Project Title: ______________________________________________
Type of Project [ ] New [ ] Expansion [ ]Exempt

Basis for exemption_________________________________________

Part I. Riparian Buffers

Area includes riparian buffers? [ ] No [ ] Yes [ ]Exempt

If yes, [ ] 50 foot [ ] 100 foot

River Basin? [ ] Neuse [ ] Cape Fear

Basis for exemption_________________________________________

Show buffers on site plan.

Part II. Nitrogen Calculations (Method 2, Appendix C):

a. Site Information

Total area of property incl. R/W
Denuded Area
Impervious Area incl. R/W
Managed open space
Protected open space
b. Pre-development loading:	Area	TN export coeff.	TN export from use
Type of Land Cover	(acres)	(lbs/ac/yr)	(lbs/yr)
Permanently protected undisturbed open space (forest, unmown meadow)		0.60
Permanently protected managed open space (grass, landscaping, etc.)		1.20
Impervious Area		21.20
TOTAL

Nitrogen Loading Rate (lbs/ac/yr) = __________

c. Post-development loading:	Area	TN export coeff.	TN export from use
Type of Land Cover	(acres)	(lbs/ac/yr)	(lbs/yr)
Permanently protected undisturbed open space (forest, unmown meadow)		0.60
Permanently protected managed open space (grass, landscaping, etc.)		1.20
Impervious Area		21.20
TOTAL

Nitrogen Loading Rate (lbs/ac/yr) = __________

Proposed BMP(s) ________________________

Nitrogen Load after BMPs = ________________

Nitrogen Load Offset by Payments = _________

Net change in on-site N Load = _____________

Part III. Control of Peak Stormwater Flow (for 1 year, design storm)

Calculated Pre-development Peak Flow __________

Calculated Post-development Peak Flow__________

Proposed BMP(s)____________________________

Post BMP Peak Flow _________________________

I, the undersigned, certify to the best of my knowledge that the above information is correct (affix seal).