20090114 Ver 4_Minor Variance_20090127

01/27/2009 09:11 2529469215
OFFICE USE ONLY: Date Reoeived
Stake of North Carolina
Department of ErrAronment and Natured Resources
Wslon of Water Quality
9911
Variance Request Form - for Minor Variances
Protection and Maintenance of Riparian Areas Rules
!VOTE: This form may be photocopied for use as an original.
Please Identify which Riparian Area Protection Rule applies.
Neuse River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (1 SA NCAC .0233)
q Tar4Pamlllco River Basin: Nutrient Sensitive Waters Management
Strategy Protection and Msatintanance of Riparian Areas Rule (15A
N CAC .0268)

Part 1: General Information
(Please include attachments if the mom provided is insufficient)
name
3.
5.
2. Print OwnerlSignir
Name:
Title:
Street address:
City, State, Zip:
Telephone:
Fax:
NCDEW DWQ PAGE 01/03
ual, etc. who owns the property):
Contact person who can answer questions about the proposed project:
Name:
Telephone: ;, cam..
Fax:
Email:
4. Project Name (Subdivision, facility, or establishment name - consistent with project name on
plans, spe~one, letters, operation and maintenance agreements, etc.):
Project Location: C- -1
Street address;
City, State, Zlp:
County:
Latitude/longitude:
Request #
Vemlon 1: February 2000
01/27/2009 09:11 2529469215 NCDENR DWQ PAGE 02/03
6. Directions to site from nearest major intersection (Also, attach an 8'/2 x 11 copy of the USGS
topographic map indicating the location of the site):
7. Stream to be impacted by the proposed activity:
Stream name (fqr unnamed, ams label as 'UT" to the nearest named stream):
Stream classification [as identified within the Schedule of Classifications 15A NCAC 28
.0315 (Neuse) or.0316 (Tar-Pamlico)]:
8. Which of the following permitstapprovals will be required or have been received already for
this project?
Required: Received: Date received: Permit Type:
CAMA Major
CAMA Minor
_ 401 Certification/404 Permit
On-site Wastewater Permit
NPDES Permit (including stormwater)
_ Non-discharge Permit
_ Water Supply Watershed Variance
Others (specify)-
Part 2: Proposed Activity
(Please include attachments if the room provided is insufficient.)
1. Description of proposed activity [Also, please attach a map of sufficient detail (such as a plat
map or site plan) to accurately delineate the boundaries of the land to be utilized in carrying
out the activity, the location and dimension of any disturbance in the riparian buffers
associated with the activity, and the extent of riparian buffers on the land. Include the area
of buffer impact in fe.:
INI
2. State reasons why this plan for the proposed activity cannot be practically accomplished,
reduced or recVlfigy redo better minimize or eliminate disturbance to the riparian buffers:
ti I
3. Description of any best management practices to be used to control impacts associated with
the proposed activity (i.e., control of runoff from impervious surfaces to provide diffuse flow,
re-planting vegetation or enhancement of existing vegetation, etc.):
a
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Variance Request Form, page 2
Version 1: February 2000
01/27/2009 09:11 2529469215 NCDEMR DWQ PAGE 03/03
4, please provide an explanation of the following:
(1) The practical diffic uflies or hardships that would result from the strict application of this

(3) If economic hardship Is the major consideration, then include a specific explanation of the
economic hardships and the proportion of the hardship to the entire value of the project.
Part 3: Deed ReatIlictiona
By your signature in part S of this application, you oertily that all structural store water best
management practices required by this variance shall be located in recorded stormwater
easements, that the easements will run with the lend, that the easements cannot be changed or
deleted without concurrence from the state, and that the easements will be recorded prior to the
sale of any lot.
Part 4: Agent Authorization
if you wish to designate submittal authority to another individual or firm so that they may provide
information on your behalf, please comp?/l/ete? this section:
Designated went (individual or firm): /y/`l
Mailing address:
CRY, state, zip: -
Telephone:
Fax:
Erroll:
part S: Applicant's Certification
p, fi/G?,i (print or type name of person
listed In Part 1, Item 2), oer* that the information included on this permit appNcation form is
correct, that the project will be constructed in conformanoe with the approved plans and that the
deed restrictions in accordance with Part 5 of this. rm will be moorded with all required permit
conditions.
Signature:
Do:
Title:
Vadence Request Form, page 3
Version 1: February 2000
(2) How these dFPNculdes or hardships result from conditions that are unique to the property
involved.
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