20221150 Ver 1_Updated Impact Table_20221013

Page 9 of 20 PCN Form Version 4.3- April 20, 2022

D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project
(check all that apply):
☒ Wetlands ☒ Streams - tributaries
☐ Buffers ☐ Open Waters
☐ Pond Construction

2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a.
Site #*
2a1.
Impact
Reason/Type*
2b.
Impact
Duration*
2c.
Wetland Type*
2d.
Wetland Name*
2e.
Forested
?*
2f.
Jurisdiction
Type*
2g.
Impact Area
(ac)*
W1 Grading Permanent Seep W1 No Both 0.004
W2 Grading Permanent Seep W2 No Both 0.292
W3 Other Permanent Seep W2 No Both 0.081
W4 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W5 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W6 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W7 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W8 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W9 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W10 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W11 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W12 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W13 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W14 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W15 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
2g1. Total temporary wetland impacts Click to enter. ac
2g2. Total permanent wetland impacts 0.377 ac
2g3. Total wetland impacts 0.377 ac
2h. Type(s) of material being discharged and the amount of each type in cubic yards:
Click to enter text.
2i. Comments:
Wetland type: Emergent seep wetlands. See Holly Branch Restoration Project Area Wetland Survey document
for additional information on the proposed impacts. W1 and W2 grading impacts for increased floodplain access
will not result in a loss of wetlands. W3 conversion impact will convert wetland area to stream area.

Page 10 of 20 PCN Form Version 4.3- April 20, 2022

3. Stream Impacts
If there are perennial or intermittent stream/ tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/ tributary sites impacted.
** All Perennial or Intermittent streams must be verified by DWR or delegated local government

Site #*
3a
Impact
Reason*
3b.
Impact
Duration*
3c.
Impact Type*
3d.
Stream Name*
3e.
Stream
Type*
3f.
Jurisdiction
Type*
3g.
Stream Width
(avg ft) *
3h.
Impact length
(linear ft) *
S1 Restoration Permanent Restoration/
Enhancement
Holley Branch Perennial Both 9 875
S2 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S3 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S4 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S5 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S6 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S7 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S8 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S9 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S10 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S11 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S12 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S13 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S14 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S15 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S16 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S17 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S18 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S19 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S20 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
3i1. Total jurisdictional ditch
impact: Click to enter. linear ft
3i2. Total permanent stream
impacts: 875 linear ft
3i3. Total temporary stream
impacts: Click to enter. linear ft
3i4. Total stream and ditch
impacts: 875 linear ft
3j. Comments:
See included plan set for details