20000891 Ver 1_COMPLETE FILE_20000707

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
Moog
NC ENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
August 17, 2000
Wilkes County
DWQ Project # 000891
APPROVAL of 401 Water Quality Certification and ADDITIONAL CONDITIONS
Mr. Michael Neaves
225 Surry Ave
Elkin, NC 28621
Dear Mr. Neaves:
You have our approval, in accordance with the attached conditions and those listed below, to place fill material in 160 linear feet (150
feet of new culvert) of streams for the purpose of constructing a residential development with road crossing at Woodies on the Bugaboo-Phase
2 as described in your application dated July 27, 2000. After reviewing your application, we have decided that this fill is covered by General
Water Quality Certification Number 3289. This certification allows you to use Nationwide Permit Number 14 when the Corps of Engineers
issues it. In addition, you should get any other federal, state or local permits before you go ahead with your project including (but not limited
to) Sediment and Erosion Control, Coastal Stormwater, Non-Discharge and Water Supply Water shed regulations. This approval will expire
when the accompanying 404 or CAMA permit expires unless otherwise specified in the General Certification.
This approval is only valid for the purpose and design that you described in your application except as modified below. If you change
your project, you must notify us and you may be required to send us a new application. If the property is sold, the new owner must be given a
copy of this Certification and approval letter and is thereby responsible for complying with all conditions. If total wetland fills for this project
(now or in the future) exceed one acre, compensatory mitigation may be required as described in 15A NCAC 2H .0506 (h) (6) and (7). For this
approval to be valid, you must follow the conditions listed in the attached certification and any additional conditions listed below.
1. Deed notifications or similar mechanisms shall be placed on all remaining jurisdictional wetlands and streams to notify the state in order
to assure compliance for future wetland and/or water impact. These mechanisms shall be put in place within 30 days of the date of this
letter or the issuance of the 404 Permit (whichever is later).
2. All areas within 30 feet of perennial streams must be revegetated once all temporary sediment and erosion control measures are removed.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You must act within 60 days of
the date that you receive this letter. To ask for a hearing, send a written petition, which conforms to Chapter 150B of the North Carolina
General Statutes to the Office of Administrative Hearings, P.O. Box 27447, Raleigh, N.C. 276 1 1-7447. This certification and its conditions are
final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If you have any questions,
please telephone John Domey at 919-733-9646.
Attachment
cc: Corps of Engineers Raleigh Field Office
Winston-Salem DWQ Regional Office
File copy
Central Files
Stephen Auffrnger; ASG Engineering
Since XL
lr Kerr T. Stevens
L
MM4
Division of Water Quality • Wetlands/401 Unit
1621 Mail Service Center • Raleigh NC 27669-1621 • Telephone [phone] • FAX # [phone]
An Equal Opportunity Affirmative Action Employer
50% recycled/10% post consumer paper

5'?a

MEMORANDUM
It I
TO: John Dorney Regional Contact:
Non-Discharge Branch WO Supervisor:
Date:
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name Michael R. Neaves
Project Number 00 0891
Recvd From APP
Received Date 7/7/00
Recvd By Region 8/9/2000
County Wilkes
County2
Region Winston-Salem
Project Type residential subdivision
Certificates Stream
Permit Wetland Wetland Wetland Stream Class Acres Feet
Type Type Impact Score Index Prim. Supp. Basin Req. Req.
14 Stream O Y O N F_- 12-48-(.7) WSIV HQW 30,701. 149.00
Mitigation Wetland
MitigationType Type Acres Feet

Is Wetland Rating Sheet Attached? O Y ON Did you request more info? O Y ON
Have Project Changes/Conditions Been Discussed With Applicant? O Y 0 N
Is Mitigation required? O Y OQ N
Provided by Region: Latitude (ddmmss)
Recommendation: O Issue 0 Issue/fond O Deny
Longitude (ddmmss)
Comments:
The WSRO recommends that this WO Certification be issued for this road crossing with the following
conditions•
The WS-IV buffers (30 feet - low density development) must be restored with vegetation
once all temporary sediment and erosion control measure- (oar Division of Land Resources
r,?gdalrements) have been removed.
9 near) restrictions must he placed on all remaining lots with surface waters to ensure
continuing compliance with DWO regulations (401 WO Certification Program and Water
Supply gegulations)
cc: Regional Office
Central Office Page Number 1
Facility Name Michael R. Neaves
Project Number 00 0891
Comments (continued from page 1):
County Wilkes
Regional Contact: Jennifer Frye
Date:
cc: Regional Office
Central Office Page Number 2
00 0891, Woodies on the Bugaboo, Wilkes Co.
