20160211 Ver 1_More Info Requested_20160314

PAT MCCRORY

Governor

DONALD R. VAN DER VAART

Secretary
S. JAY ZIMMERMAN

Director

DWR Use Only: Project # _________________
Date Received_______________

Buffer Determination Request Form
Property Owner Information
1. Owner Information
1a. Name(s) on Recorded Deed
1b. Responsible Party (for LLC)
1c. Mailing Address
1d. Telephone Number 1e. Email Address
Address of Property:
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 5d. River Basin

6. Has anyone from DWQ 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.

Please return form Sara Knies

to: 1628 Mail Service Center
Raleigh, NC 27699-1628
Email: [e-mail]

Please contact the Raleigh Regional Office at [phone] if you have any questions.

Division of Water Resources, Raleigh Regional Office, Water Quality Operations Section http://portal.ncdenr.org/web/wq/aps
1628 Mail Service Center, Raleigh, NC 27699-1628 Phone: [phone]
Location: 3800 Barrett Drive, Raleigh, NC 27609 Fax: [phone]