HomeMy WebLinkAbout20171351 Ver 1_More Info Received_20171207'l�/7—//_/�r~/
{»�c,/�/
/// , /
Office Use Only: L/
Corps action |Dno.
______
J]VVUproject no.
________
Form Version 1.3Dec 1028U8
Pre -Construction Notification (PCN) Form
A. Applicant Information
1. Processing
la. Type(s) of approval sought from the
action 404 Permit 0 Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps?
Yes
F� No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
C] 401 Water Quality Certification — Regular Non -404 Jurisdictional General Permit
n 401 Water Quality Certification — Express Riparian Buffer Authorization
1 a. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification:
Yes No
For the record only for Corps Permit:
El Yes No
1 f. 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-4ieu
fee program,
F] yes
No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
Yes
No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes
No
2. Project Information
2a. Name of project:
2c. Nearest municipality / town:
2d. Subdivision name:
project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
aure '�-MQLW'!A I R1 -e-
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
3d, Street address:
bxwg
3f, Telephone no.:
3h. Email address:
Page 1 of 11
1 4. Applicant Information (if different from owner)
4a. Applicant is:
Agent El Other, specify:
4b. Name:
re -z d,
4c. Business name
(if applicable :
...... ... .. .. '( -
LJCI
4 k,
4d. Street address:
76
4e. City, state, zip:
41'. Telephone no.:
1.6 0
�4g. Fax no.:
4
4h� Email address:
A_rl t �111-7 �c 0
S. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
. . . . . ........
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:., . . ..........
Page 2 of 11
............ . . . .......
B. Project Information and Prior Project History
1 - Property Identification
la. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees):
Latitude:35% 7�6 q3q Longitude: foT-41
2. Surface Waters
2a, Name of nearest body of water (stream, river, etc.) to
proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin: map is available at
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
3b. List the total estimated acreage of all existing wetlands on the property:
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:
3e. Describe the overall project in detail, including the type of equipment to be used:
4a, Have jurisdictional wetland or stream determinations by the
Corps of State been requested or obtained for this property
Yes
project (including all prior phases) in the past? Unknown
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
Preliminary n Final
4c. If yes, who delineated the jurisdictional areas?
Ag ncy/Consultant Company:
Name (if known):
Other-,
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Page 3of11
PONFonn—Ver ion1.3December1O.28DBVenskzn
. . .............
6. Project History
5a. Have permits or certifications been requested or obtained for
-- this project (including all prior phases) in the past? El Yes Unknown
5b. If yes, explain in detail according to "help file" Instructions.
6. Future Project Plans
6a. Is this a phased project? LJ Yes
W If yes, explain.
Page 4 of 11
Fc. Pro—pose --- - ----- --
d Impacts Inventory
I. Impacts Summary
. .............. . .
Ia. Which sections were completed below for your project (check all that apply):
F1 Wetlands n Streams - tributaries Buffers
Open waters F-1 Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each weband area impacted.
. . ...........
2a, 2b. 2c. 2d. 2e. I 2f.
Wetland impact Type of jurisdiction
number — Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ — non -404, other) (acres)
TLe �T
W1 P T
Yes
Corps
No
DWO
W2 n P F� T
Yes
Corps
No
DWQ
W3 D P F-1 T
El Yes
Corps
No
DWQ
W4 F1 P n T
n Yes
F1 Corps
. ...... . ..
. .....
No
DWQ
W5 P T
D Yes
El Corps
No
1 El DWQ
n Corps
W6 nPnT
Yes
El No
DWQ
2g. Total wetland impacts i
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 a 11 stream sites impacted,
3a.
1 3b.
3c. 3d.
U
3f,
3g.
Stream impact
Type of impact
Stream name Perennial
Type of jurisdiction
Average
Impact
number -
(PER) or
(Corps - 404, 10
stream
length
Permanent (P) or
intermittent
IDWQ — non -404,
width
(linear
Temporary M
(INT)?
other)
(fe t)
feet)
S1 nP[IT
PER
Corps
INT
DWQ
S2 P n T
n PER
Corps
INT
DWQ
S3 n P n T
n PER
n Corps
[I INT
El DWO
S4 P F-1 T
n PER
n Corps
E:1 I NT
DWQ
S5 P n T
PER
Corps
INT
El DWQ
S6 P F-1 T
PER
Corps
INT
DWQ
3h. Total stream and tributary impacts
3i. Comments:
Page 5 of 11
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 wat r impacts below,
4a.
4b.
4c.
4d.
4e.
Open water
Name of waterbody
impact number —
(if applicable)
Type of impact
Waterbody type
Area of impact (acres)
Permanent (P) or
T)
01 EIP [IT
............
