20090495 Ver 1_401 Application_20090509

09-04e5
1Ta ?? s
DIG
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-
Office Use Only.
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
KALB
-
1. Processing - ---,?_
I a. Type(s) of approval sought from the Corps: 5ifSection 404 Permit ? Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: NV or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? Yes ? No
1d. Type(d) of approval sought from the DWQ (check all that apply):
401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ
401 Certification:
53"Y'es ? No For the record only for Corps Permit

? Yes ? No
1f. Is payment into a mitigation bank or in4ieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in-lieu fee program. ?,?!
? Yes [r <O
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below. ? Yes M0
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes EM"No
2. Project Information
2a. Name of project: F. JaM
2b. County: i I MW
2c. Nearest municipality / town: MOCK&VILLE N . C. ru U11
2d. Subdivision name: IV IA MAY 0 1 Mug
2e. NCDOT only, T.I.P. or state project no: I stENR-IN4MR
3. Owner Information WTILAMMANS Raw"
3a. Name(s) on Recorded Deed: ALU F. .JU
3b. Deed Book and Page No.
raZ
I)EM
3c. Responsible Party (for ! ! C if
applicable):
t MA OWNEL F ?$ 5
BLE
3
d. Street address:
3e. City, state, zip: SVE i? N. C
3f. Telephone no.: 9 - Z
3g. Fax no.:
311_ Email address:
Pace 1 of Iii
PCN Form - Version 1.4 January 2009
4. Applicant intormation (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name: N JA
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. AgentfConsultant inf orrnation (if applicable)
5a. Name:
1 N /A
5b. Business name l
fif anplir.3hiel. i
5c. Street address:
5d. CA,, state, zip: l

i
5e. Telep.h n le no-:
1
l ?f
Fax =tea.. no.:
_ address: Facie 2 of lG

B. Project Information and Prior Project History
1. Property Identification
I a. Property identification no. (tax PIN or parcel ID): P11 2-t 55729 75 {o5r
1b. Site coordinates (in decimal degrees): Latitude: 359Z o Longitude: 80. 590
1c- Properly size: 3.7-ACRES acres
2. Surface Waters
2a. Name of nearest body of water to proposed project AR CREW
2b. Water Quality Classification of nearest receiving water
2c. River basin: YQ { 1VEZ.
3. Project Description
3a Describe the existing conditions on the site and the general land use in the vicini of theproj project at the time of 08
application: Cp111A)EQIC4L 9 TAM LAIRD UUI`T}} A k1S tN CE1/NTIOj E14CR SaDlr OF
AI
NA
A
DRAI
GE ATIJ MSS
R ON E
ST SIDE AMD WOOD,s ON PIKE
WE5T SIDE .
3b. List the total estimated acreage of all existing wetlands on the property. 0.00 ACRE
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property-. g00
3d. Explain the purpose of the proposed pmjec To PIPE EL PIX 3M-Pr WAIC? INCl VOE5
YN D 414rs 0t- CATCA 6AS106 AMb TO
?i??
OVE& ;A.
3e. Describe the overall pr "ect in detail, including the type of equipment to be used: PI f' 300 fr OTO RCP
02 HMP ADD RLL 0v1=2 Y CDAPAcr After ©r
- FILL.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
C
1 Y
F
S
orps or
-
es No ? Unknown
tate been requested or obtained for this property i
'
project includ
all or hases in the past? Comments:
4b- If the Corps made the jurisdictional determination, what type ,..,/
of determination was made? 5 Preliminary 13 Final
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known). JDAO I A
O , U, (Ups FN Other.
4d. If yes, list the dates of the Corps ju icional determinations or State determinations and attach documentation
.
mARC9 zs, 2009 Fiao V1.5rr
5. Project History
5a. Have permits or certifications been requested or obtained for ,.,/
this project (including all prior phases) in the past? Dyes No - ? Unknown
5b- If yes, explain in detail according to 'help 11i e= instructions.
6. Future Project Plans
6a. Is this a phased project? ["Yes
13 NO
6b. ff yes, explain_
.
E ZUGN1 INSTAU- IWS GW.5 &L Di -
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Page 3 of 10
PCN Form - Version 1.4 January 2009
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your projed (check all that apply):
? Wetlands Q Streams - tributaries ? Buffers ? Open Waters ? Pond Construction
2. Weiland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted. N
2a.
Wetland impact
number
Permanent (P) or
Temporary 2b.
Type of impact 2c.
Type of wetland 2d.
Forested 2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other) 2f
Area of
impact
(acres)
W1 - Choose one Choose arm Yes/No -
W2 - Choose one Choose one Yes/No -
W3 - Choose one Choose one YesINO -
W4 - Choose one Choose one Yes/No -
W5 - Choose one Choose one Yes/No
W6 - Choose one Choose one Yes/No
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all steam sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
S1 3b.
Type of impact 3c..
Stream name 3d.
Perennial (PER) or
intermittent (INT)? 3e.
Type of
jurisdiction 3f.
Average
stream
width
(feet) 3g.
Impact
length
(linear
feet)
- Choose one CULVMT 1 1b 9ftC - ! -Cobs 40 .3 %nf

S2 -
Choose ane
_ ,
S3
- Choose one _
S4 - Choose one
S5
- Choose one _
S6 -
Choose one
3h. Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form -Version 1.4 January 2009
4. Open Water Impacts N
JA
If there are proposed impacts t0 Ia
as, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other
water of
Y open
the U.S. then individual list all open water impacWts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number (if applicable) Type of impact Wm y Area of impact (acres)
Permanent (P) or type
Temporary
01 Choose one Choose
02 - Choose one choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake cxmstruction pprqopxo)sed, then complete the chart below. h(
5a. 5b. 5c- 5d. 5e

Pond ID number
Proposed use or
Wetland Impacts (acres)
Stream Impacts (feet) -
Upland
purpose of pond (acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required? Yes [3 No If yes, permit ID no:
5i. Expected pond surface area (acres):
Si. Size of pond watershed (acres): N
51C Method of construction:
6. Buffer Impacts (for DWQ) N/A
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
b
elow. If an impacts require mitigation, then u MUST fill out Section D of this form.

