23-350 Buffer Request Form

ROY COOPER
Govem<K
ELIZABETI-f S. BISER Secretary
RICHARD E. ROGERS,JR. Director
NORTH CAROLINA
Envtronmenral Quality
Date Received -iZ?}.J I DWR Use Only: Project# 2; ..-3("0
Buffer Determination Request Form
Property Owner Information
1.Owner lnfonnation
la. Name(s) on Recorded Deed -rc.okO\ --rv u o V\ °'
lb. Responsible Party (for LLC)�L}lt\ -d. /vu CJ Vl(/\-
I c. Mailing Address c;t oo, 1) 1u k 1110 Yt '1 c+ R�f e',0i � /JC -Z7tt6
Id. Telephone Number q 1 L( ,. Z � � -� /, It,. I 1 e. Email Address I �WJ>nv fR<l'O �YC,(�
Address of Property: 521( f>eA t-1 ill R. j_ b IA y" l, � W\ N C-27704-
Project Description (attach plan if available): N,,,c.rl ""' 5--n-t'.CV'V\ de. -f €..\'" W\·,, ,,. { ; o \I\ Sv.Yve__v
<Jf o y-nn-e ;.--fy ,{�e . ,f
Consultant/ Agent Information
4.Agent/Consultant Information
4a. Name, Company
4b. Mailing address
4c. Telephone no.I 4d. Email address I
5.Project and Site Information
5a. Name of project Sb. County
5d. River Basin 5c. Nearest Named Stream Neuse River/ Falls Lake
6.Has anyone from DWR visited the site? I YIN I I StaffName I I 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. North Carolina Departmenc of Environmenlal Quality I Division of Waler Resources
Sl2 North Salisbury Street I 1617 Mail Servi,e Center I Raleigh, North Carolina 27699-1617 919.707.9000
/
DO,
Neuse River/Falls Lake
Durham5211 Red Mill Road