20090794 Ver 1_Application_20090721

09 - 0 79 4
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 five(5)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 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
1kaleigh,NC 276"-1650
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Applicant Information @ �j
L Owner/Applicant Information JUL 2 r 2009 11
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ER�MName: JLV4 G(i AND S TER gRMCti
Mailing Address:
Telephone Number: Fax Number:
E-mail Address: �,rl? JJ?_S ' fie /9�A_' 1 17 z . /Je✓
2. 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: t
Company Affiliation:
Mailing Address.. a`�o't O ox -f a-WI IZI/ - A oX /3o AO
Telephone Number: , AP-S Q 9- 9'7 S 4 Fax Number: 114, - S_272
E-mail Address: _ /, L41,L /7 - C o hi
H.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.

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1. Location
County: Nearest Town:
Subdivision name or site address (include phase/lot number): ~A&At 4 e,44
Directions to site please include road numbers,landmarks, etc. (This is not necessary if an adequate
vicinity map is included): .5'e2e
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres):
4. Nearest body of water(stream/river/sound/ocean/lake): &Ve A
5. Describe the purpose of the proposed work: 7�-
6. List the type of equipment to be used to construct the project: /�,�pol !oo/.a '<< S 4 1"'
7. Amount of impact(including all excavation,backfill,rip rap,retaining walls, etc.)below the
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normal pool lake level in square feet or acres:
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:
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): Rle
Applicant/A 's Signat Date
(Agent's sign ture is vali only if an authorization letter from the applicant is provided.)

HARVEY RAY BURCH
GENERAL CONTRACTOR
Office: [phone] 2420 Oxford Road, Roxboro, NC 27574
Cell: [phone] N.C. Lic. #20438
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