20051679 Ver 1_Complete File_20050831

r.

Office Use Only:

Form Version l\larch 05

USACE Action ID No. DWQ No.
(If any particular itelll is not applicable to this project, please enter "Not Applicable" or "N/A".)

20051679

I. Processing

I. Check all of the approval(s) requested for this project:
IT Section 404 Permit 0 Riparian or Watershed Buffer Rules
o Section 10 Permit 0 Isolated Wetland Permit from OWQ
~40 I Water Quality Certification 0 Express 40 I Water Quality Certification

') Nationwide, Regional or General Permit Number(s) Requested: /J/l"tniuu..-1bt';. 1/5'

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

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

II.

5. I f 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 ~ivision of Coast~ M;]nagement Area of
Environmental Concern (see the top of page 2 for further details), chlKf@&mOW@.@

\ I. . . n
I pp H~an( InlormatlOn AUG 3 1 2005

I. Owner/Ap 11icant InI9n~.tion -' ~ _ I\~~~WATERQUAUTY
Name: ??4A/ -;v'/ IJIJ C0/-nc.'0 DSTORMW,A,TERB!VWCH
5J.." vO PI D ~ u m J1/(
, -
~O~Ox' SOL/"
A) AJ S Ao 0 {"'O De..
-2 ~g '-(
Telephone Number: 9' /CJ - 3 '"Z.l.o - 'i?Y<ttax Number:
E-mail Address:

2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization lettcr
must be attached if the Agent has signatory authority for the owncr/applicant.)
Namc:
Company Afliliation:
Mailing Address:

/1/#

i/

Telephone Number:
E-mail Address:

Fax Number:

Page 5 of I ~

,.

III. 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 devclopmcnt 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 surfaccs, 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 defincd. For administrative and distribution purposes, the
USACE requircs information to be submitted on sheets no largcr than II by 17-inch format;
however, DWQ may accept papcrwork 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 thc final version is illegible, the applicant will be informed that
the project has been placed on hold until dccipherable maps are provided.

1. Name ofproject:;?.?~/JI() E:':5777t:S {';;/f$'/,,(,I/T7 /1.6"4
2. T.I.P. Project Number or State Project Numbcr (NCDOT Only): /Y...IJ

3. Property Identification Number (Tax PIN):

AiA

,

4. Location./ /
County: ~S/tJ/U NearestTown~c?45bt?f'()
Subdivision name (include phase/lot number):~~,...w...J7/7/lW../ e:-=:J;:7i::l7$:s"
Dire~ions to site (include road l1l~n)bers/names, landmarks, etc.): /'PC1v7E /-fI p-J20/'h
\//? C K S p11.J v /I... L t:i .L. e /-1 d /V /114 117 S'r. .c x7: I I? I b /l']' If n. .J L- p:?
/J' 1')/' "1 I -
/('t.Jj(Jj) /c'/6i-/r tJIU r-~;r1It/rjJTN D/?///6 rdJ Z/lJ/'IJCI
I .

5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct waterbody.) 0
Decimal Degrees (6 digits minimum): 3 L/, 7 tJ '" tf5 ON 771 / / / :z...,o OW

, 0/
!. 0 to a c J-../

7. Name ofncarest receiving body of water: W.ht? ~~.~ eo ~

8. River Basin: (AJ,,4/~ ~a/ ~/I?~
(Note - this must be one of North Carolina's seventecn designated major river basins.
River Basin map is available at http://h2o.enJ'.state.nc.us/admin/maps/.)

6. Property size (acres):

The

9.

Page 6 of 12

,.

IV. Prior Pro,ject IIistory

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 permits and
cerlifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wctland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits iss led for prior segm~nts of the same T.I.P. project, along with
construction schedules. ~/ U ~
_~ 31"/

( ObLsr:?~

V. Future Project Plans

Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and providejustificatio 1 for the exclusion of this work from the current application.
C

VI. Proposed Impacts to 'Vaters of the Uuited States/Waters of the 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. Each impact must be
listed separately in the tables below (e.g., culvert installation ShOlild be listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wctlands and watcrs, and all strcams (intermittent and perennial)
should be shown on a delincation map, whethcr or not impacts arc propos cd to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs may be included at the applicant's discretion. I I' 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 dcscription, please attach a separate sheet.
-./

I. Provide a written description of the proposed impacts: # j/llt

Page 7 of 12

,.

