20161256 Ver 2_Determination Request_20220914

Stream Origin/Buffer Applicability Determination
NORTH CAROLINA
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Processing Information
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: *
Alice Keene District Park Determination - Pitt County
Is this a transportation project?* u Yes O No
Is this request fora mitigation site?* 0 Yes O No
What type of request is this?*
D Buffer
O Isolated Wetland
Check all that apply.
Owner/Applicant Information
C IP Stream Determination
C Stream
Owner Information
Name on the Recorded Deed:*
Pitt County
Responsible Party : Jonas Hill
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 252-902-3279
How would you like to received your determination?*
USPS Email
Mailing Address:*
Email Address:*
Street Address
1717 West 5th Street
Address Line 2
City State / Province / Region
Greenville NC
Postal / Zip Code Country
27834 US
[e-mail]
Is there an agent or consultant responsible for the request?*
Yes
0 No

Agent/Consultant Information
Project and Site Information
Project Information
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: *
F
County Home Road
Greenville
Fork Swamp
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
S P 1734522091414580. pdf 223.16KB
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
S P 1734522091414581.pdf 329.95KB
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.
Latitude:
Longitude:
Misc attachments:
35.548641
-77.34994
Address Lookup
Manually
pdf or kmz file types only

Sign and Submit
By digitally signing below, I certify that:
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*
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