20190796 Ver 1_401 Application_20190612

AMPLE AGENT AUTHORIZATION FORM A' --
L/ A1�
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO, PMCEL ID;
STREET ADDRESS: C—
Oj C-
2 0
pwase,
Property Owner:
0S \-V-LAL— L I
PrOkleft,Owner: amyn
The undersigned, registered pro
Perty MOM of, the above no
property, C10116IfebY
�authorize
(Contractor /'Agent)
(Name of consulting firm)
to act on MY behalf and take all actions necessary for the
Processing, issuance and accepta#4
,to
this permit or certificatiOn and any arid all standord knd special conditions attached.
PrOPOItY Owner's Address (if different than Properly abptve):
VC-[ Ciem
Teleftne: - O G2
/\[C- 2-1oll
We hereby certify the above information sgtiri tteEt114#640-ft-016n is true and accuratetq*
best of our knowledge.
Authorized Signature
Date:_
Authorized at e

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374 Green Meadows Dr
Todd, NC 28684
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1/2

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6
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps:
❑X Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 13 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps?
Q Yes ❑ No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
401 Water Quality Certification — Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 e. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
® Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑X No
1f. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes ❑X No
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below.
❑ Yes ❑X No
1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑X No
2. Project Information
2a. Name of project:
G
2b. County:
2c. Nearest municipality / town:
2d. Subdivision name:
2e. NCDOT only, T.I.P, or state project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
o
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
/
3d. Street address:
eq Nea ou)S rS
_
3e. City, state, zip:
o, �( 9V
3f. Telephone no.:
�3G — G�l�— 7v��
3g. Fax no.:
3h. Email address:
a uP1SC 60 13 0E veli
•Con►
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is
❑tt
[�r:_ LG•t et
4b. Name:
-0o J�4'a�N
4c. Business name
(if applicable):
:�Jlee,�eC4q)s-eap)�
4d.Street address:
53 0
.rsC
4e. City, state, zip:
e4- TeZetsw.,AX
4k'?'6f4
4f. Telephone no.:
336-M-4772 De
4g. Fax no.:
4h. Email address:
•,,� [iCrfG SCa iN . L`ar►1 GP
H
Ci tC
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no..-
o.:5g.
5g.Email address:
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
WT5-0115-
1
1 b. Site coordinates (in decimal degrees):
Latitude: /(, 'TI.3 "N Longitude: g(O M' &. /��
1 c. Property size:
, ` acres
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
WeAj ;uoz &�*a%
3. Project Description
3a. Describe the existing conditions on the site a d the eneral land a in the vicinity of th project at a time of this
applic tion: /L%%��,rl e�de MkrtN�••lC , Cur1twi--I q uacd t P G rtk
KA ee
3b. List the total estimated acreage of all existing wetlands on the property: 0
At
3c. List the total estimated linear feet of all existing streams (intermittent and perenni I) on the property: &,3 14.
on
3d. Explain he purpose of the proposed project: �� elb fowl LLtsS, r Ute
��✓' 5*PS� aKitd 40 6huze VejeG F'i-i (A 4 L f-sn"X 7c4e A 1155 f -PlA
3e. Describe the ove all project in detail t including the type of equipm�Iit/to bu used:6' e Q!,
Irl offer �°� !1 �i 2C N �i 11ZC �`i/ It0 G -%D is5f�( t�e�/S Q'f" �t.l1C CT�
Ce Sel o 6uUee S S -6 4t, d cttCl55.sn eddi�ionQ� U�C a�iQn }vfb6i� .
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (includingall prior phases)in the past?
❑ Yes ❑x No ❑ Unknown
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): I
Agency/Consultant Company:
Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
El Yes to E] Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project?
❑ Yes o
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ❑X Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary T
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1 -
Choose one
Choose one
Yes/No
-
W2 -
Choose one
Choose one
Yes/No
-
W3 -
Choose one
Choose one
Yes/No
-
W4 -
Choose one
Choose one
Yes/No
-
W5 -
Choose one
Choose one
Yes/No
-
W6 -
Choose one
Choose one
Yes/No
-
2g. Total Wetland Impacts:
2h. Comments:
3. Stream impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f
Average
st*alm
3g<
irraact'
it
feet)
Si P
Stabilization
Flat Creek
PER
Corps
nn''
S2 -
Choose one
-
-
S3 -
Choose one
-
-
S4 -
Choose one
-
-
S5 -
Choose one
-
-
S6 -
Choose one
-
-
3h. Total stream and tlrlbutary
impacts
13
3i. Comments:
bank rebuilding/stabilization
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
01 -
Choose one
Choose
02 -
Choose one
Choose
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
❑ Neuse ❑ Tar -Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number—
Permanent (P) or
Temporary T
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet
BI -
Yes/No
B2 -
Yes/No
B3 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. cally describe m sures ke #o void or miriiimize t roposed 'rmp cts in d85igt7i ,sect
��dt�+4�•(t e' bFlcrs1,v, Cc ar► der �17.a� r�t�`p C'as�adt
AC Qr gab S�iC•
� n.ec � J
1 b. Specifically d cIbe measures taken to, evdppr minimi a the -proposed irnpa9ts throu conshructo #ecli
uf� orac�r/' Pras;�► 6 4� pis, Stcv s� c�C"�o� 4l��l"�, ; Ksa' �,T3♦ e
� 8— -0 beT� la�W ilk
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes ❑X No
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑ Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature:
Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non -riparian wetland mitigation requested:
acres
4g. Coastal (tidal) wetland mitigation requested:
acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑ Yes ❑ No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
Zone
6c.
Reason for impact
6d.
Total impact
(square feet)
Multiplier
6e.
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 7 of 10

