20160526 Ver 1_Riparian Buffer Authorization_20160523

g 0SAMPLE AGENT AUTHORIZATION FORM 2 5
26
PROPERTY LEGAL DESCRIPTION: -
LOT NO. PLAN N0. PARCEL ID: j,�. ` ��� 2`
Please print:
Propzrty owner:
Proparty Owner:
fMWAY 2 1 2016
The undersigned, registered property avmers of the above noted property, do hereby authorize
Of
Car5F,p Agent) (Name of mmuld"ll flF r
to act on my behalf and take all actions necessary for the prnaaWng, Issuance and acceptance of
this permit or cerNotion and any and all standard and special conditions attached.
Property Owner's Address (if different than praperty above):
Telephone:
we hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Auftfize d Signature:
Date: 511,1110
31
C I
STREET ADDRESS;—'!)
Please print:
Propzrty owner:
Proparty Owner:
fMWAY 2 1 2016
The undersigned, registered property avmers of the above noted property, do hereby authorize
Of
Car5F,p Agent) (Name of mmuld"ll flF r
to act on my behalf and take all actions necessary for the prnaaWng, Issuance and acceptance of
this permit or cerNotion and any and all standard and special conditions attached.
Property Owner's Address (if different than praperty above):
Telephone:
we hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Auftfize d Signature:
Date: 511,1110

jo
MOWPS OR .
1
p s ave
• fi-OEC' . � -
lial
, t
{ { N 1L
J
y IA Q 0
I I �
$ o

34' WTN
Worm
Sail Map—Pamlico County, North Carolina
(393 MagrMa Lane, Arapahoe, NC)
KVSmkt:1:8651fpM*WanAj
N
0 Ill 2D 40 60
a 40 w 160 M
Map p*dIb:Web I4rsaW Coe wc=kkIgb-zVWGS84 WtI=UR4Gone IfiNWG%4
isnA
!durst Resources Web SOB SM"
aM Conservadw Service National Cooperative Sol Survey
UM016
Page 1 of 3
3p or"

LU
C? ?
to
CO
0
W
e
m
01
n
m
E
LD
s
Q
8
m
72
m
IE
- m
C tz
Ili
46 a0 Loa
m v
m m
E
�m
c 'apC
E
LM
W E -S.
E o
LL Cc
to
Im
�i • 3 p •� •,Fi
s 00
a
06
C o
LL c�CD
o aa as
13

Soil Map—panfiico County, North Carolina
Map Unit Legend
393 Magnolia Lane, Arapahoe, NC
Pasrnllco county, North Carolina (NC137)
Yap Unit SMbol
gap Unit Name
Acres in A01
Percent of A01
Dgg
Dogue fine sandy loam. l b 4
percent slopes
1.5
84.4%
W
water
0.31
15.6%
Totals for Area of Irntemst
1.8
100.0%
uvea, Natural Resources Web Soil Survey 4!2612016
Conservetton & Nvlae national Cooperadve Soh Survey Page 3 of 3

ONE"rL.-I
r
State of
surface water Classification
Stre a m
27-(118)
Index:
Stream
NEUSE RIVER
Name:
lDescription:
NeuseRiverafromcross
Wilkinson Point to
Cherry Point to Its
mouth in Pamlico
Sound (mouth of
Neuse River
described as a line
running from Maw
point to Point of
Marsh)
Classification:
SA;HQW,NSW
Classification
April 30, 1988
Date'
Zoom to
r
State of

7710
r- 1.2ml
AL
�:;e� P)�,,,j
State of
Description,
From a line across
Neuse Rlver from
Wilkinson Point to
Cherry Point to Its
mouth In Pamlico
Sound (mouth of
Neuse River
described as a line
running from Maw
point to Point of
Marsh)
Classification:
SA;HQW,NSW
Classification
April 30, 1988
kl Date:
River Basin:
Neuse
What does
More jafQ
this Class.
Mean?
r- 1.2ml
AL
�:;e� P)�,,,j
State of

o�mmKai
m7o0Za
rA0rrn�-Xz
Cpo cm,
>
Z—I��m-C
4 z
0
m
I i i
r
m
o�mmKai
m7o0Za
rA0rrn�-Xz
Cpo cm,
>
Z—I��m-C
4 z
0
m
VI
M
m
W m
m
of
&vv eot
rn
46\\
$ti
�,
♦
w
VI
M
m
W m
m
of
&vv eot
rn
46\\
$ti

