20161070 Ver 1_More Info Received_20161212

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources
15A NCAC 028 .0233 (8)(b), .0243 (8)(b), ,0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2)
Protection and Maintenance of Riparian Areas Rules - Variance Application
FORM: VAR 10-2013
PLEASE IDENTIFY WHICH RIPARIAN AREA PROTECTION RULE APPLIES:
u Neuse River Basin (15A NCAC 026.0233)
Major Variance Minor Variance
)ICatawba River Basin (15A NCAC 026.0243)
:1 Randleman Lake Water Supply Watershed (15A NCAC 026.02.50)
11 Major Variance F Minor Variance
Tar -Pamlico River Basin (15A NCAC 026.0259)
Major Variance F Minor Variance
* Jordan Lake Water Supply Nutrient Strategy (15A NCAC 026.0267)
❑ Major Variance __1 Minor Variance
U Goose Creek Watershed (15A NCAC 026.0606 & 15A NCAC 026.0607)
A. General Information
1. Applicant's Information(if other than the current property owner):
Name: boLf' ." S t%T ZUncaAerr ClA.'SViD"c mL"'�+ ,nV64eY 6, I Ylc .
Title:Lre-viei'e-t cooclap
Street Address: I�S(o Ver-�V)
City, State & Zip:�1fI�-� l�
Telephone: 0 -�J�" ���� �` fQr�"-t - 7% 1�' -1147
Email: �CCr , �Qr1C[c S�eriS Cid C�]r7�Cd l l • 1i1�`1
1. Property Owner/Signing Official (person legally responsible for the property and its compliance):
J� lIVY Vr►1r\Q
1� rName:
Title: r eSl8eylA-
Street Address: S gGLr `009` V 1 EVA 1'04
State & Zip: tku+l V A " 5 �5z
Telephone: -740-?j5q_ 2350
Email: 1A Ax 1\1a1Ie_,r a an l . r 1rY1
FORM: VAR 10-2013

2. Agent Information.
3a. Name:
Company Affiliation:
Street Address:
City, State & Zip:
Telephone:
E-mail:
3b. Attach a signed and dated copy of the Agent Authorization letter if the Agent has signatory authority for the owner.
3. Project Name (Subdivision, facility, or establishment name):
a}fey-
4. Project Location:
5a. Street Address: ZZ4 Allenc6le Circle -
City, State & Zip: __qM -WQLy1 I C, 81(Q U
5b. County: 1 re,(] 11
5c. Site Coordinates (in decimal degrees): 3 5, lr29 23q Latitude 1;&2) "1(047 Longitude
5d. Attach an 8'/: x 11 excerpt from the most recent version of the USGS topographic map indicating the location of the site.
5e. Attach an 8 % x 11 excerpt from the most recent version of the published County MRCS Soil Survey Map depicting the
project site.
5. Property Information:
6a. Property identification number (parcel ID): AW9,'O' Lp"t ([Q ! a
6b. Date property was purchased: _P
6c. Deed book U y and page number i `
6d. Map book and page number Z 1
6e. Attach a copy of the recorded map that indicates when the lot was last platted.
7. Is your project in one of the 20 Coastal Counties covered under the Coastal Area Management Act (CAMA)?
YES )(, NO
7a. If you answered yes above, in which AEC do you fall (30 ft or 75 ft)?
7b. If you answered yes above, what is the total percent of impervious cover that you have proposed within the AEC?
FORM: VAR 10-2013 Page 2 of 6

