- 6/21/2024 10:04 PM

5, Describe the existing land use or condition of the site at the time of th s applicatior. (residential,
undeveloped, etc.): 4S r
6. Describe proposed wm(k {include discussion as to how hardening of shoreline hat been avoided, or
why it is necessary); Dr- - j ,,j O' l{ 21"
'P '
7. Will work be conaucted from land? Q From water? Q
8, Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts Urfluding all excavation, backfi11, rip rap, retaining walls, etc.) In square feet:
�v L?
Temporary impacts in square.feet: ---,
i�
Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet land-
ward
Permanent Impacts IInduding back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Z.
Temporary Impacts I em rary clearing, construction corridor) in square feet:
la. Please descrlbe the vegetation above the normal pool lake level/ Normal Water Level and 50 f-et
landward to be Impacted (number of trees, for instance):
11. Signature
9y signing below, I, as the project proponent, certify to the following:
i The project proponent hereby certlfles that all information contained herein Is true, accurate,
and complete to the hest of ny knoviedge and belief
• The project proponent hereby requests that the certifying authorty review ar.d take act la-1 on
this ONA 401 certification request wlthir the applicable reasonable period of time
dwn tur* [ _ Date
'Agent's stwtvre is valid any if an nut: wizotio►r totter from the owner is provided,
12. Please approximately sketch the following information on this plan and provide dimenslons,far
each item:
a_ Ail proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Lave elevation
c, Location of rip rap or fill to be placed be4aw the Full Pond/ Normal Water Let,eI elevation
d. location of any proposed structures such as buildings, retaining walls, docks, etc.
a. Location of any engvetlon or dredging below the Full Pond/ Normal Water Level elevation
�a,r[w�Li�p�.se.rer,rrurxu:�7r� , uN�r►rr�na::,ra,wY
$x: a,nu iNi.4 rr'MA p I Wit tlrrr ! yloko' %W"t w --!nI4 —L417