20051252 Ver 1_Complete File_20050707

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OCT 1 3 2005 3

Certificate of Completion

DWQ Project No.:

05 -}25'.J-

County:

1) fH/ (,d. <; II M
- DENR.. WATER QUM.LllV
WETlANDS AND STORItNATER BRANCH

Applicant:

~b'rcrf pllko-Q ,1.. L.('
/
~ikrl- PIt'Ar~

Project Name:

Date of Issuance of 401 Water Quality Certification:

IlCA.S l4sf J:J../ 20 OS

Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 40l/Wetlands Unit, North
Carolina Division of Water Quality, 1621 Mail Service Center, Raleigh, NC, 27699-1621. This form may be
returned to DWQby the applicant, the applicant's authorized agent; or the project engineer. It is not
necessary to send certificates from all of these.

Applicant's Certification

I, J)/fIJ; dR. Q,t::\. Y' ho.€ r , hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.

Signature: Jf)CtM'j ~.~
,

Date: 1-~6-()5

Agent's Certification

I, J)lfl//'d 1(- ~ rn-e r , hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.

Signature: ,AQ~;/~.h~o_

Date: ?-~f,-o 5

If this project was designed by a Certified Professional

I, VJu..L\Atv\ I:i, MlTCk\e=u.... , as a duly registered Professional Et..i(;'t-:le~ (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to
observe (periodically, weekly, full time) the construction of the project, for the Permittee hereby state that,
to the best of my abilities, due care and diligence was used in the observation of the construction such that
the construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.

Signature: VJ~ .~ ~

Registration No.: t-ic.. 7480 Date: :3 .. 'Z !J - D .5

Ebert Place, LLC
Lexington, NC 27295

j

Michael F, Easley, Governor

William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources

Alan W, Klimek, P.E. Director
Division of Water Quality

August 12, 2005
DWQ# 05-1252
Davidson County

Mr. DavidR. Gamer
Elbert Place, LLC
11395 Old U. S. Highway 52
Winston-Salem, NC 27107

APPROVAL of 401 Water Quality Certification with Additional Conditions

Dear Mr. Gamer:

Elbert Place, LLC has our approval, in accordance with the attached conditions, to place permanent fill in 120
linear feet of intermittent stream in order to construct a road crossing for the Elbert Place subdivision located on
Arnold Road, near Lexington, in Davidson County, as described in your application received by the Division of
Water Quality (DWQ) on July 7, 2005. Mter reviewing your application, we have determined that this fill is
covered by General Water Quality Certification Number 3404, which can be viewed on our web site at
http://h2o.enr.state.nc.us/ncwetlands.This Certification allows you to use Nationwide Permit Number 14 when
it is issued by the U.S. Army Corps of Engineers. In addition, you should secure any other applicable federal,
state or local permits before you proceed with your project, including (but not limited to) those required by
Sediment and Erosion Control, Non-Discharge, and Water Supply Watershed regulations. Also, this approval
will expire when the accompanying 404 permit expires unless otherwise specified in the General Certification.

This approval is valid only for the purpose and design that you have described in your application. If you
change your project, you must notify us in writing, and you may be required to send us a new application for a
new certification. If the property is sold, the new owner must be given a copy of this Certification and approval
letter and is thereby responsible for complying with all conditions. If total wetland fill for this project (now or
in the future) exceeds one acre, compensatory mitigation may be required as described in 15A NCAC 2H .0506
(h). For this approval to be valid, you must follow the conditions listed in the attached Certification, as
well: as the additional conditions listed below:

1. The following impacts are hereby approved as long as all other specific and general conditions of this
Certification are met. No other impacts, including incidental impacts, are approved:

Amount Approved Plan Location or Reference
Streams 120 linear feet Unnamed tributary to Swearing Creek
located southeast of Arnold Road between
Conrad Sowers Road and West Center
Street Extension, near Lexington, in
Davidson County.

N.?{thCarolina
/Vo/llrnl/!!

North Carolina Division of Water Quality
Wetlands Certification Unit 1650 Mail Service Center
2321 Crabtree Blvd.
Customer Service Number: 1-877,623-6748

Raleigh, NC 27699,1650
Raleigh, NC 27604-2260

Phone (919)733,1786 FAX (919) 733,2496
Intemet http//:h2o.enr.state.nc.us/ncwetlands

An Equal Opportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper

Mr. David R. Gamer
Page 2
August 12, 2005

'.

2. Appropriate sediment and erosion control measures which equal or exceed those outlined in the most
recent version of the North Carolina Sediment and Erosion Control Planning and Design Manual or the
North Carolina Surface Mining Manual (available froni the Division of Land Resources at NCDENR
regional offices or the central office), whichever is more appropriate, shall be designed, installed and
maintained properly to assure compliance at all times with the North Carolina water quality standards
that are applicable to Class C waters as described in 15A NCAC 02B .0211 Fresh Surface Water Quality
Standards For Class C Waters. Such measures must equal or exceed the requirements specified in the
most recent version of the North Carolina Sediment and Erosion Control Manual. These measures must
be maintained on all construction sites, borrow sites, and waste pile (spoil) sites, including contractor
owned and leased borrow pits, which are associated with this project.

3. Sediment ancLerosion con!r.<:>1l11easures s.lul.ll_noJ ge pl~~d it! ~e~lands ~r wate~_ t5' the maximum extent
practicable. If placement of sediment and erosion controI' measures in wetlailas or wafersis'imavoIOable,
they shall be removed and the natural grade restored within six months of the date that the project is
completed or, if applicable, within six months of the date that the project is released by the North
Carolina Division of Land Resources.

