304 W. Delafield Avenue - Request Form

1
ROY COOPER
Ccvernor
ELIZABETH S. BISER
SerW1try
RICHARD E. ROGERS, JR.
Dlrcoor
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NORTH CAROLINA
Environmental Quality
Date Received DWR Use Only: Project #
Buffer Determination Request Form
Property Owner Information
1. Owner Information
Ia. Name(s) on Recorded Deed
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Ib. Responsible Party (for LLC)
Ic. Mailing Address
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Id. Telephone Number
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le. Email Address
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Address of Property: 30 �I , pe ,� , e d
Project Description (attach plan if available): �—
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 Sd. 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.
Joe Myers
Please return form 1628 Mail Service Center
to: Raleigh, NC 27699-1628
Email:
DEQ. RRO. Buffer. Reg uests(a,)deq.nc.gov
Please contact the Raleigh Regional Office at [phone] if you have any questions.
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