20150731 Ver 1_Buffer Determination Request_20150723

w
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Charles Wakild, P.E. John E. Skvarla III
Governor Director Secretary
Stream Origin /Buffer Applicability Determination
Applicant/Owner'ssNNa -me (corporation/individual who is legally responsible for the property and its compliance):
Applicant/Owner Address:
Applicant's phone number:
Applicant's email address:
Fax number:
Consultant/Contact person Name (if applicable): Ski V\J �r'G
Consultant address (if applicable): �� h �"UA_ �� L�� t e e 1; �(�6 \
Consultant's phone number: — Ct�� —o��� Fax number:
Consultant's email address:��tr(�CC�1�� \ \t�i��1��_ c�F�
Name of Project: County:tt
_ � 1
Nearg tt Na ed stre�p + River Basin (from USGS topographic map):
K',vY\� \rte 1>t \�tPf
PI ase provide a brief des iption of this p[oje�t (attach site an if vailaple): p \ -
_ .J ;�r. �Li -Ff�dr c1�
Please attach a map of site location indicating project boundaries using USGS 1:24,000 topo map and MRCS county soil survey.
Location of projects to - lease i clu referrenc�o'\the county, nea est named town and highway number:
Has any DWQ(staff visited the site? iC - if yes, please provide DWQ staff' name, and date of
visit: 7'
This form may be submitted via email (roberto.scheller @ncdenr.gov), faxed (252- 946- 9215), mailed or hand - delivered to:
943 Washington Square Mall, Washington, NC 27889. (Note: Submittals of the review packages on Friday after 12:00 pm will
be stamped as received on the next business day).
Please contact Roberto Scheller at 252- 948 -3940 if you have any questions regarding this form.
Water Quality Regional Program
943 Washington Square Mall
Washington, NC 27889
Internet www.ncwateraualitv.org
Phone: [phone]
FAX [phone]
An Equal OpportunitylAff rmative Action Employer— 50% Recycledl10% Post Consumer Paper