20090707 Ver 1_Initial Interest_20090617

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I ?1OC Form Version 6
January 28, 2009
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INITIAL INTEREST IN PARTICIPATION IN THE EXPRESS REVIEW PROGRAM
WITHIN THE 401 OVERSITE/EXPRESS PERMITTING UNIT
A. Applicant Information
1, Processing
? 401 Water Quality Certification (List NW(s) or GP# verified by Corps: )
? Non-404 Jurisdictional Permit
? Riparian Buffer Authorization
1a. Type(s) of actions ? Riparian Buffer Minor Variance
requested: ? Coastal General "Major' Variance
(Check all that apply) ? Stream Determination: 1 # Streams
? Non-404 Wetland Determination: # Wetlands
? Stormwater Management Plan Review (fee not additive if combined with 401):
# of Drainage Areas/Project Site
2, Project Information
2a. Name of project: Chapel Ridge Manor
2b. County: Halifax
2c. Latitude/Longitude: Lat: -77.65728 Long: 36.43603
2d. River Basin: Roanoke
2e. Tax PIN or parcel ID: 3997-07-58-5996
2e. Nearest Named Stream: Chockoytte Creek [from USGS Topographic Map]
2f. Water Quality Classification of Nearest Named Stream: C
2g. Total project acreage: (acres) [Stream or Wetland determinations may omit this item]
2h. Total built out imperviousness: (%) [Stream or Wetland determinations may omit this item]
2i. Provide a brief description of this project (attach site plan):
This project includes a road extension, a new road, and an apartment building with associated sidewalk, parking, etc.
2j. Provide directions from the nearest named town, including street names and/or or highway numbers:
The site is located in Roanoke Rapids, NC. From Interstate 95, go west on NC Hwy 158. Turn left onto southbound NC
Hwy 125/Smith Church Rd. Continue on Smith Church Rd/SR 1686, and turn right onto Southgate Dr. Turn left onto
Old Town Dr. The site is located at the end of Old Town Dr.
Please attach a map of site location using USGS 1:24,000 topographic map and the latest bound and
published County soil survey with the project/site boundaries delineated. A site plan should also be
included for all projects other than stream and wetland determinations.

3. Applicant Information
3a. Applicant is: ? Owner ?x Agent ? Other, specify:
3b. Name: Jon Frazier, PE
3c. Business name (if applicable): Crowley, Crisp & Associates, Inc.
3d. Street address: 1906 South Main Street, Ste 122
3e. City, state, zip: Wake Forest, NC 27587
3f. Telephone no.: 919.562.8860 x29 3g. Fax no.: 919.562.8872
3h. Email address: [e-mail]
4. Agent/Consultant Information (if applicable)
4a. Contact Name:
4b.Company name:
4c. Street address:
4d. City, state, zip:
4e. Telephone no,: 4f. Fax no.:
4g. Email address:
5. Proposed Impacts (include both temporary and permanent) [Determination requests may omit this section)
5a. Total 404/401 wetland impacts: (acres) 5b. Total non-404 wetland impacts: (acres)
5c. Total 404 stream impacts: Intermittent: (linear feet) Perennial: (linear feet)
5d. Total non-404 stream impacts: Intermittent: (linear feet) Perennial: (linear feet)
5e. Total riparian buffer impacts: Zone 1: (square feet) Zone 2: (square feet)
6. Project History and Additional Information
6a. Has any DWQ staff visited the site? ? Yes ?x No
If yes, provide staff name: and date of visit:
6b. Does this project require a Stormwater Management Plan? ?x Yes ? No ? Unknown

6c. Who will be responsible for the review of the
Stormwater Management Plan? n Certified Local Government:

?DWQ Stormwater Program
? DWQ 401/Express Review Unit
6d. Does this project require approval under SEPA or NEPA? ? Yes N No
6e. Is this project an after-the-fact application or has a DWQ notice of violation been issued? ? Yes No
6f. Does this project include buffer impacts that are "prohibited" in the DWQ "Red Rule Book? ? Yes No
6g. If you are aware of any local controversy concerning this project, provide details in a cover letter. Describe the
controversy and any measures that have been taken with respect to public involvement.
This form must be submitted via email c/o,Q1,c xl?iess,@rlc:rnail.nei, faxed (919-733-6893), or hand-delivered to: Parkview
Building, 2321 Crabtree Blvd. Suite 250, Raleigh, NC 27604. Applicants who are selected to participate in the Express
Review Program will be notified via email or fax. Successful applicants will then be instructed regarding detailed
procedures for full application (Note: Submittals of the review packages on Friday after 92:00 pm wilt be stamped as
received on the next business day).
Please contact Lia Myott Gilleski or Joseph Gyamfi at 919-733-1786 if you have any questions regarding this form.
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