20190312 Ver 1_PCN-Rev Pg 1_20190416

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Page 1 of 10
PCN Form — Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1a.
Type(s) of approval sought from the Corps:
❑X Section 404 Permit ❑ Section 10 Permit
1b.
Specify Nationwide Permit (NWP) number: 13 or General Permit (GP) number:
1c.
Has the NWP or GP number been verified by the Corps?
❑ Yes ❑X No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
X❑ 401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express X❑ Riparian Buffer Authorization
1e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes ❑X No
For the record only for Corps Permit:
❑ Yes ❑X No
1f.
Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes No
1g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
❑Yes ❑X No
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑ No
2.
Project Information
2a.
Name of project:
6319 Gainsborough Drive
2b.
County:
Wake
2c.
Nearest municipality / town:
Raleigh
2d.
Subdivision name:
Brookhaven
2e.
NCDOT only, T.I.P. or state project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
David, Sarah Triplett; Ashley, Bradford Cox; Guy, Margareth Galardi; Martha Waters
3b.
Deed Book and Page No.
DBO10278 PG02561; DBO17151 PG00483; DBO16026 PG00594; DB3976PG203
3c.
Responsible Party (for LLC if
applicable):
3d.
Street address:
6319 Gainsborough Dr; 6121 Battleford Dr; 6105 Battleford Dr; 6404 Margate Ct
3e.
City, state, zip:
Raleigh, NC 27612; Raleigh, NC 27612; Raleigh, 27612; Raleigh, 27612
3f.
Telephone no.:
3g.
Fax no.:
3h.
Email address:
Page 1 of 10
PCN Form — Version 1.4 January 2009