E.
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
1a.
Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules?
❑ Yes Q No
1 b.
If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2.
Stormwater Management Plan
2a.
What is the overall percent imperviousness of this project?
2b.
Does this project require a Stormwater Management Plan?
❑ Yes ❑ No
2c.
If this project DOES NOT require a Stormwater Management Plan, explain why:
2d.
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e.
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a.
In which localgovernment's jurisdiction is thisproject?
3b.
Which of the following locally-implemented stormwater management programs
apply (check all that apply):
❑ Phase II
❑ NSW
❑ USMP
❑ Water Supply Watershed
❑ Other:
3c.
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑Yes ❑ No
4. DWQ Stormwater Program Review
4a.
Which of the following state-implemented stormwater management programs apply
(check all that apply):
E]Coastal counties
❑HQW
❑ORW
❑Session Law 2006-246
[]Other:
4b.
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
5. DWQ 401 Unit Stormwater Review
5a.
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b.
Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F.
Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1 a.
Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes
Q No
use of public (federal/state) land?
1 b.
If you answered "yes" to the above, does the project require preparation of an
❑
❑ No
environmental document pursuant to the requirements of the National or State
Yes
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c.
If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (if so, attach a copy of the NEPA or SEPA final approval
El Yes
❑ No
letter.)
Comments:
2.
Violations (DWQ Requirement)
2a.
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
El Yes
Q No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b.
Is this an after -the -fact permit application?
❑ Yes
Q No
2c.
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3.
Cumulative Impacts (DWQ Requirement)
3a.
Will this project (based on past and reasonably anticipated future impacts) result in
❑Yes
Q No
additional development, which could impact nearby downstream water quality?
3b.
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4.
Sewage Disposal (DWQ Requirement)
4a. 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.
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
❑ Yes
No
habitat?
5b. Have you checked with the USFWS concerning Endange_re.d Species Act
El Yes
Q No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
-
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
USACE information
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes
Q No
6b. What data sources did you use to determine whether your site would impact Essential
Fish Habitat?
USACE information
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
Yes
❑X No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
USACE information
8. Flood Zone Designation (Corps Requirement)
❑, ... -.role
UN
-* i'l ca A' [r
liumIffift
(5 4
Q -V 1.00JQAy a
-all
8c. ..
Page 10 of 10