Other_20220816

Water Resources
Environmental Quality
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02H .0506(b)(4) Water Quality Certification,
Notification of Work in Trout Watersheds
FORM: TroutWS 11-2017
Notification of Work in Trout Watersheds Form
A. Applicant Information
1. Processing
1 a. Specify Nationwide Permit (NWP) number: j or General Permit (GP) number:
1 b. Has the NWP or GP number been verified by the Corps?
Yes ❑ No
1 c. Does the project meet all the Conditions of the applicable Water Quality
Certification
Yes No
Please note that your project may be subject to the Sediment and Erosion Control Program and/or Trout Buffers
implemented by the Division of Energy, Mineral, and Land Resources. Find more info at:
https://deq. n c. gov/about/d iv is ion s/energy-mi nera I-lan d-resources/erosion-sed i ment-control
2. Project Information
2a. Name of project:
oon 1.1 rj 5
2b. County:
ZU0", An
2c. Nearest municipality / town:
3. Owner Information
3a. Name(s) on Recorded Deed:
CJ `L. a
3b. Responsible Party (for LLC if
applicable):
3c. Street address:
3d. City, state, zip:
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3e. Telephone no.:
9 M I .4
3f. Email address:
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4. Agent/Consultant Information (if app cable) c
4a. Name:
oL
4b. Business name
(if applicable):
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4c. Telephone no.:1'
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4d. Email address:
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B. Project Information
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID):
Cru 5L4 9 Sj 1 _�)ZC)0 00
1b. Site coordinates (in decimal degrees):
Latitude: :35z. q 0:9'?Co Longitude: 5
(DD.DDDDDD) (-DD.DDDDDD)
2. Project Description
2a. Explain the purpose of the proposed project (continue on back):S'M
t i� �►'� � i�c . i ii S-100'q_

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2b. Describe the overall project in detail, including the type of equipment to be used:
remov,2j 9-v115+-1 f-) 1puxcx-,�A 'to, 0-�V� ()�,fyxj3pa arj
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C. Stream Impacts: Please list all proposed impacts to the stream
1 a. Stream Name: k e-: A 0 n 16C�kn Ch
1 b.
Type of impact
Average stream
Impact length
width (linear feet)
(linear feet)
El Bank Stabilization - Sloping and Revegetating
El Bank Stabilization - Sloping and Riprap/Armoring
Bank Stabilization - Gabion Baskets / Retaining Wall
ra, pprCx u,
'To ft /eacb sicA-(,-
❑ Culvert Installation CulvertDiameter:Diameter:
D Temporary Impacts for required dewatering activities
El Other (describe):
1c. Comments:
Zach
Owner/Agent's Printed Name
Date
f ---Owned tu- re
(Agent's signature is valid or if an at' atior letter from the owner is
provided.)