Subject: 00 0891, Woodies on the Bugaboo, Wilkes Co.
Date: Wed, 16 Aug 2000 09:51:24 -0400
From: Jennifer Frye <[e-mail]>
Organization: NC DENR Water Quality
To: "cyndi.karoly" <[e-mail]>
Staff report completed. The following note will probably make more
sense when you see the staff report.
NOTE: If we are able to require Deed Restrictions/Notifications for 401
program compliance only- I recommend that they supply some documentation
showing that the 30 ft. WS buffer will remain a vegetative buffer
(easement, covenant, etc.).
Hope you are having a great day! Still planning on going next week? I
told Bob to count me in - his e-mail/sales pitch was just TOO enticing.
Ciao!
Jen
Jennifer Serafin Frye
Division of Water Quality
NC Department of Environment and Natural Resources
Winston-Salem Regional Office
Winston-Salem, NC 27107
Voice: 336-771-4608 ext. 275 Fax: [phone]
1 of 1 8/16/00 10:14 AM
ASG Engineering
4140 Clemmons Road, Suite 102, Clemmons, NC 27012
tel: [phone] fax: [phone] email: [e-mail]
July 27, 2000
Mr. John Dorney
NC Division of Water Quality
4401 Reedy Creek Road
Raleigh, NC 27607
a' 2 8 2000.
[ }WA Wit I LANDS
?v
Re: Nationwide Permit Request
Woodies on the Bugaboo- Phase 2- ASG Project No. 00.112
Dear Mr. Dorney:
Pursuant to your letter to Michael R. Neaves dated July 18, 2000 (Wilkes County, DWQ Project
No. 000891), I offer the following in response to your numbered comments:
1. We are choosing the low density option for the development in accordance with the
provisions of 15A NCAC 02H.1006 (2):
(a) The proposal calls for single family residential development on lots of one acre or
greater;
(b) Stormwater runoff will be transported primarily by vegetated conveyances; the
proposal does not include a discrete stormwater collection system;
(c) The developer agrees to a 30' wide vegetative buffer along the tributary and all
streams within the development. The enclosed engineering plan Ml- Master Site
Plan, has been revised to include the stream easements. Two copies are provided.
2. Two copies of the USGS topo map at 1:24,000, labeled and showing the development
boundaries, are enclosed.
3. Cross sections of the roadway are included in the enclosed engineering sheet D1-Details.
Two copies are provided.
4. Sheet D1 also includes a detail on the culvert installation ("Culvert and Tailwater Pad",
note 2: Set invert of C7 0.5 feet below existing stream bed.).
Please review this information and furnish a permit to the owner with a copy to me. If you have
any questions please call me.
Sincerely,
ASG Engineering
Stephen Auffmger, P.E.
Professional Engineer
enc.
cc: Mike Neaves
John Thomas
PRACTICAL CIVIL ENGINEERING SERVICES IN NORTH CAROLINA AND VIRGINIA: COMMERCIAL & RESIDENTIAL SITE DEVELOPMENT
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MICHAEL R. NEA,
ASG Engineering 2000'CONTOUR INTERVAL 20 FEET 2000' WOODIES ON THE BUGABOO
4140 Plemmons Road, SuRe 102 WATERSHED AREA MAP
Clemmpns, NC 27012 SOUR E: DELORME TOPOQUADS, 1999 7126100
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MICHAEL R. NEAVES
ERVAL ASG Engineering 2000, CONTOUR INTow 20 FEET 2000' WOODIES ON THE BUGABOO
4140 Clemmons Road, SuRe 102 WATERSHED AREA MAP
Clemmons, NC 27012 SOURCE: DELORME 3 D TOPOQUADS, 1999 / 712(?6100
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
4 • •
dauftm?
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
July 18, 2000
Wilkes County
DWQ Project No. 000891
Michael R. Neaves
225 Surry Avenue
Elkin, NC, 28621
Dear Mr. Neaves
On July 7, 2000, the NC Division of Water Quality received your application for a 401 Water Quality
Certification for the Woodies on the Bugaboo, Phase 2 in Wilkes County. Before we can proceed with
reviewing your application, we need the following information:
1. In accordance with the conditions of General Certification 3287, describe the pre-construction and
post-construction impervious area, and how they were used to develop your stormwater
management plan;
2. Provide a copy of a labeled 1:24,000 USGS topo map with the property boundaries clearly indicated
so that compliance with water supply watershed can be determined;
3. Provide a cross-section of the roadway to determine if a floodplain passage is needed;
4. The proposed culvert must be installed to allow low-flow passage of aquatic life. Please provide
supporting documentation and platis to show this will be accomplished.
