20051550 Ver 1_Complete File_20050815

2321 Crabtree. Boulevard, Suite 250 /0)
Raleigh. NC 27604-2260 ~~ @ ~

1650 Mail Service Center ~U'f10

RoIcigh. NC 27699-1650 11~J'?:'~~1 ;) <'1l'{J<< ,

Phone #: [phone]toS'1lt,:? J
Fax #: [phone] iD,('.;;7;1</ly
''l/E'R !?D.
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William V. R~ Jr., Sccrcllrry
Nonh ('.arotiTU D~l of Environmcnt lllld Nawr:ll Rcsourtcs

Alan W. Klimek. r.B. Director
DiVIsion o(Wala- Qu;lbty

Michael P. E.'\Slcy, Governor

Division of Water Quality
Department of Environmental and Natural. Resources
401 Oversigbt/Express Review, Program Development and
Transportati.on Permitting Units

Street Address:

Mailing Address:

Contact Information:

Fax To:

David Johnson

Fax #: [phone]

Company: :J;;1V; D. JCJf/t'JSDAJ

Date: 7/26/05

Number of pages including cover sheet:

\3

Notes or special instructions: peN Applicatiollfor N1V39; No Fee; Courtesy
Copy; Submit 2 copies Laurie Dennisoll, NC-DENR, DWQ, Jfletlands/401
Unit

tf,WhCI1TQ1i1Ja
,!V1l/lirll/1v

niviliOll of Wll.lcr Q\l~Jity. W~:lnd5 :lnd Stom1'W'3lcr Branch
16S0 Moil Savicc Center. RnIcig!l. N~lh ('.'\rolin:t:27699.1650
232\ Crnhtrcc: Bnulcv"n1. Suite Z50.lUlci~h. Nartll Carolina 27604
Phone: [phone](,1 FAX 9IQ-73l-6X9ll hllCn)et: hTTn'lhln.c"r.t>!lc nc, u"ncwr.tl.mr.

"" P.QlI:ll Opportunill"^ffit",~tive Actiol) E(,IlJlloy~ - 50";' RecyckdJJO% POSI C/)!l~mcr P"flCr

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JUL-~(-~UI::r.> U';:I:C';;1 FRO/1:0WQ-WETLANDS 9197335893

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P:G/13

,

Office Use Only:

FDrm VCTI';On M01J'Ch 0.5

tJSACE Action ID No. DWQ No.
(If any particular il:I:m is not applicable to this project, please enter -Not Applicable" or "N/A-.)

L Processing

1. Check all of the ap~roval(s) requested for this project
o Section 404 Permit 0 Riparian or Watershed Buffer Rules
o Section 10 Pcnpit 0 Isolated Wetland Permit from DWQ
o 401 Water QuaJity Ccrtific.'\tion 0 Express 401 Water Quality Certification

2. Nationwide, Regional or General Pcnnit Number(s) Requested:

3. If this notification is solely a~~y copy because written approval for the 401 Certification
is nol required, check here: 1..8'

4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) .is proposed
for mitigation of impacts, attach the acceptance tetter from NCEEP, complete section VIII,
and check here: 0

S. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Manag~~~a.~ f"'. n
Environmental Co~ccm (see the top of page 2 for further details), check here: W LS ~0ls D \IjI~ @

ApplicnntInfol'mntio'n AUG ~ 5 2005 f!!}

II.

1. Owner/Applicant Infonnation
Name: '-"f1V/ f) c, :st)JrN'.So;t/
Mailing Address: 2. <f 0 j2.U/ll/IJ /;'/C; /)G61l 7f2/J1L
PI17>I]O&) / IV c.. 2.7 3/Z
I

\'':'n ~ENH. W'7~"
Ic,wJQSNiD s1c~~ QUALITY
" ~VA TER 80 AI
, V\l1'CH

Telephone Nwnber: 9/i -.5 t..j S'- S /:; 2,t;{
E-mail Address:

Fax Number. 919 - ~'1,J- {)"<./1 ?

