20180958 Ver 1_Buffer determination request form_20180712

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
Water Resources LINDA CULPEPPER
Environmental Quality Interim Director
DWR Use Only: Project fi:
Date Received:
Buffer Applicability / Stream Origin Determination Request
3.
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
1a. Name(s) on Recorded Deed
Wesleyan Pentecostal Church of Washington
lb. Responsible Party (for LLC)
Daniel J. Woods (pastor)
lc. Mailing Address
7656 Highway 264 East, Washington NC
1d. Telephone Number
252-402-5348 1 le. Email address [e-mail]
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
7656 Highway 264 East, Washington, NC
3.
Agent/ Consultant Information
3a. Agent/ Consultant Name
Daniell. Woods
3b. Company
Wesleyan Pentecostal Church of Washington
3c. Mailing address
7656 Highway 264 East, Washington NC
3d. Telephone no.
252-402-5348 1 3e. Email address
[e-mail]
4. Project / Site Information
Washington
4a. Name of project
Pentecostal Church
4c Nearest Named Stream
Sanctuary
Expansion
4b. County
4d. River Basin
S. Project Description (attach plan if available)
6. Has anyone from DWQ visited the site? I Y / N I Staff Name: Date of Visit:
7. 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 DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitigation? Nutrient offset credit?
8. Please return form to: Anthony Scarbraugh
943 Washington Square Mall Note: Submittals on Friday after 12:00 pm
Washington, NC 27889 Will be stamped as received on the
Email: [e-mail] Next business day
--` Nothtng Compares: -
State of North Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations Section -Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

Please contact Anthony Scarbraugh at the Washington Regional Office at [phone] if you have any
questions.
PROPERTY LEGAL DESCRIPTION:
LOT NO.
AGENT AUTHORIZATION FORM
PLAN NO.
PARCELID:
STREET ADDRESS: _ 76� fi/v y �G �/ e— �it/ia3�y„rq �y ✓ /✓�
Please print:
Property Owner:
Signature
Property Owner:
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The undersigned, registered property owners of the above noted property, do hereby authorize
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(Contractor / Agent) (Namd of consulting 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):
Telephone: ZS2 yd Z �3y�
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
Authorized Signature
Authorized Signature
Date: Date: