20080083 Ver 1_Initial Interest_20080107

Q$-0083
T?VrITIA(:INTFRFS`1' IN I'AR'I'IC"11'A'1'I()N IN 'I'HI.: I:~I'RE;SS RFb`lF«' PROGKAVI
WITHIN TFLI: 401 OVF,I2~iIT1:/F,XPI2I;SS P~~R'~~IITTING tiNiT
October 1, 2006
Version -I
Applicant Name: (,~b~ UE' Ca~.CJT~`{ _
Applica~lt jlddress: '~ ~ ~~ 1~Tb L `~U
Applicant's phone number: `~I~-.`~C3~'-~21Z Fasnumber:
Applicant's email address:
C;onsultantNarne (,ifapplicahle): DUl'~f~E' ~, 'S ~"',~hl,~t~T Ah1D i~'SSG'~~.11~7~5
('onsultant address (if applicable): ~ 7/~ U!~ 111 ~T~51T'f 4~ 1V,
{'onsultant's phone number: ~ Iq °`I9U ' 2q9 ~.___ Fay: number Q~q ~Y'~Q_"'~± ~~!~.~J~'
Consultant's email adch~ess: 0.~,~p_t'LGL~_~5~"..~-" `~~ r C..C? ~...... _ ..--._.
Tv°pe of action requested under the I~xpress I2evie-w Program (check all that appl}'):
^ 40l water Qualifi- Cortitication ~, Stream Orrin I7etc;rmination
^ Isolated V4'ctland Permit ~ # of Determinations Kegtaested
^ Riparian Buffer Approval ^ IntermittentlPerenniai Determination
^ Riparian Buffer Minor Variance _ # of Determinations Kcqucsted
^ Coastal General `'Major" Variance ^ Isolated ~'4'etland Determination
linear feet or acres
^ Stonri~~°ater Management Plan (this fee is not additive when appro~~al is combined with ~O1 C:ert.)
rx of Drainage AreaslProjcct Sits
Name of Project: ~jJZt~l~~_-_ ST_t?EAM 3iJFF~"~ YAR 1 ~N.GE",.__ County: _T? IIR ~-1AM
Total project acreage: "C ~ • ~_ __{"acres) "Total built out impervious area: C'.. i ~ i (acres)
Nearest Named stream + IZivcr Basin (f~~{{~m t7SGS topo map):
" ("~-I ! ~ D F'C> ii~ 1C G...2 ~ EK '-_Lacu. ~GA~c _
Please provide a brief description of this project (attach site plan if~ availahle):
~,eE'c_T 1[~n1 0 ~ FEA~C.~ /~ j-_~~x 0 M R L~%4 ~ -- P ~4 ~ ~~~ r_~ ~_ ~_v E -~
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Please attach a map cif site location usin~~ USGS 1:~'~t,000 nt<tp and county soil survey.
C,ocation of project site -please include reference to the county, nearest. name town and highwa~~ number:
~1YY OF pURHAM 1N Au2HAM Cout~tT~' ------_ _._ _---__-- -______
NEI~H&~H4aD A~zEA __ aFF r1 o_PE"__~A~._~_~~ ?4A~ _----
Proposed impacts:
Has ca~suhant
which ones.
N~A
_. _....I
Acres o1~~10-x/401 ~vctlands
Acres of isolated wetlands
Linear feet of streams
Linear feet ol~isolated streams
Square feet of protected stream buffers
applicant at ended any I~W(~)-sponsored training sessions in the past two years? If so. please list
Has anv DWQ staff visited the site`' ~~ _ if yes. please provide DW(~ staff name.
date of visit:
~~hich other environmental permits frcnn other agencies will be needed for this project? Please list the permits and
issttiing agencies below:
and
Does this project require approval under the State Environmental Policy Actor National Environmental Policy Act?
is this project an After-the-fact application or has this project received a previews Notice of Violation from UWQ?
_.._._~~
Does this project require approval of a Variance from the NC Environmental Management (;ommission? ~~
Are you aware of any local contruversv concerning this project? if su, please describe the cond-oversy and any
measures that have been taken with respect to public involvement.
This form must be submitted via email (cb 401ex~r~,ss~'rLncmaiLnet), Faxed (919-?>-6;93) or hand-delivered to the
Parkview Building, 2121 Crabtree Blvd. Suite'S0, Raleigh, NC 27604. Applicants who are selected to participate in
file F.,xpress Review Program will be notified via fax within 2 days. Successful applicants will then be instructed
regarding detailed procedures for full application (A'ote: Sarb~irittaJs~ of'ihc: reviem j~ac~kcrges r>r~ rriclav after 12:00 pnr
-cilT be stamJ~er~ cr,~ receive~~l nn 1he~ nc~.r1 hr.rsin<~.~~c c~ar~l. _
Please contact Cynthia Van Der w'iele at 919-715-347 if }~ou have any questions regarding this form.
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