4. No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas beyond the
footprint of the impacts depicted in the Pre-Construction Notification. All construction activities,
including the design, installation, operation, and maintenance of sediment and erosion control "Best
Management Practices" shall be performed so that no violations of state water quality standards,
statutes, or rules occur.

5. The culvert required for this project shall be installed in such a manner that the original stream profile is
not altered (i.e. the depth of the channel must not be reduced by a widening of the streambed). Existing
stream dimensions (including the pattern and profile) are to be maintained above and below the location
of the culvert. The culvert shall be designed and installed to prevent head cutting of the stream. If the
culvert becomes perched, the appropriate stream grade shall be re-established or, if the culvert is
installed in a perched manner, the culvert shall be removed and re-installed correctly. The Applicant
must submit a plan and receive written approval from this Office to address any head cutting that will
occur as a result of this project (e.g., use of cross vanes downstream of the culvert).

,--~_. -- _.- -

6. Where riprap is required for energy dissipation and scour protection, it shall be limited to the minimum
dimensions specified by appropriate engineering calculations. Riprap may only be used below the
normal high water level. The original grade and elevation of the stream's cross-section must be
maintained. Riprap placed in the stream bottom must be inserted into the bottom matrix to a depth
sufficient to provide the thickness of riprap required for scour protection. The elevation of the stream
bottom must not be increased by the placement of riprap. Placement of riprap must not result in
destabilization of the streambed or banks upstream or downstream.

7. Energy dissipation and sheet flow must be provided for all discharges of stormwater before such
discharges reach stream channels or wetlands.

8. All construction activities associated with this project shall minimize built-upon surface area, direct
stormwater runoff away from surface waters, and incorporate best management practices to minimize
water quality impacts. If concrete is used with any fill material, it shall not be allowed to come in
contact with surface waters until it has cured. If any stormwater must be collected for discharge into a

Mr. David R. Gamer
Page 3
AugUst 12, 2005

..

stream channel, it shall not enter the stream as a point source, but shall be slowed and discharged as
sheet flow prior to entering the riparian buffer on either side of the stream.

9. Upon completion of the project, the Applicant shall complete and return the enclosed "Certificate of
Completion" form to notify NCDWQ when all work included in the 9401 Certification has been
finished. This certificate should be sent to the 401/Wetlands Unit of the NC Division of Water Quality
at the address listed on the form. Along with the Certificate of Completion form, please send
photographs upstream and downstream of the culvert to document correct installation.

If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You
must act within 60 days of the date that you receive this letter. To ask for a hearing, send a written petition
which conforms to Chapter 150B of the North Carolina General Statutes to the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This certification and its conditions are final
and binding unless you ask for a hearing.

This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If
you have any questions, please telephone Daryl Lamb in the DWQ Winston-Salem Regional Office at 336-771-
4600, extension 293.

m@@[gUW@@

AUG 1 8 2005

Sincerely,

1Jt~

PK Alan W. Klimek, P.E.

""" OI1N.il. WAlFf{ OUA'!
""fIN.vb AMi ~jQitMW;It:I(f,J~CI1

A WKfcdl

Attachments

cc: Mr. Eric Alsmeyer, U. S. Army Corps of Engineers, Raleigh Regulatory Field Office
Winston-Salem DWQ Regional Office
Central Files
Wetlands/401 File Copy
Mr. William E. Mitchell, William E. Mitchell Associates, 1903-C Ashwood Court, Greensboro, NC 27455

fI#-

-

Michael F. Easley, Governor

William G. Ross Jr" Secretary
North Carolina Department of Environment and Natural Resources

Alan W, Klimek, P.E, Director
Division of Water Quality

August 12, 2005
DWQ# 05-1252
Davidson County

Mr. David R. Garner
Elbert Place, LLC
11395 Old U. S. Highway 52
Winston-Salem, NC 27107

APPROVAL of 401 Water Quality Certification with Additional Conditions

Dear Mr. Gamer:

Elbert Place, LLC has our approval, in accordance with the attached conditions, to place permanent fill in 120
linear feet of intermittent stream in order to construct a road crossing for the Elbert Place subdivision located on
Arnold Road, near Lexington, in Davidson County, as described in your application received by the Division of
Water Quality (DWQ) on July 7, 2005. After reviewing your application, we have determined that this fill is
covered by General Water Quality Certification Number 3404, which can be viewed on our web site at
http://h20.enr.state.nc.us/ncwetlands.This Certification allows you to use Nationwide Permit Number 14 when
it is issued by the U.S. Army Corps of Engineers. In addition, you should secure any other applicable federal,
state or local permits before you proceed with your project, including (but not limited to) those required by
Sediment and Erosion Control, Non-Discharge, and Water Supply Watershed regulations. Also, this approval
will expire when the accompanying 404 permit expires unless otherwise specified in the General Certification.

This approval is valid only for the purpose and design that you have described in your application. If you
change your project, you must notify us in writing, and you may be required to send us a new application for a
new certification. If the property is sold, the new owner must be given a copy of this Certification and approval
letter and is thereby responsible for complying with all conditions. If total wetland fill for this project (now or
in the future) exceeds one acre, compensatory mitigation may be required as described in 15A NCAC 2H .0506
(h). For this approval to be valid, you must follow the conditions listed in the attached Certification, as
well as the additional conditions listed below:

1. The following impacts are hereby approved as long as all other specific and general conditions of this
Certification are met. No other impacts, including incidental impacts, are approved:

Amount Approved Plan Location or Reference
Streams 120 linear feet Unnamed tributary to Swearing Creek
located southeast of Arnold Road between
Conrad Sowers Road and West Center
Street Extension, near Lexington, in
Davidson County.

