20190521 Ver 1_Determination Request_20190222

Stream Origin /Buffer Ap p l icab ility Determination
Processin g Information
Please note: fields mark ed with a red asterisk * below are required. You will not be able to submit the form until all
mandatory questions are answered.
Proje ct Name :*
Is this a transportation proje ct?*
What type of re que st is this?*
Owner/Ap p l ican t In formation
Owner Information
Is the re an age nt or consultant re sponsible for the re que st?*
Attach age nt authorization le tte r:*
Ag ent/Consultant Information
How would you like to re ce iv e your
de te rmination le tte r?*
Name of Age nt:*
Company Name :*
East Ridge Phase 2
Yes No
Buffer IP Stream Determination
Isolated Wetland Stream
Check all that apply.
Name on the Re corde d De e d:*
Re sponsible Party :
Te le phone Numbe r:
How would you like to re ce iv e d your de te rmination?*
Email Addre ss:*
A.T. Venters Properties, LLC
Leo Allen Venters
(for LLC, Corporations, businness, agency, etc.)
252-327-8100
USPS Email
[e-mail]
Yes
No
East Ridge Phase 2 Signed Agent
Authorization.pdf
29.88KB
PDF only
Age nt/Consultant Information
USPS
Email
Igor Palyvoda
Baldwin Design Consultants, PA
Email Addre ss:*
Proj ect an d Site Information
Has anyone form DWR done a pre v ious site v isit?*
Date of Visit:
Ne are st Highway/Stre e t:*
Ne are st Town:*
Ne are st Name d Stre am:*
Riv e r Basin:*
County:*
Ple ase attach a map of the site indicating proje ct boundarie s on the USGS 1:24,000 Topo.
TOPO map look up: https://viewe r.national map.gov/basi c/
Ple ase attach a map of the site indicating proje ct boundarie s on the NRCS Soil Surv e y.
Soil Survey Link: https://www.nrcs.usda.gov/wps/portal/nrcs/surveylist/soils/survey/state/?stateId=NC
Ple ase prov ide the Latitude and Longitude for physical location for the de te rmination that. If you hav e a
physical addre ss you can look up the Latitude and Longitude by typing in an addre ss or filling out the
information manually.
Choose be low how you would like to
prov ide this information.
Latitude :
Longitude :
ipalyvoda@baldwindesignconsultant
s.com
Proje ct Information
Yes
No
Other
Site Information
NC HWY 102 East & NCSR 1723 -
Ayden Golf Club Road
Ayden
Swift Creek
Neuse
Pitt
Click the upload button or drag and drop files here to attach document
USGS Map.pdf 291.46KB
Pdf file type only
Click the upload button or drag and drop files here to attach document
NRCS Soil Survey Map.pdf 308.55KB
Pdf file type only
Latitude and Longitude
Address Lookup
Manually
35.474874
-77.381459
M isc attachme nts:
Sig n an d Submit
By digitally signing be low, I ce rtify that:
I have given true, accurate, and complete information on this form;
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”)
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”);
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
I intend to electronically sign and submit the "Determination Request" form.”
Signature
pdf or kmz file types only
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO,
PARCEL ID: 14923 & 28404
STREET ADDRESS: On western shoulder of NCSR 1723 - Ayden Golf Club Road approximately 2,000 it from
NC HWY 102 and NCSR 1723 - Ayden Golf Club Road intersection in Ayden, NC 28513
Please print: A.T. Venters Properties LLC
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Igor Palyvoda
(Contractor / Agent)
of Baldwin Design Consultants, PA
(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):
4202 Westhaven Avenue, Ayden, NC 28513
Telephone: [phone]S2 -.32 7-- -B I DO
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authoriz Signature Authorized Signature
Date: 2 -Z- 1-/ Date:

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