S. Directions to site from nearest major intersection:
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9. Stream associated with riparian buffer to be impacted by the proposed activity:
Name
Water Quality Classification
Ise N brrYl
�J
9a. For Goose Creek only: Is the buffer in the 100 -year floodplain? -i YES ❑ NO
10. List any permits/approvals that have been requested or obtained for this project 'in the past (including all prior phrases).
Date Applied: Date Received: Permit Type:
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5 8 311 � No,+ cit INCs �pW RL
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Project Description C©n54y- CC Y'i errK11+) 1ccC0vrr,+i011 A--iI '
1a. Provide a detailed description of the proposed activity including its purpose:
Ia
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LA-viev`erl '40d I/Nirrq ti�fCiCe 0.v�C��C�c CtCC'SS ? +Lqe rj1'?pre �� ✓le
lb. Attach a site plan showing the ollowing items as applicable to the project:
0 Development/Project name
0 Revision number & date
0 North arrow
0 Scale (1" = 50' is preferred)
0 Prop erty/praject boundary with dimensions
0 Adjacent streets and roads labeled with names and/or NC State Road numbers
0 Original contours and proposed contours
0 Perennial and intermittent streams, ponds, lakes, rivers and estuaries
0 Mean high water line (if applicable)
0 Wetlands delineated, or a note on plans that none exist
0 Location of forest vegetation along the streams, ponds, lakes, rivers and estuaries
0 Extent of riparian buffers on the land including Zone 1 and Zone where applicable
0 Location and dimension of the proposed buffer impact (label the area of buffer impact in ft' on the plan)
0 Details of roads, parking areas, cul -de -saes, sidewalks, and curb and gutter systems
FORM: VAR 10-2013 Page 3 of 6

0 Footprint of any proposed buildings or other structures
0 Discharge points of gutters on existing structures and proposed buildings
0 Existing drainage (including off-site), drainage easements, and pipe dimensions
0 Drainage areas delineated
C. Proposed Impacts and Mitigation
1. Individually list the square footage of each proposed impact to the protected riparian buffers:
Buffer Impact
Number —
Permanent (P) or
Temporary (T)
Reason for Impact Buffer Zone 1 Impact
Mitigation (square feet)
Required
Zone 2 Impact
(square feet)
B1 - [aP ❑ T
$VULNUr0,J CjUpM4 ❑ Yes L No jIT
Total Impact
B2 -2P ❑T
y,J LYes LiNo
B3 ❑P ❑T
LYes LiNo
(square feet)
Total Buffer Impacts
(40(105
'Label on site plan
2. Identify the square feet of impact to each zone of the riparian buffer that requires mitigation from the table above. Calculate
the amount of mitigation required.
'For projects in the Goose Creek watershed, list all riparian buffer impacts as Zone 1
and use Zone 1 multiplier.
3. Provide a description of how mitigation will be achieved at your site pursuant to the mitigation requirements of the applicable
river basin/watershed.
3a. Is buffer restoration or enhancement proposed? L Yes X No
If yes, attach a detailed planting plan to include plant type, date of plantings, the date of the one-time fertilization in the
protected riparian buffers, and a plan sheet showing the proposed location of the plantings.
3b. Is payment into a buffer restoration fund proposed? L Yes ; ,, No
If yes, attach an acceptance letter from the mitigation bank you propose to use or the NC Ecosystem Enhancement
Program stating they have the mitigation credits available for the mitigation requested.
FORM: VAR 10-2013 Page 4 of 6
Required
Zone
Total Impact
Multiplier
Mitigation
(square feet)
(square feet)
Zone 1'
�5
3
�1 li 5
LQ
(2 for Catawba only)
Zone 2
1.5
Total Buffer Mitigation Required:
Ct Cl 15
'For projects in the Goose Creek watershed, list all riparian buffer impacts as Zone 1
and use Zone 1 multiplier.
3. Provide a description of how mitigation will be achieved at your site pursuant to the mitigation requirements of the applicable
river basin/watershed.
3a. Is buffer restoration or enhancement proposed? L Yes X No
If yes, attach a detailed planting plan to include plant type, date of plantings, the date of the one-time fertilization in the
protected riparian buffers, and a plan sheet showing the proposed location of the plantings.
3b. Is payment into a buffer restoration fund proposed? L Yes ; ,, No
If yes, attach an acceptance letter from the mitigation bank you propose to use or the NC Ecosystem Enhancement
Program stating they have the mitigation credits available for the mitigation requested.
FORM: VAR 10-2013 Page 4 of 6