NJ,{thCarolina
;V1i/llfnlly

North Carolina Division of Water Quality
Wetlands Certification Unit 1650 Mail Service Center
2321 Crabtree Blvd,
Customer Service Number: 1,877,623-6748

Raleigh, NC 27699-1650
Raleigh, NC 27604-2260

Phone [phone] FAX [phone]
Internet htto!!:h2o.enr .state .nc.uslncwetlands

An Equal Opportunity! Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper

-
-.-..,;"'!

Mr. David R. Gamer
Page 2
August 12, 2005

2. Appropriate sediment and erosion control measures which equal or exceed those outlined in the most
recent version of the North Carolina Sediment and Erosion Control Planning and Design Manual or the
North Carolina Surface Mining Manual (available from the Division of Land Resources at NCDENR
regional offices or the central office), whichever is more appropriate, shall be designed, installed and
maintained properly to assure compliance at all times with the North Carolina water quality standards
that are applicable to Class C waters as described in 15A NCAC 02B .0211 Fresh Surface Water Quality
Standards For Class C Waters. Such measures must equal or exceed the requirements specified in the
most recent version of the North Carolina Sediment and Erosion Control Manual. These measures must
be maintained on all construction sites, borrow sites, and waste pile (spoil) sites, including contractor
owned and leased borrow pits, which are associated with this project.

3. Sediment and erosion control measures shall not be placed in wetlands or waters to the maximum extent
practicable. If placement of sediment and erosion control measures in wetlands or waters is unavoidable,
they shall be removed and the natural grade restored within six months of the date that the project is
completed or, if applicable, within six months of the date that the project is released by the North
Carolina Division of Land Resources.

4. No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas beyond the
footprint of the impacts depicted in the Pre-Construction Notification. All construction activities,
including the design, installation, operation, and maintenance of sediment and erosion control "Best
Management Practices" shall be performed so that no violations of state water quality standards,
statutes, or rules occur.

5. The culvert required for this project shall be installed in such a manner that the original stream profile is
not altered (i.e. the depth of the channel must not be reduced by a widening of the streambed). Existing
stream dimensions (including the pattern and profile) are to be maintained above and below the location
of the culvert. The culvert shall be designed and installed to prevent head cutting of the stream. If the
culvert becomes perched, the appropriate stream grade shall be re-established or, if the culvert is
installed in a perched manner, the culvert shall be removed and re-installed correctly. The Applicant
must submit a plan and receive written approval from this Office to address any head cutting that will
occur as a result of this project (e.g., use of cross vanes downstream of the culvert).

6. Where riprap is required for energy dissipation and scour protection, it shall be limited to the minimum
dimensions specified by appropriate engineering calculations. Riprap may only be used below the
normal high water level. The original grade and elevation of the stream's cross-section must be
maintained. Riprap placed in the stream bottom must be inserted into the bottom matrix to a depth
sufficient to provide the thickness of riprap required for scour protection. The elevation of the stream
bottom must not be increased by the placement of riprap. Placement of riprap must not result in
destabilization of the streambed or banks upstream or downstream.

7. Energy dissipation and sheet flow must be provided for all discharges of stormwater before such
discharges reach stream channels or wetlands.

8. All construction activities associated with this project shall minimize built-upon surface area, direct
stormwater runoff away from surface waters, and incorporate best management practices to minimize
water quality impacts. If concrete is used with any fill material, it shall not be allowed to come in
contact with surface waters until it has cured. If any stormwater must be collected for discharge into a

,.. ."
Mr. David R. Garner
Page 3
Augiust 12, 2005

stream channel, it shall not enter the stream as a point source, but shall be slowed and discharged as
sheet flow prior to entering the riparian buffer on either side of the stream.

9. Upon completion of the project, the Applicant shall complete and return the enclosed "Certificate of
Completion" form to notify NCDWQ when all work included in the S401 Certification has been
finished. This certificate should be sent to the 401/Wetlands Unit of the NC Division of Water Quality
at the address listed on the form. Along with the Certificate of Completion fonn, please send
photographs upstream and downstream of the culvert to document correct installation.

If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You
must act within 60 days of the date that you receive this letter. To ask for a hearing, send a written petition
which conforms to Chapter 150B of the North Carolina General Statutes to the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This certification and its conditions are final
and binding unless you ask for a hearing.

This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If
you have any questions, please telephone Daryl Lamb in the DWQ Winston-Salem Regional Office at 336-771-
4600, extension 293.

Sincerely,

Alan W. Klimek, P .E.

A WKlcdl

Attachments

cc: Mr. Eric Alsmeyer, U. S. Army Corps of Engineers, Raleigh Regulatory Field Office
Winston-Salem DWQ Regional Office
Central Files
Wetlands/401 File Copy
Mr. William E. Mitchell, William E. Mitchell Associates, 1903-C Ashwood Court, Greensboro, NC 27455

Triage Check List

7/14/05

Date:

Project Name: Elbert Place, LLC c/o David Garner
DWQ#: 05-1252
County: Davidson

Daryl Lamb, Winston-Salem Regional Office

To:

60-day processing time: """' 7 17 !,9~~ -,p/5/05
fo:: . i
~t w i/' : . '~j
a iL~'~ './

fiLE COpy

From: Cyndi Karoly Telephone: [phone]

The file attached is being forwarded to your for your evaluation.
Please call if you need assistance.

