20090449 Ver 1_Initial Interest_20090420

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P A I Form Version 6
January 28, 2009
INITIAL INTEREST IN PARTICIPATION IN THE EXPRESS REVIEW PROGRAM
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
1 a. Type(s) of actions ? Riparian Buffer Minor Variance
requested: ? Coastal General "Major" Variance
(Check all that apply) ?x Stream Determination: 1 # 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: Life United Pentecostal Church
2b. County: Nash
2c. Latitude/Longitude: Lat: 35d 55m 48s N Long: 77d 50m 46s W
2d. River Basin: Tar-Pamlico
2e. Tax PIN or parcel ID: 3749-0915-5978
2e. Nearest Named Stream: Grape Branch [from USGS Topographic Map]
2f. Water Quality Classification of Nearest Named Stream: WS-IV; NSW
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):
Proposed church site with possible Tar-Pamlico buffer along western property line.
2j. Provide directions from the nearest named town, including street names and/or or highway numbers:
From Raleigh, take US 64 east toward Rocky Mount. Take the Winstead Ave exit and turn right onto Winstead Ave.
Winstead Ave becomes Beechwood Dr. Site is loocated just south of the intersection of Old Mill Rd (NC-1713) at 1220
Beechwood Dr.
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.
3. Applicant Information
3a. Applicant is: ? Owner X? Agent ? Other, specify:
3b. Name:
3c. Business name (if applicable).
3d. Street address:
3e. City, state, zip:
3f. Telephone no.: 3g. Fax no.:
3h. Email address:
4. Agent/Consultant Information (if applicable)
4a. Contact Name: Jon Meade
4b.Company name: Bartlett Engineering and Surveying, PC
4c. Street address: 1906 Nash St
4d. City, state, zip: Wilson, NC 27893
4e. Telephone no.: 252-399-0704 4f. Fax no.: 252-399-0804
4g. Email address: [e-mail]
5. Proposed Impacts (include both temporary and permanent) [Determination requests may omit this section)
5a. Total 404/401 wetland impacts: (acres) 5b. Total non-404 wetland impacts: (acres)
5c. Total 404 stream impacts: Intermittent: (linear 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 ?X No
If yes, provide staff name: and date of visit:
6b. Does this project require a Stormwater Management Plan? ?X Yes ? No ? Unknown

6c. Who will be responsible for the review of the
Stormwater Management Plan? ?x Certified Local Government:
? DWQ Stormwater Program

? DWQ 401 /Express Review Unit
6d. Does this project require approval under SEPA or NEPA? ? Yes

No
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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 letter. Describe the
controversy and any measures that have been taken with respect to public involvement.
This form must be submitted via email c/o 401 express cDncmail.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 12:00 pm will be stamped as
received on the next business day).
Please contact Lia Myott Gilleski or Joseph Gyamfi at 919-733-1786 if you have any questions regarding this form.
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