20160640 Ver 1_Buffer Determination Request_20160715

943 Whshtngton Square Mail, Wasbmgton NTC 27889
252-946-6481
Water Resources
ENVIRONMENTAL QUALITY
VW
PAT
Governor
DONALD R VAN DER VAART
Secretary
S JAY ZEM[N ERMAN
%� Director3
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Stream Origin/Buffer Applicability Determination
Required Information
1 Owner Information (corporation/individual who is legally responsible for the property and its compliance)
la Name(s) on Recorded Deed A. I 5,v ,-- 1 r- m 5 Lt C
1 b Responsible Party (for LLC) 1 1-4 Af^le- L - -0,00 f— rJ o+-�
lc Mailing Address ?0 tap 79 t -d 4 -.e - D e Q796 a
1d Telephone Number 1517— le Email Address a; ,ae-L b e-iD& t
2 Location of Project Site - please include the county, nearest named town and highway number �y /�
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3 Has anyone from DWR visited
the site?
Y N
Staff Name
Date of Visit?
Additional Requested Information
4 AgentlConsultant Information (if applicable) W-4
4a Name, Company r+,k-e-
4b Mailing address 0 OA„J nY ee-A C 2-9 9 10
4c Telephone no�� ,2 -g �{ —I (q' I S'4d Email addressfn L
5, Project and Site Information A, 0 LLC— ?
Y
5a Name of project 15b County
5c Nearest Named Stream P4 „ U �e.�k 5d River Basin ar-P� PCo
5e Provide a brief description of this project (attach site plan if available)
Please attach a map of the site indicatinra proiect boundaries on the USGS 1:24,000 Topo and/or NRCS Soil
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RECEIVED/NCDENR/DWR
JUN 2 0 2016
Water Quality Regional
Operations Section
Washington Regional Office

- - 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
943 Washington Square Mall
Washington, NC 27889
Note Submittals on Friday after 12 00 pm
will be stamped as
Fax IL52 946-9215
received on the next
business day
Email
anthonv scarbraugh(a�ncdenr cloy
Please contact Anthony Scarbraugh at LZ52) 946-6481 if you have any questions
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