D Stream length impacted
D Stream determination
D Wetland determination and distance to blue-line surface waters on USFW topo maps
Minimization/avoidance issues
D Buffer Rules (Neuse, Tar-Pamlico, Catawba, Randleman)
D Pond fill
D Mitigation Ratios
Ditching
D Are the stream and or wetland mitigation sites available and viable?
D Check drawings for accuracy
D Is the application consistent with pre-application meetings?
Cumulative impact concern
D
D
D

Comments: As per our discussion regarding revision of the triage and delegation processes,
please review the attached file. Note that you are the first reviewer, so this file will need to be
reviewed for administrative as well as technical details. If you elect to place this project on hold,
please ask the applicant to provide your requested information to both the Central Office in
Raleigh as well as the Asheville Regional Office. As we discussed, this is an experimental, interim
procedure as we slowly transition to electronic applications. Please apprise me of any
complications you encounter, whether related to workload, processing times, or lack of a "second
reviewer" as the triage process in Central had previously provided. Also, if you think of ways to
improve this process, especially so that we can plan for the electronic applications, let me know.
Thanks!

PAY~/lENT
RECEIVED

Office Use Only:

Form Version October 2001

USACE Action ID No.

DWQ No.

80051252

If any particular item is not applicable to this project, please enter ''Not Applicable" or "N/ A" rather than
leaving the space blank.

L ~.ro:::ll of the approvW(sf l~~d ~r~ pr:ject: ~ ~ @ ~ OW ~ W

~ Section 404 Permit JUL 0 7 Z005
o Section 10 Permit
lID 401 Water Quality Certification
o Riparian or Watershed Buffer Rules

2. Nationwide, Regional or General Permit Number(s) Requested: NWf \4

DENR ' WATER QUALITl'
~ETLANDSA~DSTORMWATERBRANCH

3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: 0

4. Ifpayment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: 0

IL' Applicant Information

1. Owner/Applicant Information
Name: % t>>.",p~. (;,6..1zNER - Eo eE~ l'1...N:e , LLc.
Mailing Address: 1 \ -:; ~a; OLp O. S. H VJY. 52
\lJLt-.1~"tl>t-J-'5~LE:M... N.C... 27107

Telephone Number: ~~(O - ~4-5 .03'39
E-mail Address:

Fax Number:

2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: S\Ll.. MlTC~~\"
Company Affiliation: WI'L1..Vo.M 6. MlTc.~El..1..A.S$OG\A"6S
Mailing Adcfress: \ .9o~ -G A.~~ w~p C::OUtc:.T
61<::.t:a:\o.15~, 1--1. G. '2.74SS
,

Telephone Number: 33(P. &;'40 ~oo~o
E-mail Address:

Fax Number: "3?G::> - S40.. ODG:lO

Page S of 12

ill. Project Information

Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surmces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defmed. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.

1. Name of project:

eu~ ~~ J u..c..

2. T.I.P. Project Number or State Project Number (NCDOT Only): \..1/,6..

3. Property Identification Number (Tax PIN): 1;&..')C t. P. \4 - \~ - 2"

4. Location
County: [l6..'\I'D$~ Nearest Town: Ls ~\~TotJ
Subdivision name (inClude phase/lot number): s. e.~~T FL.Ac& J L...U:.
Directions to site (include road numbers, landmarks, etc.): 01-1 AJZt.Jo\-O ~:..~ C!..
24-7$ \ 'M~T of CO~(Z.6l> SOWg~ 1<Ow . ~ 0' f..10JZ.7H O~ W. C.6~~
c;,~S~T ~"l'5~S.lO .. ?S M\. t 'N. O~ ~~U~G.jZ)

5. Site coordinates, ifavailable (UTM or Lat/Long): t-l/A
(Note - Ifproject is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing ofa distinct waterbody.)

6. Describe the existing land use or condition of the site at the time of this application:
UtJt7l ~"'~~ e~ /u ~pe'iet..o?E'P

7. Property size (acres):

Z t!> I ~ A.c...

8. Nearest body of water (streamlriverlsoundlocean/lake): S'NE:~l)4G. ~E.e:)::..

9. River B.asin: '(A.'t1\(.\~ - t'6g 1/a-g
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o,enr,state.nc,us/adrninlrnaps/.)

Page 6 of 12

10. Describe the purpose ofthe proposed work: Kt:>k7WAy C~SS\N.c::. 10 AcCt::.95
p~ '/!.:TV

11. List the type of equipment to be used to construct the project: T~~ ~"'>>o~..
6LH..t..l:iOz.alz. . F~"" l::.~ u>'&"t?~
,

12. Describe the land use in the vicinity of this project: ~'ES'PE. ~\\A.t... / A,(;'jZ.\GUt.."'tUl=-G

IV~ Prior Project History

If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date pennits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.

~/A

v. ! Future Project Plans
I

Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion ofthis work from the current application:
N/A

VI. Proposed Impacts to Waters oftbe United StateslWaters oftbe State

It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intennittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.

Page 7 of 12

1. Wetland Impacts

Wetland Impact Area of Located within Distance to
Site Number Type of Impact* Impact IOO-year Floodplain" Nearest Stream Type of Wetland...
(indicate on map) (acres) (yes/no) (linear feet)
,
i
. .

· List each impact separately and identitY temponuy unpacts. Impacts wclude, but are not limited to: mechanized cleanng, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
.. 10Q..Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at httD://www.fema.gov.
... List a wetland type that best descnbes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland. beaver pond,
Carolina Bay, bog, etc.)

