20140779 Ver 1_Application_20140723

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The fo3lowing is an ai& formfor tlwse ap}dybg a 401 Water Qaatity
C"Iffi nailer FIRC (Federal - ) lake shore or
for wetland or stream .Please ion cannot be ased
information as wen a sew M, and Supporting
for hnPads of to lake bottom at less than` 1 acne aid at W QTY of $24&W
or equal to 1 acre. to Jake portent of Weater
Applications should be sent to
Divis M at water Quaft 401
1650 Ma0 Swvke Center
Raleigh, NC 27699 -1650
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2.
OwnedApplirant Information
Name:
Mailin,
JI=VIJATr--,R t,,!RY
Telephone lvnmb 59- -7 3 7,�
E-mail Addms: _C ay lceti-
Agent Information (A s4pW and dated copy of the Agent Antharization letter must be attached
if the Agent has signatory ate; for the ovintevf L)
Name:
Mailing Address:
Telephone Number: Fax Neer:
E-mail Address:
IL Project h&n=a&m
as towns, location of the local such
as tD road& Also p a ,she � y �daties and
opn= Plans m relation to Pe'o . YOO may use make a
hand sketch of your P Al�`see,dte a bdow for gum below to
plan must inched �� � n anow fob of all bu&lin � � and cite
facilities must be laded. snrfaoes, or other

Location
County: 'Person Nearest Town:
Subdivision name or site address (include phase/lot number):
Directions to site please include road numbers, landmarks, etc. 's is not n if an uate
. il'lu necessary „ acleq
vicinity map is included)y jj�b m i4xb&`b HzAq S-7 AJ - &m � L)
e !z n CL,
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres): 6 r %
4. Nearest body of water ( stream/river/sound/ocean/lake): NCO
6. Describe the purpose of the proposed work: 54A iy, �Lnt-e-hd' -to
IVI A aak ervsj on
6. List the type of equipment to be used to construct the project: c S
7. Amount of impact (including all excavation, baekfill, rip rap, retaining walls, dc.) below the
normal pool lake level in square feet or acres: 113 X
8.a Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above 13 a normal pool lake level and 50 feet land -ward in square feet or acres:
8.b. Please describe vegetation above the normal pool lake level and 50 feet landwa--d to be impacted
(number of trees for instance): ��filed G / rtesb ` [ —S 4rerS'
Applicant(Agent's Signature
(Agent's signature is valid only
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an authorization letter from the applicant is provided.)

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