2. Agent/Consultant Information (A signed and cL1ted copy of th~ Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliatil;>n:
Mailing Address:

Telephone Number:
E-mail Address:

Fax Number:

Pl\BO S of!2

.JUl..-C:I-aJ~ ~:C';:I H~lJM:UWQ-WE1l.AND5 9197336893

TO: 95450293

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m Project InforrnntiOD

Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns. rivers. and loads. Also provide a detailcd site pllln 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 surfaces, O( other facilities must be included. Jfpossible. the roaps and plans should
include the appropriate' USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other I114lpS may be included at the applicant's discretion.
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no l3tgcr than 11 by 17-inch fonnat;
however, DWQ may accept paperwork of any size. PWQ prefers fuU.-size construction
drawings rather than a sequential sheet version of the full-size plans. If fujI-size plans are
reduced to a small scale sucb that the fin.'\l version is i1Iegible, the applicant will be infonned that
the project has bccn placed on hold until dcciphcl1lble maps are provided.

1. Name of project: . ~Z?/QJ C,eqg(

2. T.I.P. Project Nurnl>er or State Project Number (NCDOT Only):

3. Property IdentificaUon Number (Tax PIN):

4.

5. Site coordinates (For lineal' projects, such as a rond or utility linc, attach a sheet that
separately lists the .coordinates for each crossing of a distinct watcrbody.)
Decimal Pegrees (6 digits minimum): DN ow

6. Property size (acres): 9J 1k1ZC"i

7. Name of nearest rc,ttiving body of water: 3l)lwfli'" '- 1/1'):d;a 1/lftZ-

8. River Basin: /~ /31 t./C1JZ
(Note - this must be one of North Cuolina's seventeen designated major river basins. The
River &lsin map is available at ht1Tl~/1h2o.enr."tate.nc.lls/adm;n/mnJ)sl.)

9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this 'Wplication: 77/J1$C'/Z6'.() ~/ Y/1vJpr

PIIge 6 of 12

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10. Describe the overall project in detail, including th~ type of equipment to be uscd:
1J/lJ.9I) /2tf/Jf) /1l (/J'?/-t/ty 12f). >7J;J>. ,I /?..65Ij)6i'J,~/It-- urs '71;</$<-

11. Explain the pwposc ofth~ proposed work:

U cetJ.YSiJJu rz;iJ1JLC- Cl/$K

IV. Prior Project History

If jurisdictioni1l determinations and/or 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 Nwnber, application date. and date permits and
certifications wcre issued or withdrawn. Provide photocopies of previously issued pennit3,
certifications or other useful infonnation. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). lfthis is 3 NCDOT projcct,
list and describe permits issued for prior segmcnts of the some T.I.P. project, along wi1.h
construction schedules.

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 oftrus wor.k from the current application.
;\/0

VL Proposed Impacts to Waters ofthe United StatesIWatcrs urthe State

It i,:t the applicant's (or agent's) responsibility to detcnnine. delineate and map all impacts to
wetlands, open wa.ter; and stream channels ,associated with lhe project. Each impact must be
listed separately in the tables below (e.g., culvert installation should be listed separately from
rip rap dissipater pads). Be sure to indicate if an impaet is temporary. All proposed impacts,
pe.nnm1cnt and temporary, must be listed. and must be labeled and clearly identifiable on an
accompanying site pI;pt. All wetlands and waters. and all streams (intermittent and perennial)
should 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 desc.ribe the impact in Section vm below. If additional
space is needed for listing or description, please attach a separate sheet.

I. Provide n written description of the proposed impacts:

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2. Individually list wetland impacts. Types of impacts include, but arc not limited to
mechanized c1carii1g, grading, fill, excavation, flooding, ditching/drainage, etc. For dams,
1 r' d b dfl d

separately Jst unpacts ueta olh structure an 00 ing.
WC1J:md Impact Type of Wetland Locat~d within Distance to Area of
IOO-yenr Nearest Impact
Site Number Typ~ ofJmp:ltt (c.g., forested, nwsh, Floodplain Stream (acrc.,)
(mdlcate on map) herbaceous, bog, etc.) (yeslno) Oincar feet)
Total Wetland Impact (acTCs)

3. List the total acreage (estimated) of all existing wetlands on the property:

-0 -

4. Individually list all intermittent and perelUlial stream impacts_ Be sure to identify temporary
impacts. Stream i,mpacts include, but are not limited to p,lacement of fill or culverts, d.Jrn
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditchinglstra,ightening, etc. Ifstream relocation is proposed,
phns and profiles showing the linear. footpr.int for both the original and relocated streams
b . I d d. Tall u1' 1 I h X . dtl h d" d b 43 560

must e me u e oc cu ate acreage, m ttply engtJ WI 1, t en IVI e y ,
Stream Impact Perennial or A ver.lge Impact Mea of
Numbcr Stream Name Type ofJrnpact Intennittent7 Stre;lm Width Length Impact
(indiciltc Oil map) Before ]moact (linear feet) (aeTell)
!6:-n,P!% C/'d1l( ~'11{) [jJJ)55;;V{- I ;V11!;1!/,11if'1:M - ~I 7'6
Total Stream Impact (by lCtlgth and ;u:,cage)

,. Individually list aU open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but arc not limited to
fill .

