20180435 Ver 1_Buffer and/or Stream Determination Request_20180326

Water Resources V
Unvinuunuttal Quality
ROY COOPER
Gorcr,xa
MICHAEL S. REGAN
Set) 01,11 r
LINDA CULPEPPER
Interim Direelor
DWR Use Only: Project #.: Y
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)
la. Name(s) on Recorded Deed George Wayne Aycock It
1b. Responsible Party (for LLC)
1c. Mailing Address 2236 NC Hwy 581 Pikeville NC 27863
Sd. Telephone Number 919-222-4646 1 1e. Email address [e-mail]
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
NW corner of NC Hwy 581 and Pikeville -Princeton RD in Wayne County NC
3 Agent / Consultant Information
3a. Agent/ Consultant Name
Chris Cox
31b. Company
Cox Properties
3c. Mailing address
104 Twin Oaks Place Goldsboro NC 27530
3d. Telephone no.
919-738-9574 1 3e. Email address [e-mail]
4, Project/ Site Information
4a. Name of project
Aycock 4c. Nearest Named Stream
4b. County
Wayne 4d. River Basin
Neuse
5. Project Description (attach plan if available)
Survey attached
6. Has anyone from DWQ visited the site? I Y / N I Staff Name: No 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
Next business day
Email: Anthonv,[e-mail]
Please contact Anthony Scarbraugh at the Washington Regional Office at [phone] if you have any
questions.
State ol'Nonh Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations Section -Washington Regional Office
943 Washington Square Mail. Washington, North Carolina 27889
252-946-6481

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 2 PARCEL ID: 2673957148
STREET ADDRESS: no street address
Please print:
Property Owner: George Wayne Aycock Jr
Signature
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Chris Cox
(Contractor / Agent)
of Cox Properties
(Name of consulting firm)
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):
2236 NC Hwy 581 Pikeville NC 27863
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
Authorized Sj ature Authorized Signature
Date: -3 A 60/ Date:

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