20231546 Ver 1_More Info Received_20231214 (2)

5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): C)Z&Q-6�C.
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary).: nac� 4n. rrw-o V,,C-o 0,,& C>✓. f �-
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7. Will work be conducted from land? © From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet land-
ward
Permanent pacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet: �6 i
Temporary impacts (temporary clearing, construction corridor) in square feet:
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10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50 feet
landward to be impacted (number of trees, for instance):
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11. Signature
By signing below, I, as the project proponent, certify to the following:
The project proponent hereby certifies that all information contained herein is true, accurate,
and complete to the best of my knowledge and belief
• The project proponent hereby requests that the certifying authority review and take action on
this CWA 401 certification request within the applicable reasonable period of time
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Owner/Agent's Signature` (15A NCAC 02H .0502(f))
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Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
North Carolina Department of Environmental Quality I Division of Water Resources
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512 North Salisbury Street 1 1617 Mail Service Center l Raleigh. North Carolina 27699-1617
wwwn�s caw�emn� /� 919.707.9000