I , excl1vatl.on, dredlrinn, flooding, drainaRc, bulkheads, etc.
Opcn WDJ.cr Impact Name ofW:lIerbody T)'pc ofWlI.tcrbody Alca of
Site Number T)'pc of Impact (lake, pond, estuary, sound, bay, Impact
{indicate on map} (if applicable) ocean, etc.) (acres)
Total Open W~er impact (acres)

Pa~e 8 of 12

JUl..-c(-clj~ ~'j:.j~ I-RlJM:DWQ-hETLANDS 9197336893

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6.

.yt

7. Isolated Waters
Do any isolated w:lJ.ers exist on the property? D Yes !iEl No
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or linear feet). Please note that this section only
applies to waters that have specifically been dctermined to be isolated by the USACE.

8. Pond Creation
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 application.
Pond to be created in (check all that upply): D uplands D stream 0 wetlands
Describe the method of construction (e.g't wm/embankment, Ct:cavation, 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.):
Current land use in the vicinity of the pond:
Size of watershed draining to pond: Expected pond surface area:

VII. Impact Justificntion (Avoidance nnd Minirnb~ation)

Specifically describe measures taken to avoid \he proposed impacts. It may be useful to provide
information related 10 site constraints such as topography, building ordinances, accessibility. and
financial viability of the project. The applicant may attacb drawings ofaILcmativc.lowcr-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, disC11SS constmction
techniques to be followed during construction to reduce impacts.

Vlll. Mitigation

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 ot greater than or equal to 150 lineal' feet of total impacts to perelllljal
streams.

Page 9 of 12

.JUL -c: r -c:mT.> IT:1:.J13 1-k'llM: VWlJ-l--ETLANDS 9197336893

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USACE - In accordaJ}ce with the Fini1.l Notice of Issuance and Modification of Nationwide
Permits, published in tlJ.e Federal Register on January 15, 2002, mitigation will be required when
nccessary to ensure that adverse effects to the aquatic cnvirorunent 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. fuGunpJes of mitigation that may be appropriate and practicable include,
but arc not limited to:, reducing the sizc of the project; establishing and m:tintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquati~ fCSOW"CC functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same wata:shed.

If mitigation is required for this project, a copy of the mitigatioo 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 NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to rcview the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North CaJolin<l, available at
h tto:/Ih2o. enr. sf:! tc. n c. us/ncwetlnnds/stJTll ~ide. html.

1. Provide a bricf dcs~ption 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 (acrcagcllincar fcct)
of mitigation proPQsed (restoration, enhancement, creation, or preservation), a plan view,
preservation mee~'\nism (e.g., deed restrictions, conservation casement, etc.), and a
dcscription of the Cl,lIfen1 sito conditions and proposed method of construction. Please attach
a separate sheet if more sp.lCC is needed.

2. Mitigation may also be made by payment into the North C<lrolina Ecosystem Enhancement
Progrnm (NCEEP). Please note it is the applicant's responsibilily to contact the NCEEP at
[phone] to determine availability. and written approval from the NCEEP indicating
th,llt they are will to accept payment for the mitigation must be attached to this fonn. For
additional infortnation regarding the application process for the NCEEP. check the NCEEP
website al http://h2o.cnr.statc.nc.osfwmlindcx.hun If use of the NCEEP is proposed, please
check tbe appropriaJe box on page five Ilnd provide the following information:

Amount of str~ mitigation requested (linear feet):
Amount ofbuffex mitigation requested (square feet):
Amount of Ripari;m wetland mitigation requested (acres):
Amount ofNon,.riparian wetland mitigntion requested (acres):
Amoun.t of C~tal wetland mitigation requcstcd (acres):

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IX. Environmental DoeumentntJon (required by DWQ)

1. Does the project involve an expenditure of public (federal/stateIJocal) funds or the use of
public (federal/stall?) land? Yes 0 No 121

