWQ)
If project will impact a protected rnpanan,buffer, then complete -the chart below If yes, then individually list all buffer impacts
below If any impacts require mitigation, then you MUST fill out Section D of this form
6a Project is in which protected basin?
❑ Neuse ❑ Tar - Pamlico ❑ Catawba ❑ Randleman ❑ Other
6b
Buffer Impact
number —
Permanent (P) or
Temporary T
6c
Reason for impact
6d
Stream name
6e
Buffer
mitigation
required?
6f
Zone 1
impact
(square
feet )
6g-
Zone 2'
impact
(square
feet
B1
Yes /No
B2
Yes /No
B3
Yes /No
B4
Yes /No
B5
Yes /No
B6
Yes /No
6h Total Buffer Impacts:
61 Comments
Page 5 ,of 10

D. Impact Justification and Mitigation
1. Avoidance and,Minimization
1a Specifically describe measures taken to avoid or minimize the proposed Impacts in designing project
The site contains >200 feet of streams and 1 62 acres of isolated wetlands The proposed road corridor is approximately 3,600 linear feet and has
been designed to avoid the wetland area and the,matonty of the streams The proposed road has been designed to avoid and minimize future impacts
to streams and wetlands associated with the development of'the larger tract
1 b- Specifically describe measures taken to avoid or minimize the proposed Impacts through construction techniques
Construction limits will be,established and"Do Not Disturb" area&wdl`be marked'around sensitive features
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of,the State
2a Does the project require Compensatory Mitigation for
Impacts to Waters of the U S or Waters of the State?
❑ Yes ❑X No
2b If yes, mitigation is required by (check,all that apply)
❑ DWQ ❑ Corps
2c If yes, which mitigation option will be used for this
project?
❑ Mltigation,bank
El Payment,to in =heu fee program,
❑ Permittee Responsible,Mitigation
3. Complete if Using a Mitigation Bank
3a Name of Mitigation Bank
3b Credits Purchased (attach receipt and letter)
Type Choose one
Type Choose one
Type Choose one
Quantity
Quantity
Quantity
3c Comments
4. Complete if Making a Payment to In -lieu Fee Program
4a Approval'letter from in -lieu fee program is attached
❑ Yes
4b Stream mitigation requested
linear feet
4c If using stream mitigation, stream temperature
Choose one
4d Buffer mitigation requested (DWQ only)
square feet
4e Riparian wetland mitigation requested
acres
4f Non - riparian wetland mitigation requested
acres
4g Coastal .(tidal)'wetland mitigation requested
acres
4h Comments
5. Complete if Using a' Permittee Responsible Mitigation Plan
5a If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan
Page 6 of 1,0
PCN Form — Version 1 4.January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a- Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
Yes No
6b If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation Calculate the
amount of mitigation required
'Zone
6c,
Reason for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(square feet)
Zone 1
3,(2 for Catawba)
Zone -2
1 5
6f Total buffer mitigation required:
6g- If -buffer mitigation'is required, discuss what type of mitigation is proposed (e,g , payment to private mitigation bank,
permitteeresponsible riparian buffer restoration, payment,into an approved in -lieu fee fund)
6h Comments
Page 7 of 110

E.
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
1a-
Does the project include or is it- adjacent to protected riparian, buffers Identified
❑ Yes ❑X No
within one of the NC RI anan Buffer Protection Rules?
1 b
If yes, then is a diffuse flow plan included? If no, explain why
❑ Yes ❑ No
2.
Stormwater,Mana ement Plan
2a
What is the overall percent Imperviousness of this project?
05 %
2b
Does this project require a Stormwater Management Plan?
❑ Yes 0 No
2c
If this project DOES NOT require a Stormwater Management Plan, explain why
Each individual, parcel will be responsible to provide stormwater controls meeting the current Town of'Mooresville� requirement at the time of
development Each parcel shall be required,to control their runoff as well as any drainage from'the roadways that has not been,previously controlled
This requirement will be enforced,by the Town of Mooresville through their plan approval process,
2d_
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan
2e
Who will be responsible for,the review of the Stormwater Management Plank
Town�of Mooresville
3.
Certified Local Government,Stormwater Review
,3a
In which local government's jurisdiction is this project?
Town of'Mooresville
'❑ Phase fl
El NSW
3b
Which of the'following locally - Implemented stormwater management programs
❑ USMP
apply (check all that apply)
� Water Supply Watershed
❑ Other
3c
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑X No
attached?
4.
Stormwater Program Review
_DWQ
[]Coastal counties
1 ❑HQW
45
Which of the following, state - Implemented stormwater management programs apply
❑ORW
(check all that apply)
❑Session Law 2006 -246
❑Other
4b
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑X No
attached ?'
5.
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
❑X Yes ❑ No
5b_
Have4l of the 401 Unit submittal requirements been met?
❑X Yes ❑ No
Page 8 of 1'0
PCN Form — Version 1 4 January 2009