D. Stormwater
1. Provide a description of how diffuse flow will be maintained through the protected riparian buffers (e.g., re -planting vegetation
or enhancement of existing vegetation, gutter splash pads, level spreader to control of runoff from impervious surfaces, etc.).
/Vf0 Py -n nn--, ozA .45b)r roti wdIvar- -rQci /4V 1/4P -J 1' P5 rare DMnDnse d.
W01-01MOM 12111
1a. Show the location of diffuse flow measure(s) on your site plan.
lb. Attach a completed Level Spreader Supplement Form or BMP Supplement Form with all required items for each proposed
measure.
1c. Attach an Operation and Maintenance (O&M) Form for each proposed level spreader or BMP.
2. For Major, Catawba, and Goose Creek variance requests, provide a description of all best management practices (BMPs) that
will be used to minimize disturbance and control the discharge of nutrients and sediments from stormwater.
2a. Show the location of BM Ps on your site plan.
2b. Attach a Supplement Form for each structural BMP proposed.
2c. Attach an Operation and Maintenance (O&M) Form for each structural BMP proposed.
E. Demonstration of Need for a Variance
The variance provision of the riparian buffer rules allows the Division or the Environmental Monogement Commission to grant a
variance when there are practical difficulties or unnecessary hardships that prevent compliance with the strict letter of riparian
buffer protection.
1. Explain how complying with the provisions of the applicable rule would prevent you from securing a reasonable return from or
make reasonable use of your property. Merely proving that the variance would permit a greater profit from the property shall
not be considered adequate justification for a variance. The Division will consider whether the variance is the minimum possible
deviation from the terms of the applicable Buffer Rule that shall make reasonable use of the property possible.
FORM: VAR 10-2013 Page 5 of 6

2. Explain how the hardship results from application of the Buffer Rule to the property rather from other factors such as deed
restrictions or other hardships (e.g. zoning setbacks, floodplains, etc).
3. Explain how the hardship results from physical nature of the property, such as its size, shape, or topography, which is different
from that of neighboring property.
the- e i 4r�c� 5
i -lanae-
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n w racs
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4. Explain whether the hardship was caused by the applicant knowingly or unknowingly violating the applicable Suffer Rule.
5. For Neuse, Tar-Pamlico, Jordan Lake and Goose Creek only: Did the applicant purchase the property after the effective date of
the applicable Buffer Rule and then request a variance?
6. Explain how the hardship is rare or unique to the applicant's property, rather than the result of conditions that are widespread.
F. Deed Restrictions
By your signature in Section G of this application, you certify that all structural stormwater BMPs required by this variance shall
be located in recorded drainage easements, that the easements will run with the land, that the easements cannot be changed
or deleted without concurrence from the State, and that the easements will be recorded prior to the sale of any lot.
G. Applicant's Certification
I, Vtiray) r1 NN a) 1 er (print or type name of person listed in Section A, Item 2), certify that
the information included on this permit application form is correct, that the project will be constructed in conformance with the
approved plans and that the deed restrictions in accordance with Section F of this form will be recorded with all required permit
conditions.
Signature:
Date: 2Z — Ido
FORM: VAR 10-2013 Page 6 of 6

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Area of Interest (AOI) Soil Data Explorer Download Soils Data Shopping Cart (Free)
Printable Version) Add to Shopping Cart9
K JJA 1.1j.—iAA A S-1-11:3,980 r f 1
Warning: Soil Map may not be valid at this scale.
FOIA I Accessibility Statement I Privacy Policy I Non -Discrimination Statement I Information Quality I USA.gov I White House
http:/lwebsoilsu(vey.sc.egov.Lisda.gov/App(WebSdiSurvey.aspx 111
Catawba County, North Carolina (NC035)
Map
Map Unit Name
Acres
Percent
Unit
in
of A0I
Symbol
AOI
W
Water
6.3
2.8%
Subtotals for Soil Survey Area
6.3
2.80/a
Iredell County, North Carolina (NCO97)
Map
Map Unit Name
Acres
Percent
Unit
in
of AOI
Symbol
AOI
CeB2
Cecil sandy clay loam, 2 to
3.$
1.71/a
6 percent slopesr
moderately eroded
CeC2
Cecil sandy clay loam, 6 to
1.4
0.6%
10 percent slopes,
moderately eroded
LcB2
Lloyd clay loam, 2 to 6
2.3
1.0%
percent slopes, moderately
eroded
MaE4
Madison -Udorthents
4.4
2.0%
complex, 15 to 25 percent
slopes, gultied
PaE
Pacolet sandy loam, 15 to
2.6
1.2%
25 percent slopes
PaF
Pacolet sandy loam, 25 to
1.3
0.6%
45 percent slopes
PcC2
Pacolet sandy clay loam, 6
35.2
15.8%
to 10 percent slopes,
moderately eroded
PcD2
Pacclet sandy clay loam, 10
12.5
5.6%
to 15 percent slopes,
K JJA 1.1j.—iAA A S-1-11:3,980 r f 1
Warning: Soil Map may not be valid at this scale.
FOIA I Accessibility Statement I Privacy Policy I Non -Discrimination Statement I Information Quality I USA.gov I White House
http:/lwebsoilsu(vey.sc.egov.Lisda.gov/App(WebSdiSurvey.aspx 111