, Individually list wetland impacts. Types of impacts include, but arc not limited to
mechanized clearing, grading, till, excavation, flooding, ditching/drainage, etc. For dams,
I r I I I Ifl r

separatelY 1st Impacts t ue to )Ot 1 struct lire ant OOt l111.!:.
Wetland Impact Typ\: of Wetland Locat\:d within Distance to Arca of
IOO-y\:ar Nearest Impact
Sit\: Number Type of Impact (\:,g" fon;sted, marsh, Floodplain S tr\:am (acres)
(indicate on map) herbaceous, bog, \:tc,) (yes/no) (lin\:ar fect)
)) ~ i0 ~l1ds . /) I fi
Total W\:tland Impact (acres) 1/J/61

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

4. Individually list all intermittent and perennial stream impacts. I3e sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
I I I I T I I I . I I I X 'd I I r'd b 43 560

must Je l11C u( et . o ca cu ate acreage, mu tm1Y engt 1 WI t 1, t 1en ( IVI C >y ,
Stream Impact Pcrcnnialor A vcrage Impact Arca of
Number Str\:am Nanw Type of Impact Intermittent'! Str\:am Width Length Impact
(indica!\: onma~ -~-~ Bdi.Jre Impact (linear feet) (acr\:s)
"
j 771
/ I/IJ
/ I
7
Total Stream Impaet (by length and acreage)

5. Individually list all open wakr 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 excavation dredl.!:inl! flooding drainage bulkheads dc

, , , , , . ,
Open Wat\:r Impact Nam\: of Waterbody Type of Water body Area of
Site Numb\:r (if applicable) Typ\: of Impact (lake, pond, estuary, sound, bay, Impact
(indicate on map) 7# ocean, etc,) (acres)
Total OJ1\:n Water Impact (acres)

Page X of 12

f.

6.

7. Isolated Waters ~ /
Do any isolated waters exist on the property? 0 Yes LJ1<jo
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 determined to be isolated by the USACE.

H. Pond Creation Al /..
I f construction of a pond is proposed, 'sJCa1a ed wctland and stream impacts should be
included above in the wetland and strea 11 impact sections. Also, the proposed pond should
be describcd here and illustrated on any maps included with this application.
Pond to be created in (chcck all that apply): 0 uplands 0 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 storlmvater requirement, etc.):
Current land use in the vicinily of the pond:
Size of watershed draining 10 pond: Expected pond surface area:

VII. Illlpact .Justification (Avoidance and i\linimization)

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
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options wcre not feasible: Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, di~uss constn ction
lechniques to b~' fo lowed during construclion to reduce impacts. ~ 'J ~ r c:- eo
; ~ / .
~ ./. ~t/, -~c' .' v. t/,I-'/ '/..- P'
-/ZL 'L.t.., 1?,' ~ t/r ~ ~~" ::;.h/l'

V II I. J\ litigation

DWQ - In accordance with 15/\ NC/\C 211 .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
fi'eshwater wetlands or greater than or equal to 150 linear feet of total impacts to pcrennial
streams.

Page l) of I ~

/y-/l

I.

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, 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 prescrving 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 NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draa Technical Guide for Stream Work in North Carolina, available at
h t Ip:/ Ih 2o.en r. sla I C.llC .lls/ncwet I a nds/sl rml.! i de. hI 1ll1.

I. 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 offsite), 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 separale sheet i I' more sp'lce is needGd.
t/!!//- /J~~ 4-s ?
~~ -/ /ctnc/? ~Pl ,~4
~C r?/v~ '/ ~tJ/v/7

')

Miligation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval' from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http://h20.enr.slate.nc.us/wrp/inde.\,htm. If use of the NCEEP is proposed, please
check the appropriate box on page live and provide the following information:

)/1

/

Amount of stream mitigation requested (linear leet):
Amount ofburter 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):

I'ag~ 10 of 12

f.,

IX. Environmental Documentation (required by DWQ)

I. Docs the project involve an expenditure of public (federal/state/local) funds or the use of
public (federal/state) land? Yes D No ~

