20070043 Ver 1_Application_20070105

200700 43
e OFFICE USE ONLY: Date Received Request #
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State of North Carolina ~r ` C~'~,~~, ~~ ,~
Department of Environment and Natural Resources
Division of W ater Quality L 3 ~ ~ ~ , 5 ~' h ~ ~ ~' / ~' I
f~J~~'~- L ~ 2 7~o y
Variance Re uest Form -for Minor~`V~riances
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Protection and Maintenance of Riparian Areas Rules
NOTE: This form maybe photocopied for use as an original.
Please identify which Riparian Area (Buffer) Protection Rule applies.
^ Neuse River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (15A NCAC 02B
.0233)
^ Tar-Pamlico River Basin: Nutrient Sensitive Waters Management
Strategy Protection and Maintenance of Riparian Areas Rule (15A
NCAC 02B .0259)
^ Catawba River Basin: Protection and Maintenance of Existing Riparian
Buffers (15A NCAC 02B .0243)
Part 1: General Information ~ L5 ~ ~ ~.l V L5 D
(Please include attachments ~f the room provided is msuffic~ent.) l~l
JAN 5 2007
1. Applicant's me (the corporation., in vldual, etc. who owns the property):
17ENR -WATER QUALITY
----~f'~~~ ___~---.~_ r --_ ___ __ -__ ____-
2. Print Owner/Signing Offi ial (person legally resp slble for the property and its compliance)
Name:
Title:
-- -
Street address: 3t / ~aE«~+d~~ ~~j~_ ~~„-~ ~~ _ _
City, State, Zip: GGr , _,ir/C .~--7 ~~`~
Telephone: ~
~.~L~-, ..~ /q ~ ~~0 2 c.~ ~/ q~~3 ~ 27 / -x,10.
Fax: ~ 2Sy -~~'// __ _ __ __ _ _ _ _
3. Contact person who can answer questions about the proposed project:
Name: - _~t r_?L _
_ _ __ --
Telephone:w}
__
_ ___ -- - -
Fax: ~~ ~ _ _ _
Email:
__ _ _ __ _
4. Project Name (Subdivision, facility, or establishment name -consistent with project name on
plans, specifications, letters, operation and maint ance agre ments, etc.):
Version 2: November 2002

