20051848 Ver 1_Application_20050929

20~~
The foE[owing is an abbreviated application form for those applying fora 401 Water
Quality Certi[-cation to impact FERC (Federal Energy Regulatory Commission)
regulated lake share or bottom under the U.S. Army Corps of Engineers Permit
GP30. This Application cannot be used for wetland or stream impacts. Please
provide se~~en (7) copies of this application and supporting information as ~~~cI[ as a
non-refundable application. fee to the Division of 'L'ater Quality of 5200.00 for
impacts of to Iake bottom of less than 1 acre and 5475.00 for impacts to Iake bottom
of greater or equal to 1 acre.
Applications should be se!-t to:
Division of Water Quality Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I. Applicant Information
1. Owner/Applicant Information /
Name: J2~~ r'~' t~T, a Kel ~r ~Se i ~
Mailing Address:
u ~~~~,. lug
Telephone Numbed
E-mail Address: y~ r
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8
Q~~~oe~~
SEP 2 9 1005
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nor, ~y-h { ~ {~ s ~
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Fax Number: Sz w, .e
QK~(
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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:.
E-mail Address:
II. Project Information
Attach a vicinity map clearly showing the location of the property with respect to
local landmarks such as towns, rivers, and roads. AIso 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, sec the example below for guidance. Both the vicinity map and
site plan must include a scale and north arrow. The footprints of all buildings,
icnpcrvious surfaces, or other facilities must be included.
I. Location _ ~ ~/
County: ~"r2n'1 I~~N NearestTowit:~l~u%Sbur'
Subdi~-ision name or site address (include phase/lot number):~p ~- /~j y'S' f ~( ~~
Directions to site please include road numbers, landmarks, etc. (This is not
necessary ifan adequate vicinity map is included):
2. Describe the existing land use or condition of the site at the time of this
.application: t~,• f'~m./l,~ ~,/~-~~0 /-~ a,t~ r ~S; ~,r
3. Property size (acres):,
iX Zl~c9~
4. 1\~earest body of water (stream/river/sound/ocean/lake):~k~ /Qp y ~, ~Y
5. Describe the ucpose of the proposed work: f~tc.~k~ .i ~~ ~
6. List the type of equipment to be used
_ - c .. _J A .t- r . f
t the project: r~"~ ,t~j([Q 1/~~~~y ru
7. Amount of impact (including all excavation, backfill, rip rap, retaining
etc.) below the normal pool Lake level in souare feet or acres- ?Ll~ ,~
8. a. Amount of impact (including all clearing, back fill, excavation, rip rap,
retaining walls, etc.) above the norm p~° L lake level aad 50 eet land-ward in
square feet or acres: 8 C ~- m r a~h~y_s~ L N 0 S'A 7fi v ~ -~
b. Please describe vegetation above the normal pool lake lev [ a d 50 feet
ward to be impacted (number of trees for instance):
AppIicantlAgent`s Signature v ~ _ Date •
(Agent's signature is valid only ifan authorization letter from the applicant is provided.)
~s
t
f~2

~~ ~F~1~ ~~tad~
~~II F~~rn~i
Plee~e ~ppra~xirnate sketch the Ping f~rrnon ~n ttyis ply
geese +aai~ie n~i~ns f~ e~ item, ~~~~ ~e 1t1 tt. x'I~ tt~:
'f ~ ~## p~~~~e~ ~~#~n ~#earin~ ~prorri~e drnan~icrn$
~) l~c~atier~ of rip rip ~r fi## #~ ~e pled ab~tre the F~II Pan~# eleveti~nh
~~ toc~ti~n ~f rip ~p c-r fill to ~~ placed Meta the ~ fond elerretien
d~ "Thy iec~itfnn ~' pr~p~~e~i sutures sa~ch as buildings, ret~inin
walla ~ cl~~k~, et~~
~i the #t~cati~r~ ~f :any excavation ~r c~d~in~ below t~~e Full Fend
eleveti~n.
~~ Lo~etn !rf ~fili~tr u~Ct~-n ~C~~~~ oorTidQrs.
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