20170721 Ver 1_Buffer and/or Stream Determination_20170609

Water Resources
Environmental Quality
r,E('7141EDlN DENR/DWR
JUN 09 2017
Qa 9iiv Regional
s>vi'c i Oils section
Washington Regional Office
ROY COOPER
Govclwol-
MICHAEL S. REGAN
S. JAY ZIMMERMAN
Direecwr
DWR Use Only: Project #: o :;;L -
Date Received: Lo -91-
Buffer
9-
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 ,4 S A e
1b. Responsible Party (for LLC)
1c. Mailing Address �� �[�!w �S~/,✓e bo ✓ r%�r /I/ Lam_ �%�%3
id. Telephone Number S __jZ , r / ie. Email address Ilh4rs� aN '0 Ce 7..�
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
4d. River Basin
4. Project /Site Information
4a. Name of project f
4c. Nearest Named Stream
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4b. County a�
4d. River Basin
5. Project Description (attach plan if available)
6. Has anyone from DWQ visited the site? I Y / N I 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
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Craven GIS
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1 inch = 250 feet
U.— County does NOT warrant the frdormation stmwn on this map and should be used ONLY tar tas assessment purposes.

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Craven GIS 1 inch = 250 feet
Gave,O-ty does NOT —.1 N, --ahw sMwn,n Mtsmapmd sh,Wdhe ased ONLY trn Jaz assessmentpuryoses. , _