20040801 Ver 1_401 Application_20040518

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7'txe 1'ollowiag is an nl,t>rewiateti applirati~~n f'orn~r tc-w tl.:u~r ~-l~~~t~~fizxg k'or a 40a 'V~'~,ter
Quality Ccrti>']cntit~rYO isa impact F>~ztC: (f'eder'al l+~xter~~; i"+~~~1tt:xtary t~oxrimisaiorr)
re~at$t:ed lake 91rrrwe or• hottons urxder tlhe~ C7•S. ~.rrrrv C`<a~~i>~ of ~n.g~accrs Permit
GP30. Ttxis Agplicat€nn cannot be uaecl Fnr• w~itl~trk~l Y:r• ~tt•currx innparts. I'iexrvc!
prawyde s~eva~n r~i~" oA' is a ~ Iites~lr,n ;and sx~~pYar'tirx~ lrr6~r~~r,ation es well as n
nan-reftrndalale applicxrt3ryn fee f.o t e , t'v sroxx of ~`~.ta,Wr• (~rr:~ti~r of~~i~ for
iurpacts of°tn l,a)Ke Iiottorr~, ui` legs t'hsan 1 Acrc and ~47~.t~ta fi~nr a:t~xlw:xcts tc~ Irrke ?~nttozrr
of greater or• eyuryl its l r~crc,
Applicatiory~ shnlzlcl he sY~nt fig:
pivision o1` Wa.ter duality ~etla.nds U`ralt
16501~isit Service Cegtez•
Raleigh, NC Z7F99-) G~
I.

Applictrnt lgfarrnatri0p .° "' ~ ~' l_llU4
~7wtxerl/A~~+licaretlr~t~rrrsati~n `~``~~~"~ ~~1ALITYS~r~TIQI~ ,
l"vanxe: ~oN~~..c Evwr~2D Lt~4~T - - _-- .,
.
--- ~ --w------••-~-w ^ t I ~(
W/ N1 / N O ~..~ C,. of S 4 ~ ~, t w
•l•e:]Cplxbrrk !~]1.C11~4'l Q~O~I~,~ ~ f S~ ry j....._.-...-----
I:;-mail. Ariclrc~~ W ~T ~4 I A (~of!?~ !q..~.~ ..w~.,~..
Agent lnfc-rn3.af207~ iA silgnrcl arrd dated ~,f,.~„ raf' t:ft~~- ~,l;+:t:,tt ;~uth4~rizatiGrt leMer'
tn4z~t bt a~aChc:.~ i..k thr: Ahem has 5~r~,atar e~t,la~r~ty timr tlz<:~~'~'~~x,'ypplicant,.)
Name. .,._......... .__.._ _..-.._.. _ ...._ ......._..,..._~..w.~-,-.-,-.M...,,,_.w-;..~.,.._,,.:,„,
t~onapruav Affil.a:rtx z, ,,,~„
..
Ivlallllx~; flcldr~:~,8'
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n
'l;clopharre: ~V~,;Rn~cr~~_~-.._..__-~---~--- ~:~:~ ;~;rz3kr~x~ .~_......,,..~,.;:...,
„~,
}~-marl r~d~.tre.~~,,w.....~.....~..,.
...,..... r... W _ v. _.,..., _....... _.,.,
II. Project Inforrrxatyars
Attach a vicinity YYrztp clearly aFavvvin~t the Ivc;~hr:~zt ~3t.. wh~~ r:r•ry~rrty with respect t,~
local. iangittaer~s t~~:lt a~ sawrts, avers, and r~~c~rc~r. ~ls~ E,~~.,vide a detailed site
plztrx ~hrrv~iz~,~ pa's±;~Lrty bozusdaz~cs aaicl d~;~~t;Ivp~nzcrtir Ia4t~~:s irs relarin~s c~
sxurutuxcfirxu rt~~~pertyc5. Yotr ritldy use dh~ dittr~r~~x•,~~, C?~;~t;~x~ tc:~ r~str~lr,~= a hernd 5koccfr caf

P1l~`r'-• t~°c?0()~l ~~ ~ 4'~! FF?Cmi: G~a~'-f.~ rt~~an!!; -; 91y73 ~~~E"-+3

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your prdjtct. Alscl, aee rite example below for wirfatrce. ~s"vtli rite vicinity ntap lznd
site plant mart irzchrde a scale ntsd north $rrrw. `3`',e foot2arir,,ts of all bviJ~iz?.gs, .
impervi4~us :9usf'elrrs; yr other faciJitics must k~c im;..ltadeci,
!. ~.C1Cltlpn
Counh° S N
~ p _~ . ~Wo~o~.
Subdivision name or szt eddresq rnal.ude ~ hesrlIoi nu;lshar>:, -~-~~ _~ 0 1 `~
I7,roctiuns to site please include road numbe*;~,, ~-~.__._,~,,._ett;~,,~,,,.,-~"~,;5;~1.
lsendralatl';s, etC. (~'iszs is not ~.
necessary if an adequate vieir,i,ty rae~p is izs~itldedl:....l~Q„t~,~so~ 62.TL~
._. ~:l.:..~~ Far ~~ .~~N ~./.-7...`•9,~._L~.~ owr ~t1~.I
_.___ ._.... _...__ . _.r .. , ,
z• ACSCribt; the ezintitzg land uae czr conditic~,tt n}' tl,e sl;~; at the tense of tl,i~ -,.».
appGc7te.an: ~ '
..
~~.w
.~
_. ~
,:
___ ..= r~ ....
..,
._._.._~. ...W........,
3. Pr ~~....,.
operty aixr, (a~-rc:~): ~ ~ZSac~~
~~
.: ;
~. N~;treat body of" t4ater (stt'yam/riverJsntutd/oc<;att,~lvitir,): ~ ~c ~ ,,~~G,. ~~ ~~~L .
S, De.'~rribe~the pltrt,osa of the propbytd Lvark:,-.~, ~..__~~..~__ w« t 1 v r: F' 1:;.,., .~
6. List the type of euuip eltt to be ugod to construct thy: projc~:1: -,.. c{ ~ --
7. t~r,otent o.f xn~pact lincludin~ a.ll exrava.tivn;. bat:kfll, x~ii^ Ctlp, retaining tivr.lis, ':
eta) below the narme,l pool lake levol in squrtrc fret r)r aaz~;s;. ,~r}f-!~ o y„ Nagy _
wa,l ~ '
g• a. Amount of irssp;xct (including all clcc~xin~;, bn~*k fill;: cxcav,~.t,~~~n, ~~, rdp,
rettr.ining walls, et~~,) atmve th.e npr~as pbpl lake levr;i gtlci Sq .k~et land-walr i
square Pert or sere: A rn x ~S ~C Z2' o
'~, .
woec~ Se•. ~..__._..__ .............. ._.......~............_e
,1Q DO E4 ~ S ~ ~~, Fa ~ 4.~ ~ S [.4 W es~l.P~..,...~-~--~-~•S4~fC~S..:A~ ~17~R~r /Q 4`~
b. Please dascr;~jC ,e~wtation abgve the tx>rm~ll poa? lake 1~vcl and 50 feet laud-
. ward to be impactcel (numbe~~ ol'tr4es for inrtakl.ces o ~, '~
_: .._,..., jQ4s,
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m Kc~ ..,.,...w.,..._.. ~~ ,:.
.._.w_..__ --_--------...._....._...,.,~~ ~~ ~
Appllos-i+dAges~at`s Sicma.turr °..^.~ - .. - ... ...._
D to - ----......_ - ;r
(Agent's sigru,tue is vKiid orrl~ ii ati suthorirativn..letter~rri~.t,,e eppttcetzt is provided.}

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(y~l~as~ vl~e cn~tan~ liar ~ ism, a~uc~ as 1!0 ft. ~ ~!!Q ~. ,` /~
~~ prr.~paserd v~lan ~~ t~'~~d~ tl~~a~~~~ /YoN~
2~ ~.t~~ ~f rid ~ fi!! ~~ b~ ryla~~d ~bow~e~ fih~ i~~! l~anc~' ~f.~!lr~n itJo~v~,
~~ ~.~or~tix~ra ~' r~~ ~~p ter' it1 ~a be played ~lerv~ tha ~ ~"~t~d +~lo"Y'~ian ~oaJe..
~ ~ ~ocatloirM erf I ,y~paset~ au~~cte~rrs dlt~ ~~ ~ild~ng~. rrstr~ini~t9
w~lls~ dr,clc~„ ~~. S.~ ~ a..~ o.. ~,
S~ ~'hne Oacatinn ~ ~a!~dtlmrr~ yr ~-itdgin~ .~ ~trtt Rroetr~ IVa sue..
el~ratian,
~~ L~acatl~vr- ~ caae~wi~tlfern a~ees ~~rxludar$. ~ w..~ 17~~ :~ ~++N~.. ~o S~a.w~l~

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The map is centered near 9863 NC-1806, Norwood, NC, 28128-7401, US [-80.10,35.22] $[a1e.
5000 ft = r ~
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2000 ft ~~
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