20190899 Ver 1_Determination Request_20190708

Stream Origin/Buffer Applicability Determination
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are ansviered.
Project Name:* Patio Homes on Ayden Golf Club Road
Is this a transportation project?* r Yes r No
What type of request is this? * r Buffer V IP Stream Determination
r- Isolated Wetland r Stream
Check all that apply.
Owner Information
Name on the Recorded Deed:*
Responsible Party:
Telephone Number:
A.T. Venters Properties, LLC
Leo Venters, Manager
(far LLC, Corporations, business, agency, etc.)
252-327-8100
How would you like to received your determination?*
F USPS 9 Email
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
r Yes
t- No
Attach agent authorization letter:* Signed Agent Authorization Parcel
04933. pdf
PDF only
Agent/Consultant Information
How would you like to receive your C USPS
determination letter?* C Email
Name of Agent:* Igor Palyvoda
Company Name:* Baldwin Design Consultants, PA
Email Address:* ipalyvoda@baldWndesignconsultant
s.com
Project Information
Has anyone form DWR done a previous site visit?
C Yes
C No
0 Other
219.82 KB

Date of Visit:
Site Information
Nearest Highway/Street: * 4098 Ayden Golf Club Road
Nearest Town:* Ayden
Nearest Named Stream:* Swift Creek
River Basin:* Neuse
County: *
W
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach docurrent
USGS Topo Map.pdf 179.03KB
USGS Topo Map Excerpt.pdf 107.95KB
Rif file type only
TOPO map look up: https://viewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
nick the upload button or drag and drop files here to attach docurrent
NRCS Soil Survey Map 1.pdf 319.01 KB
NRCS Soil Survey Map 2.pdf 314.37KB
Rif file type only
Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
Please provide the Latitude and Longitude for physical location for the determination that. If you have a
physical address you can look up the Latitude and Longitude bytyping in an address or filling out the
information manually.
Choose below how you would like to provide this information.
r Address Lookup
r Manually
Latitude: 35.467800
Longitude: -77.387227
M isc attach me nts: pdf or krre file types only
By digitally signing below, I certifythat:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act")
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Determination Request' form."

Signature
Date Submitted:
Initial Review
IN*
Version*
Do you want to send for review?*
Select Reviewer:*
Select Regional Office:*
4,�� [��.2
7/8/2019
20190899
r Yes r No
Chris Pullinger:eads\rcpullinger
Washington Regional Office - [phone]

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 04933
STREET ADDRESS: On western shoulder of NCSR 1723 - Ayden Golf Club Road approximately 1,400 ft south from
NC HWY 102 and NCSR 1723 - Ayden Golf Club Road intersection in Ayden NC, 28513
Please print: A.T. Venters Properties, LLC
Property
Property Owner:
The undersigned, registered property owners of the above noted properly, do hereby authorize
Igor Palyvoda of Baldwin Design Consultants, PA
(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):
4202 Westhaven Avenue, Ayden, NC 28513
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Auth rize Signature Authorized Signature
Date: 7 Date:

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