List the total acreage (estimated) of existing wetlands on the property:
Total area ofwetIand impact proposed:

2. Stream Impacts, including all intermittent and perennial streams

Stream Impact Length of Average Width Perennial or
Site Number Type of Impact. Impact Stream Name.. of Stream Intermittent?
(indicate on map) (linear feet) Before Impact (please specify)
i 1 ~t.':~1" , 126 UT -S'JJ2.41V~az:1i1i "- It> · lNTS~M 1-r'n:~T
l~- 10.1'
,
I
. .

Ust each Impact separately and Identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gablons, etc.), excavation, ditching/straightening. etc. Ifstream relocation is
proposed, plans and p'ofiles showing the linear footprint for both the original and relocated streams must be included.
.. Stream names can be found on USGS topographic maps. If a stream has no name, list as lIT (wmamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.gOv.SeveralinternetsitesalsoallowdirectdownloadandprintingofUSGSmaps(e.g..W\\ow.topozone.com.
www.rnaoouest.com. etc.).

.

Cumulative impacts (linear distance in feet) to all streams on site: 12l'

Page 8 of 12

3. Open Water Impacts, including Lakes, Ponds, Estuaries, SOWlds, Atlantic Ocean and any
other Water of the U.S. 'NolA

Open Water Impact Area of Name ofWaterbody Type of Water body
Site Nwnber Type ofImpact* Impact (if applicable) (lake, pond, estuary, sound,
(indicate on map) (acres) bay, ocean, etc.)
.

· List each impact separately and identItY temporary impacts. Impacts mclude, but are not limited to: fill, excavation. dredgmg.
flooding. drainage, bulkheads, etc.

4. PondCreation ~/A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this ~lication.
Pond to be created in (check all that apply): 0 uplands U stream 0 wetlands
Describe the method of construction (e.g., damlembankment, excavation, installation of
draw-down valve or spillway, etc.):

Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):

Size of watershed draining to pond:

Expected pond surface area:

VII. Impact Justification (Avoidance and Minimization)

Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
fmancial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
teclmiques to be followed during construction to reduce impacts.
~o O'n.H=ll. ~cz,s "0 ~PEtz"'N - U~I,,"," MA.,c. GtlZ.&.17>5S i S/PE= SLopES
"Th M\I4\MIZC t='lt..l..; O~I~~ el-lt;::.WA,u..s AT E.a..a-\ Et-ll> OF P\~E Tl>
MI ""I M 1%.& c..l}l.VS~."r t,.€}.J(sTtl .

VIII. Mitigation \J fA

DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams. .

Page 9 ofl2

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.

If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o,em,state, nc. us/ncwetlands/strmgide. html.

1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if off site), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed. '" J . I
. N/A- ~'T Fe.~L M\-nGA"T\ON

\~ JO~" Fl EP

2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 40l/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o,enr.state,nc.us/wro/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information: ~/,6...

.Al!1ount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount ofCoast~ wetland mitigation requested (acres):

Page 100f12

IX. Environmental Documentation (DWQ Only)

Does the project involve an expenditur~ of public funds or the use of public (federaVstate/local)
land?

Yes 0

No~

If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEP NSEP A)?
Note: If you are not sure whether a NEP NSEP A docwnent is required, call the SEP A
coordinator at [phone] to review current thresholds for environmental docwnentation.
Yes 0 No 0

If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes 0 No 0

X. Proposed Impacts on Riparian and Watershed ButTers (DWQ Only) N/A.
I
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.

Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Neuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes 0 No [B) If you answered "yes", provide the following information:

Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.

Zone. Impact Multiplier Required
(sauare feet) MitiJZation
1 3
-2 I.S
Total

· Zone 1 extends out 30 feet perpendicular from near bank: of channel; Zone 2 extends an
additional 20 feet from the edge orZone I.

Page II of12

Ifbuffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
MIA. - ~'T FEEL. ~'l M\-nGJ..,-r(ol-J
\ ':> ~8c.eSS$c~

XI.

Stormwater (DWQ Only)

XII.

Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
1b"'OJ,.. ~.:: '2.f>,3k.... i A5SUM~ 4,CWS.r. 1M.~\ot.>S. ~~/U>T,c. ZoUrc5::
. \. MJ.,(:.. = ~. 0 % ., ~u...ioA'"'D\~~ -(""'200(;'"- <;;1ZA6S ~IoOS\DS' D\TQ.\e$ /SH66T"
ft.D\U~ OF'? Let'S ~. JbtL-no,..ss e,s ~ L..HZ.St..'1 1b ~\~ \JN~\Sj\.l(l.eG't1 OR-
. 13e: ~MGN'Q.L.. t...~ -t-.k) 1l:UN6t=t== ~t.$
Sewage DIsposal (DWQ Only) OS GO

Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater. generated from the proposed project, or available capacity of the subject facility.
)ND1"U~JAL.. SEPTIC- T~"- S'lSo"'"rCM$ Fo~ 6~ L.t:rr

XllI. Violations (DWQ Only)

Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
~D ~OO . .

Is this an after-the-fact pennit application?
Yes 0 No ~

XIV. Other Circumstances (Optional):

It is the applicant's responsibility to submit the application sufficiently in advance of desired
c.onstruction dates to . allow" processing. time' rot these permits. However, an applicant may
choose to list constraints associated With construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).

~ ).!Ja-viJ ~.~ 1f ~ J6'Jo~
Applicant! Agent's Signature Date
(Agent's signature is valid only uan authorization letter from the applicant is provided.)

I

Page 12 ofl2

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PAYMENT
RECEiVED

Office Use Only:

Form Version October 2001

USACE Action ID No.

DWQ No.

?()"e:::11)52

I
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.

I.

