20221125 Ver 1_Buffer Determination Request Form_20220623

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
Date Received 5-3-22
DWR Use Only: Project # 22-183
Buffer Determination Request Form
Property Owner Information
1. Owner Information
la. Name(s) on Recorded Deed
lb. Responsible Party (for LLC)
lc. Mailing Address
ld. Telephone Number
le. Email Address
Address of Property:
Project Description (attach plan if available):
Consultant/Agent Information
4. Agent/Consultant Information
4a. Name, Company
Philip Beach, Sage
4b Mailing address
4c. Telephone no.
4d. Email address
[e-mail]
5. Project and Site Information
5a. Name of project
5217, 5227 & 5305 Mt. Moriah Road,
Chapel Hill, NC
5b. County
Orange
5c. Nearest Named Stream
New Hope Creek
5d. River Basin
Cape Fear
6. Has anyone from DWR visited the site?
Y / N
Staff Name
Date of Visit?
Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.
Please return form Josh Brigham
to: 1628 Mail Service Center
Raleigh, NC 27699-1628
Email: [e-mail]
Please contact the Raleigh Regional Office at [phone] if you have any questions.
£ D_E
NORTH CAROLINA
Departnent of Environmental Quay
North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 13800 Barrett Drive I Raleigh, North Carolina 27609
919.791.4200