20180445 Ver 1_Buffer and/or Stream Determination Request_20180327

Water Resources
ENVIRONMENTAL QUALITY
PAT MCCRORY
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DONALD R. VAN DER VAART
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S. JAY ZIMMERMAN
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DWR Use Only: Project # 1 �' c/ (/
Stream Origin/Buffer Applicability Determination i /2.7 /I Y
Required Information
1. Owner Information (corporation/individual who is legally responsible for the property and Its compliance)
1a. Name(s) on Recorded Deed
Leo Allen Venters
1 b. Responsible Party (for LLC)
1700-D East Arlington Boulevard
1c. Mailing Address
1700 Tottenham Court, Winterville, NC 28590
1d. Telephone Number
252-355-3346
le. Email Address
[e-mail]
2. Location of Project Site - please Include the county, nearest named town and highway number: The project site Is located at 4545
Ayden Golf Club Road, Ayden, NC 28513.
3. Has anyone from DWR visited the site?
No
Staff Name
N/A
Date of Visit?
N/A
Additional Requested Information
4. AgentlConsultant Information (if applicable)
4a. Name, Company
Igor Palyvoda, Baldwin Design Consultants, PA
4b. Mailing address
1700-D East Arlington Boulevard
4c. Telephone no.
252-755-1390 Ext. 205
4d. Email address
ipalyvoda(a�baldwindesignconsultanls.
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5. Project and Site Information
5a. Name of project
Leo Venters Property — Ayden Golf Club
Road
5b. County
Pitt
Sc. Nearest Named Stream Swift Creek 5d. River Basin Neuse
5e. Provide a brief description of this project (attach site plan If available): The purpose of this project is to build a residential
subdivision.
Please 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 Regional Office for assistance.
DWR Use Only: Is this stream call for the purpose of _ buffer mitigation _ nutrient offset credit
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
Fax: [phone] next business day.
Email: anthony.scarbramah9hrictlemr.gov_
Please contact Anthony Scarbraugh at [phone] if you have any questions.
State of North Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations Washington Regional Office
943 Washington Square Mail, Washington, NC 27889
252.946-6481

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCELID:
STREET ADDRESS: 4545 Ayden Golf Club Road,
Ayden, NC 28513
Please prim
Property Owner: Leo Allen Venters
Property Owner:
23749
The undersigned, registered property owners of the above noted property, do hereby authorize
Igor Palyvoda of
(Contractor/ Agent)
Baldwin Design Consultants, PA
(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):
1700 Tottenham Court, Winterville, NC 28590
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Aut orized Signature Authorized Signature
Date: Z i_ Date:

545 Ayden Golf Club Rd - Google Maps
Ilttps://www.google.com/maps/place/4545+Ayden+Golf+Club+Rd,+...
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Imagery 02018 Google, Map data 02018 Google 200 ft
4545 Ayden Golf Club Rd
Ayden, NC 28513
I of 1 3/26/2018.4:37 PM

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