20230636 Ver 1_0 Mashie Dr. Stream-Buffer Request20230503_20230503

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MAY 0 3 2023
Buffer Applicability / Stream Origin Determination
Express Request ;vim 7n•ranr_z/
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
la. Name(s) on Recorded Deed
1b. Responsible Party (for LLC)
lc. Mailing Address
ld. Telephone Number
le. Email address
2. Address of Property or�Loc9tion of Project Site (including county, nearest named town, and highway or road name/ number):
3. Agent / Consultant Information
3a. Agent/ Consultant Name
3b. Company
3c. Mailing address
3d. Telephone no.
3e. Email address
4. Project / Site Information
4a. Name of project
4d. River Basin
4b. County
4e. Lat/Long
35,
4c. Nearest Named Stream
4F. Number Stream
Calls
S. Project Description (attach plan if available)
6. Has anyone from DWQvisited the site?
y
N
Staff Name:
Date of Visit:
7. Does DWR staff have permission to
access this property?
y -'
N
8. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey
If you are unable to locate either of these maps, please contact the DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitigation? Nutrient offset credit?
9. Please return Corm to: Lyn Blles
943 Washington Square Mall
Washington, NC 27889
Email: [e-mail]
»
Note: Submittals on Friday after 12:00 pm
Will be stamped as received on the
Next business day
North Carolina Department of Environmental Quality IDivision of Water Resources - Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

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_-- SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: j > <> x
STREET ADDRESS: l T/e/ lc L , ��✓
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
of
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Pro erty Owners Adder ss (if different than property above):
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best_p€our knowledge.
j.
Authorized Print Name Authorized--Sigriature
Date y _rr ' "�, `' i _ / : Date: , f
z
North Carolina Department of Environmental Quality IDivision of Water Resources - Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

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