20150248 Ver 1_Buffer Determination Request_20151230

Water Resources
ENVIRONMENTAL QUALITY
RECEIVED/NCDENR/DWR
DEC 3 0+2015
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Water Quality Regional DWR Use Only: Project# L$"-01VV]-
Operations Section
Washington Regional Oftice
Stream Origin/Buffer Applicability Determination
Required Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
1a. Name(s) on Recorded Deed
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4b. Mailing address
1b. Responsible Party (for LLC)
4c. Telephone no.
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1c. Mailing Address
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5. Project and Site Information
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1 d. Telephone Number
5b. County
1 e. Email Address
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2. Locationn of Project Site - please include arest na ed toX�theFounty, gg n ar�d highw y numger:
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3. Has anyone from DWR visited the site?
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Staff Name
(Z� s - Date of Visit?
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Additional Requested Information
4. Agent/Consultant Information (if applicable)
4a. Name, Company
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4b. Mailing address
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4c. Telephone no.
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4d. Email address
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5. Project and Site Information
5a. Name of project
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5b. County
5c. Nearest Named Stream'{'
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5d. River Basin
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5e. Provide a brief description of this project (attach site plan if available): SeEr w' L 1i N
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.
If you are unable to locate either of these maps, please contact the Regional Office for assistance.
DWR Use Only: Is this stream call for the purpose of: — buffer mitigation _ nutrient offset credit
Please return form to: Anthony Scarbraugh
Washington Square Mall
Washington,
Note: Submittals on Friday after 12:00 pm
Washington, NC 27889 will be stamped as received on the
Fax: [phone] next business day.
Email: anthonv.scarbraughoncdenr.gov
Please contact Anthony Scarbraugh at [phone] if you have any questions.
State of North Carolina I Envlromnental Quality I Water Resources—Water Quality Regional Operations — Washington Regional Office
943 Washington Square Mail, Washington, NC 27889
252-946-6481

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