35' 3159 N
35° 37 39" N
Soil Map--Iredell County, North Carolina 3:
(ROCA Company)
�O
H
35° 37 39' N
5(16190 506260 506330 506400 .506470 50GW Mto
3 3
Map ale: 1:2,870 if pnrted on A pomart (8S" x 11") meet
N 0 40 IO 160 2 hk�ta5
A0 100 200 400 600
Map proje=n: Web Merecator Carer wordwiates: WGS84 Edge firs: UTM Zom 17N VA3584
USDA Natural Resources Web Soil Survey 1013112016
±•� Conservation Service National Cooperative Soil Survey Page 1 of 3

Soil Map--Iredell County, North Carolina
(ROCA Company)
MAP LEGEND
MAP INFORMATION
Area of Interest (AOI)
:_ Spoil Area
The soil surveys that comprise your AOI were mapped at 1:12,0100.
Area of Interest (AOI)
k Stony Spot
Warning: Soil Map may not be valid at this scale.
Sails
Soil Map Unit Polygons
very Stony Spot
Enlargement of maps beyond the scale of mapping can cause
Wet Spot
misunderstanding of the detail of mapping and accuracy of soil line
y
Soil Map Unit Lines
placement. The maps do not show the small areas of contrasting
e
Soil Map Unit Points
Other
soils that could have been shown at a more detailed scale.
r Special Line Features
Special
Point Features
Please rely on the bar scale on each map sheet for map
V
Blowout
Water Features
measurements.
Streams and Canals
Borrow Pit
Source of Map: Natural Resources Conservation Service
Transportation
Web Soil Survey URL: hnp:/Iwebsoilsurvey.nres.usda.gov
Clay spot
Coordinate System: Web Mercator (EPSG:3857)
Closed Depression
Interstate Highways
Maps from the Web Soil Survey are based on the Web Mercator
Gravel Pit
US Routes
projection, which preserves direction and shape but distorts
distance and area. A projection that preserves area, such as the
Gravelly Spot
Major Roads
Albers equal-area conic projection, should be used if more accurate
Landfill
calculations of distance or area are required.
Local Roads
Lava Flow
This product is generated from the USDA-NRCS certified data as of
Background
the version date(s) listed below.
Marsh or swamp
® Aerial Photography
Soil Survey Area, Iredeil County, North Carolina
Mine or Quarry
Survey Area Data: Version 21, Sep 15, 2015
Miscellaneous Water
Soil map units are labeled (as space allows) for map scales 1:50,000
Perennial Water
or larger,
Rock Outcrop
Date(s) aerial images were photographed: Feb 11, 2011—Feb
.,�
Saline Spot
13, 2011
The orthophoto or other base map on which the soil lines were
Sandy Spot
compiled and digitized probably differs from the background
Severely Eroded Spot
imagery displayed on these maps. As a result, some minor shifting
of map unit boundaries may be evident.
Sinkhole
Slide or Slip
f
Sodic Spot
USDA Natural Resources Web Soil Survey 10/3112016
Conservation Service NationaP Cooperative Soil Survey Page 2 of 3

Soil Ma"redell County, North Carolina
Map Unit Legend
ROCA Company
USDA Natural Resources Web Soil Surrey
10/31/2016
Conservation Service Nationa9 Cooperative Soil Surrey Page age 3 3 of 3
Iredell County, North Carolina (NC097)
Map Unit Symbol
Map Unit Name Acres in A01
Percent of AOI
MaE4
Madison-Udorthents complex,
1.6
4.6%
15 to 25 percent slopes,
gullied
PaF
Pacolet sandy loam, 25 to 45
1_3
19%
percent slopes
PcC2
Pacolet sandy clay loam, 6 to 10
4,3
12.6%
percent slopes, moderately
eroded
PGD2
Pacolet sandy clay loam, 10 to
3.4
9.9%
15 percent slopes,
moderately eroded
PcE2
Pacolet sandy clay loam, 15 to
5.2
15.2%
25 percent slopes,
moderately eroded
53.9°.5
W
Water
18.3
Totals for Area of Interest
34.0
100.0%
USDA Natural Resources Web Soil Surrey
10/31/2016
Conservation Service Nationa9 Cooperative Soil Surrey Page age 3 3 of 3

