20150607 Ver 1_Buffer Determination Request_20150622

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NCDENR
North Carolina Department of Environment and Natural Resources
RECEIVEDINCDENRIDWR Division of Water Resources
Pat McCrory
Governor
JUN 2 2 2015
water Quality Regional
Operations Section
Washington Regional Office
Water Quality Programs John E. Skvarla, III
Thomas A. Reeder Secretary
Director
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)
1 a. Name(s) on Recorded Deed f (f w A 4.2 fl/ ,op-pwc-r ) e-c �� wJ� j L L6
1b. Responsible Parry (for LLC) /71 A4WAe ( f, A /�tG�� � 'T,�—
1c. Mailing Address l g3SWQSr. r,,,O( Slret/j 27YO
1d. Telephone Number 25-6 Z —q fS —/7,70 11e. Email Address
2. Location of Project Site - please include the county, nearest named town and highway number:
;-nr o)-� W, 6 st.Q&r 13(K,'L t'-tAe-
3. Has anyone from DWQ visited the site? �Y> N I Staff Name JA kt4 f k-di.. I Date of Visit? 6' V,p,,1:) rV,
Additional Requested Information
4. Agent/Consultant Information (if applicable)
4a. Name, Company
4b. Mailing address
4c. Telephone no.
5. Project and Site Information
5a. Name of project
5c. Nearest Named Stream
5e. Provide a brief descriptor
0Ji l J 6
/fuzr�. R,`�aK.dro.�/, Hid /4�,�•�.2dsvl>c . i°�- ,
Gt%2f-t- Sa�_Va '5Y- -kW
2S z_ q7S-� 3y7z 14d. Email address
/ -e Al 6 /flit A4'+1 l r
l,'9 15b. County
C�Q�tiy uv1/ Y 5d. River Basin 7-pwc- ^MIt�o
i of this project (attach site plan if available):
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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:
Please return form to: Anthony Scarbraugh
943 Washington Square Mall
Washington, NC 27889
Fax: [phone]
Email: anthonv.scarbrauah(&ncdenr.aov
buffer mitigation _ nutrient offset credit
Note: Submittals on Friday after 12:00 pm
will be stamped as received on the
next business day.
Please contact Anthony Scarbraugh at (252) 946 -6481 if you have any questions.

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