2. If yes, does the project require preparation of an environmental document pursuant to the
requirements of th~ National or North Carolina Environmental Policy Act (NEPAlSEPA)?
Note: If you are pot sur.e whether a NEPNSEPA document is required, call the SEPA
coordinator al (919j 733-5083 to review current tJuesholds for environmental documentation.
Yes 0 No 0

3. If yes, has the doc~ment review been finalized by the State Clearinghouse? If so, please
attach a C<lpy of the NEPA orSEPA fmal approvallcttcr. Yes 0 No 0

X. Proposed Impacts on RJparian llnd Watershed Duffers (required by DWQ)

It is the applicant's (o~ agent's) responsibility to detcnnine, delineate and map nil impacts to
required stntc nnd local buffers associated with the project. The appliC<Ult must also provide
justificatioll. for thcse impacts in Section VI1 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 ipIpacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropri:uc. Photographs may also be included at the
applicant's discretion.

1. Will the project impact protected riparian buffers identified within 15A NCAC 28 .0233
(Neusc), 15A NCAC 2B .0259 (Tar-Pamlieo), lSA NCAC 02B .0243 (Catawba) lSA NCAC
2B .0250 (Randleman Rules and Water Supply Buffer R.cquirements)~ or other (please
identify . )? Yes 0 No 0

2. If "yes", identify the squnre feet and acreage of impact to each zone of the riparian buffers.
If buffer mitigation is required calculate the required amoWlt of mitigation by applying the
bufli I' r

cr mu tip. Jers.
Zone- Impact Multiplier Required
(SQ\klte fect) M iliP.-ation
1 3 (2 for Catn.wba)
2 I.S
Total

· Zone J exteoo~ Qut30 fuel pc:lpCIldicul:!l from the top of the nQl b:wk ofcb.'Mcl; Zone 2 extends :In
uJ.liliDnaJ 20 feet fro~ Ihe cd&e of Zone J.

3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of PropCfty, Riparian Buffer Restoration I Enhancement, or Payment into the
Riparian Buffer Rcstoration Fund). Please attach all appropriate infotmution as identified
within) SA NCAC 2B .0242 or .0244, or .0260.

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XI. Stormwater. (required by DWQ)

Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stOl:mwatCr controls proposed in order to protect surface wnters and wetlands downstream from
the property. If pCfcent impervious surface exceeds 20%. please provide calculations
demonstrating total proposed impervious level. /-0 / 12,,oCt(V/f)Y( '\'fII?~

xu. Sewage Disposal (req~ired by DWQ)

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.

XIII. Violntiolls (required by DWQ)

Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes D No ~

Is this an after-tIle-fact permit application? Yes (g/' No 0

XlV. Cumulative Impacts (required by DWQ)

Will this project (based on past and reasonably anticipated future impacts) result in additional
development. which could impact nearby downstream water quality? Yes 0 No JkJ
If yes. please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North, Carolina Division of Water Quality policy posted on our website at
btlp:/lh2o,enr.state.nc.us(ncwetlands. Ifno, please provide a short narrative description:

xv. Other Circumstances (Opfionnl):

It is the npplicant's responsibility to submit the application sufficiently in advance of desired
construction, dates to allow processing time for these pcnnits. 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 oflhc applicant's control).

-pt-c, dJv-. 8' k/o~

Applicant/Agent's SignatufQ / / Date

~~:i~ 15~idoru:m .u:::~: ~ from the;;~~; ;Vided.)

ORA N G E

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TO: 95450293

P:1.r13

r

of( WAi~~
~~
f~~
~

Michael F. E.'\Sb:y, Governor

Willi:1m O. Ross Jr.. Scacbt)'
N()(th Carolhu Dcp:utmml oC En\1ror1mclllln:l N:11l1r.1l R~urc's

Al:1n W. KJimd:.l".E.. Director
Division otWala' ~ty

Division of Water Quality
Department of Environmental and Natural. Resources
401 Oversight/Express Review, Program Development and
Transportati,on Permitting Units

Fax To:

David Johnson

Fax #: [phone]

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Street Address:

2321 Crabtree, Boulevard, Suite 250
R.alci~ NC 27604-2260

Mailing Address;

1650 Mail Service Center
Raleigh, NC 27699-1650

Contact Information:

Phone #:
Fax#:

919-733-1786
919-733-6893

Company: ::Jf/1/1 D' JDfjt.rSO,il!