35' W 4' N
35' 37 WN m
505800 505900 506000 505100 506200 506300 505400
3
6
ER Map Scale: 1:6,490 if panted or A lanclsmpe (11" x &T) sheet
N Meters
4 50 10C 200 306
feet
0 300 600 1200 1800
A
Map projed9on: Vkb Mercatr Carr' wordrote5: Vu684 Edge tics: UTM Zone 17N VVGSB4
uSDA Natural Resources Web Soil Survey
Conservation Service National Cooperative Soil Survey
3: Soil Map—Catawba County, North Carolina, and Iredell County, North Carolina 3
5 (ROCA Company)
Ell
Ll%gn SOIC" 506700 506806 -j0690n 507000 507100
35° 37 34" N
1013112016
Page 1 of 4

Soil Map—Catawba County, North Carolina, and Iredell County, North Carolina
(ROCA Company)
MAP LEGEND
Area of Interest (AOI)
7
Area of Interest (AOI)
Soils
I—)
Soil Map Unit Polygons
+v►
Soil Map Unit Lines
E3
Soil Map Unit Points
Special
Point Features
�a
Blowout
Borrow Pit
Clay Spot
Closed Depression
Gravel Pit
Gravelly Spot
e
Landfill
Lava Flow
Marsh or swamp
Mine or Quarry
Miscellaneous Water
Perennial Water
Rock Outcrop
Saline Spot
Sandy Spot
_
Severely Eroded Spot
Sinkhole
Slide or Slip
va
Sodic Spot
Spoil Area
Stony Spot
Very Stony Spot
Wet Spot
Other
a� Special Line Features
Water Features
Streams and Canals
Transportation
r+ -W Rails
Interstate Highways
US Routes
Major Roads
Local Roads
Background
® Aerial Photography
MAP INFORMATION
The soil surveys that comprise your A01 were mapped at scales
ranging from 1:12,000 to 1:15,800.
Warning: Soil Map may not be valid at this scale.
Enlargement of maps beyond the scale of mapping can cause
misunderstanding of the detail of mapping and accuracy of soil line
placement. The maps do not show the small areas of contrasting
soils that could have been shown at a more detailed scale.
Please rely on the bar scale on each map sheet for map
measurements.
Source of Map: Natural Resources Conservation Service
Web Soil Survey URL: http://websoilsurvey.nres.usda.gov
Coordinate System: Web Mercator (EPSC:3857)
Maps from the Web Soil Survey are based on the Web Mercator
projection, which preserves direction and shape but distorts
distance and area. A projection that preserves area, such as the
Albers equal-area conic projection, should be used if more accurate
calculations of distance or area are required,
This product is generated from the USDA-NRCS certified data as of
the version date(s) listed below.
Soil Survey Area: Catawba County, North Carolina
Survey Area Data: Version 15. Sep 9, 2014
Soil Survey Area: Iredell County, North Carolina
Survey Area Data: Version 21, Sep 15, 2015
Your area of interest (AOI) includes more than one soil survey area.
These survey areas may have been mapped at different scales. with
a different land use in mind, at different times, or at different levels
of detail. This may result +n map unit symbols, so4 properties, and
interpretations that do not completely agree across soil survey area
boundaries.
Soil map units are labeled (as space allows) for map scales 1:50,000
or larger.
Date(s) aerial images were photographed: Feb 11, 2011—Feb
13, 2011
The orthophoto or other base map on which the soil lines were
compiled and digitized probably differs from the background
U� Natural Resources Web Soil Survey 10/31/2016
Conservation Service National Cooperative Soil Survey Page 2 of 4

Soil Map—Catawba County, North Carolina, and Iredell County, North Carolina
(ROCA Company)
MAP LEGEND MAP INFORMATION
imagery displayed an these maps. As a result, some minor shifting
of man unit boundaries may be evident.
usDk Natural Resources Web Soil Survey 10/31/2016
�� Conservation Service National Cooperative Soil Survey Page 3 of 4

