20230072 Ver 1_07_Princeton SouthPine_BufferDetermReqForm-RRO30Aug2022_20230112

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RJCHARD E. ROGEPS, ]R.
Director
NORTH CAROLINA
Environmental Quality
Date Received DWR Use Only: Project #
Buffer Determination Request Form
Property Owner Information
1. Owner Information
Ia. Name(s) on Recorded Deed
Town of Princeton, multiple landowners
lb. Responsible Party (for LLC)
N/A
lc. Mailing Address
N/A, multiple
Id. Telephone Number
N/A, multiple
le. Email Address
N/A, multiple
Address of Property:
Project Description (attach plan if available): Pipe repair and ditch cleanout in Princeton, NC to improve drainage and prevent flooding.
Consultant/Agent Information
4. Agent/Consultant Information
4a. Name, Company
Allison Keith — Axiom Environmental, Inc
4b. Mailing address
218 Snow Ave. Raleigh, NC 276
4c. Telephone no.
423-400-8882
4d. Email address
akeith(a axiomenvironmental.org
5. Project and Site Information
5a. Name of project
Princeton South Pine Drainage
Improvements
5b. County
Johnston
5c. Nearest Named Stream
Beaverdam Creek
5d. River Basin
Neuse
6. Has anyone from DWR visited the site?
I 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 Jim Westcott
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.
-EQ-""
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000