20070350 Ver 1_Application_20070301

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STATE of NORTH CAROLINA
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DEPARTMENT OF TRANSPORTATION `'`~~'°~'1v9T~r;'7-
MICHAEL F. EASLEY DIVISION OF HIGHWAYS LYNDO TIPPETT ~,pe~M~
GOVERNOR SECRETARY Ch'
February 26, 2007
U.S. Army Corps of Engineers
Wilmington Regulatory Field Office
Post Office Box 1890
Wilmington, North Carolina 28402-1890
ATTENTION: Ms. Jennifer Frye
NCDOT Coordinator
09p35p
SUBJECT: Nationwide 14 Permit Application for Secondary Road Construction on SR
2209 (Vista Cay Dr.), Onslow County Project Number: 3c067055 (DWQ
Permit Fee: $200)
Please find enclosed a PCN application from the North Carolina Department of
Transportation for a Nationwide 14 permit from the Army Corps of Engineers for the secondary
road improvement project on SR 2209 (Vista Cay Dr.) in Onslow County. The scope of the
project will be to widen, grade, drain and base the 1.05 mile of existing unpaved road to current
NCDOT secondary road standards of 20 ft of travel lanes and 6 ft of earthen shoulders to improve
roadway safety and stability.
IlVLPACTS TO WATERS OF THE UNTrED STATES
This project is located in the White Oak River Basin within USGS hydrologic unit 03020106
(subbasin 030501). The proposed project will impact 0.07 acres of non-riverine wet hardwood
forest, identified as Site A, B, D, F & G on the plan sheets. In addition, there will be 11 ft. of
intermittent stream impacts associated with the replacement/extension of Pipe B (Sta. 15+25) and
replacemenbextension of Pipe C (Sta. 19+75) which serve as conveyances for two unnamed
tributaries to Bear Creek that is classified as SA HQW waters. You and Ken Averitte (DWQ)
visited the site on January 11, 2007 to confirm determinations. There are no permanent or
temporary utility impacts proposed with this project.
COMPENSATORY MITIGATION
The Department has avoided and minimized impacts to jurisdiptional resources to the greatest
extent possible. Side slope designs have been reduced to 3:1 at the wetland sites and construction
124 Division Drive, Wilmington, NC 28401
PHONE: [phone] FAX: [phone]

limits within the Right of Way (R/VV) was shifted where possible to minimize wetland impacts
for construction and utility relocations. Furthermore, no onsite detours for pipe replacements are
being proposed, which will eliminate additional temporary impacts on this project. The project
was evaluated for on site mitigation and it was determined that no potential mitigation existed
within the project limits. Therefore, based upon the letter from the U.S. Army Corps of
Engineers, Wilmington District dated September 1, 2004, the remaining, unavoidable impacts to
0.07 acres of non-riverine wet hardwood forest will be offset by compensatory mitigation
provided by the Ecosystem Enhancement Program (EEP). At our field visit on January 11, 200?
it was determined that no stream mitigation would be required for this project. The Department
will submit this compensatory mitigation request to EEP for acceptance in a quarterly report and
will provide a copy to the Wilmington District office for verification and accounting purposes as
requested.
REQUEST FOR PERMIT CONDITION EXEMPTIONS
Vista Cay is a closed road system and is the only point of egress and ingress for residents on this
roadway as well as Harbor Dr. and Magnolia Lane. Therefore, there are no offsite detours
available to divert and maintain traffic during the replacement of the culverts. The culverts are
small, shallow 18" and 24" pipes that can typically be replaced within a few hours under normal
circumstances with minimal disturbance to traffic. However if dewatering were required,
replacement time would increase tremendously, traffic flow could not be maintained and an
onsite detour would likely become necessary. Therefore, NCDOT is requesting an exemption
from the standard 404 condition requiring dewatering of culvert sites in jurisdictional waters, to
eliminate potential additional temporary impacts for an onsite detour.
In addition, at our field visit on January 11, it was also determined that all pipes on this project
are to be considered equalizer pipes, and the inverts should match the natural ground elevations
adjacent to the pipes. This included pipes B & C, which have intermittent and perennial streams
at their outlets. Therefore, given this determination, NCDOT is requesting an exemption from the
standard 404 and 401 conditions that require pipes to be buried 20% in jurisdictional waters.
NATURAL AND HISTORIC RESOURCES
FEDERALLY PROTECTED SPECIES
Species with the federal classification of Endangered, Threatened, Proposed Endangered and
Proposed Threatened are protected under provisions of Section 7 and Section 9 of the Endangered
Species Act of 1973 as amended (16 U.S.C. 1531 et seq.). The United States Fish and Wildlife
Service lists fifteen federally protected species for Pender County which include American
alligator (Alligator mississippiensis), Red-cockaded woodpecker (Picoides borealis), Cooley's
meadowrue (Thalictrum cooleyi~, Golden sedge (Carex lutea), American chaffseed (Schwalbea
americana) and Rough-leaved loosestrife (Lysimachia asperulaefolia). A GIS and field review
has been conducted for these species and their habitat for this project and a determination of "No
Effect" for the listed species is recommended.
HISTORICAL RESOURCES
Pursuant to Section 106 of the National Historic Preservation Act and the Advisory Council on
Historic Preservations Regulations for Compliance with Section 106 codified at 296 CFR Part
800, this project has been reviewed and cleared for effects on historical and azcheological
resources (see attachments).
124 Division Drive, Wilmington, NC 28401
PHONE: [phone] FAX: [phone]