2. If yes, does the project require preparation of an environmental documcnt pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEP A/SEP A)?
Note: I I' you are not sure whether a N EP A/SEP A document is rcquired, call the SEP A
coordinator at (919) 733p083 to review current thresholds for environmental documentation.
Yes D No ~

3. If yes, has the document review been finalized by the State Clearinghouse'~so, please
attach a copy of the NEPA or SEPA final approval letter. Yes D No 1M

X. Proposed Impacts on Riparian and 'Vatershed Buffers (required by D'VQ)

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 butTers must be shown on a
map, whether or not impacts arc proposed to the buffers. Corrcspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.

1. Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Neuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 02[3 .0243 (Catawba) 15A NCAC
213 .0250 (Randleman Rules and Water Supply BufTer Requirements), or other (please
identify )? Yes D No D

")

If "yes", identify the square feet and acreage of impact to each zone of the riparian buffers.
if butTer mitigation is required calculate the required amount of mitigation by applying thc
bufT I . l'

er mu tiP lers.
Zonc* Impact Multiplier Required
(square feet) Mifil!ation
I 3 (2 for Catawba)
2 1.5
Total

tft

* Zone I exll:nds out 30 feet p.:rpendicular froll! the top of the near bank of channel; Zone 2 extends an
additional 20 feel Ji.oll!lhe edge of Zone I.

3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Properly, Riparian ButTer Restoration / Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appropriate information as idcntified
within 15A NCAC 213 .0242 or .0244, or .0260.

Page II 01'12

f.

XI. Stormwater (required by D\VQ)

)/fJ

Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stonnwater controls proposed in order to protect surface waters and wetlands downstream from
the property. I I' percent impervious surface exceeds 20%, please provide calculations
demonstrating total proposed impervious level.

XII. Sewage Disposal (required 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. Violations (reeJlIired by DWQ)

Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes 0 No 0

Is this an aller-the-fact permit application? Yes 0

No 0

XIV. Cumulative Impacts (required by D\VQ)

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 0
If yes, please submit a qualitative or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality IJolicy posted on our website at
hllp://h2o.enr.state.nc.lIs/ncwetlands. Ifno, please provide a short narrative description:

XV. Other Circumstances (Optional):

It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction 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).

/
{)S

Applicant/Agent's Signature )ate
(Agent's signature is valid only iran authorization letter li'om the applicant is provided.)

Page 12 of 12

v..'lite 001< River

wetland:

t.
I
162'

~
~
u
.-' 0
, .-'
~ ' co '
, ... ' V
u ~
0 -
\0 ' '-'. t.
co . . wetland:
.0' I
. ~.
'-' : ... : ( 0 11 acre ) 120'
"'0 . .. ' 0
I: . U'
::lI .0.
5 a.
. . t.
...
>- I
..
'E
::lI
E
E 300'
0
v
I
V
plantation Drive

t.

Mop SI<ctch : plantation
E:tatc::: Community
GN u n d

si:c . So acre

Impact orca 112" :tonc

737.55' Impact orca U' X 100'

Wetland: ( 1 ) Rcnoun:hmcnth

A:.tilbe
Woter In:
Dold Cyprc:::::
Lobelia
'fellow Flog

V

. ' .

L ~

8'x100'

i

/j
!
j
,

\'

":l~. i '

, 1,1

The following is a list of proposed plantings for the area noted by flags;:

Astilbe
Iris Laevigata (Water Iris)
Taxodium (Bald Cypress)
Lobelia Siphilitica (Great Lobelia
Iris Pseudacorus (Yellow Flag)

Flags for wet land area placed by Army Corps Of Engineers

r.

Office Use Only:

Foml Version March 05
20051879

USACE Action ID No. D'VQ No.
(lfany particular item is not applicable to this project, please entcr "Not Applicable" or "N/A".)

