20150038 Ver 1_Riparian Buffer Authorization_20160519

DWR
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State of North Carolina
Department of Environment and Natural Resources
Dlvlslon of Water Resources Division of Water Resources
15A NCAC 02B .0233 (8)(b), .0243 (8)(b), .0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2) - Buffer Authorization
FORM: BA 10-2013
Riparian Buffer Authorization Form
A. Applicant Information
1. Project Information
1 a. Name of project:
817 Macon Place Deck Extension
1 b. County:
Wake Country
1c. Nearest municipality:
City of Raleigh
id. Subdivision Name
North Hills
le. Is the project located in any of North Carolina's
twenty coastal counties. If yes, answer 1f below.
❑ Yes ® No
1f. Is the project located within a NC Division of Coastal
Management Area of Environmental Concern (AEC)?
❑ Yes ® No
2. Owner Information
2a. Name on Recorded Deed:
Chad Thieman
2b. Deed Book and Page No.
15796 2038
2c. Map Book and Page No.
(include a copy of the recorded
map that indicates when the lot
was created):
BM1959 PG302
2d. Responsible Party
(for Corporations):
Chad Thieman
2e. Street address:
817 Macon Place
2f. City, state, zip:
Raleigh, NC 27609
2g. Telephone no.:
317.445.9298
2h. Fax no.:
2i. Email address:
[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
❑ Agent ® Other, specify: spouse
3b. Name:
Ashley DuBray
3c. Business name
(if applicable):
3d. Street address:
817 Macon Place
3e. City, state, zip:
Raleigh, NC 27609
3f. Telephone no.:
919.819.5053
3g. Fax no.:
3h. Email address:
[e-mail]
4. Agent/Consultant Information (if applicable)
U an:AY1216
4a. Name:4b.
Business nameDEQSOURCES
(if applicable):
401 gERMITTIN
4c. Street address:
4d. City, state, zip:
4e. Telephone no.:
4f. Fax no.:
4g. Email address:
FORM: BA 10-2013 Page 1 of 4

B. Project Information'and Prior Project History
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID):
1706208228
1b. Site coordinates (in decimal degrees):
Latitude: 35 838488
Longitude: -78 65308
1c. Property size:
.31 acres acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
Shelley Lake
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
Neuse
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
Extension of existing deck
3b. Attach an 8 % x 11 excerpt from the most recent version of the USGS topographic map indicating the location of
the site
3c. Attach an 8 % x 11 excerpt from the most recent version of the published County NRCS Soil Survey Map
depicting the project site
3d. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
Not applicable
3e. Explain the purpose of the proposed project:
Extension of existing deck
3f. Describe the overall project in detail, including the type of equipment to be used:
Extension of existing deck —typical small scale building equipment
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 yes, who delineated the jurisdictional areas?
Name (if known):
Agency/ Consultant Company: .
Other:
4c. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
S. Project History
5a. Have permits or certifications been requested or obtained for this
project (including all prior phases) in the past?
® Yes ❑ No " ❑ Unknown
5b. If yes, explain and detail according to "help file" instructions.
Approval for existing screened in porch and deck in 2015
6. Future Project Plans
6a. Is this a phased project?
❑ Yes ® No
6b. If yes, explain.
FORM: BA 10-2013 Page 2 of 4