Lt►
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la- Does the project Involve an expenditure of public (federal /state /local) funds or the
❑ Yes
❑X No
use of public (federal /state)' land?
1b If you answered "yes" to the above, does the,project require preparation ,of an
environmental document pursuant`to the requirements of the National or'State
❑lY,es
❑ No
(North Carolina) Environmental Policy Act (NEPA /SEPA)?
1c If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
❑ Yes
❑ No
letter )
Comments
,2: Violations (DWQ Requirement)
2a Is,the site In violation of DWQ Wetland Rules (15A NCAC 2H 0500), Isolated
Wetland Rules (15A NCAC 2H 1300), DWQ Surface Water,or'Wetland Standards,
El Yes
❑X No
or Riparian Buffer Rules (15A NCAC 2B 0200)?
2b Is this an after - the -fact permit application?
El Yes
❑X No
2c If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s)
3. Cumulative Impacts (DWQ Requirement)
3a Will this project (based on past and reasonably anticipated future Impacts) result In
❑Yes
❑X No
additional development, which, could Impact nearby downstream water quality?
3b If you answered "yes" to the above, submit a qualitative or quantitative cumulative Impact analysis in accordance with the
most recent DWQ policy If,you,answered "no," provide a short narrative description
A second phase of the road is planned,, but no impacts to streams or wetlands are planned at this time
4. Sewage Disposal (DWQ Requirement)
4a Clearly detail the ultimate treatment methods and disposition (non discharge or discharge) of,wastewater generated from
the proposed project, or available capacity of the subject facility
Wastewater from this project will drain into the Town of Mooresville sewer system.
Page 9 of 10
PCN Form — Version 1 4 January 2009

s
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this project occur in,or near an area with federally protected species or
Yes QX No
habitat?
5b Have you checked with the USFWS concerning Endangered Species Act
Yes No
impacts?
5c If,yes, indicate the USFWS Field Office you have contacted
-
5d What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
USFWS online Critical Habitat Mapper, USFWS County Online Mapper
6. Essential Fish Habitat (Corps Requirement)
6a Willgthis protect occur in or near an area designated as ,essential fish habitat?
❑ Yes No
6b What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NOAA Essential'Fish Habitat Mapper
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
Yes No
status (e g , National Historic Trust designation or properties, significant in
North Carolina history and archaeology)?
7b What data sources did you use to determine,whether your site would' impact historic,or archeological resources?
North Carolina State Historic Preservation Office HOPWEB GIS Service
8. Flood Zone Designation (Corps Requirement)
8a Will this project occur in a FEMA- designated 100 -year floodplain?
❑ Yes ❑X No
8b If yes, explain how project meets FEMA requirements
8c What source(s) did you use to make the floodplain determination,?
FEMA Maps 3710466800J and 310467800K
1
Christina R Raymer
July 11, 2014
Applicant/Agent,'s Printed Name
Date
Applicant/Agen ' ign
(Agent's signature is val my if an authonzation
letter from the a cant is provided')
Page 10 of 10

-Infohm4on
hoOfflmlfiff,
Aw-4-1-v,g Th Build On
June 16, 2014`
Mr,. Robert Carney
'81ccit,
161 E. IredBIl Avenue
Moormvde' North Carolina 28115
704.662-6922
rob64ed6moor6sWIle.org
Ref6irence- Agent Authorkation Form
WoreWlle Industrial Park Expanstop
NC 801 and MooreWlle, SWevaid (PkN 4678287150)
Mo6rbswille, Iradell County. North Caroli6a 28115
PSI Prqje6(W6.; 0457410 7
The qndersigned, registered property owner 0!" above -noted property, ddes hereby authorize
Christina Riyrnei of Prc4esion6l Service - " lnd`ustries, Inc. (Pbl)'to act om M-y behalf and ,tako all
actions necessary f6r the processing, issuance and acce ptaift ce of ibis pemft of c�idifickion and
_
any and all'standard and s peci al conditions attached.
i
9qD21-AWkatW,( I farm VIU&MCIC. or,= Aw--WRI h%

