20161191 Ver 1_401 Application_20161205

NC Department of
Environmental Quality
Received
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NOV 3 0 2016 cis ai:btm ID no
DWO pro.*&
Winston-Salem 4
Form Version t,4 .ean"ry
Regional Office
Pro -Construction Notification (PCN) Fo" 1 6 1 1
91
A.
Applicant infoffnation
1. Proce"ing
ta. Type(s) of approval sougtd fern the Section Permit on 10 Permit
Ib. Speedy Nartiorvwide Permit (NWPI riuMber 14 of Cewai Perrnii dC°) number
i 1 NM or GP!number bew
_ vedfied the CGcps
7 `yam0 No
3a
rne(s) on Pe ded Deed,
Long ire LLC
Regularo .+.. peanit
Deed Book and Page: No.
401 Water w► a ..es'5: 0 Rioarian
Buffer: W
notification - + , only for DWO
For:, cot only fOr3 � - •
3d
because written .;p not required? 40. o
5068 Hwy 64 East
e.
El Yes No
Yes No
it
is payment Wo, a n0galbon bank ot 0-fieu fee program proposed for
Yes No
I g
mAigWoon of impacts? If sio; attach the aca0ance, Wier from mitigation bw*
or
[e-mail]
9
is the project located jO any Of NCS twerdy coastal counties. If yes. answer I h
0 Yes Y
_ NC 0CM Area of Emronmental2.
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Project Infs _ 5 a
2a
Name of prN;'ect,- Carohna Guns Gear��
e Randolph p
FranklinviMe
OT only T F1 ar state pf*ect no
i/
3a
rne(s) on Pe ded Deed,
Long ire LLC
3b
Deed Book and Page: No.
002434100779 `
Responsible: Party (for LLC if
Lee Vantine (owner) f Sal Gutierrez (rnanacger
3d
Stmt aitdtWm:
5068 Hwy 64 East
e.
CCK state,
FrankhroviDe, NC 27248
yf
Telephones no_
36-302-4111
I g
Fay no
[e-mail]
Pay: 7 of 10
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