02 P n T
03 EIPEIT
04 [1 PE3T
.... .......
0. Total open water Impacts
. .. . . ...........
4g. Comments:
S. Pond
or Lake Construction
ake construction r o te thtchart below.
6a
Pond ID
- - --------
5b, 5c, 5d. 5e.
Proposed use or purpose Wetland Impacts (acres) Stream Impacts (feet) Upland
(acres)
number
ofpond ---- — --1 . . .... ........................ — ..... ..... . ..
Flooded Filled Excavated Flooded Filled Excavated Flooded
P 1
. ... ......
P2
6f. Total
<2
5g. Comments:
5h, Is a dam high hazard permit required?
Yes El 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 ou MUST fi I out Section D of this form.
6a.
El Neuse El Tar -Pamlico Other:
Project is in which protected basin?
n Catawba Randleman
Buffer impact
6c.
6d.--
"a -------- -----------
—6f.
number —
Reason
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary (T)
impact
81 El P [I T
.1equired?
0 Yes
Q No
B2 P T
Yes
No
B3 []PnT
El Yes
El No
6h, Total buffer impacts
6i. Comments:
Page 6 of 11
D. Impact Justification and Mitigation
... . . ......
I I. Avoidance and Minimization
. .....
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project,
46 vv\
b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
4;
r 4�
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
. . . .......... . .
2a. Does the project require Compensatory Mitigation forYes
impacts to Waters of the U.S. or Waters of the State?
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) Type
Quantity
3c, Comments:
. . .................
. .
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: El warm 13cool Elcold
4d, Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non-riparian wetland mitigation requested:
acres
4g, Coastal (tidal) wetland mitigation requested: acres
. .. . ...... Comments:
I4h.—. . . . .......... . . ..
Page 7 of 11
PCN Form — Version 1.3 December 10, 2008 Version
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation pian.
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 requires
❑ Yes ❑ No
buffer mitigation? If yes, you will have to fill out this entire form — please
contact the State for more information.
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
------
Zone 1
_............. _-
r 6c.6d.
Reason for impact
------ _ _�___
Total impact
(square feet)
---------------
Multiplier
I
3 (2 for Catawba)
6e.
Required mitigation
(square feet)
_.....�
Zone 2
1.5
6f. Total buffer
_.
mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
t
Page 8 of 11
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
i
j 1, diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
El Yes F-1 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. i
Comments: El Yes ❑ No
2. Stormwater Management Plan _
2a. What is the overall percent imperviousness of this project?
%
2b. Does this project require a Stormwater Management Pian?
❑ 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:
t-
❑ Certified Local Government j
2e. Who will be responsible for the review of the Stormwater Management Plan? ❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?�
❑ Phase U
3b. Which of the following locally-implemented stormwater management programs
❑ NSW
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
4. DWQ Stormwater Program Review
❑ Coastal counties
4a. Which of the following state-implemented stormwater management programs apply
❑ HQW
❑ ORW
(check all that apply):
❑ Session Law 2006-246
❑ Other:
4b, Has the approved Stormwater Management Plan with proof of approval been
attached?
_ ..
❑ Yes ❑ No
S. DWQ 401 Unit Stormwater Review
_......... _
5a, Does the Stormwater Management Plan meet the appropriate requirements?
_...
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?�
❑ Yes ❑ No
Page 9 of 11
PCN Form —Version 1, 3 December 10, 2008 Version
.......... ____........._. _ �___..._
F. Supplementary information
—
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (fed eral/statellocal) funds or the
El Yes
.......... ----
❑ No
use of public (federal/state) land?
_............._._......__.._
lb. 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
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. 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
I
letter.)
❑Yes
❑ No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetiand Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
❑ Yes
❑ No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
_......._........_.._
__ _....
2b. Is this an after-the-fact permit application? Q 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)_-
i
3a. Will this project (based on past and reasonably anticipated future impacts) result in Yes
F1 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.
i
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.
Page 10 of 11
PCN Form — Version 1.3 December 10, 2008 Version
...........................
6. Endangered Species and Designated Critical Habitat (Corps Requirement)
. .. .
............. ----
5a. Will this project occur in or near an area with federally protected species or
M Yes M No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
M Yes M No
impacts?
...........
5c. If yes, indicate the USFWS Field Office you have contacted.
❑ Raleigh
F1 Asheville jjj
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? —�—[-iYes ❑ No
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
0 Yes M No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
. . ........... — I
--
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?
............
M Yes ❑ No
. .....
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
AppGcant/Agent's Printed Name
Applicant ligent's Signature
Date
(Agent's signature is valid only if an authorization letter from the applicant
i
provided.) I
Page 11 of 11