Processing

1. Check all of the approval(s) requested for this project:
lil Section 404 Permit
o Section 10 Permit
[R] 401 Water Quality Certification
o Riparian or Watershed Buffer Rules

/D)[g@@llWrglf.:!
W Iv.;
JUL 0 7 2005'

WEn1~~R ',WAT~R QUAL/ ry
AND STOKltlYArER BRANCH

2. Nationwide, Regional or General Permit Number(s) Requested: N\J..lf \4-

3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: 0

4. Ifpayment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: D

IL Applicant Information

1. Owner/Applicant Information
Name: % [:l&."'}:>~' ~A12.t-1ER - Eo 'CE~ Pz...N:e , u.c.
Mailing Address: t \ ?~.; OLp O. <;, H WY. S2
\JJlt-.1~~IoJ-S""L&M, N.C.. 7.7107

Telephone Number: ~~lo - ~4- 5 .03'59
E-mail Address:

Fax Number:

2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: S\LL. MlTGHE\..\..
Company Affiliation: WI~t.t1o.M 6. MlTc..\-\5/.,t.. A.S$OG\AT6~
Mailing Address: \ .9o~ -c A.~M WOOD ~~T
6K1:E:I-!S~, N. G. 274-S$
,

Telephone Number: 33(&o.?40 ..('X)~o
E-mail Address:

Fax Number: :,?le> - S40 .. 00"'0

Page S of 12

m. Project Information

Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfuces, or other facilities must be included. Ifpossible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly dermed. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.

1. Name of project:

!:I;E~ R.Al:.s.l u..~

2. T.I.P. Project Number or State Project Number (NCDOT Only): \oJ/A
3. Property Identification Number (Tax PIN): 1;&...~ t.~. \4 .. \ ~ - '2"

4. Location
County: ~"'t?$~ Nearest Town: LS ~\t--k;ToeJ
Subdivision name (inClude phase/lot number): E e.E~T PLACe., u..c.
Directions to site (include road numbers, landmarks, etc.): 01-1 AJZfoJOt..t::> ~J.D CL
2~ S \ 'N~T OF' co~\Z..U> SOW6'~~.&t:;:7 . ~ pI ~D)z'~ Or W, c.6'~~
c;,~'ti"'T ~,BJ.1Slo .. ~.S M\. tIN. 0-;: ~')(.t~G.'TZ>

S. Site coordinates, if available (UTM or Lat/Long): ~I A
(Note - Ifproject is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing ofa distinct waterbody.)

6. Describe the existing land use or condition of the site at the time of this application:
UIJf7\ ~"''tZ-~ EtI /U~De'iEt.o?E'P

7. Property size (acres):

2c!> I ~ A.t:.,.

8. Nearest body of water (streamlriverlsoundlocean/lake): SWE:Jo.lZ..l)..\G, ~E~~

9. RiverB.asin: '(A.t7~l\J - peg t?a'G"

(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/adrnin/rnaps/.)

Page 6 of12

10. Describe the purpose of the proposed work: F:..O~AY c}Z:OSS\~(;, 10 Acc&.SS
P~'f!..-r:{

11. List the type of equipment to be used to construct the project: T~~ ~ ~>>Ot5.,
6Ut..t.to:z:.B~ " F~, a\.lt) lc,6...t:>E'R,

12. Describe the land use in the vicinity of this project: tZ.:ES\t1E~"T\~ / ~1Z-\GUl.~~

IV. Prior Project History

If jurisdictional determinations andlor permits have been requested andlor obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.

~/A

V. Future Project Plans

Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
1--L / A

VI. Proposed Impacts to Waters of the United StateslWaters oCthe State

It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands. open water. and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.

Page 7 of 12

1. Wetland Impacts

Wetland Impact Area of Located within Distance to
I Site Number Type ofImpact* Impact IOO-year Floodplain** Nearest Stream Type ofWetland***
(indicate on map) (acres) (yes/no) (linear feet)

· List each unpact separately and Identify temponuy unpacts. Impacts mclude, but are not limited to: mechllYJJzed cleanng, grading, fill.
excavation. flooding. ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
.. IOo-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at htto:/Iwww.fema,gov.
... List a wetland type that best descnbes wetland to be impacted (e,g., freshwater/saltwater marsh, forested wetland, beaver pond.
Carolina Bay, bog, etc.)

List the total acreage (estimated) of existing wetlands on the property:
Total area of wetland impact proposed:

2. Stream Impacts, including all intermittent and perennial streams

Stream Impact Length of Average Width Perennial or
Site Number Type of Impact* Impact Stream Name.. of Stream Intermittent?
iindicate on map) (linear feet) Before Impact (please specify)
1 ~\'~~P{" .. t~ UT - 5\JJa~~aei5 t::. It> · It-lTs~M t-rfStJT
1.,,- I-'f'
,
:
. .

* Ust each Impact separately and tdentdy temporary nnpacts. ImpactS mclude, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and tlooding), relocation (include linear feet before and after, and net loss/gain),
i stabili7ll1ion activities (cement wall, rip-rap, crib wall. gabIons, etc.), excavation, ditching/straightening. etc. If stream relocation is
: proposed. plans and profiles showing the linear footprint for both !he original and relocated streams must be included.
** Stream names can be fo~d on USGS topographic maps. If a stream has no name, list as ur (wmamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
WWW,USgS.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., WWW.tooolone.com.
www.maoauest.com. etc.).

