20150676 Ver 1_Buffer Determination Request_20150710

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RCD D1NCDENRMWR
North Carolina Department of 4vironment and Natural Resources
'JUL 10 2015Donald R. van der Vaart
Pat McCrory ecretary
rY Water Duality Regional
Governor Operations Section
Washington Regional Office
DWR Use Only: Project #
Stream Origin /Buffer Applicability Determination
Required Information
11. Owner Information (corporation /individual who is legally responsible for the property and its compliance)
1a. Names) on Recorded Deed 5J Lfk4 v R, % UjO GU, j (n
1b. Responsible Party (for LLC) Nl1 , V
1c. Mailing Address i5ti5 Wd.r¢) C, %aP- i C.v\1(•J0.5\'k;AJkrp,,t)W1C1 X78,
1d. Telephone Number a52- 34i-A53N Ile. Email Address k•ar%sc,�i ¢'I'w. ✓l�Y4ti6il•uµ
I2. Location Site - please include the county, nearest named town and highway number:
-_
I3. Has anyone from DWR visited the Y IStaff Name I (Date of Visit?
site?
IAdditional Requested Information
14. Agent/Consultant Information (if applicable)
4a. Name, Company
4b. Mailing address
4c. Telephone no. 14d. Email address
15. Project and Site Information
5a. Name of project jA {Pkt",Tf1ubw�,'f 5b. County &- QvXor+
5c. Nearest Named Stream (.ittXtyQ%kAC✓1Gk-, 5d. River Basin Lowt ✓Tai
5e. Provide a brief description of this project (attach site plan if available):
Plupev }J owo-G- Wculd, (: KLi-o InS6, ik A C. rd55-,4q i�sa\cCR55ajoisi P,-q )!
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.
DWR 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
Fax: [phone] will be stamped as received
on the next business day.
Email:
anthonv.scarbrauah(rDncdenr.00v
Please contact Anthony Scarbraugh at (252) 946 -6481 if you have any questions.
Division of Water Resources Water Quality Rcgionnl Operations Section Washingnon Regional
oflice
94" lA'ashin&wn Square Mill. N'ashinglon. NC 27889
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