20091093 Ver 1_Application_20091015

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The follo,.ving 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
h„ttom under the U.S. Army Corps of Engineers Permit GP30. This Application cannot be used
or stream impacts. Please provide five (5) copies of this application and supporting
inl,urnration as well as anon-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
eyuid to I acre.
1plrlications Should be sent to:
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mail Service Center
Raleigh, NC 27699-1650 D s@? DPj
1. Xpplicant Information OCT 1 b 2009
Owner/Applicant Information DENR-WATER QUAUTY
WETLANDS AND STORA MATER BRANCH
\?ame? -._ v l C? ?
Mailing Address: 14, C D GC Casa PD
? ?0 9
l Jephone Number: v 2T7 55- Fax Number:
E-mail Address: Dky I b
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:
1 clephone 1\umber:
E-mail Address:
Fax Number:
1 1. 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
;,Lui !rust include a scale and north arrow. The footprints of all buildings, impervious surfaces, or other
facilities must be included.
1 :\PPI:ICATION: dcf 91 -.----
;!'}'l
Dpq ?LI?SE -
,? x':.'::11 i MAILING ADDRESS: o L%D??'G?1?f? R- Q .
15 r=55 E-
\\'\I;R(S) SIGNATURE(S):
\DPRCSS OF LAKE PROPERTY: 517 0(-0 STS'
i>U1vISIUN NAME:
BLOCK:
LOT: le 3 4--
c t :1; i, i".NF LEASE #: PIT #: yu
F1.I:PI-I0NF t FOR CONTACT "5' i 7 (HOME) (WORK)
?? lUl l I OF LOT AT SHORELINE: t 25Or
1 F :\N U PHONE # OF ENGINEER OR ARCHITECT:
C L? OG_ r?s

4e7 _510( - 2cq)41Z--
?7?? w a.?r ??t.lc c ?.l Sea
.-? I I; AND PHONE # OF CONTRACTOR
}'I:OPOSL'D CONS"CRUCTION AND/OR ALTERATION OF SHORELINE:
til:L A7-I'ACHED PLANS:
CATION CAN BE REVIEWED WITHOUT PLANS MADE IN ACCORDANCE WITH USER'S GUIDE.)
Ini43tion Pumps
individual irrigation pump permit for a lake front lot s* ($200)
Attach copy of vehicle registration
''t)c>cribe pump horsepower and give brand/model number
1'i P.:?SL REFER TO YOUR SHORE IMPROVEMENTS CHECK LIST AND USER'S GUIDE-
li HNI I I TO TIIE LAKE OFFICE OR PLANNING DEPARTMENT, P.O. BOX 429, KINGS MOUNTAIN, NC 28086
?[ ri?-1ZS110RELINGAPPLICATION.jsh
1 e v,,-, (_au- d Nearest Town:
.?.., i•i?n :iaiilc or site address (include phase/lot number): © bps
,it,: please include road numbers, landmarks, etc. (This is not necessary if an adequate

I>c ribe the existing land use or condition of the site atthe time of this application:
: ?'izc (acres): ( Qe2E'?
A"?rc;t body of water (stream/river/sound/ocean/lake): (.AKA ?GSS
I ??,? ribc the purpose of the proposed work: lei L,99P S 4O ¢EL-I tJE -rC>
p¢?,rc!Jf_AZQ1T'?a??ac. MtII iAJ a 111 S'lkoecT?t??
L l')" the type of equipment to be used to construct the project: T?K? $Ack ueE
MOL111t of impact (including all excavation,'baekfill, rip rap, retaining walls, etc.) below the
,-1 lAc lcyel in square feet or acres: 1200 Sm Pi
\nnount oI impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
h e the normal pool lake level and 50 feet land-war in square feet or acres: i 'Loo ?
u E U A -M c$4 4400- 61 i 160<t4- VpW MaST'Af-- 43;1
-t- 4455S 4 a ? es 6 T ec-?S w rec. g er V-s m a vers a Ikgvt.. 6 ??= 't1-?S S c rte`
J:::'lZ C„AA c a AJT#- 6e- 5 T Pt(S
Please describe vegetation above the normal pool lake level and 50 feet,landward to be impacted
M, trees for instance): _
?ionature Date
,irnautrc is valid only if an authorization letter from the applicant is provided.)
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