20150606 Ver 1_Buffer Determination Request_20150622

4
Pat McCrory
Governor
NCDENR
North Carolina Department of Environment and
FiECEIVED/NCDEN Ion of Water Resources
ater Quality Programs
Thomas A. Reeder
JUN 2 2 2015 Director
Water Quality Regional
operations Section
Washington Regional Office
Natural Resources
John E. Skvarla, III
Secretary
DWQ Use Only: Project #
Stream Origin /Buffer Applicability Determination
Required Information
1. Owner Information (corporation /individual who is legally responsible for the property and its compliance)
1a. Name(s) on Recorded Deed 5'0,j 7-o)5/zN /" /inn ll &o �v�t„cTS , LLC
1 b. Responsible Party (for. LLC) %/?o K rY � �joycL , / q
1 c. Mailing Address ( 30 15kitr`/ l0 < <r4 Sjitee 7- �!//grhr� -I4FU", �(-( 27?�/
1d. Telephone Number Z S�_ yy�6 — 7� �� le. Email Address
2. Location of Project Site - please include the county, nearest named town and highway number:
3. Has anyone from DWQ visited the site? (J'/ N I Staff Name I /2,, b.en7-,,,r &11kDate of Visit? I
Additional Requested Information
4. Agent/Consultant Information (if applicable)
4a. Name, Company l/dt.fcy
4b. Mailing address //0 Wef 7- S-Q Lo-c �i rt oe r rwtl,/1f Z 7y�5
4c. Telephone no. i j x - cj75 = Y ?2— 14d. Email address rr;c prc� tl wY��1%�7 vi" 6A^ 9/
5. Project and Site Information /m /f(L. LOn,� �
5a. Name of project rTNe t �%} /i'�o P fJ2 � tS 5b. County 9F'+V)Z =0K r
5c. Nearest Named Streamr'rcLo i3j �r r�� 5d. River Basin
5e. Provide a brief description of this project (attach site plan if available):
JI('�
/q 4-1( tJ -ChtTS %Irl,Idr F�.r Y`9r(7-
mil/ -Ply T i.
Please 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 Regional Office for assistance.
DWQ Use Only: Is this stream call for the purpose of: buffer mitigation _ nutrient offset credit
Please return form to: Anthony Scarbraugh
943 Washington Square Mall
Washington, NC 27889 Note: Submittals on Friday after 12:00 pm
will be stamped as received on the
Fax: [phone] next business day.
Email: anthonv.scarbrauohCc @ ncdenr.cov
Please contact Anthony Scarbraugh at (252) 946 -6481 if you have any questions.

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