5. Project Location:
Street address: ~6~.s ..5~ ~ „-, ~ ~~ ~ ~
City, State, ZiP: ~ ~ ~ ; s ~ + S ; ~U C~ ~ ~ ~ ~Y ~i
County: ~ ~- f G_ /.~.-
_ _ _ ___
Latitude/longitude:
6. Directions to site from nearest major intersection (Also, attach an 8'h x 11 copy of the USGS
_.._.
topograp is map indicating the location of the site):
.- /7
/f~/l~ ~/1 ~ L ~ t Est l.~ Unn _ ~ rUC _ _ L~ ~/ _-Z. ~j_ ~'! _. _ ~ e l~~i'
.~/Cc(/'l /~~ CS75 '~ 2, j .~+ ~S ~ ,~41C~ !~.! Lif~ ~"h//r+ ~'~ CE' ~. /
is /` /t' ~~~: ~ j'r~ yC.~C r G~j~ ('~% 1~ ~c.rf~ ~ ~/~( E'!`- l~ ~r r
t cv,ri~z ~~,,~ ~ _ ,UE..'I`~ z~rf S~ : ~_ _ ~- 1'i- r? /z_ ,_ L cr. _-..s'
L ~ 7 / ~ f- !(~~ S .s'ti ~.~,e/t ~' ~ f ~ .~c~ 3.S"Ff roc c~Z,r.,~e~- d.,
7. Stream to be impacted by the~roposed activity:
Stream name (for unnamed streams label as "UT' to the nearest named stream):
__ _ _ _.
Stream classification [as identified within the Schedule of Classifications 15A NCAC 2B
.0315 (Neuse) or .0316 (Tar-Pamlico)]: _ ____________ __ ._..______
8. Which of the followi~ermits/approvals will be required or have been received already for
this project?
Required: Received: Date received: Permit Type:
__ _ _ __ _ _ _ CAMA Major
__ ___ _ CAMA Minor
__ _ _
401 Certification/404 Permit
_____ ___ _ ____ On-site Wastewater Permit
__ _ NPDES Permit (including stormwater)
_ _ Non-discharge Permit
-- Water Supply Watershed Variance
_ Others (specify) _
Part 2: Proposed Activity
(Please include attachments if the room provided is insufficient.)
1. Description of proposed activity [Also, please attach a map of sufficient detail (such as a plat
map or site plan) to accurately delineate the boundaries of the land to be utilized in carrying
out the activity, the location and dimension of any disturbance in the riparian buffers
associated with the activity, and the extent of riparian buffers on the land. Include the area
of buffer impact in ftZ.]: ,
.~)i:~/,~'~ L:4a.-+~- .~+.,o b c~ ~~~ ~ rte( %b ~ j+tr S'~~_ ~.-~/~_ _t..~~~,/~
2. State reasons why this plan for the proposed activity cannot be practically accomplished,
reduced or configure to better minimize or eliminate disturbance to the riparian buffers:
C•,
~c~~- t
F'r ~.t~ ~
/~~
(~J t~I~~~~H. C~J..(.-s'~~l~G-/~ /i Get. f0. C7C~L C.G ~C~ f~~ 1~ !N_ ti'CC~i{ti/~tC
-t~f'~\Q-Ch9Ml~ /9rr ry,/t~~~ ~~M,~L~' i.f L~l r~a'~l C..f- C/'0.~~-
to .s,~.-c ~ f ~s ll .,~ ~ + ~ b ~ <, ~ /~ r, b..: I ~~~jo~ r~ c~cc~
x s~~..,~C r~u,r~r beet ~<,-~~.!~ ,~„/~.~~~~ ('~~~ Yfi sf ~>
Variance Request Form, page 2 , ,~
Version 2: November 2000
~1C6 - ~~~~':..- ~s, r~UGNfL~ r:. ~ ce-~s ,r ~s. ~, (~J~al~.

3. Description of any best management practices to be used to control impacts associated with
the proposed activity (i.e., control of runoff from impervious surfaces to provide diffuse flow,
re-planting vegetation or enhancement of existing vegetation, etc.):
_ _ __ _
4. Please provide an explanation of the following:
(1) The practical difficulties or hardships that would result from the strict application of this
Rule. ~r >/ / / >
- _
_ _ _
(2) How these difficulties or hardships result from conditions that are unique to the property
involved.
~~
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0_lJ _ _ P..~i r ~. __ t.r f4, __d/~ /)r ~~..,,/ _
_. __ _ _ _
__ -. __ _ /" ~~F_
(3) If economic hardship is the major consideration, then include a specific explanation of the
economic hardships and the proportion of the hardship to the entire value of the project.
Part 3: Deed Restrictions
By your signature in Part 5 of this application, you certify that all structural stormwater best
management practices required by this variance shall be located in recorded stormwater
easements, that the easements will run with the land, that the easements cannot be changed or
deleted without concurrence from the State, and that the easements will be recorded prior to the
sale of any lot.
Part 4: Agent Authorization
If you wish to designate submittal authority to another individual or firm so that they may provide
information on your behalf, please complete this section:
Designated agent (individual or firm): _ ,/~~ _
Mailing address: _ _ _ _
_ _ __
City, State, Zip: _ __ _
__.
__ _
Telephone:
Fax:
_ __
Email: __
Part 5: Applicant's Certification
Variance Request Form, page 3
Version 2: November 2000

/ ~ ~
1, __ C~%~/~~~ /~. ~, ~~ (print or type name of person
listed in Part I, Item 2), certify tat the information included on this permit application form is
correct, that the project will be constructed in conformance with the approved plans and that the
deed restrictions in accordance with Part 5 of this form will be recorded with all required permit
conditions.
Signature: ~V ~~G"`--._~~~
Date: j .~ c~
Title:
Variance Request Form, page 4
Version 2: November 2000

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