20221005 Ver 1_Determination Request_20220726

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: * Jack Jones LLC Site
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: *
Responsible Party :
Telephone Number:
Jack Jones LLC
Jack Jones LLC
(for LLC, Corporations, businness, agency, etc.)
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
Attach agent authorization letter:*
Agent/Consultant Information
How would you like to receive your
determination letter?*
Name of Agent: *
Company Name:*
Email Address:*
Project Information
IP Stream Determination
Stream
Agent Authorization form.pdf 468.82KB
PDF only
Steven Ball
S&EC
[e-mail]
LISPS
Email
Has anyone form DWR done a previous site visit?*
Yes
• No
Other

Date of Visit:
Site Information
Nearest Highway/Street: *
Nearest Town: *
Nearest Named Stream: *
River Basin: *
County: *
Pitt
Fire Tower Rd
Greenville
Swift Creek
Neuse
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
Figure 1 - USGS Map.pdf 236.78KB
Pdf file type only
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
Figure 2 - Soil Survey Map.pdf 1.05MB
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: 35.550
Longitude: -77.397
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;
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")
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");
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
o I intend to electronically sign and submit the "Determination Request" form."

Signature
Date Submitted: 7/26/2022
Initial Review
ID# *
Version *
Do you want to send for review? *
Select Reviewer: *
Select Regional Office: *
20221005
1
Yes No
Robert Tankard:eads\rbtankard
Washington Regional Office - [phone]

Project Number:
15293.W1
Project Manager:
SB
Scale: 1000'
Date:
05/31/2022
Map Title:
Figure 1 - USGS Map
Jack Jones, LLC Site
Pitt County, NC
Source:
2019 Greenville SW Quad.
0
S&
EC
(M I r1c e nter}f fG ographic Informatio
1,000 2,000
1 1 I I I 1
Feet
Soil & Environmental Consultants, PA
8412 Falls of Neuse Road, Suite 104, Raleigh, NC 27615 • Phone: [phone] • Fax: [phone]
sandee.com

Jack Jones, LLC Site
Pitt County, NC
Soil & Environmental Consultants, PA
8412 Falls of Neuse Road, Suite 104, Raleigh, NC 27615 • Phone: [phone] • Fax: [phone] i
sandec.com

Authentisign ID:645D9C18-2A8C-4602-9AD4-017BA8C1BD12
S 8
Soil & Environmental Consultants, PA
E C 8412 Falls of Neuse Road,Suite 104,Raleigh,NC 27615•Phone:[phone]• Fax:[phone]
sandec.cont
PROPERTY OWNER CERTIFICATION/AGENT AUTHORIZATION
Project Name/Description: S&EC Project#
Date:
The Department of the Army
U.S.Army Corps of Engineers,Wilmington District
69 Darlington Avenue
Wilmington,NC 28403
Attn: Field Office:
I, the undersigned, a duly authorized owner of record of the property/properties identified
herein, do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers
(Corps) and Soil & Environmental Consultants, PA (S&EC) staff, as my agent, to enter upon the
property herein described for the purpose of conducting on-site investigations and issuing a
determination associated with Waters of the U.S. subject to Federal jurisdiction under Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899. This
document also authorizes S&EC, as my agent, to act on my behalf and take all actions
necessary for the processing, issuance and acceptance of a permit or certification and any and
all associated standard and special conditions.This notification supersedes any previous
correspondence concerning the agent for this project.
NOTICE: This authorization, for liability and professional courtesy reasons, is valid only for
government officials to enter the property when accompanied by S&EC staff. You should call
S&EC to arrange a site meeting prior to visiting the site.
PARCEL INFORMATION:
Parcel Index Number(s) (PIN): k 67$6 g gqq er
Site Address: & W >Fire+D...e.� Qd.
City,County, State: 6ieeiwilre1 NS( 27gsg
PROPERTY OWNER INFORMATION:
Name: ---Ses c k Lnr 1-1—e
Mailing Address: (2$ Je/ 454fee., Rd Stier. sPnyi/ N C 2SS'71
Telephone Number: I 2SZ) 67 I — S3/3 J
06/15/2022
Property Owner(please print) Date
Authenti
tidvA#a
Property Owner Signature
We hereby certify the above information submitted in this application is true and accurate to
the best of our knowledge.