Until this information is received. I will request (by copy of this letter) that the Corps of Engineers place
this project on hold. Also, this project will be placed on hold for our processing due to incomplete
information (15A NCAC 2H.0507(h)). Please visit the 401/Wetlands Unit home page located at
http://h2o.enr.state.nc.us. I can be reached at [phone].
Sincerely,
1% .
John Domey
5?1 l ?Q
cc: Corps of Engineers Raleigh Field Office ' L
Winston-Salem DWQ Regional Office
File Copy (R)
Central Files
Stephen Auffinger, 4140 Clemmons Road, Suite 102, Clemmons, NC, 27012
000891
Division of Water Quality • Non-Discharge Branch
401/Wetlands Unit, 1621 Mail Service Center, Raleigh, NC 27699 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer • 50% recycled/10% post consumer paper
ASG Engineering
4140 Clemmons Road, Suite 102, Clemmons, NC 27012
tel: [phone] fax: [phone] email: [e-mail]

July 7, 2000
Mr. John Dorney
NC Division of Water Quality
4401 Reedy Creek Road
Raleigh, NC 27607
Re: Nationwide Permit Request
Woodies on the Bugaboo- Phase 2- ASG Project No. 00.112
Dear Mr. Dorney: 13 ® !g39 1
Enclosed are seven copies of the Pre-construction Notification form for the referenced project,
along with a check to cover the $200 application fee.
Please review this information and furnish a permit to the owner with a copy to me. If you have
any questions please call me.
Sincerely,
ASG Engineering
Stephen Auffinger, P.E.
Professional Engineer PAYMENT
enc. RECEIVED
cc: Mike Neaves
Jennifer Frye
PRACTICAL CIVIL ENGINEERING SERVICES IN NORTH CAROLINA AND VIRGINIA: COMMERCIAL & RESIDENTIAL SITE DEVELOPMENT

j
L ppp?9? PAYMENT
a.«, . RECEIVED
' ea
,' s
DWQ 1D: CORPS`iarCTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #) 14
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7)
COPIES MUST BE SENT TO THE NC DIVISION OF WATER QUALITY,
ATTN: JOHN DORNEY, 4401 REEDY CREEK ROAD, RALEIGH, NC
27607. PLEASE PRINT OR TYPE.
1. OWNER'S NAME: Michael R. Neaves
2. MAILING ADDRESS: 225 Surry Ave., Elkin, NC 28621
SUBDIVISION NAME Woodies on the Bugaboo
CITY: STATE: ZIP CODE:
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
Edwards- Keyes Road (NC Route 1932)
3. TELEPHONE NUMBER: (HOME) 336-835-7236 (WORK) 336-466-0229
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER:
Stephen Auffinjzer P E ASG En ing eering 4140 Clemmons Road Suite 102, Clemmons NC 27012
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP
OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: Wilkes - NEAREST TOWN: Elkin
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ECT.) From Elkin: Rte 268
West right onto Austin Road left onto Greenhorn Road, Right onto Edwards-Keyes Road, approximately
'/2 mile on right to entrance.
6. IMPACTED OR NEAREST STREAM/RIVER: Tributary to Big Bugaboo Creek RIVER BASIN: Yadkin-
Pee Dee
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-1 OR WS-II)? YES X NO E] IF YES, EXPLAIN: HOW
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES ? NO X
(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION? Not Applicable
8. (a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES ? NO X IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND
ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES X NO ? IF YES, DESCRIBE ANTICIPATED WORK: Possible future replacement of existing low
water bridge at Big Bugaboo. The commencement of design is pending a market evaluation.
9. (a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND: 100
(b) ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
2.2 acres based on approximate surveyed stream width plus one stream width on each side, multiplied by the length.
