20110261 Ver 2_401 Application_20170817

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the Corps:
EJ16ection 404 Permit ❑ Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps?
❑ Yes ❑ No
1d. Type(s of approval sought from the DWQ (check all that apply):
401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required?
/ V O
For the record only for DWQ
401 Certification:
❑ Yes ErNo
For the record only for Corps Permit:
❑ Yes [ErNo
1f. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes 0_14o
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes to
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes No
2. Project Information
2a. Name of project:
45,
2b. County:Ick—CA
C
2c. Nearest municipality / town:
Lo
2d. Subdivision name:
k U a ('r,
2e. NCDOT only, T.I.P. or state project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
J �r .
3b. Deed Book and Page No.
3 5 7 Q a
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
l) ox
3e. City, state, zip:
13 ' a C10/0
3f. Telephone no.:
9o_,/,;7-'70— q
3g. Fax no.:
-''-
3h. Email address:
'vC-C r G
Page 1 of 10
PCN Form — Version 1.4 January 2009
G

4. Applicant Information (If different from owner)
4a. Applicant is:
(Agent
❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. AgenVConsultant Information (if applicable)
5a. Name:
.-�
U
abk.f I
5b. Business name
(if applicable):
5c. Street address:
t
Qp co n <, br i "t Jos
5d. city, state, zip:L
L.4IS 6 ter
-hit a q) -y
5e. Telephone no.:
) °i
a • .� V a
5f. Fax no.:
02 S� ly! 78' -SSG
5g. Email address:
S r 6
i�- t~ Ir •
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees):
Latitude: Longitude:
1c. Property size:
acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
►2p d
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
. ',, j
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
3b. List the total estimated acreage of all existing wetlands on the property: 1.04
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project: b o G k
3e. Describe the overall project in detail, including the type of equipment to be used: n/o ri-C,
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project(including all priorphases) in thepast?
[2Yes ❑ No ❑ Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what typePreliminary
of determination was made?
❑Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): I
Agency/Consultant Company:
Other: Co {p —AnA Wi j h awi
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
b)t s, vo
5. Project Wistory
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
Eryes ❑ No ❑ Unknown
5b. If yes, explain in detail according to "help file" instructions. 1Il
���-�,✓ieus ,r" . 1JJAI C1 N �0Ci.
Dw(Z
6. Future Project Plans
6a. Is this a phased project?
❑ Yes No
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ❑ Streams – tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
T
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
—Temporary
W1 -
Choose one
Choose one
Yes/No
W2 -
Choose one
Choose one
Yes/No
W3 -
Choose one
Choose one
Yes/No
-
W4 -
Choose one
Choose one
Yes/No
W5 -
Choose one
Choose one
Yes/No
-
W6 -
Choose one
Choose one
Yes/No
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 -
Choose one
-
S2 -
Choose one
-
S3 -
Choose one
-
S4 -
Choose one
-
-
S5 -
Choose one
-
S6 -
Choose one
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form – Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impa (ac )
01 -
Choose one
Choose
02 -
Choose one ib 6 C
Choose,
O
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
(acres)
Flooded
Filled
E vated Flooded
Filled Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required? ❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill ou ection D of this form.
6a. Project is in which protected basin?
❑ Neuse ar-Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number —
Permanent (P) or
Temporary T
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet
6-
1�1
1) 0-J
Yes/No
B2 -
Yes/No
B3 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
6i. Comments: 0 i a b 4i of a n d
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Wate of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ 761 ❑ No
2b. If yes, mitigation is required by (check all that apply):
DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
/
❑ Mitigation bank
❑Payment to in-lieu fee program
/ ❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
/Ype: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Making a Payment In-lieu Fee Program
4a. Approval letter from in-lieu fee p gram is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, st am temperature:
Choose one
4d. Buffer mitigation requests (DWQ only):
square feet
4e. Riparian wetland mitiga ' n requested:
acres
4f. Non-riparian wetland Otigation requested:
acres
4g. Coastal (tidal) wetla mitigation requested:
acres
4h. Comments:
5. Complete if Us ng a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requir
buffer mitigation?
❑ Yes ❑ No
6b. If yes, then identify the square feet of impact to each zone of the rip ari buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
6c.
Reason for impact
6d.
Total impactMultiplier
(square feet)
6e.
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Too buffer mitigation required:
6g. If buffer mitigation is required, discuss what ty of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restorati n, payment into an approved in -lieu fee fund).
6h. Comments:
Page 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b. Does this project require a Stormwater Management Plan?
❑ Yes No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which localgovernment's jurisdiction is thisproject?
❑ Phase II
❑ NSW
3b. Which of the following locally -implemented stormwater manage t programs
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with roof of approval been
❑ Yes ❑ No
attached?
4. DWQ Stormwater Program Review
❑Coastal counties
❑HQW
ana
4a. Which of the following state -implemented stormwater mment programs apply
❑ORW
(check all that apply):
❑Session Law 2006-246
[]Other:
4b. Has the approved Stormwater Management Planwit proof of approval been
❑ Yes ❑ No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan mee a appropriate requirements?
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1a.
Does the project involve an expenditure of public (federaUstate/local) funds or the
[:1 Yes
No
use of public (federal/state) land?
1b.
If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑Yes
ONo
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c.
If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
❑ Yes
No
letter.)
Comments:
2.
Violations (DWQ Requirement)
2a.
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
❑ Yes
CfNo
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b.
Is this an after -the -fact permit application?
❑Yes
No
2c.
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3.
Cumulative Impacts (DWQ Requirement)
3a.
Will this project (based on past and reasonably anticipated future impacts) result in
❑Yes
No
additional development, which could impact nearby downstream water quality?
3b.
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4.
Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non -discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
�h nt�
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
❑Yes No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
❑ Yes L✓f no
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes o
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
❑ Yes 2<0
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA -designated 100 -year floodplain?
BYes ❑ No
8b. If yes, explain how project meets FEMA requirements:
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b'OZAZ Wil) bC usr6'rua ik� nw►-nr ►-c)u8 men— aPp�ve.oC s�
8c. What source(s) did you use to make the floodplain determination?
)157► -" l i r) C u n Zs m ) c
5 u sar3ob����y
Applicant/Agent's Printed Name
pplicanUAge is Signature
Date
(Agent's signature is valid only if an authorization
letter from the applicant isprovided.)
Page 10 of 10

