20170520 Ver 1_Buffer_StreamDeterminationRequestForm2016_WaRO_20170601

ROY COOPER
N
Governor
MICHAEL S. REGAN
Secretary
Water Resources S. JAY ZIMMERMAN
Environmental Quality Director
DWR Use Only: Project #:
Date Received:
Buffer Applicability / Stream Origin Determination Request
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
1a. Name(s) on Recorded Deed
1b. Responsible Party (for LLC)
1c. Mailing Address
1d. Telephone Number 1e. Email address
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
3. Agent / Consultant Information
3a. Agent/ Consultant Name
3b. Company
3c. Mailing address
3d. Telephone no.
3e. Email address
4. Project / Site Information
4a. Name of project
4c. Nearest Named Stream
4b. County
4d. River Basin
5. Project Description (attach plan if available)
6. Has anyone from DWQ visited the site? Y / N Staff Name: Date of Visit:
7. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey
If you are unable to locate either of these maps, please contact the DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitigation? Nutrient offset credit?
8. Please return form to: Anthony Scarbraugh
943 Washington Square Mall Note: Submittals on Friday after 12:00 pm
Washington, NC 27889 Will be stamped as received on the
Email: [e-mail] Next business day
Please contact Anthony Scarbraugh at the Washington Regional Office at [phone] if you have any
questions.
'Nothing Compares_.
State of North Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations Section -Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481