C. Proposed Impacts Inventory
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Only 1-2 feet of the edge falls within Zone 2 buffer.
1. Buffer Impacts
2. Buffer Mitigation
2a. Will the project result in an impact within a protected riparian buffer that requires buffer
mitigation?
1a. Project is in which protected basin?
❑ Neuse
❑ Randleman
❑ Tar -Pamlico ❑ Catawba
❑ Jordan ❑ Goose Creek
1 b. Individually list all buffer impacts below. If any impacts require mitigation, then you MUST fill out Section D of this
form.
Buffer impact Reason for Type of impact
number— impact (exempt, allowable,
Permanent (P) allowable w/ mitigabon)
or Temporary
Stream name Buffer Zone 1 Zone 2
mitigation impact impact
required? (sq ft) (sq ft)
61 ® P ❑ T Deck extension
Allowable
Neuse ❑ Yes ® No 24
B2 ❑ P ❑ T
2c. If buffer mitigation is required, is payment to a
mitigation bank or NC EEP proposed?
❑ Yes ❑ No
B3 ❑ P ❑ T
2e. If no, then discuss what type of mitigation is proposed.
❑ Yes ❑ No
B4 ❑ P ❑ T
❑ Yes ❑ No
B5 ❑ P ❑ T
❑ Yes ❑ No
B6 ❑ P ❑ T
❑ Yes ❑ No
Total buffer impacts
1 c Comments:
D. Impact Justification and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Only 1-2 feet of the edge falls within Zone 2 buffer.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Buffer Mitigation
2a. Will the project result in an impact within a protected riparian buffer that requires buffer
mitigation?
❑ Yes ® No
2b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation and
calculate the amount of mitigation required in the table below.
Zone Reason for impact Total impact Multiplier
(square feet
Required mitigation
(square feet
Zone 1 3 (2 for Catawba)
Zone 2 1.5
Total buffer mitigation required:
2c. If buffer mitigation is required, is payment to a
mitigation bank or NC EEP proposed?
❑ Yes ❑ No
2d. If yes, attach the acceptance letter from the mitigation bank or NC EEP.
2e. If no, then discuss what type of mitigation is proposed.
2f. Comments:
FORM: BA 10-2013 Page 3 of 4

E. Diffuse Flow Plan
All buffer impacts and high ground impacts require diffuse flow or other form of
® Diffuse flow
stormwater treatment. Include a plan that fully documents how diffuse flow will be
❑ Other BMP
maintained. If a Level Spreader is proposed, attach a Level Spreader Supplement Form.
1 a.
If due to site constraints, a BMP other than a level spreader is proposed, please provide a
❑ Yes ® No
plan for stormwater treatment as outlined in Chapter 8 of the NC Stormwater BMP
public (federal/state) land?
Manual and attach a BMP Supplement Form.
1 b.
F.
Supplementary Information
1.
Environmental Documentation
1 a.
Does the project involve an expenditure of public (federal/state/local) funds or the use of
❑ Yes ® No
public (federal/state) land?
1 b.
If you answered "yes" to the above, does the project require preparation of an
❑ Yes ❑ No
environmental document pursuant to the requirements of the National or State (North
Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c.
If you answered "yes" to the above, has the document been finalized by the State
❑ Yes ❑ No
Clearing House? (If so, attach a copy of the NEPA or SEPA final approval letter.)
Comments:
2.
Violations
2a.
Is the site in violation of DWR Wetland Rules (15A NCAC 02H .0500), Isolated Wetland
❑ Yes ® No
Rules (15A NCAC 02H .1300), DWR Surface Water or Wetland Standards, or Riparian
Buffer Rules (15A NCAC 02B.0200)?
2b.
Is this an after -the -fact permit application?
❑ Yes ® No
2c.
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
Chad Thieman 1305/19/16
Applicant/Agent's Printed Name Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided )
Send this completed form and accompanying documents to the following:
For government transportation projects sent
by First Class Mail via the US Postal Service:
NC DWR, Transportation Permitting Unit
1617 Mad Service Center
Raleigh, NC 27699 - 1617
For all other projects sent by First Class Mail
via the US Postal Service
Karen Higgins
NCDWR — 401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 - 1617
For government transportation projects sent
by delivery service (UPS, FedEx, etc.):
OR NC DWR, Transportation Permitting Unit
512 N. Salisbury Street
Raleigh, NC 27604
For all other projects sent by delivery service
(UPS, FedEx, etc.):
OR Karen Higgins
NCDWR — 401 & Buffer Permitting Unit
512 N. Salisbury Street
Raleigh, NC 27604
FORM: BA 10-2013 Page 4 of 4

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