6a. Project is in which protected basin? Neuse [] Tar-Pamlico E3 Catawba 13 Randleman a Other:
6b. 6c 6d

Buffer Impact .
Reason for impact -
Stream name 6e.
Buffer 6f
Zone 1
Zone 2
number-
Permanent (P) or mitigation impact impact

Temporary required? (square
(square
131 -
feet
feet
Yes7No
B2
-
Yes/No
B3
-
Yes1No
B4 -
Yes/No
135 -
Y
es/Rio
B6
-
YesJNo
6h. Total Buffer Impacts:
[!-C7 ments:
Page 5 of 10
D. Impact Justification and Mitigation
1. Avoidance and Minimization
I a. Specifically describe measures taken b avoid or minimize the proposed impacts in designing project
VEer SMALL MO XT WIT# CW5T/t. IDO OF -PIPIA6
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques-
rOtWV NCDENR APPAIWO -PW Copw suemnivo POUOw 576D5 TO
PAWW ANY EPOS) DO . affiS UPON COM PFTW G I#& ? I0157 UMIG ` #PP-
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a_ Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? 1:3 Yes ["No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this
project? ? Mitigation bank

? Payment to in-lieu tee pram
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:

3b. Credits Purchased (attach receipt and Letter) Type: Choose one
Type: Choose one
Type- Choose one Quantity
Quantity-
Quantity.
3c. Comments:
4. Complete if Makin a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. 0 yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed rogation plan
Page 6 of 10
PCN Form - Version 1.4 January 2009
6. Buffer Mitigation (State Regulated: Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
? Yes [RINo
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires motion. Calculate the
amount of mitigation required.
6c• 6d 6e
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10
E. Stormwater Management and D"rffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified Yes [;(No
within one of the NC Pi rian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Lm Dl mi-W 0 Yes ? No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? - %

2b. Does this project require a Stormwater Management Plan? Oyes trio
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
LOW J7 sl?'`r
2d. If this project DOES require a Stormwater Management Plan, them provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan? NA
3. Certified Local Government Stormwater Review
3a. In which local ovemmenrs jurisdiction is this proiect? NC Q LA)iNSAI 5"14 A1, C.
? Phase If
3b. Which of the following iocallY-implemented stormwater management programs 0 NSW
apply (check all that apply): NIA Iu T?AVJr COVOTY USMP
W

MOUMUE N.C. ater Supply Watershed
0 Other
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
Oyes 131?0
4. DWQ Stormwater Program Review
OCoastal counties
4a. Which of the following state4mplemented stornmwater management
programs apply
?O
RW
(check all that a
apply):
N /a Session Law 2006-246
DOther.

4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
O Yes []rNo
5. DWQ 401 Unit Stormwater Review
5a. Does the Stomnwater Management Plan meet the appropriate requirements? O Yes [] No
5b. Have all of the 401 Unit submittal requirements been met? 0 Yes 0
Page 8 of 10
PCN Form - Version 1.4 January 2009
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federallstate/local) funds or the
f
b
i
f
? Yes ,_,/
N
use o
pu
l
c (
ederallstate) land? L!1
o
1b. If you answered 'yes' to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ?Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c- If you answered 'yes' to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ? Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 21-1.0500), Isolated `
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ?Yes ?..,/
[J0 No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ?Yes o
2c. If you answered 'yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
additional develo
ment
whi
h
ld i
7 ?/
p
,
c
cou
mpact nearby downstream water quality? es LJNo
3b. If you answered `yes' to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered 'no,' provide a short narrative description.
4. Sewage Disposal (DWQ Requirement).
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater
the proposed project, or available capacity of the subject facility. generated from
N/A
Page 9 of 10
PCN Form - Version 1.4 January 2009
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected spew or Yes MIN o
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
?-,/
Yes L? No
impacts?
5c. If yes, indicate the USFWS Feld Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat? R 1, /PC
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes No
6b. What data sources did you use to determine whether your site would impact Essential fish Habitat?
N/A
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
govemments have designated as having historic or cultural preservation
t
t
N
i
l El Yes 8<
s
a
us (e.g.,
at
ona
Historic Trust designation or properties significant in 0
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
N 1A
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes o
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
-Dwe Co 2006 FLOM Zan DAPS -34S60 6N FERIA ? GAS AAOPIRU
WIcuam F JvIvKER T
x/03109
ApplicanUAgent's Printed (dame Applicant/Agenrs Signature Date
(Agents signsmre is valid only if an authorization
letter from the is provided.)
Page 10 of 10
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:yN X729?S 6SZ
STREET ADDRESS: 1t rTaSMTF L Riy F
ec SV lU.E N C 270)-
Please print:
Property owner: WiL.uAIA Jud
/Property Owner: Y -
The undersigned, registered propehi owners of the above noted property, do hereby authorize
k /A of N
(Contracbor / Agent) (Name of consultin 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):
AAIFF IIIOC .SV LLE N. C. 2702$
Telephone: 33 67 94 !-?z8q
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
f
Y Authorized Authorized Signature
Date: __APRIL 3 ??a path.
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