REGULATORY APPROVAL
Section 404 Permit: The Department of Transportation is requesting to proceed under Nationwide
14 in accordance with 67 FR 2020, January 15, 2002.
Section 401 Permit: We are also requesting by copy of this letter issuance of the 401 Water
Quality Certification 3404 from the DWQ. We have provided a method of debiting $200 to be
submitted to the DWQ for processing the WQC permit request, as noted in the subject line of this
application.
If you have any questions or need additional information please contact feel free to contact me at
[phone].
Sincerely,
Mason Herndon
Division 3 DEO
cc:
w/attachments
Mr. Brian Wrenn, DWQ Raleigh (7 copies)
Mr. Ken Averitte, DWQ Fayetteville (1 copy)
124 Division Drive, Wilmington, NC 28401
PHONE: [phone] FAX: [phone]

Office Use Only:
Form Version March OS
USACE Action ID No. ~ ~ ~ 7 ~ 3 5 0
DWQ No.
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
I. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit ^ Riparian or Watershed Buffer Rules
^ Section 10 Permit ^ Isolated Wetland Permit from DWQ
® 401 Water. Quality Certification ^ Express 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: NWP 14
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ^
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check here:
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ^
II. Applicant Information
1. Owner/Applicant Information
Name: _ H Allen Pope P E Division 3 Engineer
Mailing Address: North Carolina Department of Transportation
124 Division Dr.
Wilmington N C 28401
Telephone Number: [phone] Fax Number:_ f 910) 251- 5727
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name: Mason Herndon
Company Affiliation: Division 3 Environmental Officer
Mailing Address: North Carolina Department of Transportation
124 Division Dr.
_ Wilmington N C 28401
Telephone Number: (9101251-5724 Fax Number: (910) 251- 5727
E-mail Address: mherndon(a dot.state nc us
Updated 11/1/2005
Page 5 of 12

III. Project Information
3
5.
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must .include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17•inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size. plans. If full-size plans are
reduced tb a small scale such that the fmal version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: SR 2209 (Vista Cay Drive)
2. T.I.P. Project Number or State Project Number (NCDOT Only): 3c.067055
Property Identification Number (Tax PIN):
4. Location
County: Onslow Nearest Town: Hubert
Subdivision name (include phase/lot number):
Directions to site (include road numbers/names, landmarks, etc.): From NC 24 N neaz
Hubert take NC 172 S towards Camp Lejune turn left (a7 SR 1503 (Bear Creek Landing Rd)
Continue East for 2.3 miles and SR 2209 will be on the left.
Site coordinates (For linear projects, such as a road or utility line,
sepazately lists the coordinates for each crossing of a distinct waterbody.)
Decimal Degrees (6 digits minimum): See attached sheet °N
6. Property size (acres): N/A
7. Name of nearest receiving body of water: Bear Creek
8. River Basin: White Oak
(Note -this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http//h2o enr.state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Existingunpaved secondary road is bordered by residential
a ricultural and forested areas.
attach a sheet that
oW
Updated 11/1/2005
Page 6 of 12