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: 0.04 EXCAVATION:
FLOODING: OTHER :
DRAINAGE : TOTAL ACRES TO BE IMPACTED: 0.04
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION:
LENGTH BEFORE: 149 FT (50' upstream of ex. pipe, 99 downstream, including a badly eroded section)
AFTER: 22 FT (all on the downstream end, consisting entirely of a class A rip rap energy dissipater)
WIDTH BEFORE: 3 FT (based on normal high water contours)
AVERAGE DEPTH BEFORE: 0.5 FT AFTER: 0.5 FT (approximate)
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: X
CHANNEL EXCAVATION: CONSTRUCTION OF A DAMIFLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
EQUIPMENT TO BE USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
Removal of existing farm road and 24" culvert, installation of 42" culvert and tailwater pad per approved
Erosion and Sedimentation Control Plan. Please see the followinp- en ing eerin drawings: Ml- Master Site
Plan, G2Roadway 0+00 to 14+00, and D1- Details.
13. PURPOSE OF PROPOSED WORK: Road for residential subdivision.
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS)
This culvert with the standard NCDOT road cross section is the safest method of crossing the creek.
Measures taken included lowering the road profile to the extent practical while providing the minimum
length of vertical curve allowed for the required design speed. Additional measures include lowering the
pipe invert 0.5 feet below the existing creek bed to enable a flooded condition at the energy dissipater,
which reduced the required rip rap size and length in the stream channel. This project will fill in all of the
badly eroded stream channel on the downstream end of the existing culvert.
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY FEDERALLY
LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL
HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED: Same date as this form.
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA
WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT. DATE CONTACTED Same date as this
form.
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF PUBLIC
(STATE) LAND? YES ? NO X (IF NO, GO TO 16)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACT? YES E] NO E] Not Applicable
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE YES ? NO ? Not Applicable
IF ANSWER 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38).
ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON
THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OF 1 INCH EQUALS 100 FEET
OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
(e) WHAT IS LAND USE OF SURROUNDING PROPERTY? Agricultural and residential
(f) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? Individual septic
systems
SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
1. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
PROGRAM. 7 Sr`i'
AGENYXS36NATURE DA
to
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED).
(Authorization provided on Application for Department of Army Permit form (copy attached).
A PPLICATD N FO R D EPARTM ENT O F 71 E ARMY PERM ff I 0 M B A PPRO VA LNO. 0710-003
(33 CFR 325)
Pub is n porting burden for Ibis co M etion of inform ation is es tim ate d to a%e rage 5 k oun per response, ine riding *a too far n %kn irg ers buctiors,
s e and ing a xis ling data sour=s, galla ring and ¦ aintaining ti e data no ode d, and comp i ling and revie • ing I e co Y etion ofinfone ation. Se nd cos m e nts
regarding ti is burden es tim ab or any oti e r asps et of ti is co N etion of inform aeon, inn tiding suggestions for n during ibis burden, tD De parts ant of
Defense, ¦ ash ington i eadluarhn Somic s Directorate ofinform ation Operations and Reports, 1215 Jefftnon Davis 1 igk m ay, Suite 1204, Arington,
VA 22202-4302 ;and to ti e Office ofManagementand Budget Fbpenr ork Reduction Fkojct(0710-00031 W ask ington, DC 20503. PPiase DO NOT
RETURN yourform to •iti • roftios• addresses. Camp i ted app /rations ¦ ustbs subs itud to ti a DistrictEngines rh ming ju'sdiction ow rid* bcation
_ oft a proposed activity
FR RACY ACT STATEMENT
Aull oft: 33 USC 401, Se ction 10: 1413, Se ction 404. F%ncipa WbFpos e : Th as* her s n q uin aut orRng acti4des in, or afb cling, na Vgab i ¦ ate n
oftl a Unit d States, ti a disci ange or61r alb rice km ¦ ate rs off a Unit d Stairs, and ti • transportation ofdndge d a aft ria WDrik a purpose ofdum ping
it into oce an s at n. Routine Uses: hibm anon provided on 0 is form ¦ i Ilbe used in e%a hating th a app /ration 1br a pe no it Disc 6sun: Disc bsun
ofnluested inform actn is xe bntary. Irinfwm actn is notprDVded, h ow a %a r, 0 e pe no itapp Ication cannotbe processed nor can a perm itbe issued.
One s e t of origins t drat ings or good n producib i copies ¦ h ick slow tie bcation and d anode r of ti e proposed activg m ust be celiac/ ad to 0 is
app /ration (sea sap 1 drat ings and nstsssctiom)and be subm used IDS e D ist ictEngsseri aVng jrrisdiction o%e rtha 6cation oftl a proposed activity.