Soil Map—Catawba County, North Carolina, and Iredell County, North Carolina
Map Unit Legend
Catawba County, North Carolina (NC
Map Unit Symbol Map Unit Name Acres i
W Water
Subtotals for Soil Survey Area
CeB2 Cecil sandy clay loam, 2 to 6
Tota Is for Area of Interest
percent slopes, moderately
Iredell County, North Carolina (NCO
Map Unit Symbol Map Unit Name
Acres i
CeB2 Cecil sandy clay loam, 2 to 6
percent slopes, moderately
eroded
CeC2
Cecil sandy Gay loam, 6 to 10
percent slopes, moderately
eroded
LcB2
Lloyd clay loam, 2 to 6 percent
slopes, moderately eroded
MaE4
Madison-Udorthents complex,
15 to 25 percent slopes,
gullied
PaE
Pacolet sandy foam, 15 to 25
percent slopes
PaF
Pacolet sandy loam, 25 to 45
percent slopes
PcC2
Pacolet sandy clay loam, 6 to 10
percent slopes, moderately
eroded
PcD2
Pacolet sandy clay loam, 10 to
15 percent slopes,
moderately eroded
PcE2
Pacolet sandy clay loam, 15 to
25 percent slopes,
moderately eroded
W
Water
Subtotals for Soil Survey Area
Totals for Area of Interest
usD,x Natural Resources Web Soil Survey 10131/2016
Conservation Service National Cooperative Soil Survey Page 4 of 4

Mitigation Services
EMVIRONMENTALQUAUTY
Frank Waller
ROCA Company
165 Harborview Drive
Stout, OH 45652
Project: Waller Boardwalk
PAT MCCRORY
DONALD R VAN DER VAART
December 1, 2016
Expiration of Acceptance: June 1, 2017
County: Iredell
The purpose of this letter is to notify you that the NCDEQ Division of Mitigation Services (DMS) is willing to accept
payment for compensatory mitigation for impacts associated with the above referenced project as indicated in the
table below. Please note that this decision does not assure that participation in the DMS in -lieu fee mitigation
program will be approved by the permit issuing agencies as mitigation for project impacts. It is the responsibility
of the applicant to contact permitting agencies to determine if payment to the DMS will be approved. You must
also comply with all other state, federal or local government permits, regulations or authorizations associated with
the proposed activity including G.S. § 143-214.11.
This acceptance is valid for six months from the date of this letter and is not transferable. If we have not
received a copy of the issued 404 Permit/401 Certification/LAMA permit within this time frame, this
acceptance will expire. It is the applicant's responsibility to send copies of the permits to ISMS. Once DMS
receives a copy of the permit(s) an invoice will be issued based on the required mitigation in that permit and
payment must be made prior to conducting the authorized work. The amount of the in -lieu fee to be paid by an
applicant is calculated based upon the Fee Schedule and policies listed at hftp://portal.ncdenr.org/web/eep.
Based on the information supplied by you in your request to use the DMS, the impacts that may require
compensatory mitigation are summarized in the following table. The amount of mitigation required and assigned
to DMS for this impact is determined by permitting agencies and may exceed the impact amounts shown below.
Impact
River
Basin
CU Location
(8 -digit HUC)
Stream (feet) Wetlands (acres) Buffer f
(Sq. Ft.)
Buffer II
(Sq. Ft.)
Cold I Cool
Warm Riparian
Non -Riparian I Coastal Marsh
Catawba
03050101 0 0
0 0
0 0 665
0
Upon receipt of payment, DMS will take responsibility for providing the compensatory mitigation. The mitigation
will be performed in accordance with the In -Lieu Fee Program instrument dated July 28, 2010 and 15A NCAC
02B .0295 as applicable. Thank you for your interest in the DMS in -lieu fee mitigation program. If you have any
questions or need additional information, please contact Kelly Williams at [phone].
Sincerely,
J m s. B Stanfill
As t Management Supervisor
cc: Donna Hrko- contractor contact
State of North Carolina , E.nvimnmental Quality Mitigation Services
14552 Mail Scivka Ceutcr I Rateigth, NC 27699-1652 ' 217 W. Jones Street, Suite 3000
919 707 8976 T

