20061592 Ver 1_Initial Interest_20061004

D~=T-4-2~~D6 ©8:06 FROM:Db1Q-WETLANDS 9197336893
T0: 912524384862 P:2~3
INITIAL INTEREST IN PARTICIPATIQN IN THE EXPRESS REVIEW PROGRAM
WITHIN THE 401 OVERSITEJEXPRESS PERMITTING UNIT
Sepfiember 1, 2044
Version 3
Applicant Name:_
Appllcant Address
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Applicant's phone number
Fax number:
Applicant's email address:
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Consultant Name (if applicable):
Consultant address (if applicable);
Consultant's phone number:
Fax number:
Consultant's email address;
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Type of action requested under the Express Review Program (check all that apply):
^ ~t31 Water Quality Certification [~Strearn Origin Determination
^ Isolated Wetland Permit ___/_ # of Determinations Requested
Q Riparian Buffer Approval ^ intermittentlPerennial Determination
^ Stormwater Management Plan # of Determinations Requested
^ Mitigation Plan
Q Strom ^ Wetland ~ Buffers (check all appropriate)
blame of Project: ~ Gt, rh. f7i i` ~"~ Lt.,~ ~ ~ $~ f] t'n w~yGounty: ~a ~/ ~ ~
T~t01 pro)r_ct acreage: ~~,_(acres) Total built out impervious area: y (acres)
Nearest named stream (from USGS topo map); _ ~D~ ~~.r ~,~~ _ __
Please provide a rief description of this pro'ect (attach site plan if available):
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ACT-4-2©C36 08:05 FROM: DWQ-WET~AND5 9197336893
~~
pleasr: attach a map of site location using USGS 1;24,Ogp map and county sail survey.
location of project site -please include reference to the county, nearest name town and highway number;
~L.V 1-~ $ ~ y p ~-S.c _ A n o max. ~2 .~-, .` )L ~~ .s ~'- .~
~~
c
~ u- *~ ~' o ~. ~
t~ropvsed impa`c~:
Acres of 404 wetlands:
Acres of isolated wetlands;
Linear feet of streams:
t_inear fleet of isolated streams:
Square feet of protected stream buffers:
Has consultant or applicant attended any DWQ-sponsored training sessions in the past two years? If so, please list
which onFS. /~`D
Has any DWQ staff visited the site? /~y , if yes, please provide DWQ staff name, and
dafie of visit;
Which other environmental permits from ether agencies will be Headed far this project? Please list the permits and
issuing agencies b/e~loYw: " ~ /ry J /
2 G' /" ~ _ _ ~ cz .~ ,~ lrtl 1.`c~ ~ h_ ~ etc ..~
Does this project require approval under the State Envir©nmental Policy Act or National environmental Policy Act?
j~ J
1s fihis protect an After-the-fact application or has this project received a previous Notice of Viotatian from DWQ?
~~
Dees this project require approval of a Variance from the ND trnvironrnental Management Commission? /~~
Are you aware of any IoCal controversy concerning this project? if sv, please describe the controversy and any
m~epasures that have been taken with respect to public involvement.
/y c7
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Thi& farm must be submitted via om8il (rJo 4012xOressrd~ncmail.net). faxed (919-733-6893) or handjieiiYeted to the Parkview Building, 2321
Grabtrnr Otvd., Raleigh, NC 27604. Applicants who are selected to participate in t11e Express Review Program will bo notified via email or fax
ufcthin ?. drays, ~uccesaful applicants will then be instructed regarding detailed procedures for fup application (Please Note: Submittals Of the rovlrsw
packages rJn Frtday ,after 12:04 pm will b® stamped as r0ceived on the next buslne9s day).
P1ccg~g Contact Cynthia Van Der wiele at 919-715-3473 if you have arty question& regarding this form.

T~:912524384062 P:3'3
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