20090123 Ver 1_Initial Interest_20090209

02109/2009 14:37 9194606085 NORTHEASTERN CAROLIN PAGE 01
nr Form Version 6
January 28, 2009

INTEREST IN PARTICIPATION IN THE EXPRESS REVIEW PROGRAM
INITIAL WITHIN THE 401 OVERSITE/EXPRESS PERMITTING UNIT
A. Applicant information
1. Processing
? 401 Water Quality Certification (List NW(s) or GP# verified by Corps: )
? Non-404 Jurisdictional Permit
? Riparian Buffer Authorization
Type(s) of actions
1 a. ? Riparian Buffer Minor Variance
requested:

requested, ?
Coastal General "Major" Variance
(Check all that apply) i? Stream Determination: _ # Streams
? Non-404 Wetland Determination:. # Wetlands
? Stormwater Management Plan Review (fee not additive if combined with 401)-
# of Drainage Areas/Project Site
2. Project Information
2a. Name of project: i
161 easy'A
2b. County:
2c. t atitudelLongitude: Lat: Long:
2d. River Basin:
2e. Tax PIN or parcel ID:
[from USGS Topographic Map]
2e. Nearest Named Stream:
2f. Water Quality Classification of Nearest Named Stream:
2g. Total project acreage: (acres) (Stream or Wetland determinations may omit this item]
2h. Total built out imperviousness: (% [Stream or Wetland determinations may omit this item]
2i. Provide a brief description of this project (attach site plan):
2j. Prov directions m the nearest named town, including street qgqes and/or or highway num
a??5 i ,v,?i? ago i?a,2kr1L L¢-+t o,-- 01
Please attach a map of site location using USGS 1:24,000 topographic map and the latest bound and
published County soil survey with the project(site boundaries delineated. A site plan should also be
included for all projects other than stream and wetland determinations.
FEB-9-2005 MON 13:45 TEL:[phone] NAME:DWQ-WETLANDS P. 1
0210912009 14:37 9194606085
3. Applicant information
3a. Applicant is: ? owner ? Agent
.-
3b. Name;/ i r n n? (I-
3c, Business name (if applicable):
3d. Street address:
3e. City, state, zip'
3f. Telephone no.:
3h. Email address' y?
4. Agent/Consultant Information (if applicable)
4a. Contact Name:
4b.Company name:
4c. Street address:
NORTHEASTERN CAROLIN
Other, specify:
3g. Fax no.:
4d- City, state, zip:
4e. Telephone no-: 4f. Fax no.:
4g. Email address:
5. Proposed impacts (include both temporary and permanent) (Determination requests may omit this section)
5a. Total 4041401 wetland impacts: (acres) 5b. Total non-404 wetland impacts: (acres)
5c. Total 404 stream impacts: Intermittent: (111 near feet) Perennial: (linear feet)
5d. Total non-404 stream impacts: Intermittent: (linear feet) Perennial: (linear feet)
5e- Total riparian buffer impacts- Zone 1, (square feet) Zone 2: (square feet)
6. Project History and Additional Information
6a. Has any DWQ staff visited the site? ? Yes No
If yes, provide staff name: and date of visit:
6b. Does this project require a Stormwater Management Plan? ? yes 0 ? Unknown
? Certified Local Government:
6c. Who will be responsible for the review of the ? DWD Stormwater Program
Stormwater Management Plan?
? C7W0 401/Express Review Unit
6d. Does this project require approval under SEPA or NEf A? ? Yes © No
6e. Is this project an after-the-fact application or has a DWQ notice of violation been issued? ? Yes ? No
6f. Does this project include buffer impacts that are "prohibited" in the DWQ "Red Rule Book? ? Yes ? No
6g- If you are aware of any local controversy concerning this project, provide details in a cover i er. Describe the
controversy and any measures that have been taken with respect to public involvement.
This form must be submitted via email c/o 401expreSS ncmail.net, faxed (919-733-6893), or hand-delivered to: Parkview
Building, 2321 Crabtree Blvd. Suite 250, Raleigh, NC 27604. Applicants who are selected to participate in the Express
Review Program will be notified via email or fax. Successful applicants will then be instructed regarding detailed
procedures for full application (Note: Submittals of the review packages on Friday after 92:00 pm will be stamped as
received on the next business day)-
(]lease contact Lia Myatt Gilleski or Joseph Gyamfi at 919-733-1786 if you have any questions regarding this form.
2
FEB-9-2009 MON 13:45 TEL:[phone] NAME:DWQ-WETLANDS P. 2
PAGE 02
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X'USGS Cary, North Carolina, United States 01 Jul 1987
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