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
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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