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HomeMy WebLinkAbout20190986 Ver 1_401 Application_20190723NC Department of Environmental Quality Received J U L 18 2019 Winston-Salem Regional Office office Use On" - Corps Corps action ID no. DWQ project no. — Form Version 1.4 January 2009 Pre -Construction Notification (PCN) Form A. Applicant Information 2 0 1 9 0 9 8 6 �v 1. Processing Section 404 �Permit E] Section 10 Permit1 a. Type(s) of approval sought from the Corps: 1b Specify Nationwide Permit (NWP) number. or General Permit (GP) number: 1c. Has the NWP or GP number been verified by the Corps? 1 d. Type(s) of approval sought from the DWQ (check all that apply): j _401 Water Quality Certification — Regular I/❑ 401 Water Quality Certification — Express Yes ❑ No ❑ Non -404 Jurisdictional General Permit n Riparian Buffer Authorization le. Is this notification solely for the record For the record only for DWQ because written approval is not required? 401 Certification: ❑ Yes ELNo 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. 1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h below. 1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? 2. Project Information 2a. Name of project: 2b. County: l 2c. Nearest municipality/ town: 2d. Subdivision name: 2e. NCDOT only, T_I.P. or state project no: 43c.Responsible ner Information me(s) on Recorded Deed: 1 ed Book and Page No. Party (for LLC if 3d. Street address: C_'Je 'AC< ,- t3e. Cit, sate, zip: 3f. Telephone no.: 3g. ' 3h. Email address: For the record only for Corps Permit: ❑ Yes ❑ Yes [XNo ❑ Yes IVNo ❑ Yes L�Na Page 1 of 10 PCN Form — Version 1.4 January 2009 n 'i' 2 Applicant Information (if different from owner) 4a. Applicant is: 4b. Name: Agent ❑ Ofher, p rfy: 4c. Business name Cd aPPlicable): 4d. Street address: 4e. City, state; zip: 4f.- Telephone no.: . 49. Fax no.: 411_ Email address: 5- Agent/Consultant Information (if applicable) 5a. Name: 5b. Business name (d applicable): 5c. Street address: 5d. City, state, zip: 5e. Telephone no.: 5f. Fax no.: 59. Email address: Page 2 of 1 o B. Project Information and Prior Project History 1. Property Identification la. Property identification no. (tax PIN or parcel ID): 1b. Site coordinates (n decimal degrees): I Latitude: a00 Longitude: C / 1c. Property size: acres 2. Surface Waters 2a. Name of nearest body of water to proposed project: 2b. Water Quality Classification of nearest receiving water- ater2c. 2c.River basin: 3. Project Description 3a. Describe the existing conditions on the site and the geperal land use in the vicinity of the project at the time of this application: L G,t/YU.L, 3b. List the total estimated acreage of all existing wetlands on the property: 3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 00 � 3d. Explain the purpose of the proposed project: 1Jted ` - Y n0 -.,l S 1 J3 6u Q 14 3e. Describe the overall project in detail, including the type of equipment to be used: 4. Jurisdictional Determinations 4a. Have jurisdictional wetland or stream determinations by the Corps or State been requested or obtained for this property / project(including all priorphases) in thepast? ❑ Yes i ❑ 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): Agency/Consultant Company: Other. 4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation. �.J�.,es \os,IV � .51� ��;, 1��q - adj. �o 5. Project History 5a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past? []Yes *0 ❑ Unknown 5b. If yes, explain in detail according to "help file" instructions. 6. Future Project Plans 6a. Is this a phased project? ❑ Yes No 6b. If yes, explain. Page3of10 2. Wetland Impacts If there are wetland impacts proposed on the site, then comple 2a. Wetland impact 2b. 2c. Type of impact Type of number Permanent (P) or Temporary W1 Qq8°^� 5twcse W2 - Choose one Choose W3 Choose one Choose W4 Choose one Choos( W5 Choose one Choos4 W6 Choose one Chops 2h. Comments: ow j' Szp-p a 3. Stream Impacts If there are perennial or intermittent stream impacts (inciudinc question for all stream sites impacted. 3a. 3b. 3c. Stream impact Type of impact Stream name number Permanent (P) or Temporary (T) S1 - xlt°°se°"r S2 - Choose one S3 - Choose one S4 Choose one S5 - Choose one S6 - Choose one 3i. Comments: to this question for each wetland area impacted. a temporary impacts) proposed on the site, then complete this 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 indi dually list all open water impacts below. 4a. Open water impact number Permanent (P) or Temporary 4b. Name of waterbody (if applicable) 4c. Type of impact 4d. Waterbody type 4e. Area of impact (acres) O1 - Choose one Choose O2 - 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 50. 5d. 5e. Wetland Impacts (acres) Stream Impacts (feet) 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 6c. Reason for impact 6d. Stream name 6e: Buffer mitigation required? 