20121012 Ver 1_Application_20121102

20121012
The following is an abbreviated application form for those applying for a 401 Water Quality
Certification to impact FERC (Federal Energy Regulatory Commission) regulated lake shore or
bottom under the U.S. Army Corps of Engineers Permit GP30. This Application cannot be used
for wetland or stream impacts. Please provide seven (7) copies of this application and supporting
information as well as a non - refundable application fee to the Division of Water Quality of $240.00
for impacts of to lake bottom of less than 1 acre and $570.00 for impacts to lake bottom of greater
or equal to 1 acre.
Applications should be sent to:
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mail Service Center "
Raleigh, NC 27699 -1650
I.
1.
2.
Applicant Information
Owner /Applicant Information
Name: �) 1
Mailing Address: f y <
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Telephone Number: 76V f Y S:Z Fax Number:
E -mail Address:
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Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the owner /applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
II. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local landmarks such
as towns, rivers, and roads. Also provide a detailed site plan showing property boundaries and
development plans in relation to surrounding properties. You may use the diagram below to make a
hand sketch of your project. Also, see the example below for guidance. Both the vicinity map and site
plan must include a scale and north arrow. The footprints of all buildings, impervious surfaces, or other
facilities must be included.

1. Location f ,,
County: W I � 14 65 Nearest Town: �k� 1 �� fly bo(y
Subdivision name or site address (include phase/lot number): WI Vidam b\
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): r4 & 9 W -e s+ 4-0 ZK-t wCls -60,.J
I c
+UrvV Ie44 c-Aid- Gcj -%i , cAc. F
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres): �J f`tCC C_Jq, N
4. Nearest body of water (stream/river /sound/ocean/lake): Y�rd�►`n
5. Describe the purpose of the proposed work: E ('ySkl Cyy ( oN +,c-CS
6. List the type of equipment to be used to construct the project: S W-I ( E t L t cL o,+ r
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: o(� )l g
8.a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above the normal pool lake level and 50 feet land -ward in squ,�rr feet or acres: .51
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): y S PnA // , j U-5 A 3 "' l�,q
of I rss 1 S r,--c•.k k Tyr c e GQ - S- S i i c 3� t4
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Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

Please approximately tely sketch the folowing i foranation on tMs plan
(pleaae l lde dl nsions for each item, such as 10 ft. x Igo ft):
1) All proposed vegetation ctearing (provide dimensions) /7 ' )(85-
A Location of rip rep or fill to be placed above the Ptull Pony! elevation 16-")c
85
3) Location of rip rap or fill to be placed below the FBI Pond elevation
4) The location of any proposed shudures mch as buildings, retaining
vndls, docks, ete. &00 Sg FV f 4;0 Re,12
6) The location of any excavation or dridging below the Full Pond
elevation.
6) Laen of eonstruc.n artcs corridors.

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Get Google Maps on your phone
Text the word "GMAPS to 46645 3
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3PERTY
,IATIO,
E\IE \'T LI \E
NORTH

Rip rap area is designated in
blue,
17' X 85' total area of
project, Vegetation will be
removed in this area,
The bank will be sloped no
greater than 2 to 1,
15' X 85' above f ull oond
elevation.
2' X 85' below
elevation.
Dock located
f ull pond
in middle of
APPROXIMATION
FLOOD EASEMENT