10. Describe the overall project in detail, including the type of equipment to be used: .
To widen, erade, drain and base the existing road to NCDOT secondary road standards
to 20 ft of travel lanes & 6 ft shoulders usin~standazd road construction equipment
11. Explain the purpose of the proposed work: To improve the existing roadwa~by bringing it
up to NCDOT standards to provide a better and safer roadway for residents and school buses
that utilize this facilty.
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.N/A
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
No additional permit requests are anticipated at this time
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. Each impact must be
listed separately in the tables below (e.g., culvert installation should be listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs may be included at the applicant's discretion. If this proposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
1. Provide a written description of the proposed impacts: Impacts will include 0.07 ac.
of fill in wetlands for shoulder construction & ditch relocation; 11 ft of intermittent stream and
and 10 ft perennial stream impacts for pipe replacements and extensions
Updated 11/12005
Page 7 of 12

2. Individually list wetland impacts. Types of impacts include, but are not limited to
mechanized clearing, grading, fill, excavation, flooding, ditching/drainage, etc. For dams,
t 1 list im acts due to both structure and floodin .
se ara

Wetland Impact
Site Number
(indicate on map) e

~
Type of Impact
T e of Wetland
Yp
(e.g., forested, marsh,
herbaceous, bog, etc.)
Located within
100-year
Floodplain
es/no
Distance to
Nearest
Stream
(linear feet
Area of
Impact
(acres)
A fill forested No 100 0.001
B fill forested No adj to S 0.027
D fill forested No adj to SA 0.035
F fill forested No 350 0.004
G fill forested No 1500 0.003

Total Wetland Impact (acres) 0.07
3. List-the total acreage (estimated) of all existing wetlands on the property:N/A
4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization .activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
t be included To calculate acreage multiply length X width, then divide by 43,560.
mus
Stream Impact
Number

(indicate on ma
S - Pipe B

Stream Name

UT Bear Creek

T e of Im act
~ p

24" x 50 ft CAP
Perennial or

Intermittent?

Intermittent
Average
Stream Width
Before Im act

8
Impact
Length
(linear feet)

I 1
Area of
Impact
(acres)

0.002
SA - Pipe C UT Bear Creek 18" x 50 ft CAP Perennial 9 10 0.002

Total Stream Impact (by length and acreage) 21 0.004
5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but are not limited to
x,11 nvnwotinn rlrarlcrina flnnrlina rlrainage_ bulkheads. etC.
1111, \+AV
Open Water Impact
Site Number
indicate on ma) UV U~avia, as.avvE,.aab, a=v.+.
Name of Waterbody
(if applicable) ...-.=D7 -""'-'-"O-~

Type of Impact '
Type of Waterbody
(lake, pond, estuary, sound, bay,
ocean, etc.
~e a t
p
acres
N/A N/A N/A N/A N/A

Total Open Water Impact (acres) N/A
Updated 11/1/2005
Page8of12

6. List the cumulative impact t~ all watPrc ~f+>,A r r e ,. ~,,,+:
- --- .. ~..,. iVJUaLlll llvlll
Stream Im act (acres): u1G ro eCL
0.004
Wetland Im act (acres): 0.07
O en Water Im act acres : N/A
Total Im act to Waters of the U.S. (acres) 0.074
Total Stream Impact linear feet): 21
7. Isolated Waters
Do any isolated waters exist on the property? ^ Yes ®No
Describe all impacts to isolated waters, and include the type of water (wetland or stream) and
the size of the proposed impact (acres or lineaz feet). Please note that this section only
applies to waters that have specifically been determined to be isolated by the USACE.
N/A
8. Pond Creation N/A
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ^ uplands ^ stream ^ wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): N/A
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): N/A
Current land use in the vicinity of the pond: N/A
Size of watershed draining to pond: N/A Expected pond surface area: N/A
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Shoulder slopes reduced to 3.1. Construction limits was shifted where possible to minimize
impacts. Strict enforcement of sedimentation & erosion control BMP's will be enforced Onsite
detours for pipe replacements will not be constructed
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 lineaz feet of total impacts to perennial
streams.
Updated 11/12005
Page 9 of 12

USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal.. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North Carolina, available at
http •//h2o.enr.state.nc.us/ncwetlands/strmgide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
N/A
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http•//h2o enr.state.nc.us/wrp/index.htm. If use of the NCEEP is proposed, please
check the appropriate box on page five and provide the following information:
Amount of stream mitigation requested (linear feet): N/A
Amount of buffer mitigation requested (square feet): N/A
Amount of Riparian wetland mitigation requested (acres): N/A
Amount of Non-riparian wetland mitigation requested (acres): 0.14
Amount of Coastal wetland mitigation requested (acres): N/A
Updated 11/1/2005
Page 10 of 12

IX. Environmental Documentation (required by DWQ)
1. Does the project involve an expenditure of public (federaUstate/local) funds or the use of
public (federaUstate) land? Yes ® No ^
2. If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ^ No
3. If yes, has the document review been finalized by the State Clearinghouse? If so, please
attach a copy of the NEPA or SEPA fmal approval letter. Yes ^ No ^
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts aze proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
1. Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), l5A NCAC 2B .0259 (Taz-Pamlico), 15A NCAC 02B .0243 (Catawba) 15A NCAC
2B .0250 (Randleman Rules and Water Supply Buffer Requirements), or other (please
identify)? N/A Yes ^ No
2. If "yes", identify the squaze feet and acreage of impact to each zone of the riparian buffers.
If buffer- mitigation is required calculate the required amount of mitigation by applying the
buffer multinliers_
Zone* Itnpact Multiplier Required
(s oars feet) Miti ation
1 3 (2 for Catawba)
2 1.5
Total N/A N/A
* Zone 1 extends out 30 feet perpendicular from the top of the near bank of channel; Zone 2 extends an
additiona120 feet from the edge of Zone L
3. If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e.,
Donation of Property, Riparian Buffer Restoration /Enhancement, or Payment into the
Riparian Buffer Restoration Fund). Please attach all appropriate information as identified
within 15A NCAC 2B .0242 or .0244, or .0260.
N/A
Updated 11/1/2005
Page 11 of 12

XI. Stormwater (required by DWQ)
Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surface exceeds 20%, please provide calculations
demonstrating total proposed impervious level.
Strict implementation of Sedimentation and Erosion Control BMPs will be enforced during
construction to protect wetlands and waters of U S
XII. Sewage Disposal (required by DWQ)
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.
N/A
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ^ No
Is this anafter-the-fact permit application? Yes ^ No
XIV. Cumulative Impacts (required by DWQ)
Wiil this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby downstream water quality? Yes ^ No
If yes, please submit a qualitative, or quantitative cumulative impact analysis in accordance with
the most recent North Carolina Division of Water Quality policy posted on our website at
http://h2o.enr.state.nc.us/ncwetlands. If no, please provide a short narrative description:
Undeveloped area restricted bYzonina and area, lower portion developed or under developement
currently
XV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
N/A
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter. from the applicant is provided.)
Updated 11/1!2005
Page 12 of 12

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Name: HUBERT Location: 034.6498975° N 077.1926028° W
Date: 2/26/2007 Caption: Stream Locations
Scale: 1 inch equals 2000 feet SR 2209 (Vista Cay Dr.)
Onslow County
Copyright (C)1997, Maptech, Inc

Markers
Name: Stream "S"
Short Name: StrmS
Coordinates: 034.6528900° N, 077.1935300° W
Name: Stream "SA"
Short Name: StrmS
Coordinates: 034,6517200° N, 077.1930300° W

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CONCURRENCE FORM FUR ASSE5SIVIEN'p OF EFFECTS
FOR STA'T'E FUNAET) 5ECONAARX 1.tO~P_~4~3IFC'TS O
Project Description: Grade, drain, base, and pave 1.05 milt SR 2209 (Vista Cay)
On October 18,2006 representatives of the
X North Carolina Department of~Transpi~rtation (NGDOT)
X North Carolina State 1'--listoric Preservation Office (T=[PO)
^ Other
Reviewed the subject project and agreed
^ 1~tere are no effects ort the 1~lational 1Zeoister-listed property/properties located
within the project's area of potential etl~ects and listed on the reverse.
^ There is an effect on the National Register-listed property/properties located
within the project's area oi'potential effects. The propertyipropcrtics and the
effect(s) are listed on the reverse.

Slg7l ed:
Representative, N
Date
Representative, I1PU
. tate Historic Preservation Officer
hate
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c0'd iOST STL ETE 31J0-0H0 lUQJPJ SO:bi 900c-Ei-100

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