Cr�ical Habitat Map
Mooresville Industrial Park Expansion
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Iredell County Endangered Species, Threatened Species,Federal Species of Concern, and` .. Page 1 of 2'
U.S. Fish & Wildlife Service
Endangered Species, Threatened Speeies,Federal Species of
Concern,, and Candidate Species,
Iredell County, North Carolina
BOER $F �4
Marc
Updated: 09 -22 -2010
Comm_ on Name Scientific name Federal Record Status
Status
Vertebrate:
Allegheny wood'rat
Neotoma magister
FSC
Current
Bo turtle urtle
Clemmys muhlenbergur
T (S /A)
Current
Invertebrate:
Vascular Plant:
Dwarf- flowered heartleaf
Hexastylis naniora
'T
Current
Prairie b'irdsfoot- trefoil
Lotus umfoliolatus var. helleri
FSC
Historic
Nonvascular Plant:
Lichen:
Definitions of Federal,Status Codes:
E = endangered —A taxon "in danger of extinction throughout all or a significant portion of its range."
T = threatened. A taxon "likely to become endangered within the foreseeable future throughout all or
a significant portion of its range "
C = candidate A taxon under consideration for official listing for which there is, sufficient information
to support listing (Formerly "C1" candidate species )
BGPA =Bald and Golden Eagle Protection Act. See below:
FSC = federal species of concern. A species under consideration for listing, for which there is
insufficient information to support listing at this time. These species may or,may not be fisted in the
future, and many of these species were formerly recognized as "C2 "' candidate species.
T(S /A) = threatened due to similarity of,appearance. A taxon that is threatened due to similarity of
appearance with.another listed species and is listed for its protection. T.axa listed as T(S /A) are not
biologically endangered or threatened and are not subject to Section 7 consultation. See below.
EXP = experimental population. A taxon listed as experimental (either essential or nonessential)
Experimental, nonessential populations of endangered species (e g., red wolf) are treated a& threatened
http• / /www fws.gov /raleigh /,species /cntylist/iredell.htmi 6/9/2014

Iredell County Endangered Species, Threatened Species,Federal Species of Concern,, and .. Page 2 of 2
species on public land, for consultation purposes, and as species proposed for listing on private land
P = proposed. Taxa proposed for,offtcial listing as endangered or threatened will be noted as "PE" or
"PT ", respectively
Bald and Golden Eagle Protection Act (BGPA):
In the July 9, 20071`ederal Register( 72 37346- 37372), the bald eagle was declared recovered, and
removed (de- listed) from the Federal List of Threatened and Endangered wildlife. This delistmg took
effect August 8;2007. After delisting, the Bald and Golden Eagle Protection Act (Eagle Act) (16
U.S.C. 66M68d) becomes the primary law protecting bald eagles. The Eagle Act prohibits take of
bald and golden eagles and provides a statutory definition of "take" that'includes "disturb ". The
USFWS has developed National Bald Eagle Management Guidelines to provide guidance to land
managers, landowners, and others as to _how to avoid disturbing bald eagles. For mor information,
visit - http: / /www.fws. og v /mi rg atorybirds /baldeagle.htm
Threatened due to similarity of appearance(T(S /A)):
In the November 4, 1997 Federal Register (55822- 55825), the northern, population of the bog turtle
(from New York south to Maryland), was, listed as T (threatened), and the southern population (from
Virginia south to Georgia),was listed as T(S /A) (threatened due to similarity of appearance). The T
($/A) designation`bans the collection and interstate and international commercial trade of bog turtles
from the southern population The T(S /A) designation has no effect on land managerrient�activities'by
private landowners in North Carolina, part of the southern population of the species. In addition to its
official status as T(S /,A), the U.S. Fish and Wildlife Service considers the. southern population of the
bog turtle as a Federal species of concern due to habitat loss.
Definitions of Record Status:
Current - the species has been, observed in the county within, the last 50 years.
Historic - the species was last observed in the county more than 50 years ago.
Obscure - the date and /or location of observation is uncertain'.
Incidental /migrant - the species was observed outside of its normal range or habitat.
Probable /potential - the species is considered likely to occur in this county based on the proximity of
known records (in adjacent counties), the presence of`potentially suitable habitat, or both.
http. / /www .,fws.gov /raleigh /species /cnty`,list/i'redell.htmi 6/,9/2014

