1_FINALSAW-JD-REQUEST-FORM-2018-10-09

urisdictional Determination ReQuest
US Army Corps
of Engineers
Wllhninr�, ton O�iStnCd
This form is intended for use by anyone rec�uesting a jurisdictional detei-mination (JD) from the
U.S. Anny Corps of Engineers, Wihnington District (Coi-ps). Please include all supporting
information, as described within each category, with your request. You may submit your request
via mail, elech-onic �nail, or facsi�nile. Requests should be sent to the appropriate project
manager of the county in which the property is located. A current list of project managers by
assigned counties can be fouild on-line at:
littp://www.saw.usace.ai�ny.mil/Missions/ReaulatoiyPei�nitPrograin/Contact/CotultyLocator.aspx,
by calling 9l 0-251-4633, or by contacting any of the field offices listed below. Once your
request is received you will be contacted by a Corps project manager.
ASHEVILLE & CI�ARI.OT"I`E REGULATORY
FIELD OFFICES
US Ai�i�y Corps of Enginccrs
I 51 Patton Avenue, Room 208
Ashcvillc, Nortl� Carolina28801-5006
GeueralN�imber: [phone]
I'ax Nui��ber: [phone]
RALEIGH REGULATORY 1�'IELD OFFICE
US Anuy Co�ps aF Engineers
3331 Hcritagc Tradc Drive, Suitc 105
Wake Forest, Nortli Carolina 27587
Gcncral Numbcr: (919 ) 554-4884
Fax Number: [phone]
1NSTRUCTIONS:
WASHINGTON REGULATORY P'IELD OFFICE
US /�rmy Corps of Enginccrs
2407 West Fifth Street
Washington, North Carolina 27889
General Nurnber: [phone]
Fax Numbcr: [phone]
WILNIINGTON R�GULATORY FIELD OFFICE
US Arnry Corps of Engineers
69 Darlinaton Avei�ue
WilmingYon, Noril� Carolina 28403
Gcneral Number: 910-25 I -4633
Fax Number: [phone]
All requestors must complete Parts A, B, C, D, E, F and G.
NOTE TO CONSULTANTS AND AGENCIES: If you are requesting a JD on behalf of a
paying client or your agency, please note the specific subinittal requirements in Part H.
NOTE ON PART D— PROPERTY OWNER AUTHORIZATION: Please be aware that
all JD requests �nust i��clLide tlle current propet-ty ovv��er authorization for the Coips to
proceed with the detei-mination, which may iilclude inspection of the propei-ty when
necessary. This fonn ��nust be signed by the curt-ent pl-operty owner(s) oi�- the owner(s)
authorized agent to be considered a complete request.
NOTE ON PART D- NCDOT REQUESTS: Property owner authorization/notification for
JD requests associated with North Carolina Departme��t of Transportation (NCDOT)
projects will be conducted according to the clu-�ent NCDOT/USACE protocols.
NOTE TO USDA PROGRAM PARTICiPANTS: A Corps approved oi- preliminary JD
inay not be valid for the wetland conservation p�-ovisions of the Food SecLirity Act of
1985. If you or your tenant are USDA Program pai-ticipants, or anticipate participation in
USDA programs, you should also request a certitied wetland determination from the local
office of the Natural Resources Consei-vation Service, prior to starting work.
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Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: HICkOry Tree ROad
city, state: Winston Salem, NC
B.
C.
County:
Davidson
Parcel Index Number(s) (PIN): NA
REQUESTOR INFORMATION
Name: Amy Euliss, NCDOT-PDEA
Mailing address: 375 Silas Creek Parkway
Winston Salem, NC 27127
Telephone Number:
Electronic Mail Address:
Select one:
336-747-7800
[e-mail]
� I am the current property owner.
� I am an Authorized Agent or Environmental Consultantl
� Interested Buyer or Under Contract to Purchase
� Other, please eXplain. NCDOT Division Environmental
Officer
PROPERTY OWNER INFORMATIONZ
Name: Il/a
Mailing Address:
Telephone Number:
Electronic Mail Address:
1 Must provide completed Agent Authorization Form/Letter.
2 Documentation of ownership also needs to be provided with request (copy of Deed, County GIS/Parcel/Tax Record).
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Jurisdictional Determination Request
D. PROPERTY ACCESS CERTIFICATION3,a
By signing below, I authorize representatives of the Wilmington District, U.S. Army Corps of
Engineers (Corps) to enter upon the property herein described for the purpose of conducting on-
site investigations, if necessary, and issuing a jurisdictional determination pursuant to Section
404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of 1899. I, the
undersigned, am either a duly authorized owner of record of the property identified herein, or
acting as the duly authorized agent of the owner of record of the property.
Print Name
Capacity: ❑ Owner ❑ Authorized AgentS
Date
Signature
E. REASON FOR JD REQUEST: (Check as many as applicable)
� I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all aquatic resources.
� I intend to construct/develop a project or perform activities on this parcel which would be
designed to avoid all jurisdictional aquatic resources under Corps authority.
✓❑ I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps, and the JD would be used to avoid and minimize
impacts to jurisdictional aquatic resources and as an initial step in a future permitting
process.
� I intend to construct/develop a project or perform activities on this parcel which may
require authorization from the Corps; this request is accompanied by my permit application
and the JD is to be used in the permitting process.
� I intend to construct/develop a project or perform activities in a navigable water of the
U.S. which is included on the district Section lO list and/or is subject to the ebb and flow of
the tide.
� A Corps JD is required in order obtain my local/state authorization.
� I intend to contest jurisdiction over a particular aquatic resource and request the Corps
confirm that jurisdiction does/does not exist over the aquatic resource on the parcel.
� I believe that the site may be comprised entirely of dry land.
