Buffer Determination Application 303 Robert

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 Jeanne Carol Olderman
1b. Responsible Party (for LLC)
1c. Mailing Address 303 Robert Street, Cary, NC 27511-3233
1d. Telephone Number 919-608-9483 1e. Email Address [e-mail]
Address of Property: 303 Robert Street, Cary, NC 27511-3233
Project Description (attach plan if available):

Consultant/Agent Information
4. Agent/Consultant Information

4a. Name, Company Melissa Schambs, Berkshire Hathaway HomeServices YSU Realty
4b. Mailing address 109 New Edition Court, Cary, NC 27511
4c. Telephone no. 919-796-9408 4d. Email address [e-mail]
5. Project and Site Information
5a. Name of project 303 Robert Street 5b. County Wake
5c. Nearest Named Stream Swift Creek 5d. River Basin Neuse
6. Has anyone from DWR visited the site? Y / N 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.