6f. Zone 1 impact (square feet) 6g. Zone 2 impact (square feet 131 - Yes/No 82 - Yes/No B3 - Yes/No B4 - Yes/No B5 - Yes/No B6 - Yes/No 6h. Total Buffer impacts: 6i. Comments: Page 5 of 10 60OZ Ajenuer t,• 1, uoisJan — waod NOd 01, 10 g 96ed •ueld uoi;e6i;lw pesodoid eql;o uollduosap a epinold 'ueld uoge6gPu elglsuodsai aelllwiad a 6ulsn;l •eg ueld uoge6g!W algisuodsab eaniuuad a Bulsn:p a;aidwo3 -g :sluawwoo -gl, sa�oe :palsenbai uoge6glw puellem aepll) lelseoO -61t S013e :pa;s9nb91'uoge6glw puellem ueuedu-uoN •;t, saloe :palsenbai uoge6glw pueflem ueuedib -air 1991 axenbs :(Aluo DMQ) palsenbal uoge6glw .tal}ng -pts quo gsoogO :einleiadwal weags 'uoge6glw weags 6uisn}1 ob 1991 ieau►1 :palsanbal uoge6glw weals -qtr se), ❑ -pagoelle sl wei6aad aa; nail-ul wool legal lenoiddV -e{, utel old 95=1 nail -51 01 4uGUJAvd a bui eW;l a;ai wo3 'V - s4u9wwoo -OS :Alguenp :Alguenp :Alguent quo asoogo :edAl quo asoogo :edAl quo asoogo :edAl (vagal pue ldlaoal goelle) pasegand sl!paJO 'q£ :Xueg uoge6glw to MEN •e£ )luee uoge rp a ulsn 11 alai woo -£ uoge6glw elglsuodsa�:l aalllwlad ❑ wel6oid ail nail-ul of luawAedZ;oefold ❑ �lueq uoge6glw ❑ sly sol pasn eq 111muogdo uoge6glw golgnr► 'saA ll 'OZ sdioO ❑ bMa ❑ :(Aldde legl Ile Woago) Aq pannbaj si uoge6glw `saA 11 'qZ oN (� sad ❑ &alels etq 3o sia;em to •s,n oql to sialem o; spedw1 sol uoge6glw Ajolesuadwoo aimba haloid agl saoa 'eZ ems eta }o sia;em jo •g`g ate; to sia;eM o; specItuliol uoge glpll fjolesmatuO3 •Z P"Irv()Iv a -C i U, VA rryVi Al senblugoal uogonjlsuoo g6nojg} shedwl pasodo.id)agl ezlwluiw jo plone of uaXel sanseew equosep Alleogmadg -q I. r a AQ(V /b p •loafoid 6u1u61sap w sloedwl pasodoid eql aziwlulw jo plone of ua)lel samseaw equosep Alleagroads 'e 4 uogezlwiwW pue aoueploAV -y uoBe6g1W pue uogeogpsnp;oedwl -Q 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 60.. 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: 69. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank, permittee responsible riparian buffer festoration, payment into an approved in -lieu fee fund). 6h. Comments: Page 7 of 10 E. Storrnwater Management and Diffuse Flow Plan (required by DWQ) 1. Diffuse Flow Plan 1 a. Does the project include or is it adjacent to protected riparian buffers identified ❑ Yes ❑ No within one of the NC Riparian Buffer Protection Rules? 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 local governments jurisdiction is this project? ❑ Phase 11 ❑ NSW 3b. Which'of the following locally -implemented stormwater management programs ❑ USMP apply (check all that apply): ❑ Water Supply Watershed ❑ Other: 3c. Has the approved Stormwater Management Plan with proof of approval been []Yes ❑ No attached. 4. DWQ Stormwater Program Review ❑Coastal counties ❑HQW 4a. Which of the following state -implemented stormwater management programs apply ❑ORW (check all that apply): ❑Session Law 2006-246 ❑ Other. 4b. Has the approved Stormwater Management Plan with proof of approval been ❑ Yes ❑ No attached? 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. Envirsonment it Documentation (DWQ Requirement) 1 a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land? ❑ Yes ❑ No 1b. if you answered "yes" to the above, does the project require preparation of an" environmental document pursuant to the requirements of the National or State ❑ Yes ❑ No - (North Carolina) Environmental Policy Act (NEPA/SEPA)? 1c. If you answered 'fres" 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 letter.) ❑ Yes ❑ No 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, [ es ❑ No or Riparian Buffer Rules (15A NCAC 2B .0200)? 2b. Is this an after-the-fact permit application? Yes ❑•No 2c. If you answered `fres" to one or both of the above questions, provide an explanation of the violation(s): IqVV rou'd Awn, -Dw(L. A 3. Cumulative Impacts (DWQ Requirement) 3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, :E07Yes O�No 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. Vl/ill this project occur in or near an area with federally protected species or El Yes orwo habitat? 77 � 5b. Have you checked with the USFWS concerning Endangered Species Act Yes [Ao 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? 6. Essential Fish Habitat (Corps Requirement) 6a. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes VNo, 6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat? CA;V,( _r,;%k 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 �eNo 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? 8. Flood Zone Designation (Corps Requirement) 8a. Will this project occur in a FEMA -designated 100 -year floodplain? 7-11 Yes (Vo - 8b. If yes, explain how project meets FEMA requirements: ry- 8c. What source(s) did you use to make the floodplain determination? kobid r% 0 �S % Applicant/Agents Printed Name Applicant/Agents Signature Date (Agent's signature is valid only if an authorization letter from the applicant isprovided.) Page 10 of 10