20151221 Ver 1_401 Application_20151115

TRANSMITTAL
DATE: 11/19/2015
TO: NC DWQ
PROJECT: 33 HUNTINGTON PLACE SMITHFIELD, NC 27577
FOR: CHRIS CONRAD 407 N. SUMNER ST SELMA, NC 27576
ATTACHED:
-PCN FORM
- DRAWINGS
-1 CHECK FOR 240.00 (APPLICATION FEE)
MESSAGE: PLEASE CONTACT ME WITH ANY QUESTIONS. 919 - 879 -5141
� PAID
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DWQ project o.pFnic ..
Form Version Janua'ry 2009
Pre - Construction Notification (PCN) Form
A. Applicant Information rk/7 n
1. Processing =- l`g II
1 a. Type(s) of approval sought from the Corps:
Section 404 Permit d UI q Sect�n,A it
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps?
Yes. ❑ No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
Rf 401 Water Quality Certification - Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification - Express ❑ Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required?
Q
For the record only for DWQ
401 Certification:
❑ Yes dNo
For the record only for Corps Permit:
❑ Yes WN0
1f. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes YNo
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑Yes [�No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes 5fNo
2. Project Information
2a. Name of project:c
S j 7'
2b. County:
T044k 1W
2c. Nearest municipality / town:
S M /'/ flab
2d. Subdivision name:
I C M 3 D /NT J aL7DjiltS IoAf
2e. NCDOT only, T.I.P. or state project no:
,q
3. Owner Information
3a. Name(s) on Recorded Deed:
e ,e/
3b. Deed Book and Page No.
D 'Zook 44(oll PA66 q
3c. Responsible Party (for LLC if
applicable):
C*Z ai(,/"
3d. Street address:
7 /1/, s(eN4A -CX 5r
3e. City, state, zip:
5 EL_tn A/ G 75 1
3f. Telephone no.:
qll-- _ 971- 'r/1/1
3g. Fax no.:
q1 q - 3 sy - Z 7-38
3h. Email address:
z- Atis con W
A C me- eJee "fi" r czd . crrn
Page 1 of 10
PCN Form - Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
S. Agent(Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
A,/
Sc. Street address:
5d. City, state, zip:
A/ 714
5e. Telephone no.:
A
5f. Fax no.:
Al 6
5g. Email address:
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
5 ' DONA Pft(,eL m
1 b. Site coordinates (in decimal degrees):
Latitude: 3S.
00qq Longitude: p 3 7,D
1c. Property size:
1.7 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
�j j AUK CRCE9 WL 1` LAW)
AW
2b. Water Quality Classification of nearest receiving water.
N& W
2c. River basin:
Neu S 6451h /V F vo
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicini of the project at the time of this
application: �,
rr o n: �;S �Artg� s S Lam: rti n - i�rw ,� S r i � � cOcC i� � C.� ` S
p�,rcrs c./e 14- All j + 1J
ie, reS "c1 i f;c, vS e .
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project: 4!i, dd e,,J S i' jq /,P— -",'I 17�vhv__ n
;,,►.be,� b�� k�ect� c-hc� re -b,,� �� of eX4S fi zibtk . J
3e. Describe the overall project in detail, including the type of equipment to be used:
co to 4,K be_-s u.lv% I pro / %ofcla l: R ,� Ic� wo -� dock w� y-c, •1 e�,.
U�Q ��n �ct/Av1 J�n
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
❑ Yes ❑ No [Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known):
Agency /Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
NIA
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
El es . No ❑ Unknown
5b. If yes, explain in detail according to "help file" instructions.
A114
6. Future Project Plans
6a. Is this a phased project?
❑ Yes JRr No
6b. If yes, explain.
A)1
Page 3 of 10
PCN Form —Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
O( Wetlands ❑ Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
2b.
2c.
2d.
2e.
2f.
Wetland impact
Type of impact
Type of wetland
Forested
Type of jurisdiction
Area of
number
Corps (404,10) or
impact
Permanent (P) or
DWQ (401, other)
(acres)
Temporary
W1
Choose one
Choose one
Yes/No
-
!"
IitiAl Qd! �I
/,
l/ �1 �C,v►owh
Yew
e
W3
Yes/No
-
W4
Yes/No
-
W5
Yes/No
-
W6
Yes/No
-
2g. Total
Wetland Impacts:
2h. Comments:,
YZr t4;4' &I ut,�,�ev► O�rea, 6e,4Er-Lz.,
b,A k
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
3b.
3c.
3d.
3e.
3f.
3g.
Stream impact
Type of impact
Stream name
Perennial (PER) or
Type of
Average
Impact
number
intermittent (INT)?
jurisdiction
stream
length
Permanent (P) or
width
(linear
Temporary M
(feet)
feet)
S1
Choose one
S2
S3
S4
S5
S6
3h. Total stream and tributary impacts
3i. Comments:
/VO $T4*M IMPACT-5
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
01 7
7
I% bujk
0r
02
03
04
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction Proposed, the com lete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
5f. Total:
r
5g. Comments: "*) w rd ; �, ��., 1 k d �a ex +3 '� s as re. 11
5h. Is a dam high hazard permit required?
❑ Yes No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
l
6. Buffer Impacts (for DWO)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
iNeuse ❑ Tar - Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number —
Permanent (P) or
Temporary
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet )
6g.
Zone 2
impact
(square
feet
B2
j k-kt
/
e
B3
Lake
Al
B4
B5
86
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically descri measures taken to avoi or minimize the proposed impacts in designing project..
-Aw �,,,� be- to c1- 10 y ,,,� . '.u,,11 �C_ ��a/ ;s�p�cf
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
N*vb .130 0-
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes 5J/No
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑ Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank: Q
3b. Credits Purchased (attach receipt and letter)
Type:
Type:
Type:
Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in4ieu fee program is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature:
Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non - riparian wetland mitigation requested:
acres
4g. Coastal (tidal) wetland mitigation requested:
acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Reguiated Riparian Buffer Rules) — required by DWQ _
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑Yes E(No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
6c.
Reason for impact
6d.
Total impact
(square feet)
Multiplier --
6e.
Required mitigation
(square feet)
Zone 1 '
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved,in -lieu fee fund).
6h. Comments:

