20090161 Ver 1_Major Variance_20090501

2009016
OFFICE USE ONLY: Date Received _ Request #
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State of North Carolina FEB 7
Department of Environment and Natural Resources zoo
Division of Water Quality
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"General" Major Variance Application Form -
From the Neuse and Tar-Pamlico Riparian Buffer Protection Rules for residential structures
on existing lots within the coastal counties as defined by the Coastal Area Management Act
(As approved by the Water Quality Committee of the Environmental Management Commission on 5/9/2001)
Please identify which Riparian Area Protection Rule applies.
Neuse River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (15A NCAC .0233)
? Tar-Pamlico River Basin: Nutrient Sensitive Waters Management
Strategy Protection and Maintenance of Riparian Areas Rule (15A
NCAC.0259)
NOTE:
To constitute a complete application, all of the information requested in this form
must be provided. Incomplete applications will be returned to the applicant. The
original and two copies of the completed "General" Variance Application Form and
any attachments must be sent to the DWQ 4011Wedands Certification Unit, 1650 Mail
Service Center, Raleigh, NC 27699-1650, 919-733-1786 to constitute a complete
submittal. This form may be photocopied for use as an original.
Part 1: General Information
(Please include attachments if the room provided is insufficient.)
1. Applicant's name (the corporation, individual, etc. who owns the property):
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2. Print Owner/Sic
Name: v
Title:
Street address:
City, State, Zip:
Telephone:
Fax:
fining Official (person legally responsible for the prc
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perty and its compliance)
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3. Contact person who can answer questions about the proposed project:
Name:
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Fax: z ? z '1
"General" Variance Application Form
Version 1: May 2001
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4. Project Name (Subdivision, facility, or establishment name - consistent with project name on
plans, specifications, letters, operation and maintenance agreements, etc.):
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5. Project Location:
Street address: _ n `7 /,,J cc cr S c- V/ [ e 4 G c- 2Q
City, State, Zip: s/ Q
County: , ," I -k 3
Latitude/longitude: ct c,c?' 0C)" 6. Directions to site from nearest major intersection (Also, attach an 8 % x 11 copy of the portion
of the USGS topographic map indicating the location of the site):
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7. Stream to be impacted by the proposed activity:
Stream name (for unnamed streams label as "UT" to the nearest named stream):
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Stream classification [as identified within the chedule of Classifications 15A NC?16 2B
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.0315 (Neuse) or.0316 (Tar-Pamlico)]: 5/4 . la U+- S i,t l d "-r -7, 7-('
8. Which of the following permits/approvals 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
Active Connection to Sanitary Sewer System
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.:
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2. State reasons why this plan for the proposed activity cannot be practically accomplished,
reduced or reconfigured to better minimize or eliminate disturbance to the riparian buffers:
"General" Variance Application Form, page 2
Version 1: May 2001
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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.):
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4. Please provide an explanation of the following:
(1) The practical difficulties or hardships that would result from the strict application of this
Rule.
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(2) How these difficulties or hardships result from conditions that are unique to the property
involved.
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(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.
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Part 3: Deed Restrictions
By your signature in Part 5 of this application, you certify that all structural stormwater best
management practices required by this variance shall be located in recorded stormwater
easements, that the easements will run with the land, 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 complete this section:
Designated agent (individual or firm):
Mailing address:
City, State, Zip: _
Telephone:
"General" Variance Application Form, page 3
Version 1: May 2001
Fax:
Email:
Part 5: Applicant's Certification
C-?_ _--_------_------- ___ (print or type name of person
listed in Part I, Item 2), certify that the information included on this permit application form is
correct, that the project will be constructed in conformance with the approved plans and that the
deed restrictions in accordance with Part 5 of this form will be recorded with all required permit
conditions.
Signature:
Date:
Title:__-

"General" Variance Application Form, page 4
Version 1 : May 2001
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