20190781 Ver 1_Stream Determination_20190612

ROY COOPER
Gommor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Quality
Express Buffer Applicability / Stream Origin
Determination Request
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and Its compliance)
Ia. Name(s) on Recorded Deed South Greenville Church of Christ
lb. Responsible Party (for LLC) Bill Crandol
lc. Mailing Address 669 S Memorial Dr Greenville NC 27834
id. Telephone Number 252-754-2222 1 le.Emailaddress
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
Pitt County located approximately 1,035 if west of the intersection
of Staton House Road and Flemming School Road on Staton House Road.
3. Agent / Consultant Information
3a. Agent/ Consultant Name
3b. Company Inner Banks Engineering
3c. Mailing address P.O. Box 154 Washington NC 27889
3d. Telephone no. 252-945-29831 3e.Emailaddress [e-mail]
4. Project / Site Information
4a. Name of project IS Greenville Church of Christ 4d. River Basin Tar Pamlico
4b. County
1pitt 4e. Lat/Long 35.663056 / -77.393056
4c. Nearest Named Stream
Johnson 4P. Number 2
Mill Run Stream Calls
5. Project Description (attach plan if available)
New church construction on a portiio-n� of a large 35 +/- AC lot.
6. Has anyone from DWQ visited the
site]
y
Staff Name:
Date of Visit:
7. Does DWR staff have permission to
access this property?
y
N
8. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey
If you are unable to locate either of these maps, please contact the DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitigation? .. Nutrient offset credit?
9. Please return form to: Chris Pullinger
943 Washington Square Mall Note: Submittals on Friday after 12:00pm
Washington, NC 27889 Will be stamped as received on the
Email: [e-mail] Next business day
Please contact Chris Pullinger at the Washington Regional Office at [phone] if you have any
questions. �F�
North Carolina Depamnent of Environmental Quality ]Division of Water Resourees - Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCELID:TAX MAP 02360 / PIN 4679699521
STREETADDRESS: STATON HOUSE RD GREENVILLE NC 27834
Please print:
Property Owner:
SOUTH GREENVILLE CHURCH OF CHRIST
PropertyOwner: JOSHUA MOSS
The undersigned, registered property owners of the above noted property, do hereby authorize
BILL CRANDOL of DBS CONSTRUCTION, LLC
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
669 S MEMORIAL DR GREENVILLE NC 27834
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
JaQ4,oA N1o5S
Authorized Signature
Date: 6/12/19
Authorized Signature
Date:

1 2125'
N
ENGINEERING
282 283
USGS MAP FOR SOUTH GREENVILLE
CHURCH OF CHRIST
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77°22'30"
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ENGINEERING
282 283
USGS MAP FOR SOUTH GREENVILLE
CHURCH OF CHRIST
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"50
40'
"49
"48
"47
"46°
35°:
77°22'30"

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IGNEERING E
R'Ills'
P.O. Box 154
WASHINGTON, NC 27889
PHONE [phone]
[e-mail]
To:
Date: 06/12/2019 No. 19010
N.C. DEQ - Washington Regional Office
Stream Origin Determination Request Form
Chris Pullinger
943 Washington Square Mall Washington NC
Re: South Greenville Church of Christ (Staten
House Rd) - Stream Origin Determination Request
1
USGS To o ma
1
NRCS Soil Survey ma
1
Check for $200
WE ARE SENDING YOU E Attached ❑ Under separate cover via
the following items:
❑ Shop drawings ❑ Prints E Plans ❑ Samples
❑ Copy of letter ❑ Change order
❑ Specifications
COPIES
DATE No DESCRIPTION
1
Stream Origin Determination Request Form
1
Agent Authorization Form
1
USGS To o ma
1
NRCS Soil Survey ma
1
Check for $200
THESE ARE TRANSMITTED as checked below
E For approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FOR BIDS DUE 20_ ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS:
Please call with questions.
Marie U. Peedin, PE.