� Other:
For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E.
If there are multiple parcels owned by different parties, please provide the following for each additional parcel on a
continuation sheet.
5 Must provide agent authorization form/letter signed by owner(s).
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F.
�
�❑
�
G.
�
Jurisdictional Determination Request
JURISDICTIONAL DETERMINATION (JD) TYPE (Select One)
I am requesting that the Corps provide a preliminarX JD for the property identified herein.
A Preliminary Jurisdictional Determination (PJD) provides an indication that there may
be "waters of the United States" or "navigable waters of the United States"on a property.
PJDs are sufficient as the basis for permit decisions. For the purposes of permitting, all
waters and wetlands on the property will be treated as if they are jurisdictional "waters of
the United States". PJDs cannot be appealed (33 C.F.R. 331.2); however, a PJD is
"preliminary" in the sense that an approved JD can be requested at any time. PJDs do
not expire.
I am requesting that the Corps provide an approved JD for the property identified herein.
An Approved Jurisdictional Determination (AJD) is a determination that
jurisdictional "waters of the United States" or "navigable waters of the United
States" are either present or absent on a site. An approved JD identifies the limits of
waters on a site determined to be jurisdictional under the Clean Water Act and/or
Rivers and Harbors Act. Approved JDs are sufficient as the basis for permit
decisions. AJDs are appealable (33 C.F.R. 331.2). The results of the AJD will be
posted on the Corps website. A landowner, permit applicant, or other "affected
party" (33 C.F.R. 331.2) who receives an AJD may rely upon the AJD for five years
(subject to certain limited exceptions explained in Regulatory Guidance Letter OS-
02).
I am unclear as to which JD I would like to request and require additional infortnation
to inform my decision.
ALL REQUESTS
Map of Property or Project Area. This Map must clearly depict the boundaries of the
review area.
✓❑ Size of Property or Review Area 245 acres.
❑ The property boundary (or review area boundary) is clearly physically marked on the site.
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Jurisdictional Determination Request
H. REQUESTS FROM CONSULTANTS
� Project Coordinates (Decimal Degrees): Latitude: 35.985536
Longitude: -80.247033
� A legible delineation map depicting the aquatic resources and the property/review area.
Delineation maps must be no larger than l 1x17 and should contain the following: (Corps
signature of submitted survey plats will occur after the submitted delineation map has been
reviewed and approved).6
■ North Arrow
■ Graphical Scale
■ Boundary of Review Area
■ Date
■ Location of data points for each Wetland Determination Data Form or tributary
assessment reach.
For A�roved Jurisdictional Determinations:
■ Jurisdictional wetland features should be labeled as Wetland Waters of the US, 404
wetlands, etc. Please include the acreage of these features.
■ Jurisdictional non-wetland features (i.e. tidal/navigable waters, tributaries,
impoundments) should be labeled as Non-Wetland Waters of the US, stream, tributary,
open water, relatively permanent water, pond, etc. Please include the acreage or linear
length of each of these features as appropriate.
■ Isolated waters, waters that lack a significant nexus to navigable waters, or non-
jurisdictional upland features should be identified as Non-Jurisdictional. Please
include a justification in the label regarding why the feature is non jurisdictional (i.e.
"Isolated", "No Significant Nexus", or "Upland Feature"). Please include the acreage
or linear length of these features as appropriate.
For Preliminarv Jurisdictional Determinations:
Wetland and non-wetland features should not be identified as Jurisdictional, 404,
Waters of the United States, or anything that implies jurisdiction. These features can be
identified as Potential Waters of the United States, Potential Non-wetland Waters of
the United States, wetland, stream, open water, etc. Please include the acreage and
linear length of these features as appropriate.
aCompleted Wetland Determination Data Forms for appropriate region
(at least one wetland and one upland form needs to be completed for each wetland type)
6 Please refer to the guidance document titled "Survey Standards for Jurisdictional Determinations" to ensure that the
supplied map meets the necessary mapping standards. http://www.saw.usace.army.miUMissions/Re u,g latory-Permit-
Pro,gram/Juri sdiction/
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a
✓❑
✓❑
�
❑
Jurisdictional Determination Request
Completed appropriate Jurisdictional Determination form
PJDs, please complete a Preliminary Jurisdictional Determination Form' and include the
Aquatic Resource Table
AJDS, please complete an Auuroved Jurisdictional Determination Formg
Vicinity Map
Aerial Photograph
USGS Topographic Map
Soil Survey Map
� Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site
Plan, previous delineation maps, LIDAR maps, FEMA floodplain maps)
� Landscape Photos (if taken)
� NCSAM and/or NCWAM Assessment Forms and Rating Sheets
� NC Division of Water Resources Stream Identification Forms
� Other Assessment Forms
� www.saw.usace.army.mil/Portals/59/docs/re u,g lato .r�gdocs/JD/RGL 08-02_A�_A_Prelim JD_Form fillable.pdf
g Please see http://www.saw.usace.army.mil/Missions/Re u� latorv-Permit-Program/Jurisdiction/
Principal Purpose: The information that you provide will be used in evaluating your request to determine
whether there are any aquatic resources within the project area subject to federal jurisdiction under the regulatory
authorities referenced above.
Routine Uses: This information may be shared with the Department of Justice and other federal, state, and local
government agencies, and the public, and may be made a�ailable as part of a public notice as required by federal
law. Your name and property location where federal jurisdiction is to be determined will be included in the
approved jurisdictional determination (AJD), which will be made available to the public on the District's website
and on the Headquarters USAGE website.
Disclosure: Submission of requested information is voluntary; however, if information is not provided, the
request for an AJD cannot be evaluated nor can an AJD be issued.
Version: May 2017 Page 6