STATE OF NORTH CAROLINA
DIVISION OF ARCHIVES AND HISTORY
I
0
H[STORIC, SITES SURVEY
NAME
HISTORIC
SEE INSTRUCTIONS IN HOW TO COMPLETE NATIONAL REGISTER FORMS
TYPE ALL ENTRIES -- COMPLETE APPLICABLE SECTIONS
AND /OR COMMON
Du r) my re- Fa lrrn s
19LOCATION
STREET& NUMBER r M fL a l 614' IV c
—NOT FOR +PUBLICATION
CITY, TOWN r p CONGRESSIONAL DISTRICT
' I'tn O _ VICINITY OF _
SSTATE �„! d� in �, �j JJ _ CODE �OUrITY,, „ � CODE
CLASSIFI+CATI ON
CATEGORY
OWNERSHIP
STATUS
PRESENT USE
_DISTRICT
_PUBLIC
— OCCUPIED
— AGRICULTURE
— MUSEUM
= BUILDINGS)
— PRIVATE
— UNOCCUPIED
— COMMERCIAL
—PARK
— STRUCTURE
_BOTH
—WORK IN PROGRESS
— EDUCATIONAL
— P,RIVATEAESIDENCE
_SITE
PUBLIC ACQUISITION
ACCESSIBLE
— ENTERTAINMENT
— RELIGIOUS
— OBJECT
_IN PROCESS
_YES RESTRICTED
— GOVERNMENT
_SCIENTIFIC
_BEING "CONSIDERED
_YES UNRESTRICTED
— INDUSTRIAL
— TRANSPORTATION
—NO
— MILITARY
—OTHER
OWNER OF
PROPERTY
-
-
NAME
STREET & NUMBER
CITY: TOWN STATE
VICINITY OF
soft
LOCATION OF LEGAL DESCRIPTION
COURTHOUSE,
REGISTRY OF DEEOS,,ETC
STREET & NUMBER
CITY, TOWN STATE
REPRESENTATION IN EXISTING'SUIRVEYS
TITLE
DATE
DEPOSITORY FOR
SURVEYRECORDS
CITI,TOWN
_FEDERAL _STATE — COUNTY _LOCAL
STATE

SIGNIFICANIdE
PERIOD
AREAS OF SIGNIFICANCE -- CHECK AND JUSTIFY BELOW
-PREHISTORIC
ARCHEOLOGY- PREHISTORIC
- COMMUNITY PLANNING
- LANDSCAPE ARCHITECTURE
_RELIGION
_1400.1499
ARCHEOLOGY- HISTORIC
_CONSERVATION
-LAW
_SCIENCE
_1600 -1699
_AGRICULTURE
- ECONOMICS
_LITERATURE
_SCULPTURE
_1600.1699
1ARCHITECTURE
_EDUCATION
MILITARY
- SOCIAL/HUMANITARIAN
1700.1799
-ART
= ENGINEERING
-.MUSIC
_THEATER
x- 1600.1899
_COMMERCE
- EXPLORATION /SETTLEMENT
_PHILOSOPHY
_TRANSPORTATION
_1900-
_COMMUNICATIONS
JNDUSTRY
- POLITICS /GOVERNMENT
_OTHERI(SPECIFY)
JNVENTION
SPECIFIC DATES , 6 �o
BUILDER /ARCHITECT
STATEMENT OF SIGNIFICANCE

' MAJOR RI I.IOGRAPHICAL REFERENCES
a
( GEOGRAPHICAL DATA
ACREAGE OF NOMINATE01PROPERTY
UTM,REFERENCES'
Al 1 111 r t t( 1 r t 1 1 t i B f r 1 l I I LL L
c IZONEI i A' TIN I I ' NORTHING- ( DIZON I IE IST,N ( NO
' , I I,
LIST ALL STATES AND COUNTIES FOR PROPERTIES OVERLAPPING STATE OR COUNTY BOUNDARIES
STATE CODE COUNTY CODE
STATE CODE COUNTY CODE
FORS PREPARED BY
NAME %TITLE ,,p a 5
ORGANIZATION DATE
STREET &•NUMBER TELEPHONE
CITY OR TOWN
ATE
STATE HISTORIC PRESERVATION OF'FICE'R CERTIFICATION
THE EVALUATED SIVNIFICANCE'OFTHIS PROPERTY WITHIN THE STATC�IS!
NATIONAL STATE LOCA/I//Z
As the,designated State Historic PreseivatiorPOfficer for the National, HIStorIc Pr`eservation,Aut,oV1966 (Pdbli6U E!9 -665), I
hereby nominate this propErty for Inclusion In the Ndtional Register and certify that it`has been evalbated according to the
criteria and procedures•set forth by,the Natlonal,Park Service
FEDERAL REPRESENTATIVE,SIGNATURE
TITLE DATE
R Ii } PS USE' OP)LY
I HERE3Y ( IEATIf`Y'T14ATTHIS PROREFITY ISANCLUDED IN THE NATIONAL REGISTER
DATE
DIRECT OR, T} mcc -Or, iqQ- IE0L0GY-ANDHISTORIGPRESERVAT!ON
ATI EST ' ;, DATE,
KEEPER Of- TI!F N4ilON/at_ rS,`_GISTER

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