An app kation ti ate not cc m p i b d in f{r Nm i Nbs n tome d.
(ffEMS 1 T1 RU 4 TO BE FILLED BY TI E CORPS)
1. APPLCATDN N0. 12. FIELD OFFICE CODE 1 3. DATE RECEIVED I4. DATE APPLICATONCOMPLETED
-1 (ITEMS BELOW TO BE FILLED BY APPLICANT) r
5. APPLCANT'S NAME 1 8. AUT1 ORII ED AGENT'S NAME AND TITLE (anagentisnotmgL"d)

I0
6. APPL CANT'S ADDRESS 9. AGENT'S ADDRESS
22S Jvrol Z4 te ff- F
?, ?Sv? /0 2
Cl?'??nrr ic/C 2 741/ Z
7. APPLICANT'S RI ONE NOs. W /AREA CODE 10. AGENT'S P1 ONE NO s. W /AREA CODE
!O"778-OB99
a. Residence J3lv-8.35^7Z3G a. Residence
b. Business ?3G- 9'>!i!/-OZ29 b. Business ro-778-?/I/
11. STATEM ENT O F Am 0 R[ A TD N
I k ereby au orize, J h?rJ.f?+fr ?" w actin m y bek a fas m y age ntin ti e processing ofik is app Ication and w fumisk , upon
re q ues?sdop i m e nta lini* atiorYlin support oftl is pe nn itapp ication.

A
- Z)?- ?C°
DATE
NA M E, LO CA TO N, A ND D ESCR MD N 0 R PRO JECT 0 R ACTMTY
12. PROJECT NAME 0R TITLE (see instucoons)
Afle - %'.s .01', 7A ? a6oo
13. NAME OFWATERBODY, IF
Ui»?r. erg 774&
15. LOCATION OFPROJECT
I (ifapicabf)
6?? 01W-4
,?lG
PROJECT STREET ADDRESS (if app icab! )
?? ,euJ? /43 2
16.0-111 ER LD CA TD N DESCR 1PT0 NS, IF K NOW N (see insbuciions) Section, Tar f o 4• Rang, LAM, a.Ur Aeeessors's Pao IWO Mr, for exam p s.
0.4g /h%Irl ?'? ? ?ia,?/??i? o?iP?r?/x332 ?' 2/?9 7?/.ae?dr ???,
17. D RECT D NS TO TM E S ITE
4.?
Xle- -z-'o
alp E>c??..b -?t"T
IHrle
ENG FORM 4345 (ONLNE) EDITDN OFSEP91 6 OBSOLETE (Pmponent CECW-0 R)
16. Nature of ActVty (Delc,'"onofpnFn•.rrwcaateaures)
??? C??STfc-t??i
19 . Rt?y rt. Rlrlxrs a (Umerbe Ike mason or pur lxm of d P. pv!y M, see imnucidorm)
USE BLDCUS 20-22 FDREDGED ANDAR FILLMATERIRL6 TO BED SCI ARGED
20. Reason(s) ibr Disck arge

21. Type(s)ofMaieria (Being Disci arged and the Am ountofEacl Type in Cubic Yards
Oor ?i `y tc?tr? 3 ?r.,I• a`e t 3
lZ` >!texh ? '•rle C?,sr?? '}/o?? ? G-Y.
22. Surfiarx Area in Acres ofWetbnds orO* er W aters F Rd (see insvroctiom)
(/ f -, K / Joe ? = ex 00'4"
+2 3v/x' / 51::P/ im d. </ 14
23. Is Any Wrtion oftl e W ork A to ady Com p i W ? Yes _ No.Al IFYES, DESCR BE TI E CO M PLETED W 0 RK
24. Addresses of Adjoining Property Owners, Lessees,Elr.,Wlose Property Adpinstle WaVerbody(emannaneanbeensredben.pla aLbasuppimernnresa
12a &PeAe.-
0
AolvJ6.1 ?Q? 7v
25. Ustof0u er Certifications orApprowliDenin t Received from otk er Federal Stan, or Loca (Agencies for W ad Described in Ti is Appication.