State of North Carolina
Dwt' K Department of Environment and Natural Resources
Division of Water Resources
DMSJ= of Water Resources
15A NCAC 02B.0233 (s)(b)..0243 (8)(b), Also (11)(b),.0259 (B)(b), .0267 (11)(C), Aho? (e)(2) — Buffer Authorintlon
BA "33
Riparian Buffer Authorization Form
A Applicant Inbnnadon
rf!
1 a. Name of project Are,
ib. County:
1 c. Nearest mun' slily:
1d. Subdivision name:
1e. Is the project located in any of North Carolina's as ❑ No
hv" coastal counties. If yes, answer 1f below.
if. Is the project located within a NC Division of Coastal Yes E] No
Mangy Area of Environmental Concern (AEC)?
2. Owner InfbmvMon
2a. Name on Recorded Deed:
2b. Deed Book and Page No.
2c. Map Book and page No.
(inciude a copy of the mcomWd
map that IndkWes when the lot
was created): j
2d. Responsible Party
(for Corporations):
2e. Street address:
2f. City, stabs, zip: P
2 . Telephone no.:
2h. Fax no.:
21. Email address:
3. Applicant Wwnw tion (If dWerent from owner)
3e. Applicant is: ❑ Agent r, specify:
3b. Name:
3c. Business name
3d. Sheet address: c-1 U yam••". �v
3e. City, stets. Zip:
3f. Telephone no.: Z.S �- Co 1 - cs U t -4-
3g. Fax no.:
3h. Email address: 140 - C-111,
4. Ag.WConsultant informmadon (N applUmble)
4a. Name.
4b. Business name
4c. Street address:
4d. City, state, zip:
4e. Tetephone no.:
41. Fax no.:
4a. Email address:
Page 1 of 4
FORM: BA 10-2013

B. Project Infonnadon and Prior Project History
1. Propem luenulmummi
1a. Property iden"on no. (tax PIN or parcel ID): PT.�t% 4q(0 9 ong�Fi-X .
It
1b. Site coordinates (In decimal degrees): Latitude: .1. g
1c. Property size: acres
2. Surface waters
2a. Name of nearest body of water to proposed Project
2b. Water Quality Classification of nearest receiving water.
2c. River basin: l R•
3. O°nat e of this
3a. Desc rW the existing conditions on the site and the general land use in the vicinity of the project the time
application: cqsti> �9T v� /t/1 Air AVIO'/� l'..vGil (T f t•+4bea ��r
6 N,� &O r A"$ p�cd JWA Q J� CoaKstw�G RdS
3b. Attach aZP
x 11 excerpt the most recent version of the USGS toMmphic map indicating the location of
the site of the published County NRCS Sal Survey Map
3c. Attach an 8 % x 11 excerpt frrx� the most E9221tt verb
dePi9 p1Oject site t/
perennial) on the property: �S /
3d. List the total estimated linear feet of all existing streams (Intermittent and pererr )
3e. Explain the purpose_of the proposed Project: Co�S dGT 441le DAV04'4' Ado �
A#6 cs
3f. Describe the overall project in detail, including the tAA of e4I
4. JUfISdkctional Deberminatinns
4a. Have jurisdictional wetland or stream ddetierminations by the
Corps or State been requested or obtained this Property/
project (Including all prior phases) in
4b. If yes, who delineated the jurisdictional areas?
to be used:
❑ Yes
Cornrnents:
❑ Unknown
Agency! Consultant Company:
Other.
Name (if known)•
4c. if yes, list the dates of the Corps jurisdktiional determirmtions or State detertninati�rs and attach documentation.
5. Project NtsrorY
5a. Have permits or certifications been requested or obtained for this ❑ Yes
project (including all prior phases) in the past?
5b. if yes, explain and detail according tD 'help fife" instructions.
tions.
6.Future Project Plans
(W is this a phased project?
tab. if yes. explain.
FORM: BA 10-2013
Yes
Unknown
Page 2 of 4

D. Impact Justification and Mitigation
1 a. Specifically describe measures talW tc avoid or minimize the proposed impacts ' de rng �h /� fj
{�.Sa�.�l � Z C.� fl+' P'-1. 11 r", .� ..ntC6jn 4e� 'eajAeA- JA
1b. Spedficaiiy describe measures talo to avoid or minimize the proposed impacts through construction tedmiques.
L Buffer Mitlgatlon
2a. Will the project result in an impact within a protected riparian buffer that requires buffer ❑ Yes No
mitigation? -
2b. it 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.
7nnaReason for impact Total impact Multiplier Required mitigation
_ rare Jars fAml
- •- - --
1
mitigation is required, is payment to a
N
=Yes[3
n bank or NC EEP Poposed?
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. Cornnm ts.
FORM: BA 10-2013
Page 3 of 4

E. Diffuse Flow Plan
All buffer impacts and high ground impacts require diffuse flow or other Than 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 b. If you answered "yes" to the above, does the project require preparation of an
If due to site constraints, a BMP other than a level spreader is proposed, please provide a
environmental document pursuant to the requirements of the National or State (North
plan for stormwater treatment as outlined in Chapter 8 of the NC Stormwater BMP
Carolina) Environmental Policy Act (NEPA/SEPA)?
Manual and attach a BMP Supplement Form.
1c. If you answered "yes" to the above, has the document been finalized by the State
F. Supplementary Information
I. Environmental Documentation
1 a. Does the project involve an expenditure of public (federaVstate/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)?
1c. If you answered "yes" to the above, has the document been finalized by the State
❑ Yes Leo
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 E94o
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
C17
Applicant/Agent's Printed Name Applicant/ gent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Send 3 complete sets of this 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 Mail 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, Fed&, etc.):
OR Karen Higgins
NCDWR — 401 & Buffer Permitting Unit
512 N. Salisbury Street
Raleigh, NC 27604
FORM: BA 10-2013 Page 4 of 4