20090916 Ver 1_Initial Interest_20090824

Print Form

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NCDENR

Form Version 62
June 29,2009

INITIAL INTEREST IN PARTICIPATION IN THE EXPRESS REVIEW PROGRAM
_____ WITHIN THE 401 OVE~SIGHT/EXPRESS PERM!ITING UNIT

A. Applicant Information

1, Processing

1 a. Type(s) of actions
requested:
(Check all that apply)

D 401 Water Quality Certification (List NW(s) or GP# verified by Corps: _)
D Non-404 Jurisdictional Permit
I D Riparian Buffer Authorization
o Riparian Buffer Minor Variance
o Coastal General "Major" Variance
[9/ Stream Determination: ....:1:....- # Streams
o Non-404 Wetland Determination: _ # Wetlands
Stormwater Management Plan Review (fee not additive if combined with 401):
# of Drainage Areas/Project Site

I 2, Project Information

2a. Name of proJ~~t.:--..____ L [.1)"'-11 ~ Eo LLI S" .__.__,.._.
I VU 'l.H A IV1
L~~. ,j", 1_.~7;q.~-
.. River Basin bl e. V "?~____
2e. Tax PIN or ParceIID:e~_~_.._ O~ ".L__? - 0 '.:_:!_Ct -~~1=1 ~I.+
2f. Nearest Named Stream ... ~ r e,oc K ~ C~f..'1:2:k....
i 29 W~ter Qua!lty Cla~~~~Catlon ~f- Ne~~~~d Str~~~.__ __ --.---.-.---
12h. Total project acreage (~tream or w:~la_nd determ:~~tions may ~~~t_thiS item): 7. I (acres)
21 Total Built Out Imperviousness (Stream or wetland determinations may omit this item):

-\ Long: 7)'. t3//L_____

I
----I

Latitude/Longitude

rID

I C) '0'L70'

%

2j Provide a brief description of this project (attach a site plan):

l. L-ot

SUISi:>iVI'S>IO"J

2k_ Provide directions from the nearest named town, including street names and/or highway numbers:
F(z';;> ,'" YJ rOtA1Vl-(0 u'S S.:> I fJ 0..'1-'-,- ~ @ /'t.\ l..1t T O~ l> tA- ~ A IZ 0 .

(~ (A,,-WT D,J 61-i...1 S ~\;"'L @) t T c."'; @.LIS n-J

G.2 5 I '\ (. ~~~~ lW:;: eJ.l. u\,.) ~,

Please attach a map of the site location using USGS 1 :24,000 topographic map and a copy of the latest bound
and published County soil survey with the project/site boundaries delineated. A site plan should also be included
for all projects other than stream and wetland determinations.

Initial Interest Form v6.2 Cant.

. 3, Applicant Information

.3a Ap~icant is IO-owner 0 Agent D Other:
13" Nam"c i Siephl Pu,,-k~B-
2c ~_usiness ~al11e(if appliCab~e): _.
~.3d.Streeta~dress: '.__ 15"55 N,C 5'(. ..-~
. 3e. C~~, Sta~ L \u~ M. '00(( N c '2.. ~7 5 z. ~-----1
i 31Telep~~~.-t"-10 - "5"2.3- 8"-')CD~~' Fax no.: [_'j7ICY~_.~?-~' - $_(.:YZ~_.
I 3h:~mail~~dre_s_s~ I ::;;,"'1 P,::,,~~-+t- (tt p...>cK~t+ s'-'r:~_C"::..<;L.L'_f::?',:,____
~ AgentJConsultant Information (if applicable)
4a- Contact N~~-e: I ---.-
'.'-1'--- ....----- .--.---..

L1~~~~:~:.:~:R=-----

~~lePhone -~;.~"-L-.. ~x no,: 1--
[4g Email addr_~ .. .
I.~:p.':.oposed Impacts (include both temporary and permanent) [Determination requests may omit this item]_
r 5a. T (acres)
c-.-. .
i 5c. T

----1
I
..~
i

. 5d. T
5e. T

.. --.----. I 5b. Total non-404/401 'v'o':!land impact~
otal 404/401 wetland impacts: (acres)
otal 404 stream impacts: Intermittent: (linear feet) Perennial: (Ii
. -. ---- --,-
otal non-404 stream impacts: Intermittent: (linear feet) Perennial: (Iin
~ ___n-
otal riparian buffer impacts: Zone 1: (sq. feet) Zone 2: (sq. f
-"-'-"- ..- --.-.-,-

near feet)
ear feet)
~----_...-
eet)

L__"....

. 6. Project History and Additional Information
t . .- . --- . .-...---.
I 6a. Has any DWQ staff visited the site? DYes G-'No
If yes, provide staff name: _ and date of visit:
6b~D~~~-this project r~quire a Stormwater Management Plan (SMP)? I DYes 0"'~o.._- D Unknown
:__. .... ......._.. . I
D Certified Local Gov't
o DWQ Stormwater Program
o DWQ 401 lEx press Review Unit

6d Does this project require approval under SEPA or NEPA?IO-Yes s' No D--Unknown
____..........___....___ I _..,.._____._.._ ___._______.__
6e. Is this project an after-the-fact application or has a DWQ notice of violation been issued? : 0 Yes [f}-No
--..... -- --
61 Doesthis project include ~~=~mpacts that are "prohibited" in the DWQ "Red Rule Book"? _lg Yes [3-No

6g. If you are aware of any local controversy concerning this project, provide details in a cover letter, Describe the
controversy and any measures that have been taken with respect to public involvement
_."-_.~._..__. -
This form must be submitted via email (c/o [e-mail]), faxed (919-733-6893), or hand-delivered to:
Parkview Building, 2321 Crabtree Blvd. Suite 250, Raleigh, NC 27604. Applicants who are selected to participate in the
Express Review Program will be notified via email or fax, Successful applicants will then be instructed regarding detailed
procedures for full application (Note: Submittals of the review packages on Friday after 12:00 pm will be stamped as
received on the next business day).

i
..----j

i 6c lMlo will be responsible for the review of the SMP?

Please contact Lia Myott Gilleski or Joseph Gyamfi at 919-733-1786 if you have any questions regarding this form.

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