Cumulative impacts (linear distance in feet) to all streams on site: t.2l'

Page 8 of 12

3. Open Water Impacts, including Lakes, Ponds, Estuaries, SOWlds, Atlantic Ocean and any
other Water of the U.S. 'N/A

Open Water Impact Area of Name of Water body Type of Water body
Site Nwnber Type ofImpact* Impact (lake, pond, estuary, sound,
(indicate on map) (acres) (if applicable) bay, ocean, etc.)
.
.

· List each impact separately and IdentifY temporary impacts. Impacts mcJude. but are not limited to: till, excavation. dredgmg.
flooding. drainage, bulkheads, ctc..

4. Pond Creation t-.\ IA
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this ~lication.
Pond to be created in (check all that apply): 0 uplands U stream 0 wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):

Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stonnwater requirement, etc.):

Size of watershed draining to pond:

Expected pond surface area:

i
VII. Impact Justification (Avoidance and Minimization)

Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
fmancial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
t-30 0'fl-}elZ- ACce.5S 1''' PJz.?PEtrN - U~I~~ MA')C. 412.&.t;)55 i SI17E= SLopSS
"n> NN..UMI:z.s f='tt..t..; \,)Sl~c. e)o.1C>WA.lJ..$ AT E~ E~!> <* Plt:'E Tl>
MII-JIM lz.S. WL.V=~.:, \..~CsiH

vm. Mitigation \J fA

DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams. .

Page 9 of 12

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.

If mitigation is required for tWs project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o,em,state. nc, us/ncwetlandsl strmgide. html.

1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or inap, if off site), affected stream and river basin, type and amount (acreage/Iinear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
, a separate sheet if more space is needed.

~/A- t?ctJ'T Fe~L M\-nC:A\\b~
\~ JO<5L\ Fl ED

2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 40l/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o,enr.state.nc.us/wro/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information: }"l!A

A!pount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):

Page 10 of12

IX. . Environmental Documentation (DWQ Only)

Does the project involve an expenditur~ of public funds or the use of public (federal/state/local)
land?

Yes 0

No~

If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEP NSEP A)?
Note: If you are not sure whether a NEP NSEP A docwnent is required, call the SEP A
coordinator at [phone] to review current thresholds for environmental docwnentation.
Yes 0 No 0

If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEP A or SEP A fmaI approval letter.
Yes 0 No 0

X. Proposed Impacts on Riparian and Watershed ButTers (DWQ Only) N/J..-

It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.

Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Neuse), 15A NCAC 2B .0259 (Tar-PamIico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )1
Yes 0 No [g] If you answered "yes", provide the following information:

Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.

Zone. Impact Multiplier Required
(square feet) MitiJlation
1 3
'2 1.S
Total

· Zone 1 extends out 30 feet perpendicular from near bank: of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.

Page 11 of12

Ifbuffer mitigation is required, please discuss what type of mitigation is proposed (ie., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
~/A. - ~\T FEEL- ~'f M\-nGA,\,lC>-N
\"::> ~SGgSS"'~

XI.

Stormwater (DWQ Only)

Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property. .
1b-w.. ~. = '2.c.~k... j A5SUMlS' 4,lXlO'S.p: lM~\ot>s ,A.1Zg~/U>T,c. ZoL.ctS::-
. \. MAG.. ::. ~. 0 % ., ~u...{oFr"'t7\~~. "t~2.00G>~ t;;1U6S. 'tze~$\~ D\T'Q.\ES /sHarr
ft.ow~ OF'? t.o'r5 ;.' fbtt.-n~$ ct- ~ L..nz.til.."( 1b ~\~ Ot-JQ\S11>>-6G7t7 o~
. 13e;~MG~ L~ -~kUfoJ6FF ~t...s
Sewage Disposal (DWQ Only) OS fdO

xu.

Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater. generated from the proposed project, or available capacity of the subject facility.
)t-.\DlVLttJAJ- SEPTIc- T~K. S'I$ISM$ Fo~ 6N::H La"("

XIII. Violations (DWQ Only)

Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
~D ~OO .

Is this an after-the-fact pennit application?
Yes 0 No rRI

XIV. Other Circumstances (Optional):

It is the applicant's responsibility to submit the application sufficiently in advance of desired
c,Onstnlction dates to . allow" processing. time' for these permits.. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).

~ )JJ0NiJ ~.~ :t '7 JS-ID~
Applicant! Agent's Signature Date
(Agent's signature is valid only ifan authorization letter from the applicant is provided.)

Page 12 of 12

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GWYN LONG &
MITCHELL BROWN
DB 1036 PG 1924

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EXISTING IRON PIN
IRON PIN SET
RIGHT -OF-WA Y
EDGE OF PAVEMENT
EDGE OF GRAVEL
CONCRETE MONUMENT
PO'M::R POLE
MINIMUM BUILDING LINE
LIGHT POLE
OVERHEAD SER\IlCE LINES
POINT

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ci(;arin\); in:;tall ,;;' ~ f(~nCf~, ,'(Jl't'l t)tc.rniS f. rex:).:
('"[',Pek cici1r~; ;~'l t.h se(l~: .~~nt tr;I~;;j

LEGEND

TOWNSHIP: REEDY CREEK

CHARLES KOONTZ
DB 508 PG 592

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VICINITY MAP
NOT TO SCALE

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"", 1 ~; 1 "r-""~; 1 mll:';d i (1 t., l '!.

