20191017 Ver 1_Determination Request_20190729

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:* Barb Kloth LLC Property - 3909 Bill Adams Rd
Is this a transportation project?* r Yes r No
What type of request is this? * r Buffer r- IP Stream Determination
r- Isolated Wetland V Stream
Check all that apply.
Owner Information
Name on the Recorded Deed:* Barbara Kloth
Responsible Party: Barb Kloth LLC
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 252-717-2471
How would you like to received your determination?*
F USPS 9 Email
Email Address:* [e-mail]
11 ......... .....................
Is there an agent or consultant responsible for the request?*
r Yes
r No
Project Information
...............................................................................................................................................................................................................................................................
Has anyone form DWR done a previous site visit?*
0 Yes
G No
d Other
Date of Visit:
Site Information
Nearest Highway/Street:* 43
Nearest Town:* chicod
Nearest Named Stream:* Clayroot Swamp
River Basin:* Neuse
County:*

Pitt
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
Barb Kloth LLC Property USGS
3.55M6
Topographic Map.pdf
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.
Click the upload button or drag and drop files here to attach docunEnt
Barb Kloth LLC Property Soil Map.pdf 4.71 MB
Barb Kloth LLC Property Google Earth
13.37M6
Imagery.pdf
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 by typing in an address or filling out the
information manually.
Choose below how you would like to provide this information.
f• Address Lookup
r Manually
Project Look Up Address:
Latitude
Longitude
Misc attachments:
Street Address
3909 Bill Adams Rd
Address Line 2
aty
Grimesland
Postal / Zip Code
27837-8968
35.4329725
-77.2577551
By digitally signing below, I certify that:
pdf or larn file types only
State / Province / Pbegion
NC
Country
US
• I have given true, accurate, and complete information on this form;
• 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")
• 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");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• 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:*
7/29/2019
20191017
F Yes f No
Robert Tan kard:eads\rbtan kard
Washington Regional Office - [phone]

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