Date: 7/26/05

Number of pages including cover sheet:

\3

Notes or special instructions: peN ApplicatwTljor JV1Y39; No Fee; COllrtesy
Copy; Submit 2 copies Laurie Dennisoll, NC-DEND, DWQ, JYetlandsl401
Ui,it

rf,WhCuro]j.oa
lVahirl1u!/

l)ivi1ion orw~ Q\I~lity. WaJ':lIlds QIl(J ~lC' Dr.u1Cll
J650 Mail Savia: Calla'. RnIci&h, Nqrth Qro!in327699.J6S0
2321 Crl1hlra: OnuJcvmf. Suite 250. Ralcil;h. NCJ1lI CIlrolina 27604
Phone: 919.733-l7llf,' FAX 919-7J~91/11ltcn)cI: hl'TJ1:'/l'l1o.01r..t>;renc.u"no.dln:nr.

A" P.qu:lI OpJlQl11lcit)'/AffiNn~ti~e Actio<) EmpJoy~- Stn~ RccyckdlJO," POJI Con~m.::r P:lpCr

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TO: 951150293

P:6J'13

Office Use Only:

form Vcnrion M=h os

USACE Action ID No. DWQ No.
(Tf:my particular item is not applicable to this projcct, pl~ enter -Not Applicable" or "N/A-.)

L Processing

1. Check all of the approva1(s) requested for this project
o Section 404 Permit 0 Riparian or Watershed Buffer Rules
o Section 10 Permit 0 Isolated Wetland Permit from DWQ
o 40 1 Water Quality Certification 0 Express 401 Water Quality Certification

2. Nationwide, Rcgion.'\l or General Permit Number(s) Requested:

3. If this notification is solely a ~~y copy because written Dpproval for the 401 Certification
is nol required. check here: ~

4. If payment into the North Camlina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach tbe acceptance letter from NCEEP, complete section VIIl,
and check here: 0

II.

5. If your project is located in any ofNorlh Carolina's twenly constat counties (listed on page
4), Wld the project is within a North Carolina Division of Coastal Management Areil of
Environmental Co~cem (see the top ofpagc 2 for further debils). check here: 00 @ ~ 0 W ~ rm

Applicant Infonnntio'o 1M L=::J ~
AUG 1 5 Z005

1. Owner/Applicant Infonuation
Name: '''"'/)I1V/ f) c.. :sDJI'NSo;1/
Mailing Address: 2.'10 jZ>>/llAl /)/e; /JGel?_ 71C/f1L
P/77>/1012/) "IV C, 2.7 3/Z
I

rV:NR . WATFR QUALITY
WETlANDS AND STORMWATER BRAIJCH

Telephone Number: ql'1- 5''1 S'- S b 2:~
E-mail Address:

FaxNwnber. 91'1- S''1S-D'Z/l l'

2. Agent/Consultant 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:
Company AffiliatiQn:
Mailing Address:

Telephone Number:
E-m.ail Address:

Fax Number.

PIl8" .s ofl2

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m Project InformntioD

Attach a vicinity mnp clearly shO\ving the location of the property with respect to local
landmarks such as towns, rivers, and lOads. Also provide a detailed Bite pJ:lO showing property
boundaries and development plans in relation to surroun.ding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious sunnccs, O{ other fucilities must be included. Jfpossiblc, the maps and plans should
include the appropriate" USGS Topogrnphic Quad M~J> 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 3tld distribution purposes, the
USACE requires infonnation to be submitted on sheets no huger than 11 by 17-incb format;
however, DWQ may accept paperwork of any size. DWQ prefers fuU.-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans arc
reduced to a small scale such that the fin.1l vrnion is illegible) the applicant will be infonned that
the project has bctn placed on hold until decipberable maps are provided.

1. Name of p~ject: . Fz?1CIJ C~

2. T.I.P. Project Nwnl>er or State Project Number (NCDOT Only):

3. Proptrty Identifica~ion Number (Tax PIN):

4.

:J,

5. Site COOrdinatC3 (For lin~ projects, such as a road or utility line, attach a sheet that
separately lists the .coordinates for each crossing of a distinct watabody.)
Decimal Degrees (6 digits minimum): ~ ow

6. Property size (llcres): '73 /kfl.C'i

7. Name of n~est rc,cciving body of water: 3D I wA;u '- ~ 121 t/C'tZ..

8. River Basin: /mw R/ t/CJJ'Z.
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Ibsin map is available at httf)~/1h2o.enr.st:tte.nc.us/adm;n/lJulJ)sl.)