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I HEREBY CERTlFY THAT THE SUBDIVlSION PLAT
SHOWN HEREON HAS BEEN FOUND TO COMPLY
~7rN~~~~~I't~~~U~~G~);ttP9t1~l~BcgA~ASPN
HAS BEEN APPROVED ACCORDING TO THE
PROCEDURES FOR APPROVAL OF MINOR SUBDIVISIONS

"Anplete lJrac1inq, peT/iI"J ilr.:l \It:; i t'y' lr':st.l1 jat ::,1';'
;).,~;r..,r.(~L t 1 Y S"-;H\.} ,,1; ell s t urbed an"b wi t 1'11 n 1 k, W- it''.:: :i'J
':<1'/.-.; ;;r 30 calendar ,lays {whichever is shorter:
::,l;~in'J cCT.l)leticr. ;,f (:.)m;tr'L'~i""i: inst.'111 nettinq'
instrtll stone di tch 'r:"":I:;; ",~,,;t,\ ~:,' ,.,.,1 ,,1': plan:;.

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o

(JAr -, ...- ---- --:;UBDI vrSIONAT5MiNISTRATOR

WILLIAM LEATHERMAN
DB 572 PG 143
DB 601 PG 294
DB 1030 PG .359

AN Y FURTHER RESUBDIVlSlON OR DEVELOPMENT
OF THE LOTS SHOWN ON THIS PLAT MUST MEET
ALL BUILDING AND DEVELOPMENT REGULA TlONS
OF THE APPROPRIATE LOCAL GOVERNMENT,

DATE

SUBDIVlSION ADMINISTRATOR

OWNER:
EBERLEE FARMS LLC / CDPK DEVELOPERS
236 EAST CENTER STREET
LEXINGTON, NC 27292
336 - 249 - 2988

TOTAL ACREAGE... 20.314 AC,

20 PROPOSED LOTS
+- 1770' OF PROPOSED ROAD

M AX WALSER
DB 445 PG 531

SETBACKS'

30' MINIMUM FRONT BUILDING LINE
20' MINIMUM BUIDING LINE REAR
10' MINIMUM SlOE BUILDING LINE

EBERT PLACE

STATE OF NORTH CAROLINA
COUNTY OF DAVlDSON

1" IRON PIPE BENT
. .l~ 0.28" COUTH OF UNE
'"

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I. ~~--,,-~-.REVlEW OFFICER Of DAVIDSON COUNTY, CERTIfY
THAT THE MAP OR PLAT TO WHICH THIS CERTIFlCATlON IS AFfIXED MEETS ALL STATUTORY
REQUIREMENTS FOR RECORDING.

1/2. IRON '<>~
PIPE 'Q
.CONlROL CORNER" t5', .

.. RE\1EW omCi.R

BAR SCALE

APPROVAL OF THIS PLAT DOES NOT IMPLY THE APPROVAL
BY DAVIDSON COUNTY OF A DRIVEWAY PERMIT AS
REQUIRED BY NCDOT THROUGH ITS POLICY ON STREET AND
DRIVEWA Y TO NORTH CAROUNA HIGHWAYS. lHE DEVELOPER
HAS THE RESONSIBIUTY FOR OBTAINING PERMISSION FROM
NCDOT TO CONNECT WITH THE PUBLIC ROAD

SUR~Y FOR

EBERT PLACE, LLC
ARNOLD ROAD

PRoPERY--O~ER /DEVf:LOPER/SURVEYOR

DATE

I

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or---
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weD
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100

50

100

I

200

TAX 10:

1 4 - 19 - 26

I W. LEE COMER CERTIFY THAT THIS MAP WAS DRAWN NDER MY SUPERVISION
FROM AN ACTUAL SURVEY MADE UNDER MY SUPERVISION. DEED DESCRIPTlON
RECORDED IN DEED BOOK (as noted), PAGE (as noted) etc,: THAT THE ERROR
OF CLOSURE AS CALCULATED BY LATITUDES AND DEPARTURES IS 1/10.000,
THA T THE BOUNDARIES NOT SURVEYED ARE SHOWN AS BROKEN LINES PLOTTED
FROM INFORMATION FOUND IN DEED BOOK (as noted) PAGE (as~e R ELI M I N A R Y P LA T
THIS MAP WAS PREPARED IN ACCORDANCE WITH G,S, 47-30 AS
WITNESS MY HAND AND SEAL THIS ___ DAY Of _____ . 200 .

Q3)
f:0.691 AC.

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PLANNING & ZONING STAFF

DATE

DRAWING DATA
SCALE: 1" - 1 00'
DRAWN BY: TA
SURVEYED BY: LC, TA

COUNTY: DAVIDSON

DWG. No.:
052221
DATE:
03/29/05

REVlSION
DA TES

-

...>

- \;
224,O~ -J L--
-- N 83.48'33"W 385.35'

t

STATE: NC

TRI.COUNTY LAND SURVEYING
11 1/2 WEST MAIN STREET
THOMASVILLE N.C. 27360
THOMASVILLE . [phone]
LEXINGTON A [phone]
WINSTON-SALEM. [phone]

NOT FOR RECORDATION
CONVEYANCES OR SALES

-----

STONE

THIS PLAT IS SUB..ECT TO ANY EASEMENTS.. AGREEMENTS
OR RIGHT-Of-WAYS PRIOR TO THE DATE O~ THIS PLAT,

NO UABILlTY IS ASSUMED BY THE UNDERSIGNED FOR ANY LOSS RESULTING
FROM THE EXERCISE OF ANY GOVERNMENTAL AGENCY AFFECTING THE USE Of
THE PREMISES AND IS SUB..ECT TO ANY FACTS (PRIOR EASEMENTS AND CON-
VEYANCES OF RECORD OR EASEMENTS), THAT MAY BE DISCLOSED BY AN AB-
STRACT OR FULL AND ACCURATE TITLE SEARCH,

KENNETH LEONARD
DB 705 PG 147