I. Processing

I. Check all of the approval(s) requested for this project:
B" Section 404 Permit 0 Riparian or Watershed Buffer Rules
o Section 10 Permit 0 Isolated Wetland Pennit from DWQ
~40 I Water Quality Cel1ification 0 Express 401 Water Quality Certification

2. Nationwide, Regional or General Pennit Number(s) Requcsted: pt17'; ci;.jl,vJ 1)1;. I ~>

3. If this notification is solely a couI1esy copy because written approval for the 40 I Cet1ification
is not required, check here: ~

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

5. 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 Coast~ Mg~ement Area of
Environmental Conccrn (sce the top of page 2 for further details), chl^r~~llW@ fii)

Applicant Informalion AVG 3 1 2005 .~

II.

I.

~~~;'DWATER QUALITY
nil STORMWATER B

Tclephone Number:
E-mail Address:

2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization lettcr
must be attach cd if the Agent has signatory authority for thc owner/applicant.)
Name:
Company Affiliation:
Mailing Address:

Telcphone Numbcr:
E-mail Addrcss:

Fax Number:

Page 5 of 12

"

III. 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 ~howing 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, 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 defined. 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 vcrsion is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.

1. Name ofproject:;?.?4JJ7JIIU ~7E:5 6//#/t/tflITll .d4~
2. T.I.P. Project Number or State Project Number (NCDOT Only): /Y...IJ

3. Property Identification Number (Tax PIN):

AlA

,

4. Location / /
County: t7/1 S/iJkJ Nearest Town~.('I'n.sOt?)/O
Subdivision name (include phase/lot number):~~A1~/'#7/t?y L==:-~5.
OireEions to site (include road m~nJbers/names, landmarks, etc.): ;fJovrg 2.~ p-J2al1?
V/?cKSUn.Jf//I-Lti, LR/y tl?t/ ,wt:lJl1 ~r: cx7: I /?16/1') 1In..I "-iU,P
/?t)flJD /216;:;r tJtU pJ,./llt-r'ftT/N D/?/t/c /2' f/1J/'/PCT,
I

5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct waterbody.) 0
Decimal Degrees (6 digits minimum): 3 ~ 7 t) <.J tfS' ON 771 /11 :z..- 0 OW

6. Property size (acres): I 8 h a. e J-J

7. Name of nearest receiving body of water: w~1C, t7a~. e;/ ~

8. River Basin: pJ.4/~ ~a/ r:3!/~
(Note - this must be one of North Carolina's seventeen designated major rivcr basins. The
River Basin map is available at http://h20.cnr.state.nc.lIs/admin/maps/.) ,

9.

Page 6 of 12

,.

IV. Prior Project History

If jurisdictional detenninations 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 10 Number, DWQ Project Number, application date, and date pennits and
certifications were issued or withdrawn. Provide photocopies of previously issued pennits,
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 iss led for pri~l/segmSl1ts of the same T.I.P. project, along with
construction schedules. . ~"/ . c- -
"3 "/

(OOs9~

V. Future Project Plans

Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and providejustificatio 1 for the exclusion of this work from the current application.
C.

VI. Proposed Impacts to \Vaters of the United States/Waters of the 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. Each impact must be
listed separately in the tables below (e.g., culvert installation sho\lld be listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. 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 describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
0-../

I. Provide a written description of the proposed impacts: .# IJlIt

Page 7 of 12

t.

2. Individually list wetland impacts. Types of impacts include, but are not limited to
mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For dams,
se Jaratel list im acts due to both structure and tloodin

Wetland Impact
Site Number
(indicate on map)

Type of Impact

Type ofWctland
(e.g., forested, marsh,
hcrbaccous, bog, etc,)

Located within
lOO-ycar
Floodplain
( es/no)

Distance to
Nearest
Stream
(linear feet

Arca of
Impact
(acres)

Total Wctland Impact (acres)

18

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

4. Individually list all inte1111ittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
t b . I d d T I I I . I I I X 'd I I d"d b 43 560

mus e mc 1I e . o ca cu ate acreage, mu tlply engt 1 WI t 1, t 1en IV! e )y ,
Strcam Impact Pcrennial or A vcrage Impact Area of
Numbcr Stream Name Typc of Impact Intcrmittcnt? Stream Width Lcngth Impact
(indicate on man) Beforc Impact (linear fcet) (acrcs)
f\
J 1/
/ 1/17
/ I
I
Total Strcam Impact (by length and acrcage)

5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any othe~ water of the U.S.). Open water impacts include, but arc not limited to
fill, excavation, dred in ,floodin ,draina e, bulkheads, etc.
Opcn Water Impact Type ofWatcrbody
Name ofWatcrbody
Site Numbcr (if applicablc) Type of Impact (lake, pond, cstuary, sound, bay,