AGENCY TYPE AFFRO VA L' DENTMATD N NUMBER DATE APPLIED DA TE APPRO VIED DATE DEN FD
z?Ae%lp 07-w/470
/fIGQ??.e '6DXrA ?,?!c?.)re'F9?T ?? e3o'wj altZzllga
26. App Ication is If e mby m ade for a perm it. or perm its m autl or¢e tl =described described in b is app Ication_ I certify * attk a inform ation in * is
app on is com p i to rid accurate. I turd e r ce rt]fy 0 at I possess A a auld ority ip urKbrtA a 0 e w ork descrdxd t e rein or am acting as $ e
du o tie app icart
Tn L_zr
51GNATURE0F PPLCANT DATE S IGNATURE 0 F AGENT DATE
Ti a alip Lation m ust be signed by 0 e pe rson w 1 o des ire s w unde rut e tl a proposed actisity (app k ant) or it m ay be signed by a du y
autk orized agentiftl a stMm entin b ba 11 1 as been fi kd outand signed.
18 U.S.C. Section 1001 pro\kks tl at W k oe xer. in any m anner w it in 0 e jlrisdiction of any departs entor agency oftl a Unitrd States
t now ing y and w i Wu ly fa tifies, eexxeat. or co\ers up any trick , w;h em e, or disguises a m ate ria Ifact or m ak es any fa te, fictitious or
fraudu tnt statem a n19 or re pre se ntations or m ak es or uses any fir to w riting or docum a rttk now ing sam a to contain arty 'Fit te, fictitious or
ifaudu irttstatem ents or entry, s1 a He fined notm ore tl an $10,000 or in prisoned note on tl an fi\e years orbod .
LNG FORM 4345 (ONL NF) L t)IT IDN 0 F SEP91 4 OBW Et I E (Rqx" nt CLLW -() R)
7 2000
a
PAYMENT
DWQ ID: CORPS ACTION ID: RECEIVED
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #) 14
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7)
COPIES MUST BE SENT TO THE NC DIVISION OF WATER QUALITY,
ATTN: JOHN DORNEY, 4401 REEDY CREEK ROAD, RALEIGH, NC
27607. PLEASE PRINT OR TYPE.
1. OWNER'S NAME: Michael R. Neaves
2. MAILING ADDRESS: 225 Siga Ave., Elkin, NC 28621
SUBDIVISION NAME Woodies on the Bugaboo
CITY: STATE: ZIP CODE:
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
Edwards- Keyes Road (NC Route 1932)
3. TELEPHONE NUMBER: (HOME) 336-835-7236 (WORK) 336466-0229
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER:
Stephen Auffinger P E ASG Engineering 4140 Clemmons Road Suite 102, Clemmons NC 27012
LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP
OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: Wilkes - NEAREST TOWN: Elkin
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ECT.) From Elkin: Rte 268
West right onto Austin Road left onto Greenhorn Road Right onto Edwards-Keyes Road, approximately
'/2 mile on right to entrance.
6. IMPACTED OR NEAREST STREAM/RIVER: Tributary to Big Bugaboo Creek RIVER BASIN: Yadkin-
Pee Dee
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-I OR WS-II)? YES X NO E] IF YES, EXPLAIN: HOW
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES ? NO X
(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION? Not Applicable
Air,
8. (a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES ? NO X IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND
ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES X NO ? IF YES, DESCRIBE ANTICIPATED WORK: Possible future replacement of existing low
water bridge at Big Bugaboo. The commencement of design is pending a market evaluation.
(a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND: 100
(b) ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
2.2 acres based on approximate surveyed stream width plus one stream width on each side, multiplied by the len 1hh.
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: 0.04 EXCAVATION:
FLOODING: OTHER :
DRAINAGE : TOTAL ACRES TO BE IMPACTED: 0.04
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION:
LENGTH BEFORE: 149 FT (50' upstream of ex. pipe, 99 downstream, including a badly eroded section)
AFTER: 22 FT (a11 on the downstream end, consisting entirely of a class A rip rap energy dissipater)
WIDTH BEFORE: 3 FT (based on normal high water contours)
AVERAGE DEPTH BEFORE: 0.5 FT AFTER: 0.5 FT (apyroximate)
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: X_
CHANNEL EXCAVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? WHAT IS THE EXPECTED POND SURFACE AREA?
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
EQUIPMENT TO BE USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
Removal of existing farm road and 24" culvert, installation of 42" culvert and tailwater pad per approved
Erosion and Sedimentation Control Plan. Please see the following engineering drawings: M1- Master Site
Plan, G2Roadway 0+00 to 14+00, and DI- Details.
13. PURPOSE OF PROPOSED WORK: Road for residential subdivision.
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS)
This culvert with the standard NCDOT road cross section is the safest method of crossing the creek.