9. Describe the existinz; conditions on the site and general Janrl use in the vicinity ofthe project
at the time of this iWpIication: /l/J1gC~.() y i//JvJ~,rr

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10. Describe the overall project in detail, includina the type of equipm.ent to be used:
/Jflh.9() 12t17'lf) yo (~//1/ry 120. ~m>. J /2G6//J5/l/$/ft... L.tr/S if !"v/lt(..,

11. Explain the pwposc of the proposed work:

, {!,e()Sypo 7bihfJLc- o.f2&K

tv. Prior Project Ilbtory

If jurisdictional detenninations and/or pennits 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 Nwnber, application date, mld date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued pennits,
C(:rtiflCations or other usefUl infonnation. Describe previously approved wc:t1:md, stream and
buffer impacts, WODS with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the smne T.J.P. project, along with
construction schedules.

V. Future Project Plans

Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for tho ex.clusion orthis wOJ.'k fTom the cwrcnt application,
Il/I)

VI. Proposed Impacts to Wnters oUbe United Stites/Waters of the State

It i, the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water; and stream cblUlJlels .associated with the project. Each impact must be
listed scpamtcly in the tables below (e.g., culvert installation should be listed separately from
riprap dissipatc:t pads). Be sure (0 indicate if an impact is tcmpomy. All proposed impacts,
pCIl'rulIlCnt and tcmpomy, must be listed, and must be labeled and clC<lJ'Jy identifiable on an
accompanying site plOJI1. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts arc proposed to these systems.
Wetland and stream evaluation and delineation f0rtn3 should be included as appropriate.
Photographs may be ;nc1uded at the applicant's discretion. lfthis proposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section vm below. If additional
space is needed for listing or description, please attach a separate sheet.

J _ Provide a wriucn description of the proposed irnp3cts:

P:lSC 1 of J2

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P:9'13

2. Individually list wetland impacts. Types of impacts include, but arc not limited to
mechanized clcariDg. grading, flU, excavation, flooding, ditching/drainage. etc. For dams,
I r' d b

separately .lst unpacts ucto oth structure and flooding.
Wctl:md Irnp:u:t Type of Wetland Located within Distance to Area of
Site Number Type ofJmpact (c.g., forested, mnrsb, lOD-yellr Nearest Impact
Floodplain Sln:am (acn:.,)
(mdic:1tc on map) herbaceous. bog, ClC.) (ves/no) Oinenr feel)
ToW Wetland Impa.ct (nacs)

3. List the total acreage (estimated) of all existing wetlands on the property:

-0 -

4. Individually list all intermittent and perennial stream jm~cts- Be sure to identify temporary
impacts. Stream tmpacts include, but arc not limited to placement of fiU or culverts, dam
construction, flooding. relocation, stabilization activities (e.g., cement waIls. rip-rap, crib
walls, gabions, etc.). excavation, di.tcbinlistraightening. etc. If ~ relocation is proposed,
plans and profiles showing the linear footprint for both the oriBinal and relocated streams
be' J dcd. T alcuJ ul' I I gth X 'd1l th di.d b 43560

must mcu DC ate acreage, m tJolv en WI 1, en VI C Y ,
Stream JmpilCl Perennial or A ver.1ge Impact ^reaof
Number Stream Name Type of Jmpnct Imennittcnt1 Sb:c3m Width Length Impact
(indicate 01) map) Before Im=ct (Jjnear feet\ (acre~)
76:.J]jJt.ff (je{;t1t., ~A{) ~551J1fC !/.IT!:lU:I/i{;.;, L- 'it I 7'6
Total Slleam Impact (bytcngth omd ~ge)

s. Individually list 3U open water impacts (including lak~ ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but arc not limited to
fil1 . deed' fl

1 . excavau.on, IJtin~. oodinn, drainaRc, bulkhcads, etc.
Open Warr.r lmpnct Name ofW:ueJ'body Type ofWlltcrbody AIC"J of
Site Number Type ofImpact (lake, pond, estuary, sound, bay, Impact
(indicate 011 mn.n) (ifllppli~Je) ocean, etc. \ (acres)
Tout Open W~er lDlpl1Ct (aaes)

Pa8~ 8 0112

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TO: 95450293

P:Hl"13

6.

.y~

7. Isolated Waters
Do any isolated \V:llers exist on the property? 0 Yes IZ8J No
Describe all impacts to isolated waters, and include the type ofwater (wetland or stream) and
the size of the propDsed impact (acres or linear feet). Please note that this section only
applies to waters lhat have specifically been determined to be isolated by the US ACE.