(indicate on ma 1) ocean, ctc.)

Area of
Impact
(acres)

Total Open Water Impact (acres)

Pagc 8 of 12

r.

6.

7. Isolated Waters ~ /
Do any isolated waters exist on the property? 0 Yes LJ1<Jo
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 determined to be isolated by the USACE.

8. Pond Creation ~
If constmction of a pond is proposed, s la ed wetland and stream impacts should be
included above in the wetland and strea n 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, 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.):
Current land use in the vicinity of the pond:
Size ofwatcrshed draining to pond: Expected pond surface area:

VII. Impact Justification (A voidance and Minimization)

Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
infonnation related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of altemative, 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, dis uss constn ction
techl iq~'es~ tq be fo lowe during cons},ruction to reduce impacts. ~ .eo
~ ~ ~ ~C.
ta..; 'V Y:

VIII. .Mitigation

DWQ - In accordance with 15A NCAC 21-1 .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

)/11

!:-

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessmy 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 US ACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP conCUlTence 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
hltp://1120.enr.state.nc.us/newetlands/strmgjde.l1tml.

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 offsite), 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 sl~~l11orc ~'CC is ncc~od. 1 . ./! /..1. Lt

~#i~~~!:~!n~' ~;;V#~ ~~ ~

2. Mitigation may also be made by payment into thc North Carolina Ecosystem Enhancemcnt
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to detennine availability, and written approval' from the NCEEP indicating
that they arc will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http://h20.enr.state.nc.us/wrp/index.htm, If use of the NCEEP is proposed, please
check the appropriate box on page five and provide the following information:

ill

/

Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requcsted (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requestcd (acres):

Page IOofl2

r..

IX. Environmental Documentation (required by D\VQ)

I. Does the project involve an expenditure of public (fcderal~~/local) funds or the use of
public (federal/state) land? Yes 0 No ~

2. 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 AlSEP A)?
Note: If you are not sure whether a NEPAlSEPA document is required, call the SEPA
coordinator at (919) 733~083 to review current thresholds for environmental documentation.
Yes 0 No Gr'

3. If yes, has the document review been finalized by the State ClearinghouseZ-. I'-y>o, please
attach a copy of the NEPA or SEPA final approval letter. Yes 0 No Lt1'

X. Proposed Impacts on Riparian and \Vatershed Buffers (required by D\VQ)

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.

I. Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Ncuse), 15A NCAC 28.0259 (Tar-Pamlico), 15A NCAC 028.0243 (Catawba) 15A NCAC
28 .0250 (Randlcman Rules and Water Supply Buffer Requirements), or other (please
identify )? Yes 0 No 0

2. If "yes", 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
buff I . r

ttM

er mu tIP lers.
Zone" Impact Multiplicr Rcquired
(sauare fcet) Mitigation
I 3 (2 for Catawba)
2 1.5
Total

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

3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Property, Riparian Buffer Restoration / Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appropriate infonnation as identified
within 15A NCAC 2B .0242 or .0244, or .0260.

Pngc II ofl2

r..

XI. Stormwater (required by D\VQ)

)j!J

Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the propel1y. If percent impervious surface exceeds 20%, please provide calculations
demonstrating total proposed impervious level.

XII. Sewage Disposal (required by D\VQ)

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. Violations (required by D\VQ)

Is this site in violation of DWQ Wetland Rules (I5A NCAC 2H .0500) or any Buffer Rules?
Yes 0 No 0

Is this an after-the-fact permit application? Yes 0

No 0

XIV. Cumulative Impacts (required by D\VQ)

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 0
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
http://h2o.enJ'.state.nc.lIs/ncwetlands. Ifno, please provide a short narrative description:

XV. Other Circumstances (Optional):

It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these pemlits. 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 o( the applicant's control).

i
()0

Applicant/Agent's Signature ate
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

Page 12 of 12

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