20071178 Ver 1_Application_20070705

07-117s
The following is an abbreviated application form for those applying fora 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 $200.00 for
impacts of to lake bottom of less than 1 acre and $475.00 for impacts to lake bottom
of greater or equal to 1 acre.
Applications should be sent to:
Division of Water Quality Wetlands Unit PAYMENT ~ ;
1650 Mail Service Center RECEIVED t~,~ -~'- 4:,
Raleigh, NC 27699-1650 E i.' i_, ~~ J u /

I. Applicant Information
1. Owner/Applicant Information
Name: ~oiyf ~ ~~Ll~-~Z7~
Mailing Address: 5 o a~ W o c~ D(~ ~k., o r,, T / (..~C r" 12 Y
MpuivT G~LCpp NC ~~-3c~C~
Telephone Number: 9l D -~f-~iq - 5~_3 J Fax Number:
E-mail Address:~~ -~~.t ,6~.~-r- FJ N-U~A-ft--• ~-~'v` -
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
County: MD ~T ~.,ax~l-- (~. `J Nearest Town: IA l~jC MA QL
Subdivision name or site address (include phase/lot number): Wo©1~afL ~ ~ ,1..~ T ~+J ~ ~l
Directions to site please include road numbers, landmarks, etc. (This is not
necessary if an adequate vicinity map is included):
2. Describe the existing land use or condition of the site at the time of this
application: F-L !j T r w i 11-f /'~I ld L.C ~{ ~Ew inC&- ~ "~t~ ~. ~ 4 ~T=~~_
A T ~l S ~) ~ E l~ ~ ~ ~ ti ~- y (--~ [S ra c~T" l " L> ~l'~ . y Z7"L y
Stfl4uow c6v~
3. Property size (acres): 5~6v ~4 t-L 1 ~A ~t' ~ , ~~ ~... ~< ~, / ;'~ ~' f ~~= ~I" [, r r~.~ ~'y
4. Nearest body of water (stream/river/sound/ocean/lake): L x~ /~-C 7`fC...L. i~= r'~~.-~
5. Describe the purpose of the proposed work: /~vS i14 ~- ~ S CX!-w, /a Lc.._ i}h'a-7` rs.
~C~ ~)~~-~~-~ ~12T 4
6. List the type of equipment to be used to construct the project: Mil ~ ~ ~- L_ C:4-frfZ__
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.) below the normal pool lake level in square feet or acres:- _ ~7~
~' X X02' = ~ y ~~' ~-T
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
square feet or acres: .' = /~/~~ u T S`~~ n S~ , FT
b. Please describe vegetation above the normal pool lake level and 50 feet land-
ward to be impacted (number of trees for instance): ti~ l/F-r-~F-r ~i~nr~ j7 }t-~2~
Ercc_c-YET GvEc,C~s i~"~`1-~~- A-/~~ ~Z~ T~-~ ~S %~-~.~~

Applicant/Agent'~Signature Data
(Agent's signature is valid only if an authoriza ' n letter from the applicant is provided.)
~ 3 IG-~--

Lake (Fu11 Pond}

FuNI P~a~d
.~~hAr@~In~

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Please approximately aketeh the foflorrving iniorrr-ation on this plan
(pkease provide dimensions for each item, such as 90 ft. x 1Q0 ft):
1 ~ ,~! proposed vegetation clearing ~pravide dirnensians)
~~ I~QCation 41- rip rap 4r fill #a k~e placed above the dull Panel elevation
3) Location of rip rap or Fill to be placed bel~ow- the Full Pond elevation
~~ The location of any prapased structures such as buildings, retaining
vYall$a docks, etc.
~y Tl~e location of any excava#io~n ar dredging bela~v the Full Bond
elevation.
6~ Location Qf canstructie~n access corridar~.

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