8. Pond Creation
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 application.
Pond to be created in (check all that apply): 0 uplands 0 stream 0 wetlands
Describe the method of construction (e.g., dam/embankment, cc;cavation, installation of
draw-down valve or spillway, etc.):
Proposed use OT purpose of pond (c.g., livestock watering, irrigation, aesthetic, trout pond.
local stormwater requirement. ctc.):
Current land use in the vicinity of the pond:
Si7.e of watershed draining to pond: Expected pond surface area:

VII. Impact Justification (Avoidance and Minimi7.3tion)

Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related 10 site constraints such as topography. building ordinances, accessibility. and
finnnc;aJ vi.ability of the project. The applicant may attach drawings of altcmativc. lower-impact
site layoulc;, and explnin why these design options were not feasible. Also discuss how impacts
were min;.ni7-OO on~e the desired site plan was developed. If applicable, disc1lsS constnlction
techniques to be followed during consttDction to reduce impacts.

VID. Mitigation

DWQ - In accordance with lSA NCAC 2M .0500, mitigation may be required by the NC
Division of Watet Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands ot greater tkm or equal to J50 lineal;' feet of total impacts to perennial
streams.

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USACE - In accordaI}ce with the FiJuJ Notice of Issumee nnd Modification of Nationwide
Permits, published in t4e Federal Register On January IS, 2002, mitigation will be required when
necessary to ensure that ndverse effects to the &quatic cnviromnent are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic n:sOlU'CC will be considered in determining acceptability of approprfutc and pmcticable
mitigation as proposed. Ex<:mpJes of mitigation that may be ~propriatc nnd practicable include,
but are not limited to:. reducing the size of the project; establishing <lI1d nuintaininlJ wetland
and/or upfund vegetated buffers to protect open waters such as streams; <lI1d replacing Josses of
aquatic resOW"CC functions and values by creating, restoring, enhancing, or preseIVing similar
functions and values. prefeIi1ble in the same wateJ:shcd.

If mitigation is required far this project. a copy of the mitigation plan must be attached in ordeT
for USACE or DWQ ,to consider the <:pplication complete for proccS$iog. Any ;:pplication
1ackinB a required mitigation plan oX' NCEEP concurrence shall be placed on bold as incomplete.
An applicant may also cltoosc to review the cur.rcnt guidelines for stream restoration in DWQ's
Draft Technical Guide for Stremn Work in North CzroIin.Ol, available at
h ttD:/1h2o. enr.statc.nc. us/ncwetlnndslSlrmtPde.html.

1. Provide a brief dcs~tion of the proposed mitiuation plan. The description should provide
as much information as possible, includinlJ, but not limited to: site location (attach directions
and/or m..", if offsite), affected stream and river basin. type and mnount (acrea,gc/linclU' feet)
of mitigation propqsed (~tion, cnh:mctmcnt. creation. or preservation), a plan view,
preservation met~ism (c.g.~ deed restrictiOD3. consexvatton casement. etc.), and a
description of the C\UIcnl site conditions and proposed method of constmcti.on. Pleaso attl.Ch
11 sepnmte sheet if more ~ is needed.

2. Miti1Jation may OlIso be mtdc by payment into tho North Qrolina Ecosystem Enhancement
Progrnm (NCEEP). Please note it is the applie<:nt's responsibility to contact the NCEEP at
[phone] to determine availability, and \"mtten ~rovaJ from the NCEEP indicating
that they an: wiD to nccept payment for the mitigation must be nttacl1ed to Ihi3 form. For
additional infommion ICgording the application process for the NCEEP, check the NCEEP
website &t httD://h2o.cnr.stlltc.ne.uslwmlinde~.l1tm. Ifwc of the NCEEP.is proposed, please
check the approprin~e box on page five and provide the following infoImauon:

Amount of s~ mitigation requested Qincar fc;:t):
Amount ofbuffcz mitigation requested (square feet):
Amount of Rip:::rian wctltmd mitigation requested (<1crcs):
Amount ofNon..ripiU'iim wetland mitigntion requested (&lcres):
Amouut or~bl wetland mitigation requcsted (acres):

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TO: 95450293

P: 12"13

IX. Environmental J>oeu~tl1tfon (requ.ired by DWQ)

1. Does the projcct involve an expenditure of public (fcderall5tatel1ocaJ) fWlds or the use of
public (fcderaJlstat<<r) land? y cs 0 No m.

