20171359 Ver 1_Buffer and/or Stream Determination Request_20171016

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
Water Resources _ S. JAY ZIMMERMAN
Enviromnental 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)
Ia. Name(s) on Recorded Deed L
1b. Responsible Party (for LLC)
lc. Mailing Address
1d. Telephone Number qlq7 - i f 3 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
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3b.
3b. Company
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3c. Mailing address
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3d. Telephone no.
0 3t/ _ 3e. Email add ess
4. Project / Site Information
4a. Name of project
-5 4c. Nearest Named Stream
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4b. County
L --”4d. River Basin
S.+Project Description (attach plan if available) -5y ;C' Ir-,t� r,\,-0-- bp— j..._
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6. Has anyone from DWQ visited the site? I Y / ) Staff Name: Date of Visit:
7. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or MRCS 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.
r --"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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Users of the GIS information/data contained in this web mapping application are hereby notified that the information was compiled from recorded deeds, plats and other
public records and data. Users are notified that the aforementioned public primary information sources should be consulted for verification of the data contained in this
information. The County of Wayne and the mapping companies or other entities assume no legal responsibility for the information contained herein. By accepting this
disclaimer you aciree and understand the disclaimer.