Measures taken included lowering the road profile to the extent practical while providing the minimum
length of vertical curve allowed for the required design speed. Additional measures include lowering the
pipe invert 0.5 feet below the existing creek bed to enable a flooded condition at the energy dissipater,
which reduced the required rip rap size and length in the stream channel. This project will fill in all of the
badly eroded stream channel on the downstream end of the existing culvert.
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY FEDERALLY
LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL
HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED: Same date as this form.
.r
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA
WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT. DATE CONTACTED Same date as this
form.
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF PUBLIC
(STATE) LAND? YES ? NO X (IF NO, GO TO 16)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACT? YES ? NO ? Not Applicable
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE YES ? NO ? Not Applicable
IF ANSWER 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. C14RYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38).
ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON
THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OF 1 INCH EQUALS 100 FEET
OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
(e) WHAT IS LAND USE OF SURROUNDING PROPERTY? Agricultural and residential
(f) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL? Individual septic
systems
SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
1. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
PROGRAM. -7
TURE DA
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED).
(Authorization provided on Application for Department of Army Permit form (copy attached).
f
A PPLICATD N FO R D EFRRTM ENT OF TIE ARMY PERM if I 0 M B A PPRO VA LNO. 0710-003
(33 CFR 325)
Rib lea porting burden for t is eo Yetion of inform ation is estimated 1a aye rage S i oun per response, ine tiding to time for n viewing instructions,
search ing a xis ling data sources, gat @ ring and m aintaining t e data ne a de d, and con p i ling and re vie ¦ ing to co ti C*0 ofinform ation. Se red cons* nu
regarding t is bu be n e s tim at or arty of e r ape et of t is co Y etion of inform ation, inc riding suggestions for re ducing t is burden, to De partm • nt of
Defense, M ash ington I a adq uarte n Service Din ctorab: of inform aeon Ope rations and Reports, 1215 Je fii non Dads 1 igh w ay, Suite 1204, Arkrgtien,
VII 222024302 ;and tote Office ofManagementand Budget Fbperw on Reduction Pko ct(0770-00031 W ask ingtors, DC 20503. Piase DO NOT
RETURN yourform IDrill • roft os• addresses. Coo piled app ications ¦ ustbe subm itbd to Ike DistrietEngirweri aving_juisdiction ourt a bextion
oft a proposed activib.
FR MiCY ACT STATEIM ENT
Aut ority: 33 USC 401, Section 10: 1413, Section 404. Rircga Warposs: n is* N s require aut oriri g activities in, or afictM, navigabi w alen
oft • United Steles, t e disci angs orfi Ir atenia Into w alers oft a United States, and t • tnumportation ofdredged ¦ ateria Ifor't • purpose ofdum ping
it into ocean w elers. Routine Uses: Inform ation pro%ided on* is form w i Ube used in *%abating t e appieation 1br ape no it Discbsure: Disc bsure
ofrequesled inform acon is W 6ntary. Ifinform actn is notprovided, how a u r, t e perm itapp ication cannotbe processed nor can a perm itbe issued.
One s e t of origins 1 dray iogs or good n producib i copies ¦ i ici show to bcation and d arade r of t e proposed activiq m ust be attacked to t is
app ication (see sam pi drat igs and i strrrctions)and be subw itad 1D Ike D ist KetEngineerk ax" ji isdietion ore rtk a bcation oft a proposed activity.
An aDD ication t atis notcom piled in fu Hui Kbe returned.
(ffEMS 1 TI RU 4 TO BE FILLED BY TI E CORPS)
1. APPLCATDN NO. ( 2. FIELD OFFICE CODE 1 3. DATE RECEMD 14. DATE APPLICATDN COMPLETED
I (ITEM S BELO W TO BE FILLED BY A PPLCA W) e
5. APPLr-ANT'S NAME r 8. AUTI ORE ED AGENT'S NAME AND TITLE (anaWntisnotretured)
.e. .4/,ears
.o19!57
6. APPLCANT'S ADDRESS 9. AGENT'S ADDRESS
22S .5Z ro /411-0 ? Aj' e
C'lr????.r ,c/G 270 2
7. APPLJCANT'S P1 ONE NOs. W AREA CODE 10. AGENT'S R ONE NOs. W AREA CODE
r/O"778-?8?9
a. Residence 97&-Br3S=7Z3G a. Residence
b. Business 73G - '?!s!/-- oZZ 9 b. Business Ar -778-////
11. STATEM ENT OF ANTI OR [ ATD N
I k ere by aup orize, ?7??//f?`?? ID actin my bei a fas my agentin 'Me processing oft is app ication and to furnish, upon
req ues,p)s p im enta linf* atio"n supportoft is perm itapp ication.