2. If yes, does lhe p~ject require preparation of an environmental document pmsuant to the
requirements of th~ National or North Carolina Environmental Policy Act (NEP A1SEP A)?
Note: If you are POI sure whether a NEPNSEPA document is required, call the SEPA
coordinator at (919j 733-5083 to review current tlueshoJds for environmental documentation.
Yes 0 No 0

3. If yes, has the docJjment review been finalized by the State Clearinghouse? If so, please
attach a copy of the NEPA orSEPA fmal approval letter. Yes D No 0

x. ProJUlsed Impacts on Riparian nnd Watersbed Duffcrs (rcquind by DWQ)

It is the applicant's (o~ agent's) responsibility to detennine, delineate ;)Dd map all impacts to
required state nu.d local buffers ::.ssociated with the project. The applicant must ruso provide
justificatioll for these iIppacts in Section vn above. AU proposed impacts must be listed herein,
and must be clearly ideptifiable on the accompanying site plan. AU buffers must be shown on a
map, whether or not ipIpac13 are proposed to tho buffers. Correspondence from the DWQ
RceionaJ Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.

1. Will the project imp:lct protected riparian buffers identified within 15A NCAC 2B .0233
(Neusc), 15A NCAC 2B .0259 (far-Pamlico), 15A NCAC 02B .0243 (Catawba) lSA NCAC
2B .0250 (Randleman Rules tnd Water Supply Buffer Requirements), Of other (please
idcntify, . )1 Yes 0 No 0

2. If "ycs", identify the SquDIC feel and llCreage of impact to each zone of the riparian buffets.
If buffer mitigation is required calculate the required amount of mitigation by ~ppIying the
buffi lli l'

ef mu Jpi leTS.
Zone- ImpllCt Multiplier Required
(square feet) Mitir,ation
] 3 (2 for Catawba)
2 I.S
Total

· Zocte 1 e~ 011130 fuc1 pcxpc:ldicul::r from the top Qr the near ~ of eb:lIll1cl; Zone 2 extends :m
OOditiDnal2f)rcct ~ me wgcorZo:lo I.

J. If buffcr mitigation is required, please disalSS what type of mitigation is proposed (i.e.,
Donation of PropCitY, Riparian Buffer Restoration I Fnhancemcnt, or Payment into the
Riparian Buffer Restoration Fund). Please nttach 1111 nppropriate infotmation <tS identified
within I SA NCAC 2B .0242 or .0244, or .0260.

Page J J of12

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XI. Stormw1ltcr (required by DWQ)

Describe impervi.ous a~reage (existing and proposed) versus total acreage on the site. Discuss
stonnwatcr controls proposed in order to protect surface waters and wetla.uds downstream from
the property. If percent impervious surface exceeds 200/0. please provide calculations
demonstrating total proposed impervious lcvcl. /~o / /J1,ot!1?v/()!/) ','!/er/fClff

xu. Sewage Disposal (req~ircd by DWQ)

CJearly detail the ultimate treatment methods and disp03ition (non-discharge or discharge) of
wastewater generated from tbe proposed project. or available capacity of the subject facility.

XIII. ViolntiOJJ5 (required by DWQ)

Is this site in violation Qf DWQ Wetland Rules (ISA NCAC 2H .0500) or any Buffer Rules?
Yes D No ~

Is this an after-the-fact permit application? Yes rg./ No 0

XIV, Cumulative Impacts (required by DWQ)

Will this projcet (based on past and reasonably anticipated future impacts) result in additional
development, which eo1.Jld impact nearby downstream water quality? Y cs 0 No JI<j'
If yes, please submit a qualitative or quantitative cumulative impact analysis in acco.rdance with
the most recent North. Carolina Division of Water Quality policy posted on our website at
J1ttP:/lh2o.enr.~ate.nc.us/ncwetlands. Ifno, please provide a short narrative description:

xv. Other CircumstaJlCC5 (Optional):

It is the applicant's responsibility to submit the :lpplication sufficiently in advance of desi.red
construction dates to allow processing time for these pcnn.its. However, an applicant may
choose to list constrmn.ts associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schcdules for lakcs, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).

y:tc,dlw-- 8'k/Pc-'

Applicant/Agent's SignallU'C / / Date

~(_A gcnt:~ll~ auiliorization 1= from the ;!:J;~~ p'O\Ooed.)

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. DENR - WATER QUALITY
\ ,'ETWms AIID STORllNATER BRAlJCH