DIVISION OF MITIGATION SERVICES (DMS)
IIS -LIEU FEE REQUEST FORM Revised 4/23/2015
Complete requested information, sign and date, email to kellv.williams-ncdenr.gov . Attachments are acceptable for clarification
purposes (location map, address or lat long is required). Information submitted is subject to NC Public Records Law and may be
requested by third arties. Review meetings are held on Tuesday afternoons._
CONTACT INFORMATION APPLICANT'S -466N# ! APPLICANT
1. Business/Company Name
�2.Contact Person
3. Street Address or P O Box
4. City, State, Zip
5. Telephone Number
6. E -Mail Address
7. Project Name
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PROJECT INFORMATI
8. Project Location (nearest town, city)
J. Lat-Long Coordinates or attach a map
10. County
11. River Basin & Cataloging Unit (8 -digit)
(See Note 1)
12. Project Type "indicate owner type and
write in project type (e.g. school, church, retail,
resdential, apartments, road, utilities, military,
etc.')** _..._ ...
13, Riparian Wetland Impact (ac.) (e.g., 0.13)
14. Non -Riparian Wetland Impact (ac.)
15. Coastal Marsh Impact (ac.)
16. Stream Impact (ft.) (e.g. 1,234)
17. Riparian Buffer Impact (sq. ft.)
Include subwatershed if Jordan or Falls Lake:
18. Reoulatory Aaencv Staff Contacts
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Owner Type: Q Government • Private
Project Type:
Warm
Zone 1: , ?(e 5 4.
NCDW R:
Cool
Zone 2:
Cold
USACE: !Other:
Check (4) below if this request is for a By signing below, the applicant is confirming they have
revision to a current acceptance read and understand the DMS refund policy posted at
! nceep.net and attached to this form.
renewal of an expired acceptance i Signature of Applicant or^uthorized Agent:
i
E
extension of unexpired acceptance
Date: �(J
Note 1: For help in determining the Cataloging Unit, visit:www.nceep.net or contact DMS
Direct questions to Kelly Williams at 919-707-8915 or kelly.williams(dricdenr.gov or to the front desk at 919-707-8976

Print Form
DMS ILF Mitigation Request Statement of Compliance with §143-214.11 & 143-214.20
(link to G.S. 143-214.11)
Prior to accessing the Division of Mitigation Services (DMS), all applicants must demonstrate compliance
with G.S. § 143-214.11 and 143-214.20. All requests MUST include this form signed and dated by the
permit applicant or an authorized agent. Please refer to DENR's Implementation Policy for more details.
Compliance Statement:
I have read and understand G.S. § 143-214.11 and 214.20 and have, to the best of my
knowledge, complied with the requirements. I understand that participation in the DMS is
voluntary and subject to approval by permitting agencies.
Please check all that apply:
Applicant is a Federal or State Government Entity or a unit of local government
meeting the requirements set forth in G.S. 143-214.11 and is not required to
purchase credits from a mitigation bank.
Ohere are no listed mitigation banks with the credit type I need located in the
hydrologic unit where this impact will take place (link to DWR list)
Mitigation bank(s) in the hydrologic unit where the impacts will occur have been
contacted and credits are not currently available.
F1 The DWR or the Corps of Engineers did not approve of the use of a mitigation
bank for the required compensatory mitigation for this project.
This is a renewal request and the permit application is under review
credits were not available at the time the application was submitted.
Enter date permit application was submitted for review:
Bank
Note: It is the applicant's responsibility to document any inquiries made to private mitigation
banks regarding credit availability.
v I have read and understand the DMS refund policies (attached)
in,riar here
a ure of Applicant or Agent Printed Name
l l- ZZ- 1 lP
Date
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Project Name
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Boundary and Physical Survey
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ALLENDALE POINT
LOT 20
Fallstown Township, Iredell County, NC
PIN# 4628-69-7676 M D.R. 1812--816 — P.B. 7-21
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NORMAN
Boundary and Physical Survey
224 Allendale Circle
ALLENDALE POINT
LOT 20
Fallstown Township, Iredell County, NC
PIN# 4628-69-7676 M D.R. 1812--816 — P.B. 7-21
Property of. LOCA COMPANY

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