Davis Driveway, Rutherford Co

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
I. Processing
la. Specify Nationwide Permit (NWP) number: or General Permit (GP) number.
1b. Has the NWP or GP number been verified by the Corps?
❑ Yes No
1c. 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 Energy,
of Mineral, and Land Resources. Find more info at:
https://deq.nc.goviaboutldi visions/energy-mineral-land-resources/erosi on -sediment -control
2. Project Information
2a. Name of project:
2b. County: V
-
CA
2c. Nearest municipality / town:
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Responsible Party (for LLC if
applicable): R
p ✓ �� �Yl �l �('✓ �, S
3c. Street address: r"c�
3d. City, state, zip. �� n
3e. Telephone no.: 7 L
3f. Email address: /f
4. Agent/Consultant Information (if applicable)
4a. Name:
4b. Business name
(if applicable):
4c. Telephone no.
4d. Email address
B. Project Information
1. Property Identification
la- rroperty Identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees):
Latitude: 4 1
(DD.DDDDDD)
33 Longitude: -,S) -
(-DD.DDDODD)

2. Project Description
2a. Explain the purpose of the proposed project (continue on back):
2b. Describe the overall project in detail, including the type of equipment to be used:
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C. Stream Impacts: Please list all proposed impacts to the stream I
1a. Stream Name: U h nc�, VA,) r A
1b•
Type of impact
Average stream Impact length
width (linear feet) (linear feet)
❑ Bank Stabilization - Sloping and Revegetating
❑ Bank Stabilization - Sloping and Riprap/Armoring
❑ Bank Stabilization - Gabion Baskets / Retaining Wall
Culvert Installation
I Culvert Diameter ) Ll
, (� _ C r
❑ Temporary Impacts for required dewatering activities
❑ Other (describe):
1c. Comments:
Seed O e mu lC,keA (—wond) e pose l -5v. t
Owner/Agent's Printed Name ner/Agent's gignature Date
(Agent's signature is valid only if an auth on ration letter from the owner is
Drovided.l