1508 Mt. Vernon Church Rd. Raleigh 27614_1508 Mt. Vernon Rd. BufferDetermReqForm-RRO-20230622

North Carolina Department of Environmental Quality Division of Water Resources
512 North Salisbury Street 1617 Mail Service Center Raleigh, North Carolina 27699-1617
919.707.9000

Date Received___ DWR Use Only: Project #

Buffer Determination Request Form
Property Owner Information
1. Owner Information
1a. Name(s) on Recorded Deed George Todd Smith, Melissa D. Dobbins
1b. Responsible Party (for LLC)
1c. Mailing Address 3429 Apache Drive, Raleigh, NC. 27609
1d. Telephone Number 919-274-3119 1e. Email Address [e-mail],
[e-mail]
Address of Property:
Project Description (attach plan if available): 1508 Mt. Vernon Church Rd. Raleigh, NC. 27614

Consultant/Agent Information
4. Agent/Consultant Information
4a. Name, Company
4b. Mailing address
4c. Telephone no. 4d. Email address
5. Project and Site Information
5a. Name of project 5b. County
5c. Nearest Named Stream 5d. River Basin
6. Has anyone from DWR visited the site? Y / N Staff Name Date of Visit?
Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.

Please return form
to:

Joe Myers
1628 Mail Service Center
Raleigh, NC 27699-1628
Email:
[e-mail]

Please contact the Raleigh Regional Office at [phone] if you have any questions.