20180932 Ver 1 - Buffer_and_or_Stream_Determination_Request - 7/5/2018

Submittal
Project Name:
Is this a transportation project?
What type of request is this?
300394-2018
r Yes r No
PF Buffer r IP Stream Determination
F Isolated Wetland r Stream
Check all that apply.
Owner Information
1a. Name on the Recorded Deed: Weyerhaeuser
1 b. Responsible Party (for LLC): Cliff Tyson
Telephone Number: (xxx)xxx-xxxx
How would you like to received your determination?
F W au
1c. Mailing Address: Street Address
Address Line 2
City State / Province/ Region
Fbstal / Zip Code Country
Email Address: [e-mail]
Agent/Consultant Information
Is there an agent or consultant responsible for the request?
r Yes
r No
How would you like to receive the r USPS
determination letter? r Email
Name of Agent:
Company Name:
Email Address:
Project Information
Has anyone form DWR done a previous site visit?*
r Yes
r No
r Other

Staff Name:
Date of Visit:
Site Information
Highway Number:* Cherry Run Road
Nearest Town:* washington
Nearest Named Stream:* Tranters Creek
River Basin:* Tar -Pamlico
County:
Beaufort
Please attach a map Click the upload button or drag and drop files here to attach document
of the site indicating Rttffile type only
project boundaries
on the NRCS Soil
Survey.
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
(lick the upload button or drag and drop files here to attach docurrent
Pdf file type only
Project Look Up Address: Street Address
Address Line 2
Oty State / R'ovince / Region
Rbstal / Zip Code Country
Latitude: 35.718
Longitude: -77.166
M isc attach me nts: pdr or lom file types only
By digitally signing below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act")
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the "Determination Request' form."
Signature
r��fC114--w
Date Submitted: 7/5/2018
Initial Review

Select Regional Office:*
Select Reviewer:*
ID#*
Version
Do you want to send for review?*
Washington Regional Office - [phone]
Robert Tankard: eads\rbtan kard
20180932
F Yes
r No