20100210 Ver 1_401 Application_20100317

20 100 2 1 0
fated application form`. for a 40r,,Water Quality
?, , (?dcrul 1';ncrgy Regulatory mOussion) regulated lake shore or
A rim, Corps of Engineerge? Application cannot be used
a plieitl&,and supporting
,, :, n1 impacts. Please provide T of $240.00
Quality
,< < l i ;,IS a non-refundable applies on of'
1„) t [()Ill o f less than 1 acre an , cts to lake bottom of greater or
he sent to: pA i
versight/Expr ., g
;,[c, Oua ity X101 O
u,cl j
pli,;in( Information IJ'
AR 1 70 ZCiO
I ;(rmafi??n DENR-WATER-OAgy
WERI,ANOSAND STORY VATElt B__?_
--------------------
uj ?6 Cc- r)-
Pay
011 I and dated copy of the Ag
:;:,s signatory authority for the owner/apple

N ,,,ilber:
nt,Authorization letter must be attached
1

i? inity snap clearly showing the location?gf - landmarks such
,t! J roads Also provide a detailed . es and
w to make a
?,';?<<_? surrounding properties. You mayusertMe?
X oance Bohr ty,map and site
o?cct.:11so, see the example below for
1,,?? ;, scale and north arrow. The foo p' 8? Tdi ga; ? us aces, or other:

. ll 1) IZES S : --------
C -Z
1,U N-L(S)v
\KF PROPERTY:
BLOCK:. LOT: c?
PIT4. 4?,t rA
(HOME) (WORK)
l -SfIORI,LINE:
OF L:NGINFER OR ARCHITECT: -------
-c ,? i?=r t? rv a ra+a p e (7 o a) AA-1
1) Pi IONF # OF CONTRACTOR: t
1) ct>S•I RUCTION AND/OR A
,i 1'L?lyS:
\N BF RFIV ILWED WITHOUT PLANS MADE INACCQRUANCE SBx'S GUIDE.)
PUMPS
: ct iJua( irrigation pump permit for a lake front lot !0 (5200)
•Art,,eh copy of vehicle registration
ump horsepower and give brandlmodel nu'in6er
.. .- to
Lr i K TO YOUR SF-{ORE IMPROVEMENTS CHECK I.ISTAND US A'S QU NC 28086
W, HE LAKE o -FICE 011 PLANNING DEW ..
:yYk
x
I_ocalloil
? _1_ c.. t_ 4 tit Nearest To,N
ision name or site address (include ghasell`
i )i:.:L bons to site please include road numbers, l,_
l ncluded): 1?f

A'? hL

as

a C- 43 T,E'ap
,O t, if an adequate G
S e+r? : F

_ ;.1, ibc the existing land use or condition of tl'e site - ' tofthis application:
Property size (acres):
.

L-A k t=
carest body of water (stream/river/sound/ '52
X

?.
r:
Trf - the purpose of the proposed work: 11? ? 't6 ? PP -L -- kn

;
f
r
I ist the type of equipment to be used to cons d? 6kr? f
!;oust ol'impact (including all excavation, backfill, rip rap, retaining wads, etc.) below the
normal pool lake level in square feet or acres: C. aQ f 5q .F-C-
?fi?6 x..:lypw,h s?,
\mount of impact (including all cle?rictg„ l $ walls, etc.) x, ?

.
r
-i norural pool lake level and 50
f 4

?
'5 1 00
?

?
' and to be impacted
I L,,ISC describe vegetation above the normal G =
nuulbcr of trees for instance): t5,-,Z rajaf -©- o !$-- sz e?;
t h : ?•. ??6 .? ? ?1? ?^ - .,W '?+'`-; (rc•Lt `114 ?`"?

r\1!l?li?alll?Agent S Signature
_.-
(Agent's signature is valid only if an autho '
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