DATE
NAME, LOCATION, AND DESCRPrDN OR PROJECTOR ACTWHY
12. PROJECT NAME OR TITLE (see instructions)
Gf/OGb;?, f A-t 7A ? O?ioo
13. NAME 0FWATERBODY, IFKNOWN ofeppi;abo 14. PROJECT STREET ADDRESS Vappicabi)
P U???ri?et9 7ri=6v © C? ?? .?tJilG /43 2
15. LOCATONOFPROJECT /
16. 0 TI ER LO CATD N DESCR IPrD NS, IF KNOW N (tie insvucdons) ssceen, Tom id p, Paw, utAon, ovL4w Aeeesson's Pao errm ber, fare:ape.
17. D RECTDNS TO Ti E SITE /` on? •??`-'? •21 le ?yo
jr T ,eo4="' ???•a?
ENG FORM 4345 (ONLNE) EDITON OFSEP91 S OBSOLETE (Proponent CECW-0R)

18. Nature ofActiuty ((kur?xrcrnof"FxnFct.ncYdeatlkarurs)

19- %n ctRrFpaee (Uncrte Se remmo purpEm nr ao prceprt,scr imtnu time)
USE 6LDCKS 20-22 IF DREDGED AND?OR RU-MATERWL S TO BE D 60 ARGED
20. Reason(s)forDisckarge

21. Type (s)ofMate a (Being Disci arged and the Am ountofEack Type in Cubic Yards
O crrtl, ?i `y ?v/,mar r? ?w. ?e t 3 e-.F" s• ze-e Cos-d) -740'
'l/? Cv/r?+' !Z'?w•.? t ?2` mss. -'ere Ce' ; 'pow ez? cf;
Z2. SurFacx Area in Acres ofWetbndsorOberWatrsF kd (xeinsvmto .)
/AO 1, 47. 000
3vr?r / &Pt im a'41 c/ t4
23. Is Any Raton ofb a Work A toady Com piW? Yes _ No.A' IFYES, DESCR13E Tk E COMPLETED WORK
24. Addresses ofAdpin'nrg Property Owners, Lessees, Etr.. Wiose Pn3pertVAQpinsbe Watarbody(Ifeonnm,canbeermadbem.pi?auiMasuppOmentalisO
12 P
A 70
25. List ofO11arCaruficationsorApprotiair) eniaiRecei\adfrom olk erFe de rnIState,or Loco lAgenciesfbrWad 0as cribedin Ti isApp ication.
AGENCY TYFE APPRO VA L7 DENTIFICATONNUM13ER DATE APPLE D DATEAPPRO\jED DATE DENIED
NCDaT -a?Ae%lp
6?Wo/,A.sYlr??fS??? C''al/zz/oa
26. App i ation is i are by m ade for a pe rm it; pe rm its =2 orae b e w ark described in b is app Ication. I certify is attk a inform ation in b is
app C 'on is cam p i to rid accurate. 1 furtk e r ce rtify -0 at I possess b e aub oriigr to undertak e b e w ork described k e re in or an acting as b e
du a " d n 4 e'' d`am, scant
?/ K ^ z f -ZCvj
S16NATUREOF PPI?ANT n DATE SIGNATURE 0 F AGENT DATE
The appicationmustbe signed by tie person wko desires m undertake tie proposed actiuty (app k:ant)or itmay be signed by a duy
autk oraed agentifb a stattem entin b ba 11 k as been fi tkd outand signed.
18 U.S.C. Section 1001 provides b at W i oe per. in any m anne r w it in the jurisdiction of any de parUF entor agency of b e United States
k now ing y and w i Wu hr fa tifies, cornea t. or cobc rs up any trick, sct em e. or disguises a m ate ria I factor makes any fate, fictitious or
frrudutntstalemerM orrepresentations ormakes or uses any time w ruing or documentknow ing some to contain any fate, fictitious or
ftaudu irttstatem ants or entry. sk a tlbe lined notm ore ban $10,000 or in prisoned notm ore ban five years orbob .
LNG FDRM 4345(ONUNF) LOII'DNOFSEP41 5OBSOLLIL (Pg3porentCLLW-OR)