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. o2Q &� PLAN NO. PARCEL ID:
STREET ADDRESS: / .� �a H a oY� ✓ 1 V
l.ovbiS�ur.�. �JC� 'vZ%s�r%
Please print: i
Property Owner: J -t e r y F.
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) (Nam of consulting fir
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
PO B&se 2-14 REsh,10VV t. SQ- —29'0/L)
Telephone: %/ q, a 7 g-/ 9 3 y
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Auty6rized Sp nature Authorized Signature
Date: O Date:

9194968136 FC Environmental Health 04:27:14 p.m.
7,5-7- ` 4-( 7 y- - S S—(p h
Franklin Countv Health Department
Division of Environmental Health
107 Industrial Drive -Suite C
Louisburg, North Carolina 27549
Phone: [phone]
Permit Number: 9369 Type: I
Applicant: JERRY LAW
PO BOX 814
BISHOPVILLE, 29010
Telephone: [phone]
05-16-2017
PAGE 1 OF 2
SEPTIC PERMIT Fax: [phone]
PIN: 2840-06-1189 Date: 4/21/2017
Owner: JERRY LAW
PO BOX 814
BISHOPVILLE, 29010
Telephone: [phone]
Subdivision: LAKE ROYALE Lot Number: 2035 Size: 1.000
Physical Address/ Location /Directions 1115 SAGAMORE DR
Description: LifeTime 5 Year k
TYPE FACIL 5 r `> # EMPLOY # BEDRMS GPD 345'61 LTAR 3
TYPE WAT (fe M TYPE SYS PorA TYPE REP i`J14 BSMT ^3 BST FX rI�
SIZE TANK Uv SIZE CHB ldeWSIZE NITR 3x270MTD W f r
� (J o�-.n U, r` b
COMMENTS: �'.t cR r c`� l` r � (-
�iY• �..v-.J on
s c�
Septic Contractors are responsible for notifying the health department for final Inspections, between a:00-9:00 AM on the day
of completion, Monday - Friday. Any request for final Inspections received afterwards will be scheduled the same day, If
possible, or the next workday. Have permit number and owner/appllcanfs name ready when making the call.
Actions of representatives of state or local agencies engaged In the evaluation and determination of measures required to
effect the compliance with the provisions of this permit shall In no way be taken as a guarantee that wastewater disposal
systems permitted and approved will function In a satisfactory manner for any given period of time, or that such employees
assume any liability for damages, consequential or direct which are caused, or may be caused, by a malfuction of this
wastewater treatment and disposal system.
Proper precautions must be taken to assure the proper functioning of the system after It has been covered. Do not run any
heavy equipment over the system, as soft earth will allow damage to the tank and lines. Pipe all roof drains away from the
septic system site to prevent flooding of the lines from surface water. Terrace the ground to prevent excessive drainage
from higher areas adjacent to the system. Do not construct driveways over any part of the septic system unless proper
provisions were made when the septic system was constructed. Only grass, not trees or shrubbery, should be cultivated
over the lines. All plumbing fixtures should be carefully Inspected periodically and any problems repaired Immediately. All
septic tanks should be pumped off by a permitted pump operator on a regular schedule, not to exceed every five years.
The Improvement permit and construction authorization Is a site approval, for the future installation of a wastewater
treatment and disposal system. Changes in ownership of the site do not affect the validity of this permit. However, any
alteration of the site or soil conditions, changes in the location of the proposed facilty, changes to the wastewater flow and/or
characteristics, or submittal of false Information with the application or misrepresentation of the property lines may subject
this permit to suspension or revocation.
FOR THIS TO BEA VALID CONSTRUCTION AU HORIZATION, A LAY O dT SHEET MUST BE ATTACHED
IMPROVEMENT PERMIT DATE fit, f EHS
CONSTRUCTION AUTHORIZATION DATE EHS
Vist www.franklincountyenvimnmentalhealth.com for permit Information and tracking.
112

9194968136 FC Environmental Health 04:27:26 p.m. 05-16-2017
PAGE 2 OF 2
Franklin County Health Department
Name: LAW
CONTRACTOR
WELL INSTALLED YES
Permit Number 9369
TANK MANU -- ANU DATE
NO SYSTEM CODE
SEPTIC SYSTEM LAYOUT
(SKETCH SYSTEM LAYOUT HERE)
SEPTIC SYSTEM AS -BUILT
(IF DIFFERENT FROM INITIAL LAYOUT)
ON REVERSE
OPERATIONS PERMIT DATE EHS
2/2

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