20180746 Ver 1_Stream Buffer Determination Request_20180530

Water Resources
ENVIRONMENTAL OUALITY
RECEIVED/NCDENR/DWR PAT MCCRORY
MAY 3 0 2018 DONALD R. VAN DER VAART
Water Quality Regional S. JAY ZIMMERMAN
Operations Section
Washington Regional Office
DWR Use Only: Project 4 �'� �7yly
Stream Origin/Buffer Applicability Determination
Required Information
1, Owner Information (corporationrindividual who is legally responsible for the property and its compliance)
1a. Name(s) on Recorded Deed
A. T. Venters Properties, LLC
1 b. Responsible Party (for LLC)
Leo Allen Venters
1c. Mailing Address
4202 Wesihaven Avenue, Ayden, NC 28513
1 d. Telephone Number
252-355.3346
11 a. Email Address
I leoventers®mail.com
2. Location of Project Site - please include the county, nearest named town and highway number: The project site is located at the
intersection of NC 102 and NCSR 1746 — Stanley Road in Ayden, Pitt County, NC.
3. Has anyone from DWR visited the site?
No
I Staff Name
I N/A
Date of Visit?
I N/A
Additional Requested Information
4. Agent/Consultant Information (if applicable)
4a. Name, Company
Igor Palyvoda, Baldwin Design Consultants, PA
4b. Mailing address
1700-D East Arlington Boulevard
4c. Telephone no.
252-756-1390 Ext. 205
4d. Email address
ipalyvoda®baldwindesignconsultants.
com
5. Project and Site Information
5a. Name of project
Harris Ridge Phase 2
5b, County
Pitt
5c. Nearest Named Stream
Indian Well Swamp
5d. River Basin
I 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
Washington, NC 27889 Note: Submittals on Friday after 12:00 pm
will be stamped as received on the
Fax: [phone] next business day.
Email- anihony.scarbrauchOncdenccov
Please contact Anthony Scarbraugh at [phone] if you have any questions.
State of North Carolina I Environmental Quality l Water Resources -Water Quality Regional Opersuons-Washington Regional Office
947 Washington Square Mall. Washington, NC 27889
252-946-6481

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 04862
STREEyyDDRESS, At the intersection of NC 102 and NCSR 1746 -
Stanley Road in Ayden, NC 28590
Please Pmpeny Ov jr f1T �&LI7CCCI[n&i'T1EtLLC,
Property Owren:
The undersigned, registered property owrers of the above noted property, do hereby audnrtm
Igor Palyvoda Of Baldwin Design Consultants, PA
(CanbedW Agent) (Name of owtsuWng firm)
to as on my behalf and take all action necessary fa the Prcrasing, Issuance and acceptance of
this permit or certification and any and all standard am special conditions attached.
Property Owners Address (N dttferent than property above):
4202 Westhaven Avenue, Ayden, NC 28513
Telephone: [phone]
We hereby cardry the above Infarmatlan wbrn bed in this application Is true and amoste to the
best of as knavbige.
Au lzad Slgnatura Autborhed Signature
Date: Date:

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