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
R(Yes ❑ No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Afhe- 7o �� aC��a,Gl r�' iD KO pu" "_ gowc-f- .
❑ Yes j(No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
0%
2b. Does this project require a Stormwater Management Plan?
❑ Yes RfNo
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: .
BOA-r- DOCV, -10 6E: GaA,97:z<1G4tT6 Al yaL,gJ A'b '10 P Gc>Alyll�.v �
r:'QStW 141ERon). amE ��✓.5/W1,T1.01J %b
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stonnwater Review
3a. In which local governments jurisdiction is this project.?
❑ Phase II
3b. Which of the following locally - implemented stormwater management programs
❑ NSW
apply (check all that apply):
❑ USMP
❑ Water Supply Watershed
[Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
❑Yes [VVo
attached?
4. DWQ Stormwater Program Review
❑Coastal counties
❑HOW
4a. Which of the following state- implemented stormwater management programs apply
❑ORW
(check all that apply):
❑Session Law 2006 -246
❑Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
❑Yes [�No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form = Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal /state/local) funds or the
❑ Yes
VNo
use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document to the the National
,_,�/
pursuant requirements of or State
❑ Yes
L4q No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.)
❑ Yes
No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
❑ Yes
No
or Riparian Buffer Rules (15A NCAC 213 .0200)?
2b. Is this an after - the -fad permit application?
❑Yes
&?(No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
❑Yes
D(No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non - discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
'v /A
Page 9 of 10
PCN Form —Version 1.4 January 2009

6. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
Yes �No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
Yes No
5c. If yes, indicate the USFWS Field Office you have contacted.
SC
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat? .�
11.. __ II
��4 W� 10CJ A,Q -- in -Tot, h&49., �q{�,
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
Witt% 44AiS
7. Historic or Prehistoric Cultural Resources (Corps equirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status National
El Yes o
(e.g., Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
(
8. Flood Zone Designation (Corps Requirement?
8a. Will this project occur in a FEMf- designated 100 -year floodplain?
eryes ❑ No
8b. If yes, explain how project meets FEMA requirements:
�P� /V0 Ye+v 4-kul �7�it�•� b'wMJcr -J J4W yn�nvr��•�
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8c. dat source(s) did you use to make the floodplain determination?
,�v► p'c /1G
�fie� tam rn t; c�L
Applicant/Agent's Printed Name
Applicant/Agent's S ggna ure
Date
(Agents signature is valid only if an authorization
letter from the applicant is provided)
Page 10 of 10

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