20181203 Ver 1_Determination_Request_20180829

Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are ansmred.
Project Name:* Cypress Ridge
Is this a transportation project?* r Yes r No
What type of request is this?* r% Buffer rJ IP Stream Determination
r- Isolated Wetland r Stream
Check all that apply.
Owner Information
Name on the Recorded Deed:* Sasser Home Builders
Responsible Party: Ronald R. Sasser, III
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: (xxx)xxx-xxxx
How would you like to received your determination?*
F W
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?
F Yes
r No
Attach agent authorization letter:* Buffer App - Stream Origin Determination
1.21 MB
Req uest-20180829151802. pdf
FDF only
Agent/Consultant Information
How would you like to receive your r USPS
determination letter?* F Email
Name of Agent:* Bryan K Jones
Company Name: * Bryan K Jones Consulting
Engineers, PA
Email Address:* [e-mail]
Has anyone form DWR done a previous site visit?*
C Yes
F No
r Other

Date of Visit:
Site Information
Nearest Highway/Street:*
Bardon-Scott Rd
Nearest Town:*
Goldsboro
Nearest Named Stream:*
Howell Branch
River Basin:*
Neuse
County:*
Wayne
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach docurrent
USGS Northeast Goldsboro.pdf 5.87MB
Fttf file type only
TOPO map look up: https://viewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
Click the upload button or drag and drop files here to attach docurrent
Soil map14.pdf 999.4KB
Fttf file type only
Soil Survey Link: https://vmw.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
Please provide the Latitude and Longitude for physical location for the determination that. If you have a
physical address you can look up the Latitude and Longitude by typing in an address or filling out the
information manually.
Choose below how you would like to provide this information.
r Address Lookup
r Manually
Latitude: 35.429843
Longitude: -77.974911
M isc attach me nts: pdf or krre file types only
By digitally signing below, I certify that:
o I have given true, accurate, and complete information on this form;
o 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")
o 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');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Determination Request' form."
Signature Sign

Date Submitted:
Initial Review
IN*
Version
Do you want to send for review?*
Select Reviewer:*
Select Regional Office:*
8/29/2018
20181203
r Yes r No
Robert Tan kard:eads\rbtan kard
Washington Regional Office - [phone]

14
N
WAYNE COUNTY, NORTH CAROLINA - SHEET NUMBER 14
N
0

Water Resources
Environmental Quality
ROY COOPER
Governor
MICHAEL S. REGAN
Secretury
LINDA CULPEPPER
interim Director
DWR Use Only: Project #:
Date Received:
Buffer Applicability / Stream Origin Determination Request
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
Ia. Name(s) on Recorded Deed SA,-S$FQ 00/-167 BO/LD S IM6
lb. Responsible Party (for LLC) 1JRt t�
1c. Mailing Address (y -Z t� s �� �, O t D5 30 NL 530
1d. Telephone Number 9 lii _ 22 1e. Email address (On 5 g C- >:'-'
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
3.
Agent / Consultant Information
3a. Agent/ Consultant Name
13f_)tw V JOnI
3b. Company
?` 4i t< OKlrr �e5/CFdialC�!'+�- t'G�
3c. Mailing address
pD X /Ogos G.0LD513Cse'C> L 2 7S3 Z
3d. Telephone no.
q 19 L 1 - z m-1 3e. Email address I 6p, "L � "'e' //: C-1
4, Project / Site Information
4a. Name of project
Lcypilt3s ) �
4c. Nearest Named Stream
���t� &2+W4
�,
4b. County
4d. River Basin
IOt
I�fUSE
5. Project Description (attach plan if available)
6. Has anyone from DWQ visited the site? Iy /V 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
Next business day
Email: [e-mail]
Please contact Anthony Scarbraugh at the Washington Regional Office at [phone] if you have any
questions.
Nothing Compares=...._
State of North Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations Stolon -Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

PROPERTY LEGAL DESCRIPTION:
LOT NO.
AGENT AUTHORIZATION FORM
PLAN NO. PARCEL ID: _ SL O j4 Zg 4VP
STREET ADDRESS: 10 4- P 01 rJ CSS D a. 6 o KSP o O19 AiC 2 75 a
Please print:
Property Owner:
Signature Q
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) (Name 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: 1/7- 242 ` 78. 7
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowled e.
°
v
QSf nature
Date: ��
Authorized Signature
Date: